Group Health Insurance

Master Policy

This is the policy issued to the policyowner, in group health insurance.

Certificates of Insurance/Coverage

Evidence of coverage issued to individuals under coverage in a group insurance plan. These state what is covered in a policy and how to file a claim, how long the coverage will last and how to convert the policy into an individual policy.

Experience Rating vs. Community Rating

Group health insurance is usually subject to experience rating, where the premiums are determined by the experience of this particular group; individual health insurance are subject to a community or pool rating where the premium is based on the overall c

Multiple-employer Trusts (MET)

This is made up of two or more employers in similar or related businesses who do not qualify for group insurance on their own. In this group of employers jointly purchase a single benefits plan to cover employees of each separate employer

Multiple-employer Welfare Arrangment

Any entity other than a duly admitted insurer, that establishes an employee benefit plan for the purpose of offering providing accident and sickness or death benefits to the employees of at least two employers, including self-employed individuals and thei

Blanket Policy

This policy covers members of a particular group when they are participating in a particular activity.

Associations

The group must have 100 member, be organized for a reason another than buying insurance, have been active for at least two years, have a constitution, by-laws, must hold at least annual meetings.

Creditor Group

A specialized use of group life and group health insurance that covers debtors (borrowers); it protects the lending institution from losing money as the result of a borrower's death or disability

Insurer Underwriting Criteria (Employer Group Health Insurance)

- certificates are guaranteed issue with no individual underwriting
- premiums are determined by age, sex and occupation of the entire group
- the reasons for forming the group are other than purchasing insurance
- a certain level of participation must be

Characteristics of a group

In groups of 50 or more, medical information cannot be required of plan participants. In small groups, even one bad risk can have an impact on the claims experience of the group.

Contributory plan

Employees contribute to payment of premium. 75% of all eligible employees must participate in the plan.

Noncontributory plan

100% of eligible employees must be included, and participants do not pay part of the premium.

Administrative Cost of Group Health

Per-capita administrative cost of group health insurance is less than that of individual health insurance

Employment Eligbility

Under the PPACA employers must extend coverage to all employees who work more than 30 hours/week

Dependent Eligibility

- spouse
- child younger than limiting age, which includes natural children of the insured, stepchildren, children legally placed from adoption, and legally adopted children
- unmarried children under the limiting age, regardless of whether they are atten

Coordination of Benefits (COB) Provision

Loss - Amount provided by primary plan = Amount covered by Secondary Plan

Prohibited Actions of a COB

cannot be used to reduce benefits on a plan because:
- the insured failed to enroll in their secondary plan
- a person is enrolled in a secondary plan (with the exception of Medicare Part B)
- the insured enrolled in another plan that provides a lower lev

Notice of Covered Persons

All plans must include the following statement in the explanation of its benefits. "If you are covered by more than one health benefit plan, you should file all your claims with each plan.

No-loss/no-gain statutes

The theory of indemnification and the concept of placing the insured in the same economic position after a loss as the insured was prior to the loss. When changing health insurance, benefits must be paid for ongoing claims regardless of preexisting condit

Coverage for employees will be terminated on the earliest date in which one of theseoccur

- employee terminates
- the employee ceases to be eligible
- the date the overall maximum benefit for major medical benefits is received
- the end of the last period for which the employee has made the required premium payments comes about
- the master co

Coverage for dependents will be terminated on the earliest date in which one of theseoccur

- dependents fail to meet the definition of dependent
- the date the overall maximum benefit for major medical benefits is received
- the end of the last period for which the employee has made the required premium for dependent coverage passes

Consolidate Omnibus Budget Reconciliation Act of 1985 (COBRA)

Any employer with 20 or more employees is required to extend group health coverage to terminated employees and their families after a qualifying event. Qualifying events include:
- voluntary termination of employment
- termination of employment for reason

Group Health Plans in Louisiana can only be discontinued because of

- nonpayment of premium
- fraud or intentional material misrepresentation
- failure to comply with the employer contribution or group participation rules
- coverage termination of a particular type of insurance in the entire market by the insurer

Continuation of Coverage for the Surviving Spouse must not be terminated, except for the following reasons

- nonpayment of the required premium
- eligibility of Medicare benefits
- eligibility to participate in another group health insurance plan
- if the insured spouse remarries
(90 days)

Conversion Privilege

Terminate employees are permitted to convert their group health coverage to individual insurance without evidence of insurability if the termination voluntary or involuntary, except for termination due to gross misconduct. Must be exercised within 31 days

Reinstatement of Coverage for Military Personnel

An employee covered under a group health plan who leaves employment to perform military service and reapplies for coverage upon release, must be reinstated for coverage without any restrictions or clauses for pre-existing conditions

Small Employer

Any person, firm, corporation, partnership, or association that is actively engaged in business that employed on an average at least 2 but no more than 50 employees on business days during the preceding calendar year

Availability of Coverage

Each small employer carrier must provide the small employer health benefit plan without regard to health status related factors

Small employer medical plan must be renewable unless

- nonpayment of premiums
- fraud or misrepresentations
- noncompliance with the carrier's minimum participation or employer contribution requirements
- repeated misuse of a provider network provision
- the small employer carrier elects to nonrenew all of

Disclosure Requirements

- how premium rates are adjustable due to the claim experience and health status of the employees and their dependents
- the provisions concerning the insurer's right to change premiums
- the provisions relating to pre-existing conditions
- the provisions

In lousiana, group health plans may not determine coverage eligibility based on any of the following

- health status or medical condition
- claims experience or use of health care services
- medical history or genetic information
- evidence of insurability, including conditions caused by domestic violence
- disability

Employee Retirement Income Security Act (ERISA) of 1974

Federal law that was enacted to to ensure that employees receive the pension and other benefits promised by their employers.

employee benefit welfare" plans

This an overarching term for all forms of health care, life insurance, prepaid legal services, and disability insurance

Permitted Reductions in Insureds Benefits

An employer may reduce benefits based on age only if the cost of providing the reduced benefits to older workers is the same cost as providing benefits to younger workers

Permitted Increase in Employee Contributions

An employee's contribution can be increased whenever the cost of providing benefits is increased on all employees, but not solely related to the increased age of the employee

Requirements for Medical Expense Coverage

The obligation of the employer for retiree health benefits is to provide the value of benefits that is at least as comparable to benefits provided under the Social Security Act below age 65, and 1/4 of the benefits for age 65 and above

Pregnancy Discrimination Act

This act states that pregnancy, childbirth and any related medical conditions must be covered to the same extent as any other medical condition under the policy