SolveYourProblem eLearning Series:
Health Insurance: Your Questions Answered
What does everything mean & how to choose the right policy
( 18 pages )

Group Health Insurance

Most people have a general idea of the nature of ‘group’ coverage. The most common type of group coverage is provided via employment. Many employers provide group health coverage as a benefit to their employees, either by paying the entire premium or sharing in the premium.

In a group situation, a single policy covers a specific group of people as opposed to a single person as individual policies do. Because of this special nature, insurance companies have to make certain that the number of people covered by a group policy stays at or above a certain level.

Some states also have their own regulations that control the minimum number of people required under a group plan. The number can differ from state to state so check local regulations.

In order to be considered a group, the entity must have the same employer or other commonality. As we discussed above, there are many different types of groups that may be considered, but for our purposes we will consider an employer/employee group.

A single master policy is issued to an individual or entity representing the group of people. As we stated, for our purposes we will call this the employer. It is the employers responsibility to apply for coverage for the group, own and hold the master policy and collect and make premium payments to the insurer when due.

Eligibility and eligibility period. In an individual policy situation where each person is evaluated separately in terms of risk, the normal practice in a group situation is to include all eligible employees regardless of physical condition or age.

One condition must be met, however, for all people regardless of their physical condition before they may be included in a group plan. That condition is that they must apply for coverage during a specified eligibility period. Failing to enroll in that time period will result in a requirement to take a physical examination and they will be selected on an individual basis just as if the policy were an individual policy. An initial 90 day employment period is typical for group coverage, after which the employee has a 31 day eligibility period. If the employee fails to apply during that eligibility period, then the employee will be required to take a physical examination and must qualify as if on an individual basis.

This is how an insurer can afford to cover a group of people without individual selection. Otherwise, some people might choose not to enroll until they discover they have an illness or they become disabled, and requiring a physical exam after the eligibility period helps to preclude this event.

This same concept also applies to determining who receives specific benefits. For example, an employer may choose to offer certain groups of people within the total employee group, a different set of benefits.

For instance, this can award certain benefits for those employed less than 5 years and a different set of benefits for those employed over 5 years. This arrangement can be differentiated in many other ways as well using salary level, position within the company and so on. The only stipulation is that such divisions may not have an adverse effect on the insurer.

Further, any such special benefit provision must apply to everyone within that specified group who meet the selected criteria. All who are designated must automatically become eligible as soon as they qualify.

How premiums are paid depends on which of two different types of plans a group selects. The two types are contributory and non-contributory. In the case of non-contributory, the employer pays the full cost of the premium, while the contributory type requires a shared cost between the employer and employee.

When applying for a contributory group plan, the employer needs to solicit enough employees to demonstrate to the insurer that a sufficient percentage want the coverage and are willing to pay a share of the premium. For a non-contributory plan, 100% of the eligible employees must be included.

There are several considerations that the insurer has when determining the group premiums. Average age of the group is an important consideration. The higher the average age of the group, the more instance of potential claims resulting in a higher premium.

Another consideration is the maximum indemnity period for loss of time benefits. The longer an insurer pays disability benefits, the higher the rate will be.

If a group policy covers occupational illness and/or injury, the degree of occupational hazard becomes an important factor. Again, the higher the occupational hazard, the higher the rate.

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