H2: Health Insurance Basics (Section II)

Frage	Antworten
Franchise Health	provides 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.
Association	an organized body of people who have an interest, activity, or purpose in common. 100+ members, 2 years active, constitution, Bylaws, annual meetings, contributory/noncontributory
Self-Insured (Self-Funded) Plan	arrangement in which employer assumes some or all of the risk of a group plan
Self Insured= Self-Funded	Self Insured= Self-Funded
Self-Insured plans CANNOT be used for DEATH BENEFITS (Life Insurance)	Self-Insured plans CANNOT be used for DEATH BENEFITS (Life Insurance)
the following may opt for a SELF-INSURED medical and disability plan:	Labor Unions, Fraternals, Co-Ops (Cooperative)
Stop-Loss Coverage AKA Retention Limit	insurance purchased by self-insured plans that limits their liability to a specified dollar amount.
Multiple Employer Trust	trust created by a group of small employers in order to: Qualify for group rates and create self-insured plan
Individual Health UW Factors	Age, Sex, Physical Conditions, Occupation, Zip Code, Hobbies/Avocations
Health Underwriter	No Physical Exam required So Agent must be good field underwriter
Group Health UW Factors	Group demographic, industry, carrier history, contributory/noncontributory, employers zip, partcipation
Accidental Death (AD)	pays benefit when insured dies accidentally, death must occur within specified time after accident, dangerous hobbies might be excluded
AD&D	covers AD and dismemberment, schedule lists amount paid, benefits usually paid in LUMP SUM
Principal Sum	100% of AD&D coverage amount
Capital Sum	Less than 100% of AD&D coverage amount
The 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	The 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
COBRA	federal law requiring employers with 20+ employees to extend health coverage to terminated employees for 18-36 months after a qualifying event.
COBRA	Employee= 18mos Dependents=36 mos Employee will have to pay premium up to 102%
COBRA applies to only Group Health NOT Group Life	COBRA applies to only Group Health NOT Group Life
Cal-COBRA	State Law requiring employers with 2-19 employees to extend health coverage to employees and dependents for up to 36 months after a qualifying even
COBRA=Federal Cal COBRA= Cal State	COBRA=Federal Cal COBRA= Cal State
Qualifying Events to Qualify for COBRA/ CAL COBRA	Death/Retirement, Termination, reduction in work hours, divorce/legal separation, loss of dependent status, eligibility for Medicare
ERISA	Federal law enacted to protect group plan participants, establish pension equality, and mandate strict reporting and disclosure requirements
ERISA	fiduciary standards benefit PLAN PARTCIPANTS & BENEFICIARIES. Partcipants must be provided with: PLAN DESCRIPTIONS & BENEFIT STATEMENTS
Right to Terminate	provision in a health insurance contract that spells out the rules regarding the rights of both parties to terminate the contract.
Americans with Disabilities Act (ADA)	prohibits employers from rejecting job applicants or firing employees with disabilities that do not interfere with the job being done.
FMLA	entitles employees up to 12 weeks of leave during any 12month period for certain events.
Covered FMLA events	birth and care of newborn child, adoption or foster care placement, care for sick spouse, child or parent, sick leave for employee
CFRA= State Law FMLA= Federal Law	CFRA= State Law FMLA= Federal Law
CFRA provides employees up to 12 weeks for maternity leave	CFRA provides employees up to 12 weeks for maternity leave
Maternity/Pregnancy	state law requires group (not individual) plans to cover maternity. preganncy CANNOT be considered a pre-existing condition
Pregnancy Discrimination Act	requires employer health plan to cover expenses for pregnancy-related conditions on same basis as other medical conditions
Women's Health & Cancel Rights Act	requires group health plans, insurance and HMO to offer mastectomy patients to cover reconstructive surgery

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H2: Health Insurance Basics (Section II)

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