Flashcards
H2: Health Insurance Basics (Section II)
Flashcards do conjunto (33)
- 1Franchise Healthprovides coverage for small groups that are too small to qualify for group insurance.
Individual polices NOT certificate of insurance is issued.
Premiums are less than Individual but more than group. - 2Associationan organized body of people who have an interest, activity, or purpose in common.
100+ members, 2 years active, constitution, Bylaws, annual meetings, contributory/noncontributory - 3Self-Insured (Self-Funded) Planarrangement in which employer assumes some or all of the risk of a group plan
- 4Self Insured= Self-FundedSelf Insured= Self-Funded
- 5Self-Insured plans CANNOT be used for DEATH BENEFITS (Life Insurance)Self-Insured plans CANNOT be used for DEATH BENEFITS (Life Insurance)
- 6the following may opt for a SELF-INSURED medical and disability plan:Labor Unions, Fraternals, Co-Ops (Cooperative)
- 7Stop-Loss Coverage AKA Retention Limitinsurance purchased by self-insured plans that limits their liability to a specified dollar amount.
- 8Multiple Employer Trusttrust created by a group of small employers in order to:
Qualify for group rates and create self-insured plan - 9Individual Health UW FactorsAge, Sex, Physical Conditions, Occupation, Zip Code, Hobbies/Avocations
- 10Health UnderwriterNo Physical Exam required
So Agent must be good field underwriter - 11Group Health UW FactorsGroup demographic, industry, carrier history, contributory/noncontributory, employers zip, partcipation
- 12Accidental Death (AD)pays benefit when insured dies accidentally, death must occur within specified time after accident, dangerous hobbies might be excluded
- 13AD&Dcovers AD and dismemberment, schedule lists amount paid, benefits usually paid in LUMP SUM
- 14Principal Sum100% of AD&D coverage amount
- 15Capital SumLess than 100% of AD&D coverage amount
- 16The DOI has jurisdiction over entities that provide coverage designed to pay for health care provider's services and expenses UNLESS health care providers are appropriately licensed or certified by other governmental agenciesThe DOI has jurisdiction over entities that provide coverage designed to pay for health care provider's services and expenses UNLESS health care providers are appropriately licensed or certified by other governmental agencies
- 17COBRAfederal law requiring employers with 20+ employees to extend health coverage to terminated employees for 18-36 months after a qualifying event.
- 18COBRAEmployee= 18mos
Dependents=36 mos
Employee will have to pay premium up to 102% - 19COBRA applies to only Group Health NOT Group LifeCOBRA applies to only Group Health NOT Group Life
- 20Cal-COBRAState Law requiring employers with 2-19 employees to extend health coverage to employees and dependents for up to 36 months after a qualifying even
- 21COBRA=Federal Cal COBRA= Cal StateCOBRA=Federal
Cal COBRA= Cal State - 22Qualifying Events to Qualify for COBRA/ CAL COBRADeath/Retirement, Termination, reduction in work hours, divorce/legal separation, loss of dependent status, eligibility for Medicare
- 23ERISAFederal law enacted to protect group plan participants, establish pension equality, and mandate strict reporting and disclosure requirements
- 24ERISAfiduciary standards benefit PLAN PARTCIPANTS & BENEFICIARIES.
Partcipants must be provided with:
PLAN DESCRIPTIONS & BENEFIT STATEMENTS - 25Right to Terminateprovision in a health insurance contract that spells out the rules regarding the rights of both parties to terminate the contract.
- 26Americans with Disabilities Act (ADA)prohibits employers from rejecting job applicants or firing employees with disabilities that do not interfere with the job being done.
- 27FMLAentitles employees up to 12 weeks of leave during any 12month period for certain events.
- 28Covered FMLA eventsbirth and care of newborn child, adoption or foster care placement, care for sick spouse, child or parent, sick leave for employee
- 29CFRA= State Law FMLA= Federal LawCFRA= State Law
FMLA= Federal Law - 30CFRA provides employees up to 12 weeks for maternity leaveCFRA provides employees up to 12 weeks for maternity leave
- 31Maternity/Pregnancystate law requires group (not individual) plans to cover maternity. preganncy CANNOT be considered a pre-existing condition
- 32Pregnancy Discrimination Actrequires employer health plan to cover expenses for pregnancy-related conditions on same basis as other medical conditions
- 33Women's Health & Cancel Rights Actrequires group health plans, insurance and HMO to offer mastectomy patients to cover reconstructive surgery
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- Accident & Health Agent FlashCards sobre H2: Health Insurance Basics (Section II), criado por Det Ferraris em 11-06-2013.
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- Det Ferraris
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