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  1. Types of Group Health Insurance
    • Disability 
    • Medical Expense
    • Dental Expense
    • Long Term Care
  2. Employee and Dependents
    Employee required to work 24 hrs per week to qualify

    Coverage is written for participating employees and dependents 

    Could include retired employees and dependents

    Dependents - spouse and dependent children
  3. Coordination of Benefits
    Purpose- to avoid double payment

    Married - working couples can have double coverage

    • Insurer covering employee is primary
    • Covering the spouse is secondary

    • Dependent Child 
    • The "Birthday Rule" - Insurer of the parent with birthday occurring first in the calendar year is primary coverage
  4. Conversion Privilege to Individual Policy
    Oklahoma State Law: group member or dependent no longer eligible for group coverage regardless of the reason, must be offered the opportunity to convert to an individual health policy, without proving insurability.  NO evidence of insurability required.
  5. Conversion Privilege to Individual Policy CONT..
    • Must be exercised within 31 days
    • Coverage applies under the group policy during the 31 days

    • Ineligibility Created:  
    • Employment Terminated 
    • Reduced number of working hours 
    • Child reaches age that coverage ceases
  6. Health Insurance Portability and Accountability Act of 1996 (HIPPA)
    Permits an insured to change jobs and still maintain continuous health benefits

    Limits preexisting conditions to a maximum of 12 months on a group insurance policy for a new hire without previous health insurance

    Applies to a group of 2 or more employees
  7. Consolidated Omnibus Budget Reconciliation Act (COBRA):
    Employee or dependent no longer eligible for group coverage due to qualifying event to continue the same group health benefits for a specified period of time 

    ONLY applies to group insurance 

    Qualifying Events

    • Termination                             18 months
    • Reduction in Work Hours           18 months
    • Divorce                                    36 months
    • Death of Employee                   36 months

    • The ineligible employee pays the premium 
    • 2% surcharge can be added
  8. Small Group Health Insurance
    2-50 Employees 

    51+ = "Large Group"
  9. Dental Insurance
    Standard Dental Coverage- for each type there is a specific maximum dollar amount that is paid on a lump sum basis

    Routine Dental Care - preventive care such as teeth cleaning is provides on a first dollar coverage without deductible or co-pay

    Non Routine Dental Care - Deductible; ie filling, root canal, etc.

    Co-Pay - Applies to non routine treatment
Card Set:
2015-07-23 00:17:11
Group Health

Group Health Insurace
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