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Group Health Insuran

TN Accident & Health (Group Health Insurance)

Group Health Insurance A plan of insurance provided by a business or association (i.e. the plan sponsor) for the benefit of its employees or members (i.e. the plan participants)
Self-Insured Plans The employer funds and pays for member claims and benefits. Common in cases where the insured group is small with healthy members and few claims. Use the services of an insurance company to act as a 3rd party administrator of the plan.
Partially Self-Insured Plans An employer may share the risk of covering claims by buying stop-loss insurance coverage from an insurance company. Stop-loss policies are most effective for large employers that face the risk of significant losses.
Insured Plans An insurer takes over the risk of covering member claims and benefits. The employer's premiums are given directly to the insurance company.
Contributory Plans May require plan participants to CONTRIBUTE a portion of the premium. Typically done through payroll deduction.
Non-Contributory Plans Does NOT require participants to make premium contributions.
10 The IRS requires that a group (atleast a single-employer group) have a minimum of ____ members
Primary Coverage If a person is covered under BOTH a group insurance plan AND Medicare, the group plan is the...
Medicare Carve-Out Plan Covers only the DIFFERENCE between what Medicare pays and what the employer's group medical plan would pay without Medicare. Makes Medicare the PRIMARY payor. "carves out" (subtracts) Medicare's payment and then pays the difference.
Waiting Periods The time that must pass BEFORE a person is ELIGIBLE to be covered for benefits under the terms of the plan.
Pre-existing Conditions A health condition that the insured was diagnosed with or treated for, or for which treatment was recommended within the 6 months before the insured enrolled in the plan.
Conversion Privilege Group medical expense insurance plans that allow individual participants to CONVERT their group coverage to an individual plan with the same insurer.
Coordination of Benefits (COB) Provision Avoids overinsurance by preventing the duplication of benefits when a participant is covered by more than one group plan.
Subrogation A legal right that allows one party (e.g., your insurance company) to make a payment that is actually owed by another party (e.g., the other driver’s insurance company) and then collect the money from the party that owes the debt after the fact.
Employment Retirement Income Security Act of 1974 (ERISA) In addition to covering qualified retirement plans _____ regulates and protects those enrolled in group health plans.
Age Discrimination in Employment Act In regards to group health insurance, Prohibits employers from discriminating against those who are atleast 40 years old.
Women's Health and Cancer Rights Act Enacted in 1998, _______ supports women with breast cancer by requiring most group insurance plans that cover mastectomies to also cover breast reconstruction.
Family and Medical Leave Act (FMLA) Gives certain employees up to 12 weeks of unpaid leave per year while protecting their employed status. Employees can take leave for family and medical reasons. (i.e. birth of a newborn)
Consolidate Omnibus Budget Reconciliation Act of 1985 (COBRA) Protects those who are no longer covered by an employer's health insurance plan or its benefits. Unless its for gross misconduct, they have the right to continue their group coverage at their expense for up to 18 months.
No Loss/ No Gain (No Loss of Coverage) Means simply that an employee can neither gain or lose any earned rights under the new coverage just because their EMPLOYER changed the insurer or plan. (i.e. cannot be required to re-satisfy a probationary period, pay a new deductible, etc.)
The employer or the insurer Who can terminate a group plan?
Guaranteed Issue Health insurers that market in the small employer market (as defined by the state) must accept every employer that applies and qualifies for small employer coverage. This is known as...
Created by: Tiphanie_Dyme
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