North Dakota · Life, Accident & Health SampleInteractive Mind Map
Group Underwriting and Eligibility
A visual breakdown of Group Underwriting and Eligibility — one of the concepts you can count on seeing on the exam.
The TESTivity Interactive Mind Mapping Graphic we picked for the North Dakota Life & Health sample is Group Underwriting and Eligibility — and this is a concept you can count on seeing on your pre-licensing exam. Get the structure straight once and those questions turn into free points.
So explore it. Click through, see how the pieces relate, and let the layout do some of the remembering for you.
Explore by topic
Choose a Cluster to Study
The whole reason group coverage skips the medical exam: the insurer underwrites the GROUP, not each person.
One member’s high claims are diluted across the entire pool — so eligible employees get guaranteed issue without proving individual insurability.
📊
What the Insurer Evaluates
Group-level risk factors
Group size: larger groups spread risk; small groups (2–50) are riskier — one big claim moves the numbers.
Composition: age, gender, occupation — young office workers differ sharply from older workers in heavy industry.
Industry & occupation: some fields carry higher illness/injury rates.
Claims experience: for larger groups, the insurer reviews historical medical costs to project future ones.
Persistency: groups that frequently switch carriers may signal poor experience.
How they test thisThe key idea: risk is judged at the group level, not the individual level. That’s what makes guaranteed issue (no medical exam for eligible employees) possible — the pool absorbs any one person’s claims.
Two ways to price a group — and the ACA changed which one applies to small groups. Experience rating uses the group’s own history (large groups). Community rating pools everyone (ACA small groups).
📉 Experience Rating
🏘️ (Modified) Community Rating
Basis
The group’s own claims history — high claims, higher premium.
Basis
The whole community’s experience — the group’s own claims don’t drive its rate.
Who
Large groups (typically 51+).
Who
ACA small group (1–50) and individual markets.
Trait
More accurate, but can be volatile.
Allowed factors
Vary only by age, geography, family composition, tobacco — never health status.
🎯
The ACA small-group rule, locked
For small groups (1–50), the ACA requires modified community rating: premiums may vary only by age, geographic area, family composition, and tobacco use — not by health status or claims history. Large groups (51+) may still be experience-rated.
Who’s eligible, and when can they enroll? Miss your window and individual underwriting can sneak back in.
Know the 90-day waiting-period cap and the late enrollee consequence.
👤
Eligible Employees
Usually full-time (30+ hrs/week) employees who’ve cleared the waiting period. Generally not eligible: part-timers, independent contractors, temp-agency placements.
⏳
Eligibility Waiting Period
Time after hire before coverage can begin — the ACA caps it at 90 days. (This is about when coverage starts, not about pre-existing conditions.)
📅
Enrollment Windows
Initial (right after eligibility), annual open enrollment (no evidence of insurability), and special enrollment (30 days, triggered by marriage/birth/loss of coverage).
⚠️
Late Enrollees
Miss your initial window with no qualifying event → the insurer may demand evidence of insurability. This is where individual health underwriting can reappear in a group plan.
👪
Dependents
Spouses and children to age 26; disabled adult children may continue past 26. Adding a dependent off-cycle needs a qualifying life event.
The trap they setAn employee skips initial enrollment, then applies after a new diagnosis — the insurer may require evidence of insurability as a late enrollee. That timing is exactly the adverse selection the rule guards against. A qualifying life event would have bypassed the penalty.
🎯
Top Exam Tips — Group Underwriting & Eligibility
1. Group underwriting evaluates the group as a whole — enabling guaranteed issue with no individual medical exam. 2. Experience rating = the group’s own claims history (large groups, 51+). Community rating = pooled (ACA small groups). 3. ACA small-group rating factors: age, geography, family composition, tobacco — NEVER health status. 4. Eligibility waiting period is capped at 90 days under the ACA. 5. Late enrollees may have to show evidence of insurability — the one place individual underwriting reappears in a group plan. 6. Full-time employees past the waiting period are the eligible core; part-timers, contractors, and temps usually aren’t.
Exam vocabulary
Key Terms to Know
Experience Rating
Setting group premiums on the group’s own claims history; used mainly for large groups (51+).
Community Rating
Setting premiums on the community’s experience rather than the group’s own; required by the ACA for small groups and individuals.
Modified Community Rating
Community rating allowing variation only by age, geography, family composition, and tobacco use — not health status.
Eligibility Waiting Period
The period after hire before an employee may enroll; capped at 90 days under the ACA.
Open Enrollment Period
An annual window to elect or change group coverage without evidence of insurability.
Late Enrollee
An employee who missed the initial enrollment window; may face evidence-of-insurability requirements.
Special Enrollment Period
A 30-day window triggered by a qualifying life event (marriage, birth, loss of other coverage).
Evidence of Insurability
Health documentation required from late enrollees or those seeking coverage outside enrollment periods.
Small Group Market
Generally employers with 1–50 employees; subject to ACA community rating and guaranteed issue.
Large Group Market
Generally employers with 51+ employees; may be experience-rated; not subject to all small-group ACA rules.
Persistency
How long a group has stayed insured; frequent carrier-switching can signal poor experience.
Like learning this way? There's a whole library of them.
If the old manual you inherited from the office breakroom isn't cutting it and this
format fits how your brain actually works, you'll want the rest. There are
52 Interactive Mind Maps like this one in the
TESTivity Platinum Life, Accident & Health package — covering the full curriculum, right alongside
the practice questions, exam simulators, and study guides.
