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11 Cards in this Set
- Front
- Back
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Characteristics of Group Insurance |
Insured many people in one contract Usually less expensive than individual insurance Sponsors receive master contract Participants receive a certificate of insurance Premium |
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Experience Rating |
Based on claims history of the individual group |
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Community Rating |
Based on pooling groups |
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Eligible Groups |
Group can’t exist solely for the purpose of buying insurance Employer Sponsored Multiple Employers combined Multiple Employer Trust (MET) Multiple Employer Welfare Management (MEWA) Labor Unions-Taft Hartley Trust Trade or Professional Associations Lender Group
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Group Underwriting Considerations |
Size of group (2-50 small over 50 large) Composition of group Flow of members through group Plan design Contributory (members pay part or all cost min. 75% participation) Non-contributory (employer pays all 100% participation) Persistency Administrative capability |
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Eligibility for Group Insurance |
Employee Full Time Actively at work Completed probationary period Dependents Spouse Children younger than 26 Disabled child regardless of age Enrollment Follows probationary period No medical questions Open Enrollment Once per year No medical questions Late enrollment Medical questions |
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Coordination of Benefits |
Applies when person has two group policies One is primary other is secondary Employee plan is primary Children- primary plan is whose parent come first in the year. Custody may also determine primary |
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Change of Insurers |
No loss or benefit for current claims |
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Termination of Group Coverage |
Employer Terminates plan Employer did not pay premium Employee quits, laid off or reduction in hours Dependents Divorce Employers Dies Employee termination Too old |
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COBRA |
Federal law Apply to employers who employ 20 or more Employers must allow employee or dependents to remain on the group plan Applies to medical and dental not life insurance Extends coverage for 18 months if employees employment is terminated or there is a reduction in hours. Extends coverage for 36 months if dependents no longer qualify due to divorce, age, death. Premium is 102% of a regular group premium employer does not contribute. Cobra automatically ends Premium not paid Employer stops the group plan Individual becomes covered by another plan Individual becomes eligible for Medicare OBRA 29 months if disabled at time of termination |
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HIPPA |
Pre-existing conditions Includes most health coverage Guaranteed 48 hour hospital stay for regular delivery 96 for C-section. Small employers cannot be denied. |
