The policyholder maintains all records regarding the protected plan. The policyholder prepares premium statements for each payment date and submits it with the check to the insurance company.
A periodic report of the number of employees insured, the covered volume or insured payroll, adjustments for prior periods, and the amount of premium currently due. May be prepared by the employer (referred to as self-billing) or the insurer (home-office, list, or direct billing). Also called a Bill.
The employer pays 100% of the premiums. When an employer pays the full premium of the coverage, all eligible employees should be covered under the policy. Employees are generally not given the opportunity to refuse the insurance coverage when the employer is paying the full cost of the program. Participation is expected to be 100%. Also known as an Employer-Paid plan.
A provision in an insurance plan where a person insured by a prior carrier does not lose coverage solely because of a change in carrier. Also known as “No Loss/No Gain”, “Takeover”, and/or D&R (discontinuance and replacement).
Agreement to insure individuals or a class of individuals who would normally fall outside the parameters of the contract. Also known as Grandfathering.
The highest amount a policy will pay in any benefit period.
The document that explains the terms and conditions of the contract of insurance and the rights and obligations of the parties involved. Also known as a Contract or Certificate.
The business entity responsible for handling the functions of the group insurance plan. Also known as a Benefit Administrator.
A specific period of time which uninsured employees and/or their dependents may obtain coverage under an existing group plan without presenting evidence of insurability or any similar late enrollee provision. Differs from an annual open enrollment period contained in a group insurance plan that allows a participant to switch plans of benefits or between different carriers (i.e.; HMO and indemnity, Section 125 etc.).
Employees pay 100% of the premium through payroll deductions. It is common for an employer to supplement their employer-paid coverage with a voluntary plan. Sometimes called an Employee Pay All plan or Employee-Paid plan.
A dependent child who is continuously incapable of self-sustaining employment by reason of mental retardation, developmental disability, mental illness or physical handicap; and primarily dependent upon the employee for financial support and maintenance on a continuous basis.
The period of time that an individual must satisfy by being actively employed with the policyholder before they become eligible to be enrolled under the plan. The period in which there is a delay between the first day of employment and the first day of coverage under the plan. Sometimes referred to as qualifying period.
The offer to a prospective policyholder to underwrite specified insurance benefits at stated premium rates.
Third Party Administrator
Employee Assistance Program
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