Group Health, Long-Term Care and Other Health Coverages
Group health fundamentals
Group insurance uses a master policy held by the employer or sponsor, with certificates issued to participants. Underwriting is done on the group as a whole - individual evidence is generally not required. Open enrollment allows eligible members to join; contributory plans (employees pay part) typically require 75% participation, while noncontributory plans require 100% of eligible employees. Group coverage is experience rated, using claims of the group rather than the individual.
Know COBRA (applies to employers with 20+ employees; continuation generally 18 months for termination, up to 29 months for disability, 36 months for dependents), HIPAA portability (creditable coverage and the 63-day break rule), conversion privileges to individual coverage, coordination of benefits, and the distinction between fully insured and self-funded (ERISA) plans, including stop-loss insurance and TPAs.
Long-term care
LTC covers custodial care - help with ADLs (bathing, dressing, eating, toileting, transferring, continence) - that Medicare does not cover long term. Benefit triggers for tax-qualified policies: unable to perform 2 of 6 ADLs for at least 90 days, or severe cognitive impairment. Key contract terms: elimination period, daily/monthly benefit, benefit period, inflation protection, guaranteed renewability, nonforfeiture, and waiver of premium. Medicare pays limited skilled care; Medicaid is the means-tested payer of last resort, and state partnership programs allow asset protection.
Other coverages
Compare hospital indemnity, critical illness, cancer, accident, dental/vision, short-term medical, and worksite products. Trap: LTC insurance reimburses qualified long-term care, not acute hospital bills; and Medicare does not pay for custodial care.
Worked example: a 68-year-old with a tax-qualified LTC policy and a 90-day elimination period enters a facility in January - benefits begin after the elimination period is served, provided the ADL or cognitive trigger is certified.