Group Health Insurance and Other Health Coverages
How group insurance works
One master policy is issued to the employer or association, and participants receive certificates. Eligibility rules such as waiting periods and actively-at-work requirements, plus participation requirements, limit adverse selection. Contributory plans generally require a minimum percentage of eligible employees to enroll; noncontributory plans require all eligible employees. Experience rating lets a group's own claims history drive renewal, while community rating spreads risk across a broader pool.
Continuation and conversion
COBRA applies to employers with 20 or more employees and provides 18 months of continuation after termination or reduced hours, 29 months when disability is involved, and 36 months for dependents after events such as divorce or a child aging out. A conversion privilege lets a departing member buy an individual policy without evidence of insurability; converted group life is typically term.
Coordination of benefits
When two plans cover the same person, COB prevents double payment. The plan covering the patient as an employee pays before the plan covering the patient as a dependent. For dependent children, the birthday rule makes the plan of the parent whose birthday falls earlier in the year primary.
Account-based and public programs
FSAs are use-it-or-lose-it within a grace period. HSAs require a qualifying high-deductible health plan and are portable and triple tax-advantaged. HRAs are employer-funded. Medigap supplements Original Medicare, and Medicaid is income-tested.
Traps
COBRA timeframes and the birthday rule are the highest-yield facts. Do not assume a converted group policy keeps the group rate.
Rule of thumb
Remember 18 – 29 – 36 for COBRA, and earlier birthday in the year means primary coverage for a dependent child.