The national guide covers the general group concepts: group underwriting, master contract and certificates, contributory plans and COBRA. Indiana's state questions on group health focus on coordination of benefits (760 IAC 1-38.1), required group provisions (IC 27-8-5-19), and the small employer law (IC 27-8-15).

National concepts in brief

• The employer holds the master contract, and members get certificates.
• Federal COBRA lets eligible people continue group coverage for a limited time at their own cost.
• Experience rating prices a group on its own claims history.

Coordination of benefits (760 IAC 1-38.1)

• Nonconforming plans: a plan without a conforming COB provision is always primary (12(b)).

• Employee versus dependent: the plan covering the person as an employee or subscriber pays before the plan covering them as a dependent (12(d)).

• Children of married parents (the birthday rule): the plan of the parent whose birthday comes earlier in the calendar year is primary. Only the month and day count, not the year (13(a)). If both parents share a birthday, the plan that has covered a parent longest is primary.

• Children of separated or divorced parents, absent a court decree, pay in this order:

  1. the custodial parent;
  2. the custodial parent's spouse;
  3. the noncustodial parent;
  4. the noncustodial parent's spouse.

  The custodial parent is the one with custody, or the one the child lives with, for more than half the year.

Required group provisions (IC 27-8-5-19)

• Grace period: 31 days. Coverage continues unless the policyholder gave advance written notice of discontinuance.
• Contestability: after two years, a member's statement can be used to contest coverage only if it is in a signed writing and a copy was given to the member.

Small employer coverage (IC 27-8-15)

• Small employer: 1 to 50 employees, for non-grandfathered plans.
• Eligible employee: works 30+ hours a week and has met any waiting period. The term includes sole proprietors, partners and S corporation owners, but not temporary or seasonal workers.
• Whole-group coverage: carriers must cover all eligible employees and dependents and can't cover only part of the group. Minimum participation and contribution rules are allowed (IC 27-8-15-33).
• Conversion (IC 27-8-15-31):
  • Who qualifies: an employee covered at least 90 days who loses coverage and isn't eligible for COBRA.
  • Deadline: the employee may request a conversion policy within 30 days.
  • Price cap: no more than 150% of the group rate.

Common exam traps

• The birthday rule uses the month and day only. The earlier birthday's plan pays first.
• A plan with no COB provision is always primary.
• Small group conversion: 90 days of coverage, request within 30 days, premium capped at 150%.
• The group grace period is 31 days.