Federal Laws & Health Insurance Programs

Questions and Answers

What federal law regulates companies that set up employee health and pension plans?

ERISA

What health insurance program is available for federal government employees?

FEHB

What may be used to modify the terms of an insurance contract?

Rider

What type of contract involves a third-party claim administrator for a self-funded health plan?

Administrative services only contract Signup and view all the answers

What is a common reason why people elect to enroll in individual health plans?

Because they are able to continue their health insurance coverage between jobs Signup and view all the answers

Who is not a common purchaser of individual health plans?

Employers Signup and view all the answers

How often do open enrollment periods usually occur?

Once per year Signup and view all the answers

What is one way that an employer can reduce prices for their group health plans?

Carve out benefits during negotiations to change the coverage Signup and view all the answers

What type of plan do employers or employee organizations typically offer to their employees?

Group health plan Signup and view all the answers

Who may be covered under a group health plan?

Employees, families, and former employees Signup and view all the answers

How can employees customize their group health plan policies?

By choosing levels of premiums and deductibles Signup and view all the answers

What document do self-funded plan members receive that outlines their benefits and legal rights?

SPD Signup and view all the answers

How can third-party administrators help self-funded health plans?

By handling collection of premiums, processing claims, and keeping a list of members Signup and view all the answers

Third-party claims administrators are classified as what?

A separate company, often a managed care organization or insurance carrier Signup and view all the answers

What type of contract binds a third-party administrator to provide services for a fixed fee per employee?

ASO Signup and view all the answers

If a state law is more restrictive than federal law, what law is followed?

The state law is followed Signup and view all the answers

What advantage do employers gain by offering group health plans?

They offer an important benefit to employees; thereby making the employer more attractive Signup and view all the answers

Which organization runs ERISA?

EBSA Signup and view all the answers

Self-funded health plans pay premiums to whom?

No one because they assume the risk Signup and view all the answers

Approximately what percent of the population is covered under individual health plans?

10% Signup and view all the answers

What is the term for the time that must pass before an employee can enroll in a health plan?

Waiting period Signup and view all the answers

What term refers to an individual who enrolls in a health plan after the original enrollment date?

Late enrollee Signup and view all the answers

What type of deductible must be met for each separate enrollee?

Individual deductible Signup and view all the answers

What type of deductible can be met by combining payments?

Family deductible Signup and view all the answers

The term maximum benefit limit applies to what?

A monetary amount Signup and view all the answers

What name is given to the time between the date of an employee's hire and the earliest effective date of insurance coverage?

Waiting period Signup and view all the answers

What is a list of drugs covered under an insurance plan called?

Formulary Signup and view all the answers

What type of provider performance would be reimbursed at the highest level in a tiered network?

Practice provides quality healthcare at a low cost Signup and view all the answers

What type of plan permits the funding of premiums with pretax payroll deductions?

Section 125 cafeteria plan Signup and view all the answers

Define parity as it relates to medical insurance.

Concept of equality with medical/surgical benefits Signup and view all the answers

What benefit does COBRA offer to employees leaving a job?

The right to continue health coverage under the employer's plan for a limited time at his or her own expense Signup and view all the answers

In conjunction with COBRA, what must be considered when an employee joins a new plan?

Creditable coverage Signup and view all the answers

Study Notes

Key Federal Laws and Programs

ERISA regulates employee health and pension plans.
FEHB is the health insurance program for federal government employees.

Insurance Contract Modifications

A rider modifies the terms of an insurance contract.

Insurance Administration

An Administrative Services Only (ASO) contract involves a third-party administrator managing self-funded health plans.
TPAs help self-funded plans by handling premium collections, processing claims, and maintaining member lists.

Health Insurance Plans

Individual Health Plans (IHPs) are often chosen to continue coverage between jobs, mainly by individuals and not typically by employers.
Group Health Plans (GHPs) are offered by employers or employee organizations and can cover employees, their families, and former employees.

Enrollment and Deductibles

Open enrollment periods occur annually.
Employees can customize GHP policies by selecting various premium and deductible levels.
Waiting period defines the time before employee enrollment in a health plan is permissible.
Late enrollees join health plans after the original enrollment period.

Deductibles

Individual deductibles must be met separately for each enrollee, while family deductibles are cumulative across family members.

Coverage Limits and Formularies

Maximum benefit limit refers to a specified monetary cap under an insurance plan.
A formulary is a list of drugs covered by an insurance policy.

Cost Management and Provider Performance

Employers can reduce costs for GHPs by negotiating benefit carve-outs.
In tiered networks, providers that deliver high-quality care at lower costs receive higher reimbursement.

Plan Features and Benefits

Section 125 cafeteria plans allow premium funding using pretax payroll deductions.
Parity in medical insurance signifies equality in benefits for medical and surgical services.

Employee Benefits and COBRA

COBRA provides employees the right to continue health insurance after leaving a job for a limited time, at their own expense.
When joining a new plan post-COBRA, employees must consider their past creditable coverage.

Organizations and Regulatory Bodies

EBSA oversees the implementation of ERISA.
Self-funded health plans do not pay premiums as they assume the risk directly, covering costs as they arise.

Population Coverage

Approximately 10% of the population is covered under Individual Health Plans.

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Description

This quiz covers essential federal laws related to health and pension plans, including ERISA and FEHB. It also explores modifications to insurance contracts and the role of third-party administrators in managing health plans. Test your knowledge on individual and group health plans, enrollment periods, and deductibles.