Section 6 - Group Disability (Accident and Health) Insurance

Noncontributory plan

The employer pays the entire premium and the employee does not contribute to the premium payment. 100% of all eligible employees must be covered

Contributory plan

Both the employer and the employee contribute toward
the premium; 75% of all eligible employees must be covered

Master policy

Issued to the employer under a group plan; contains all the insuring clauses defining employee benefits.

Certificate of insurance

lists what the policy covers and it explains to the insured such things as how to file a claim, the term of insurance and the rights to convert from group coverage to an individual policy

Experience rating

Rating system that bases insurance rates on claims history

Employment-related Groups

Group disability insurance policies may be issued to small employer groups, associations, including a labor union which has been organized for purposes other than obtaining insurance

Multiple Employer Trusts (METs)

A legal trust established by a plan sponsor that brings together a number of small, unrelated employers for the purpose of providing group medical coverage on an insured or self-funded basis. The trust gives these small businesses the greater benefits and

HIPPA

The look back period for pre-existing conditions is limited to six months and a pre-existing condition becomes covered 12
months after enrollment (18 months for late enrollees). Pregnancy is not a pre-existing condition and newborns and adopted children m

Small employer group coverage (HIPPA)

All small employer groups (2 to 50 employees) must be accepted for insurance without regard to the health status of the employees. Small and large groups must be renewed, EXCEPT for fraud or nonpayment of premiums

Who sets Group eligibility standards

The group policyholder, often the employer, sets the eligibility standards. Normally, full time employees are eligible, but new employees may have to wait for the annual open enrollment period to occur before they can sign up. Many groups also
permit depe

Coordination of Benefits Provision

Guidelines to determine which company will pay as primary insurer and which will pay as secondary insurer when a working couple (or their dependents) have a claim that's covered by more than one group insurance policy. Coverage where I work is primary. Co

Change of Insurance Companies

In cases in which one group insurance contract replaces a
similar plan of another carrier, the prior carrier shall remain liable for all pending claims. The succeeding (new) carrier must also continue to cover each person who was covered under the prior p

Events that Terminate Coverage

The individual will have the right to convert his insurance to individual insurance; The time for converting is usually 31 days after ineligibility

COBRA

Consolidated Omnibus Budget Reconciliation Act
A federal law that requires employers with 20 or more employees to provide for continuation of benefits under the employer's group insurance plan for former employees and their families (at 102% of the group

HIPAA requirements

An individual is eligible for individual coverage, if:
1. Their most recent health coverage was group insurance or a church or government plan:
2. They have at least 18 months of prior creditable coverage;
3. There was no lapse in coverage greater than 63