Insurance Continuing Education - Group Health Insurance

Insurance Continuing Education - Group Health Insurance

The Group Policy is a document between the employer and the insurance company, mostly of an administrative nature. The individual employee's coverages are provided in a Certificate of Coverage and details of coverage, benefits and provisions are provided in the Certificate. For purposes of this text, the provisions of the Certificate will be discussed.

As stated earlier, there are many similarities between the provisions of a Major Medical individual policy and a Group Certificate of Coverage. Therefore, the provisions that are similar will be only mentioned below, with special attention to those provisions that pertain only to Group Insurance.

Since a Group Contract can cover from one (in some states) to several thousand employees, the benefit structure will vary greatly. Most insurers offer coverage for small groups (such as those from 1 or 2 to 10 employees), medium size groups (from 11 to 50 employees) and large groups (51 employees and up). Additionally, the types of groups available include Health Maintenance Organizations (HMO's), Preferred Provider Organizations (PPO's), Point-of-Service Plans (POS), Fee-for-Service Plans (FFS) and a wide variety of Provider organizations and plans offering flexibility between the FFS (highest flexibility) and the HMO (least flexibility). Additionally, there are plans sold under ERISA, administered by Trusts.

For simplicity purposes, a POS plan Certificate of Coverage is used as an illustration. A POS plan has many of the cost-containment features of the PPO with a little more flexibility of the PPO, and is quite popular.

In 1996, H.R. 301, the Kassebaum-Kennedy bill, Health Insurance Portability and Accountability Act (HIPAA) was enacted. Because of this Act, some provisions in Group Insurance will change in respect to coverage for employees who leave their employment and who want to continue with their health insurance coverage. Many details are still in transition, but the bill will be discussed separately at the end of this Section.

Provisions are listed in order as they appear in a typical Certificate of Coverage. However, the arrangement can vary decidedly, therefore the order they are shown is of little consequence.

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