130227
Description
Flashcards by Det Ferraris, updated more than 1 year ago
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Created by Det Ferraris
over 11 years ago
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| Question | Answer |
| 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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