Group Medical Insurance
Health insurance protects against the risk of incurring catastrophic medical, surgical, or pharmaceutical expenses and can reduce or eliminate the costs associated with routine preventive care. This coverage is provided by major carriers such as BlueCross BlueShield, Cigna, UHC and Aetna and there are also smaller carriers that offer mostly regional coverage such as Kaiser.
The most comprehensive medical coverage is provided by plans that are compliant with the Affordable Care Act (ACA). ACA compliant plans covers all preventative care with no copayment and no coinsurance. ACA plans also provide financial protection through their out-of-pocket limit. The OOP provides a set limit on the amount of money the policy holder might pay for medical services. Once the OOP limit is reached the carrier will pay all additional medical expenses through the end of the that plan year.
Medical plans come in 3 primary designs: Health Maintenance Organization (HMO), Point of Service (POS), and Preferred Provider Organizations (PPO). HMO’s tend to be the most cost efficient because they have a set network of doctors/providers that members may access and the prices for procedures have been negotiated up front. If an individual wants access to more doctors they can opt for the POS plan. This plan includes the use of an HMO doctor network but also includes out-of-network benefits which allows members to see any provider they wish but at reduced benefit coverage. The PPO plan offers members the largest, typically nationwide, network of providers usually the highest cost for that privilege.
Individuals should balance the level of coverage a plan provides with the cost associated with that coverage.
Group Medical Insurance plans require a minimum of two full time, unrelated employees to enroll.
We require a census with detailed information, including member names, dependents, date of birth, gender and zip codes.
The ACA mandated different medals, namely, bronze, silver, gold and platinum. The differences in these plans lies in the deductible, coinsurance and out-of-pocket maximum.
A deductible (link) is the first dollars spent prior to the carrier providing coverage on an annual basis, this is an annual amount that varies by policy.
A coinsurance (link) is a percentage the insured pays based on their plan design, this is subject to an annual out-of-pocket maximum.
A copay (link) is a fixed dollar amount paid per visit, also subject to the annual out-of-pocket maximum.
An annual out-of-pocket maximum is a dollar figure that delineates the maximum an insured individual will pay in any plan year, including deductibles, coinsurances and copays.
In order to implement the group plan chosen, you need the following: Group Application, Employee Applications, Quarterly Wage and Tax Report and a check for the first month’s premium. In the event of a new business, additional documentation may be required.
What is the deadline for providing the implementation documentation? How long will it take for the plan to be active?
The insurance carriers require all completed documentation to be received by the 15th of the month, prior to the plan effective date. It is prudent to have all completed documentation by the 10th to comply with the insurance carrier’s guidelines. Plan implementation and the mailing of ID Cards may be delayed if the information is not received in a timely fashion. The DC Exchange may have more stringent guidelines.
COBRA is the Consolidated Omnibus Budget Reconciliation Act of 1985. This allows terminated employees to keep their benefits and pay for the cost of benefits out of pocket for a maximum duration of 18 months.