Regulation of Group Health Insurance (NM)

What does ERISA NOT require of claims procedures and appeals under a group health plan?

• They must provide written rules for appeals on denials of coverage.

• They must provide written rules for filing claims

• Claimants may designate the plan's fiduciary as their representative.

• Appeal processes must be fair and timely.

Answer explanation

ERISA requires group health plans to have written rules that specify how claims must be filed and how participants appeal denials of coverage. Appeal processes must be fair and timely.

What is the purpose of the fiduciary in a group health insurance plan?

• to process claims

• to advise the enrollees

• to administer the plan in a financially responsible manner

• to process appeals

Answer explanation

ERISA requires a group health plan to designate a fiduciary to administer the plan in a financially responsible manner that is in the best interests of the enrollees.

How does the Pregnancy Discrimination Act prevent discrimination against pregnant employees?

• They must receive more benefits than are provided to non-pregnant employees.

• They must be treated the same under the plan as non-pregnant employees.

• Non-pregnant employees who participate in the employer's group health plan can be charged a higher premium.

• Non-pregnant employees who do not participate in the employer's health plan can be prevented from joining it.

Answer explanation

Pregnant employees must receive the same treatment that employers give to non-pregnant employees.

HIPAA applies to group health insurance plans that cover at least how many people?

• 20

• 50

• 100

• 2

Answer explanation

HIPAA applies to group insurance plans that cover two or more people.