Medical Alternate or Level Funded Plans
-
Employer sets up a self-funded medical plan, which pays for employees’ medical benefits directly, and employers just have to cover their level funded monthly bill.
-
Part of the risk for medical expenses is taken on by the plan rather than by an insurance company. The rest of the financial risk for medical expenses is covered by stop-loss insurance.
Medical Fully Insured Plans
-
The risk for medical expenses is taken on by an insurance company. This is also known as Community Rated Plan, which means the premium rates are set the age of the employees. The rate is the average risk of a person in the range which may also consider gender.
Medical HMO - Health Maintenance Organization
-
An HMO is made up of a group of medical insurance providers that limit coverage to medical care provided through doctors and other providers who are under contract to the HMO.
-
You pay the least if you use a provider in the Designated Network. You pay more if you use a provider in the Network. You will pay the most if you use an out-of-Network provider.
-
These plans will pay some or all of the costs to see a specialist for covered services but only if you have a referral before you see the specialist
Medical PPO - Participating Provider Option
-
It's a type of health plan that lets you choose where you go for care, without a referral from a primary care physician or having to only use providers in your plan's provider network. It typically has higher monthly premiums and out-of-pocket costs like copays, coinsurance and deductibles.
-
You pay the least if you use a provider in the Designated Network. You pay more if you use a provider in the Network. You will pay the most if you use an out-of-Network provider.
-
You can see the specialist you choose without a referral.
Medical EPO - Exclusive Provider Organization
-
EPO health insurance got this name because you have to get your health care exclusively from healthcare providers the EPO contracts with, or the EPO won’t pay for the care.
-
You can see the specialist you choose without a referral.
-
Out of Network providers are not covered
Medical Ineligible Occupations and Industries
-
Typical exclusions are Non-ERISA Groups, Municipalities, Professional employer organizations (employee leasing firms)
-
Employee eligibility - An eligible employee is a regular full-time employee who is scheduled to work at least 29 to 30 hours per week (vary by carrier)
-
Retirees are not eligible for coverage for most carriers.
Medical - Enrollment Periods
-
Open Enrollment Periods
-
Enrollment for New Hires
New Hire Waiting Periods may be selected
-
Late Enrollments - Most Carriers WILL NOT allow enrollments If an enrollment form is received later than 31 days from the date an employee or dependent is first eligible to enroll, coverage will be postponed until the medical plan’s next anniversary renewal date.
Medical - Eligible Dependents
-
Eligible dependents include the employee’s spouse/domestic partner, employee’s or employee’s spouse’s child who is under age 26 (or age 30 depending on state), including a natural child, stepchild, a legally adopted child, a child placed for adoption or a child for whom employee or employee’s spouse are the legal guardian; or an unmarried child age 26 or older who is or becomes disabled and dependent upon employee.
-
Dependents may not enroll in the Plan unless employee is also enrolled.
-
If employee and employee’s spouse are both covered under the company’s medical plan, only 1 parent may enroll a child as a dependent.
Medical - Effective Dates of Coverage
-
Open Enrollment Periods
-
New Hires
-
Addition of a Newly Acquired Dependent
-
Special Enrollment Periods after Open Enrollment
Marriage, Birth of dependent newborn child, adoption of dependent child or legal placement of child for adoption, Loss of eligibility for other coverage, termination of another
Medical - Medicare Eligible
-
Eligibility rules for your employees who are Medicare eligible can be confusing. The responsibility for compliance generally rests with the employer. Generally, if a group employs 19 or fewer employees, Medicare is considered primary and if your group employs 20 or more employees, the group health plan is considered primary.
Medical State Requirements for continuation coverage
-
Impacts those that are not met by offering COBRA coverage. Review your state's requirements to see if the requirements apply.
Medical Cobra Continuation
-
Federal Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) provided covered employees and or their covered dependent with the right to continue group health care benefits for a specific period of time if they experience a qualifying event which results in termination of coverage. COBRA applies to groups with 20 or more eligible employees.
Medical Participation Requirements
-
Most Carriers require 50% of eligible employees to participate
Medical Contribution Requirements
-
Most Carriers require the employer is required to contribute a minimum of 50 percent of the employee-only cost for the lowest-cost medical plan sponsored by the employer.
Dental Group Coverage - What to consider when choosing coverage
-
Calendar-year annual maximum - This is the maximum benefit (excludes orthodontia services) for a calendar year. This averages between $1,000 to $2,000 and certain Carriers offer extended annual maximums
-
Preventive services - Most plans cover 100% of preventive services with no deductible, and costs do not apply against annual maximum
-
Basic Services - This includes fillings, stainless steel crowns, teeth extractions, root canals, ect. Deductible plus coinsurance - Most plans cover 80% and costs count towards annual maximum
-
Major services - This includes Bridges, Dentures, Inlays ect. Deductible plus coinsurance - Most plans cover 50% and costs count towards annual maximums
-
Orthodontia services - Whenever someone says Orthodontics or Orthodontists, people's minds automatically race to images of braces. But orthodontics provides services for more than just braces, Orthodontists have many treatment options and services to fix all different problems, including the alignment of teeth and the repositioning of a jaw. Most plans cover Child Orthodontia through age of 18 and have separate annual maximum
Vison Group Coverage - What to consider when choosing coverage
-
Eye Exam Cost and Frequency - How often you may receive an eye exam. Most plans offer every 12 months
-
Lenses or Contact Lenses Cost and Frequency- Member costs and frequency. Important to review the costs based on lens type (Polarized, Premium Progressive, Anti-Reflective Coating, Single, Bifocal ect.). Contact may have different pricing for conventional vs. disposable.
-
Frames Cost and Frequency - Member cost and frequency of new frames vary by plan.
Group Life and AD&D - What to consider when choosing coverage
-
Death Benefit Cost per Thousand- Important to review the Life Rate per $1,000 of coverage which is calculated by total volume (example - $10,000 flat benefit for 20 employees is $200,000 volume) divided by the monthly premium. The employer pays 100% of the Group Life Premiums and the employees are eligible without a medical examination.
-
Age Reduction schedule - When employee reaches a preset age, the life benefit will reduce
-
Voluntary Employee Life and AD&D - Employees will have option to purchase extra life and AD&D.
Underwriting
The group size, group’s prior coverage, and prior coverage type play a role in underwriting. Usually, plans will require employees to submit individual applications for groups without prior coverage. Otherwise, most carriers will leverage prior claims data (Tier 1 and Tier 2) and will not require individual applications from employees.
Stop-loss insurance
Puts a cap on the plan’s medical claims payment risk. This cap is based on the amount the plan must pay for an individual’s medical claims (called the “specific deductible”), as well as the combined amount of all eligible medical claims the plan must pay in a given period (called the “aggregate attachment point”). With stop-loss insurance, the employer self-funded plan is protected from high individual medical claims and high overall claims expenses.
Specific stop-loss coverage
Protects the plan from unexpected large medical claims incurred by covered individuals in the group.
Specific stop-loss deductible
Is the amount of eligible medical claims the plan pays for any individual member before the stop-loss insurance begins to reimburse the plan (within the contract period). For example, if an Alternate Funding plan had a specific deductible of $15,000 per covered member, and a member has medical claims of $22,000, then the plan covers $15,000 of those eligible expenses and the stop-loss insurance covers the rest.
Deficit carry-forward
If a group had a really bad claims experience year (say $1 million in actual claims), the stop-loss insurance would cover it. But the insurance company might decide to hold back all renewal refunds until that huge sum is paid back. In other words, the insurance company could carry the deficit from the one bad claims experience year forward to future years. Check Plan Details to see if Carrier has Deficit carry-forward
Contact me to help you compare your coverage options and decide what coverage is right for you.
