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Questions and Answers
How would the insurer handle a group health policy if 15 out of 50 members have major health issues?
How would the insurer handle a group health policy if 15 out of 50 members have major health issues?
Accept or reject the whole group.
What group medical plan provision applies when a claim has coverage under more than one health plan?
What group medical plan provision applies when a claim has coverage under more than one health plan?
Coordination of benefits.
What percentage of eligible employees must participate in a noncontributory group health plan before it can be put in effect?
What percentage of eligible employees must participate in a noncontributory group health plan before it can be put in effect?
100%
Who is financially liable for the payment of covered claims in a fully insured group health plan?
Who is financially liable for the payment of covered claims in a fully insured group health plan?
Buy-Sell Plans are typically funded by which two types of insurance?
Buy-Sell Plans are typically funded by which two types of insurance?
A non-contributory group health plan must cover all eligible members.
A non-contributory group health plan must cover all eligible members.
Which of the following is NOT typically covered under vision care insurance?
Which of the following is NOT typically covered under vision care insurance?
What must an eligible individual do to obtain group health insurance without providing evidence of insurability?
What must an eligible individual do to obtain group health insurance without providing evidence of insurability?
Coverage is limited for vision and dental insurance in all of the following ways, EXCEPT?
Coverage is limited for vision and dental insurance in all of the following ways, EXCEPT?
How many employees must an employer have for COBRA to apply?
How many employees must an employer have for COBRA to apply?
What issue does the problem of overinsurance address in health insurance?
What issue does the problem of overinsurance address in health insurance?
What is the purpose of minimum participation standards in group health insurance plans?
What is the purpose of minimum participation standards in group health insurance plans?
In an employer-sponsored group accident and health plan, a master contract is issued to the?
In an employer-sponsored group accident and health plan, a master contract is issued to the?
What does Coordination of Benefits allow?
What does Coordination of Benefits allow?
Under HIPAA, what does the employee's new Group Health Plan verify regarding Creditable Coverage?
Under HIPAA, what does the employee's new Group Health Plan verify regarding Creditable Coverage?
What are Credit Accident and Health plans designed to do?
What are Credit Accident and Health plans designed to do?
Health insurance involves two perils, accident and ________.
Health insurance involves two perils, accident and ________.
When can a group health policy renewal be denied according to HIPAA?
When can a group health policy renewal be denied according to HIPAA?
Which statement is TRUE regarding continued employment after 65 and coverage?
Which statement is TRUE regarding continued employment after 65 and coverage?
What will happen to COBRA election for continuation of health coverage?
What will happen to COBRA election for continuation of health coverage?
How many employees must an employer have for a terminated employee to be eligible for COBRA?
How many employees must an employer have for a terminated employee to be eligible for COBRA?
What is issued to each employee of an employer health plan?
What is issued to each employee of an employer health plan?
Under the subrogation clause, legal action can be taken by the insurer against the?
Under the subrogation clause, legal action can be taken by the insurer against the?
What happens to an employee's payroll contribution to an HSA without a Section 125 Plan?
What happens to an employee's payroll contribution to an HSA without a Section 125 Plan?
What does Business Overhead Expense Insurance pay for?
What does Business Overhead Expense Insurance pay for?
What does Key Person Disability Insurance pay benefits to?
What does Key Person Disability Insurance pay benefits to?
If Ron cannot have more than a _____ day gap without previous health insurance after changing employers?
If Ron cannot have more than a _____ day gap without previous health insurance after changing employers?
What is the limited period of time given to all members to sign up for a group health plan called?
What is the limited period of time given to all members to sign up for a group health plan called?
What type of group Disability Income plan pays tax-free benefits to covered employees?
What type of group Disability Income plan pays tax-free benefits to covered employees?
A common exclusion with Vision plans is:
A common exclusion with Vision plans is:
How are disability income benefits from a group policy treated for tax purposes?
How are disability income benefits from a group policy treated for tax purposes?
Who is considered a possible applicant and contract policyholder for group health benefits?
Who is considered a possible applicant and contract policyholder for group health benefits?
Which type of business insurance covers the costs of continuing to do business while the owner is disabled?
Which type of business insurance covers the costs of continuing to do business while the owner is disabled?
On what basis may group health plans deny participation?
On what basis may group health plans deny participation?
Sole proprietors are permitted tax deductions for health costs paid from their earnings in the amount of?
Sole proprietors are permitted tax deductions for health costs paid from their earnings in the amount of?
Which provision would be payable under a disability income policy if the cause of an injury is unexpected and accidental?
Which provision would be payable under a disability income policy if the cause of an injury is unexpected and accidental?
Who is the policyholder for a group health benefit plan considered to be?
Who is the policyholder for a group health benefit plan considered to be?
What is the change called when an insured individual changes coverage from a group health insurance plan to an individual plan with the same insurer?
What is the change called when an insured individual changes coverage from a group health insurance plan to an individual plan with the same insurer?
Which of the following regulations does NOT apply to Coordination of Benefits?
Which of the following regulations does NOT apply to Coordination of Benefits?
What is the purpose of the Coordination of Benefits provision in group accident and health plans?
What is the purpose of the Coordination of Benefits provision in group accident and health plans?
Which of the following decisions would a Health Saving Account (HSA) owner NOT be able to make?
Which of the following decisions would a Health Saving Account (HSA) owner NOT be able to make?
According to HIPAA, what kind of information is considered as 'individually identifiable health information'?
According to HIPAA, what kind of information is considered as 'individually identifiable health information'?
Health insurance typically covers which of the following perils?
Health insurance typically covers which of the following perils?
In which type of policy can a master contract and certificate of coverage be found?
In which type of policy can a master contract and certificate of coverage be found?
Which of the following would evidence ownership in a participating health insurance contract?
Which of the following would evidence ownership in a participating health insurance contract?
According to HIPAA, what happens when an insured individual leaves an employer and immediately begins working for a new company that offers group health insurance?
According to HIPAA, what happens when an insured individual leaves an employer and immediately begins working for a new company that offers group health insurance?
When can a group health policy renewal be denied according to the Health Insurance Portability and Accountability Act (HIPAA)?
When can a group health policy renewal be denied according to the Health Insurance Portability and Accountability Act (HIPAA)?
What does COBRA of 1985 allow an employee to do?
What does COBRA of 1985 allow an employee to do?
What are the rights called that an insurer has to recover payment made to the insured from the negligent party?
What are the rights called that an insurer has to recover payment made to the insured from the negligent party?
Which of the following would NOT provide continued coverage under COBRA?
Which of the following would NOT provide continued coverage under COBRA?
What is the contract called that is issued to an employer for a Group Medical Insurance Plan?
What is the contract called that is issued to an employer for a Group Medical Insurance Plan?
What provision applies when a claimant has coverage under more than one health plan?
What provision applies when a claimant has coverage under more than one health plan?
Which of the following is INELIGIBLE to participate in a Section 125 Plan?
Which of the following is INELIGIBLE to participate in a Section 125 Plan?
If an employee contributes 50% toward a disability plan premium, what would be considered the taxable income of a $1,000 monthly disability benefit?
If an employee contributes 50% toward a disability plan premium, what would be considered the taxable income of a $1,000 monthly disability benefit?
What is the coverage issued to a person covered with an individual health plan?
What is the coverage issued to a person covered with an individual health plan?
When are group disability benefits considered to be tax-free to the insured?
When are group disability benefits considered to be tax-free to the insured?
In an employer-sponsored contributory group Disability Income Plan, how much tax is applicable on benefits paid if the employer pays 60% of the premium?
In an employer-sponsored contributory group Disability Income Plan, how much tax is applicable on benefits paid if the employer pays 60% of the premium?
On what date would Sonya have coverage after applying for a health insurance policy?
On what date would Sonya have coverage after applying for a health insurance policy?
According to COBRA, a terminated employee's benefits must meet which requirements?
According to COBRA, a terminated employee's benefits must meet which requirements?
Under group health insurance, which document is issued to the employee?
Under group health insurance, which document is issued to the employee?
What type of contract is known as a single contract issued to an employer for group medical insurance?
What type of contract is known as a single contract issued to an employer for group medical insurance?
Which of the following is typically NOT eligible for coverage in a group health policy?
Which of the following is typically NOT eligible for coverage in a group health policy?
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Study Notes
Health Insurance Overview
- Underwriting for group health policies may lead insurers to accept or reject the entire group based on health issues discovered.
- Claims can be managed under multiple plans through coordination of benefits, ensuring no more than 100% of a claim is covered.
Group Health Insurance Requirements
- For noncontributory group health plans, 100% participation from eligible employees is required before activation.
- The insurer is financially liable for claims in fully insured group health plans.
- A non-contributory plan must cover all eligible members without contributions from members.
COBRA and Continuation of Coverage
- COBRA applies to employers with at least 20 employees, allowing terminated employees to maintain health coverage by paying premiums.
- Benefits under COBRA must match what employees had previously, and premiums cannot exceed 102% of the cost.
Essential Health Insurance Provisions
- Coordination of Benefits helps manage overlapping coverage and addresses overinsurance issues.
- Minimum participation standards exist to prevent adverse selection in group health plans.
Tax Implications and Coverage Types
- Disability benefits can be taxable depending on who pays the premiums, affecting the tax status of received benefits.
- Key Person Disability Insurance pays benefits directly to the employer to cover business expenses.
Enrollment and Eligibility
- Individuals must enroll within a specified eligibility period to obtain group health insurance without proving insurability.
- A 63-day gap without prior insurance can make individuals ineligible for pre-existing condition coverage under new group plans.
Health Savings Accounts and Contributions
- A Section 125 Plan is essential for non-taxable payroll contributions to Health Savings Accounts (HSAs); otherwise, contributions are taxed.
- HSA owners cannot dictate employer contributions, which are separate from employee decisions.
Types of Health Insurance Policies
- A master policy is issued to employers for group health insurance, providing coverage for employees through certificates of coverage.
- Temporary employees generally do not qualify for group health policies, which typically cover full-time or eligible employees.
Important Policy Features
- Conversion from group health to individual plans occurs after job termination, ensuring continuity of care.
- The subrogation clause allows insurers to seek recovery from responsible third parties for claims paid out.
Definitions and Special Circumstances
- Business Overhead Expense Insurance helps manage ongoing business costs during disability.
- Vision care typically does not cover eye surgery, highlighting the importance of understanding policy exclusions.
HIPAA Regulations
- Under HIPAA, individuals moving to new employers with health plans are eligible for immediate coverage if they leave previous insurance.
- Individually identifiable health information under HIPAA includes specific health claim details.
Claims and Benefits
- Group disability income plans that offer tax-free benefits only apply if employees pay the premiums.
- Vision plans often limit coverage, commonly excluding laser surgery for vision correction.
Conclusion
- It's vital to understand various aspects of health and accident insurance, including enrollment periods, tax implications, and the structure of group plans, to make informed decisions regarding health coverage.
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