group health insurance
small group coverage is for employers with
1 to 50 employees
a qualified association must provide health coverage to at least
1,000 employees and/or their dependents
Experience Rating
Group health insurance is usually subject to experience rating, where the premiums are determined by the experience of this particular group as a whole
Individual Employer Groups
Group health insurance plans may be purchased by individual employers, qualified associations, or licensed purchasing alliances to provide health care to employees and their dependents.
Group Contract
In group insurance the policy is called the master policy, and is issued to the policy owner, which could be the employer, an association, a union, or a trust.
community rating or pool rating
Individual policies are subject to ____________ ___________ where the premium is based upon the overall claims experience of the insurance company.
HIPAA
The Health Insurance Portability and Accountability Act is a federal law that protects health information
Insurer Underwriting Criteria
1.) Certificates are guaranteed issue with no individual underwriting 2.) Premiums are determined by age, sex and occupation of the entire group 3.) The reasons for forming the group are other than purchasing insurance 4.) A certain participation level must be maintained 5.) flow of new members 6.) everyone has the same coverage
large group coverage is available for employers with
51 or more employees
Self-funded programs
a non insured plan that uses a trust fund to pay for employees' health care expenses directly
a qualified association must meet the following requirements
1.) Have been in existence for at least 10 years prior to January 1, 1995 2.)Have the primary purpose other than providing health coverage 3.) Conduct regular meetings within the state, with the notice to all members at least 30 days prior to the date of any meeting
Annual Open Enrollment
30-day open-enrollment period is available once a year to employees who reject coverage during the initial enrollment period and later wish to have coverage or to add dependent coverage
Debtor
a borrower of funds
Creditor
a lender of funds
Certificate of Coverage
The individuals covered under a group insurance plan are issued evidence of coverage in the form of certificates of insurance, or certificates of coverage. The certificate of insurance cannot contain provisions or statements that are unfair, misleading or deceptive. The certificate tells what is covered in the policy; how to file a claim, how long the coverage will last, and how to convert the policy to an individual policy.
Extension of Benefits
a provision that allows coverage to continue beyond the policy's expiration date for employees who are not actively at work due to disability or who have dependents hospitalized on that date (coverage continues only until the employee returns to work or the dependent leaves the hospital)
One of the differences between group underwriting and individual underwriting is that in groups of 50 or more,
medical information cannot be required of plan participants
Underwriting
risk selection and classification process
Employer Group Health Insurance
the group must be formed for a purpose other than obtaining group health insurance.There are generally 2 types of groups eligible for group insurance: employer-sponsored, and association-sponsored.
Adverse Selection
the tendency of poorer risks seeking out insurance protection.
Persistency
the tendency or likelihood of insurance policies not lapsing or being replaced with insurance from another insurer
Insurer Underwriting
the underwriter evaluates the group as a whole rather than each individual member. The group's risk profile determines whether the group will be accepted or rejected. As with any type of underwriting, the underwriter tries to avoid adverse selection