Introduction to Health Care and Group Benefit Plans Outline

Lesson 1: Introduction to Group Health Medical Benefits

1. Health Care in the United States
2. Types of Group Health Coverage in the United States
3. How Group Health Plans Started and Spread in the United States
4. Full Service vs. Indemnity and Commercial Insurance Companies
5. Tax Advantages of Group Health Medical
6. The Rise and Fall of Retiree Plans
7. Why Employers Offer Group Medical Plans
8. Definition of Health Care

Lesson 2: Group Health Care Plan Concepts

1. Definition of Group Medical Plans and Group Insurance
   1. Underwriting rules for group insurance
2. Employer-Sponsored Voluntary Plans
3. State Department of Insurance
4. Types of Group-Insured Plans
   1. Community rating
   2. Experience rating
5. Other Group Arrangements
6. Self-Insurance or Self-Funding
   1. Stop-Loss insurance for self-funded plans
      1. Aggregate
      2. Specific
   2. Types of self-insured plans
7. Plan Administration
8. Plan Professionals
9. Core Plan Design Issues

Lesson 3: Group Health Care Plan Sponsors

1. Single Employer Plan
   1. Plan operations
      1. Eligibility, decision making, funding and contract holder
2. Multiemployer Plans
   1. Plan operations
      1. Eligibility, decision making, funding and contract holder
      2. Hour bank and trust arrangements
3. Multiple Employer Welfare Arrangements (MEWAs)
   1. Plan operations
      1. Eligibility, decision making, funding and contract holder
4. Governmental and School District Plans
   1. Plan operations
      1. Eligibility, decision making, funding and contract holder
      2. Exemption from COBRA and ERISA

Lesson 4: Health Care Plan Design

1. Traditional Medical Plans, Plan Design and Provider Reimbursement
2. Evolution of Managed Care
3. HMO Specifics
   1. Capitation
   2. Primary care physician
   3. Types of HMOs
4. Preferred Provider Organizations (PPOs)
5. POS Plans
6. How to Evaluate Managed Care Plans
7. Other Managed Care Approaches
   1. Second surgical opinion
   2. Utilization review
   3. Precertification of hospital admission

Lesson 5: Preventive Care / Disease Management / Chronic Conditions / EAPs

1. Relationship Between Health and Medical Plan Cost
2. Disease Management
   1. Diseases targeted
3. Wellness Programs
   1. Health risk assessments
   2. Health coaches
   3. Health fairs
   4. Health articles
4. Employee Assistance Programs
5. Health Screenings and Health Promotion

Lesson 6: Tax-advantaged Plans

1. Why Tax-Advantaged Plans Evolved
2. Requirements of a Section 125 plan
   1. Plan document
   2. Written salary reduction
3. Premium-Only Plans (POP)
4. Dependent Care Spending Accounts (DCSA)
5. Flexible Spending Accounts
   1. Uniform coverage code
   2. Use-it-or-lose-it provision
6. Full Flexible Benefit Plans
7. Discrimination Testing of Section 125 Plans
8. Why Employers Offer Section 125 Plans
9. Section 125 Plan Communications

Lesson 7: Defined Contribution and Consumer-Driven Health Plans

1. Evolution of Defined Contribution Plan and Consumer-Driven Health Care
2. Defined Contribution
   1. Overview
3. Consumer-Driven Health Care
   1. High-deductible plan
   2. Health reimbursement arrangements
   3. Web-based tools
   4. Health savings account
4. Health Savings Account Specifics
   1. Eligibility
   2. Contribution limits
   3. Distributions

Lesson 8: Carve-Out Plans / Prescription Drug / Dental / Mental Health / Alternative Health Care / Vision / Hearing Plans

1. Overview of Carve-Out Plans
2. Prescription Drug Plans
   1. Pharmacy benefit managers (PBMs)
3. Dental Plans
   1. Traditional
   2. Nontraditional
4. Mental Health Plans
5. Vision Plans
6. Hearing Plans
7. Alternative Health Care Networks

Lesson 9: Employee Retirement Income Security Act of 1974 (ERISA)

1. Pre-ERISA and Overview
2. ERISA Plan Documents
   1. Summary plan description (SPD)
   2. Summary of material modification
   3. Summary annual report
3. Fiduciaries
   1. Exclusive benefit rule
   2. Prudent person rule
   3. Prohibited transactions
   4. Breach of fiduciary duties
4. Participants Right to Appeal
5. ERISA Preemption

Lesson 10: Other Laws Affecting Employee Benefits health plans

1. Overview of State and Federal Legislation
2. State-Mandated Benefits
3. Consolidated Omnibus Budget Reconciliation Act (COBRA)
   1. Qualifying for COBRA and length of coverage
   2. Notification requirements
4. Health Insurance Portability and Accountability Act (HIPAA)
   1. Personal health information (PHI)
   2. Business associate agreements
   3. Privacy officer
   4. Credible coverage
5. Mental Health Parity Act
6. Newborns’ and Mothers’ Health Protection Act
7. Women’s Health and Cancer Rights Act
8. Family and Medical Leave Act
   1. Conditions required
   2. 50 employees in a 75-mile radius