Ch 13

An employer may not discriminate against an employee while on leave under the Family and Medical Leave Act, and must provide the employee with the same benefits normally provided to an employee who is:

In the same leave or part-time status

Events that will cause termination of continuing health coverage under COBRA include all of the following, except:

The employee fails to convert to an individual health insurance plan on the day it is offered Events that will cause termination of continuing health coverage by COBRA include failure to pay premiums on time, cessation of group health coverage by the employer, and employee eligibility for Medicare benefits. Conversion is a separate benefit. Include: -The employee becomes eligible for Medicare benefits -The employer ceases to maintain any group health insurance plan -Timely premium payments are not made

A "Large group" for health insurance in California is a single employer with more than _____ full-time employees.

100

A Small Employer is defined as any person, firm, corporation, partnership, or association that is actively engaged in business and has ______ employees or less.

100

The Mental Health Parity Act applies to employer-related group plans with ______ or fewer employees and was amended to also apply to individual health insurance coverage.

100

An employer may require a former employee who has COBRA coverage to pay up to _____% of the premium.

102

The pregnancy discrimination act applies to groups with ______ or more employees.

15

Cal-COBRA permits the insurer to charge employees up to ___% of the premium.

150 California residents have the additional protection of Cal-COBRA, which provides coverage to employees not covered under COBRA, a time extension for those whose COBRA eligibility has expired, but under either case, Cal-COBRA permits the insurer to charge up to 150% of the premium.

HIPAA laws apply to groups of _____ or more.

2

Employers who have ______ or more employees are required to offer the same health benefits, under the same conditions to employees age 65 or over and to employees' spouses who are age 65 or over, as offered to the younger employees and spouses.

20

Employers with fewer than ______ employees are not required to offer continuing coverage under COBRA.

20

A Group Health plan with _____ or more employees is primary to Medicare and pays first.

20 A Group Health plan with 20 or more employees is primary to Medicare and pays first.

COBRA applies to employers with ______ or more employees.

20 or more employees

Small employers with _____ or fewer employees who average less than $50,000 in annual income may be eligible for federal premium tax credits of up to 50% of the employee premium for a health plan purchased through California's Small Business Health Options exchange (SHOP).

25

For an employee to be eligible to participate in an employer's group health insurance plan, he/she must be considered full-time and work a minimum of _____ hours as established by the Affordable Care Act.

30 To be eligible, an employee must be considered full-time and work a minimum of 30 hours as established by the Affordable Care Act.

There is a conversion period of _______ days in which the employee may, upon termination of eligibility and without evidence of insurability, convert group benefits to an individual policy.

31

Most companies are required to extend benefits for up to _____ months when the individual is allowed less than that amount of coverage under COBRA.

36 Most companies are required to extend benefits for up to 36 months when the individual is allowed less than 36 months under COBRA, this extension of benefits under Cal-COBRA includes family/medical leave and maternity benefits as covered under COBRA.

A carrier replacing employer group coverage is not required to cover all employees and dependents covered by, or eligible for, coverage under the previous policy if the replacement takes place more than _____ days after of the previous policy's termination.

60 If the replacement is not within 60 days of the previous policy's termination, the carrier replacing the coverage is not required to cover all employees and dependents covered by, or eligible for, coverage under the previous policy as of its date of discontinuance.

Until yesterday, J. J. worked for his father's company and was covered by the company's large group health plan. He stopped working to go to college. He is 26 years of age and wants to keep the same coverage until he earns his degree in approximately 24 months. Which of the following statements is true?

A good option for J.J. is to exercise the COBRA option under his father's group plan Since J.J has lost his dependent status, but still wants the same group coverage, he can continue that coverage under COBRA for up to 36 months.

Regarding ERISA employer-sponsored employee retirement and welfare and benefit plans, which one of the following is false?

An annual financial report must be filed with the state of California's Department of Insurance Regarding ERISA employer-sponsored employee retirement and welfare and benefit plans an annual financial report must be filed with the IRS.

Concerning COBRA, which of the following is correct?

Applies to employers with 20 or more employees Federal law mandates that employers with 20 or more employees provide a COBRA option. Termination of employment provides only 18 months of continuation. Qualifying events for dependents only (not employees) permit continuation up to 36 months.

Group _________ insurance policies do not name specific individuals as insureds, the insured organization/business must certify a covered person's claim as legitimate.

Blanket

Which statement would be considered inaccurate regarding the underwriting of a group plan?

Contributory plans require 100% employee participation Contributory plans require both the employee and the employer to contribute to the premium, and 75% participation is required. accurate? -The insurer can require a minimum percentage of the group to be enrolled to guard against adverse selection -The cost of a group policy is determined by the type, size, and average age of the group and claims experience with previous insurers -The insurer may use experience or community rating to determine premiums

In a group health policy as specified by the California Insurance Code, employees added to the plan after the inception of the policy each have their own period of contestability with regard to:

Enrollment application misrepresentations and concealments

The Americans with Disabilities Act (ADA) regulations require that disabled employees be given _______ access to the same health benefits that are provided to other employees.

Equal

All of the following are accurate statements, except:

Group insurance normally covers occupational injury or disease Group insurance normally covers nonoccupational injury or disease. Workers' Compensation Insurance is designed for occupational injury and disease.

All of the following groups are eligible for group rates, except:

Groups formed to reduce premiums Employers, labor unions, and associations are eligible plan sponsors.

All of the following are true of the Coordination of Benefits Provision under a group plan, except:

In the event children are covered under two group plans, the insurer for the parent who is the oldest is primary, and the other parent's plan is secondary Under the Coordination of Benefits Provision, the insurer for the parent whose birthday is first in the calendar year is primary, not the plan for the parent who is oldest. True: -It is a method of determining primary and secondary coverage when an insured is covered by more than one group policy -Secondary carriers will only pay claims that are in excess of the primary carrier's responsibility -In a spousal situation, the insurer for the claim of an employee is primary, with the spouse's plan being secondary

An employer group health insurance sponsor does all of the following, except:

Issue the policy The group sponsor applies for coverage, provides information for underwriting, maintains the policy, and makes premium payments. Only insurers issue policies.

Regarding COBRA, which of the following is not true?

It covers participants who have resigned for 36 months following the date of their resignation Termination of employment other than for gross misconduct allows former employees and their dependents a maximum of 18 months of continuation.

The Mental Health Parity Act prevents group health plans and health insurance issuers that provide mental health or substance use benefits from imposing ___________ on those benefits than on medical/surgical benefits.

Less favorable benefit limitations The Mental Health Parity Act is a federal law that originally prevented group health plans and health insurance issuers that provide mental health or substance use benefits from imposing less favorable benefit limitations on those benefits than on medical/surgical benefits.

Under Cal-COBRA all of the following benefits are provided, except:

Life Under Cal-COBRA, health, dental and vision plans are covered.

The entity that is formed by unrelated businesses in the same or related industrial classification allowing small to medium sized employers with limited numbers of employees to combine their employees into a single, larger group to obtain more favorable health insurance premiums is considered a:

Multiple Employer Trust (MET) Multiple Employer Trusts (METs) are entities formed by unrelated businesses in the same or related industrial classification and/or third-party administrators who are called sponsors, thus allowing small to medium sized employers with limited numbers of employees to combine their employees into a single, larger group in order to obtain more favorable life and health insurance premiums and increased benefits as well as providing access to other employee benefit plans, such as defined contribution or defined benefit retirement plans.

When employers who self-fund their employee benefits form a larger group in order to offer health insurance benefits to each employer's workers, it is called a (an):

Multiple Employer Welfare Association (MEWA) A MEWA allows larger employers that self-fund employee benefits to form a group to reduce the cost of providing those benefits. A MEWA provides economy of scale, as would a Multiple Employer Trust (MET) for smaller employers.

When group health insurance is being replaced, ongoing claims under the former policy must continue under the new policy, overriding any preexisting condition exclusion. This is a requirement under which of the following?

No Loss - No Gain Statutes The question describes the No Loss-No Gain legislation, sometimes called a Hold-Harmless Agreement.

In a group health policy as specified by the California Insurance Code, the validity of the policy can be contested for ____________ regardless of how long it has been in force.

Nonpayment of premiums

Under the Family and Medical Leave Act, an employer must maintain the employee's existing level of health coverage (including family or dependent coverage) under a group health plan during the period of, provided the employee:

Pays his or her share of the premiums Under the Family and Medical Leave Act (FMLA), an employer always must maintain the employee's existing level of health coverage (including family or dependent coverage) under a group health plan during the period of FMLA leave, provided the employee pays his or her share of the premiums.

Which one of the following is not eligible for Cal-COBRA?

Self-insured plans Eligibility for Cal-COBRA extends to church plans, indemnity policies, PPOs, and HMOs only but self-insured plans are not eligible.

Group blanket insurance covers a group of individuals whose membership changes frequently, such as students, passengers traveling on a common carrier, sports teams, volunteer firefighters, or other groups of people while being exposed to a(n) _______ risk:

Specific

If an employee under a group policy becomes entitled under the terms of the policy to have an individual policy issued without evidence of insurability, the employee is required to:

Submit an application with the initial premium

Under COBRA, coverage for dependents of an employee may continue up to 36 months for any of the following events, except:

Termination of the employee If the qualifying event under COBRA is termination of employment, the coverage may be continued only for 18 months.

Which is not a qualifying event for the continuation of dependent coverage under the Consolidated Omnibus Budget Reconciliation Act?

Termination of the employee for theft This would be termination for gross misconduct and neither the employee nor his/her dependents would be eligible for continuation under COBRA. Qualifying event: -Termination of the employee for theft -Death of the employee -Divorce or legal separation

A firm with 50 employees replaces its existing group health plan. With regard to ongoing existing claims, the replacing insurer will be:

The No Loss-No Gain law (a.k.a. the Hold Harmless Agreement) establishes mandatory risk transfer.

Events that will cause termination of continuing health coverage under COBRA include all of the following, except:

The employee fails to convert to an individual health insurance plan on the day it is offered Events that will cause termination of continuing health coverage by COBRA include failure to pay premiums on time, cessation of group health coverage by the employer, and employee eligibility for Medicare benefits. Conversion is a separate benefit.

Which statement is incorrect regarding COBRA?

The employee or beneficiary must respond to the notification of his/her right to continue coverage within 90 days, if he/she wants to continue the coverage The employee or beneficiary must notify the employer within 60 days if he/she wants to continue the coverage. Correct: Coverage continues for 29 months for individuals receiving Social Security disability