Identify, define, and discuss an individual's requirements for eligibility for insurance

Question

What will be an ideal response?

Answer 1

Answer:
When individuals have met the eligibility requirements, they are eligible for insurance. Therefore, as far as insurance is concerned, eligibility means those qualities or requirements that a person must meet to be covered by the plan. Do not confuse "eligible" with "effective." In insurance, these are two very different concepts. A person can be eligible for coverage without the coverage ever becoming effective.
The definition of an eligible person varies from plan to plan. However, most plans have separate definitions for eligible employees or subscribers compared with eligible dependents. The requirements for the insured can include such things as the number of hours worked for the policyholder and a minimum of months that the employee has been employed by the policyholder. The requirements for the dependents of the insured can include such things as being a lawful spouse, domestic partner, or dependent child of the insured, being under a certain age limit, or attending school full-time. The eligibility of these relationships varies by plan as well as by insurance company. Before verifying eligibility and benefits, be sure to review the plan definition of an eligible dependent and the company policy for covering domestic partners.
It is important for the medical biller and health claims examiner to understand the concept of eligibility and the eligibility requirements under each contract in order to process claims correctly.
Most contracts define participants according to the minimum number of hours that the employee or subscriber must work per specified period of time, which is usually per week. Generally, part-time employees and full-time employees working fewer than 30 hours per week are not considered eligible for coverage.