Group Health Insurance
Domain 8 tests employer-sponsored coverage: eligibility rules, COBRA continuation, coordination of benefits, and the distinction between insured and self-funded plans.
Group underwriting
Underwriting focuses on the group, not the individual: group size, industry, age and gender mix, prior claims, and participation. In a noncontributory plan (employer pays the full premium) 100% of eligible employees must participate; in a contributory plan at least 75% must. Eligibility waiting periods (often 30–90 days) delay coverage. HIPAA special enrollment rights allow mid-year changes after marriage, birth, adoption, or loss of other coverage. A master policy is issued to the employer; employees hold certificates of coverage.
Plan types
Insured plans buy a policy from a carrier; self-funded plans pay claims from employer funds, are governed by ERISA, and often use a TPA plus stop-loss coverage. A conversion privilege lets a departing employee buy an individual policy without proving insurability within a stated window.
COBRA
Applies to employers with 20+ employees. Qualifying events: 18 months for termination or reduction in hours; 29 months when the qualified beneficiary is determined disabled under Social Security within the first 60 days (premium up to 150%); 36 months for divorce, death of the employee, or the employee's Medicare entitlement. The employer must notify the plan within 30 days; the plan administrator notifies the beneficiary within 14 days; the beneficiary elects within 60 days; the first premium is due within 45 days after election. Premium may be 102% of cost.
Worked example
An employee terminated April 30 elects COBRA on May 20.
- Election within 60 days is timely, and coverage is retroactive to May 1.
- Payment is due by July 4 (45 days after election); the plan cannot demand it earlier.
- Maximum continuation is 18 months, ending October 30 of the following year.
Traps
- Applying 36 months to a voluntary termination (18 months applies).
- Allowing the plan to demand premium before the 45-day window closes.
- Mixing up the 75% contributory rule with the 100% noncontributory rule.
- Treating a conversion policy as continued group coverage.