How many employees do I have to have in order to be a “group”?
Typically, a minimum of 2 employees or 75% of the eligible employees, that do not have other coverage, whichever is more. However, some programs will allow as little at 60% participation. |
What is the minimum amount I (Employer) must contribute toward the cost of premium for my employees?
The general rule is 50% of the employee’s premium, however there are carriers that require 75%. There are some limited benefit plans that can be as inexpensive as $25 per month. |
Do my employees have to contribute toward the premium?
No, however the growing trend is to have the employees engaged in the cost of insurance. |
Can my employees get better rates if they go out on their own and buy individual insurance?
Individual plans can be less expensive at times because they underwrite individually, and can deny anyone based on health conditions. So, it is not “guarantee issue” like group products are. |
What is the cutoff between small and large group?
A small group is between 2-49 employees, a large group is 50+. |
Can my employees be denied coverage in a “group” policy?
For groups 2-49 employees, as long as all the “group” criteria are met, then a carrier cannot deny any employee coverage, no matter what medical condition they are picking up. |
Do I have a 1 year contract with my insurance carrier?
Some carriers rates are only guaranteed for 6 months at a time, however most are guaranteed for 1 year. You can always move away from a carrier to another carrier at anytime (mid year) as it is a month to month agreement. |
Are my rates based on my group size or health conditions?
Both. If you are a group between 2-49 employees, a carrier can either raise or lower your rates 10% based on the size & health of your group. |
Can I get better rates by shopping on-line, without an Agent/Broker?
No, the rates and plans are identical online as they are in an Agent’s office |
Why do I need an Agent/Broker?
An Agent/Broker should be marketing your group for you at least on an annual bases making sure you are still with the right carrier/plan. As well as performing other duties such as helping with administration, materials, claim problems, provider issues, COBRA issues, enrollment meetings, & employee education. |
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Click here for a list of insurance agents and brokers. |
Can I switch Agents without changing plans?
Yes. |
Can I have employees on different plans within the same carrier?
Most carriers will allow small groups to offer different plan options. However, you need to be careful not to discriminate. |
Can I have different contributions/benefits for different “classes” of employees?
Yes, as long as you do not discriminate within the classes. |
Which plans are most accepted by providers in this area?
This changes from year to year, but for now the most accepted carriers are: Blue Cross, Blue Shield, & Pacificare/United. |
What is the difference in “PPO” and “Non PPO” providers?
PPO is also known as “IN Network”. These are the providers that have a contract with the carrier. Non PPO or “Out of Network” are all the other providers that DO NOT have a contract with that carrier. Click here for our glossary of terms. |
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What does UCR mean?
UCR is short for Usual, Customary & Reasonable. This term is used when a patient is utilizing “NON PPO” providers. Some carriers will reimburse the patient/provider based on the UCR charges in their area. Other carriers will reimburse only a percentage of their contracted rate (much less than UCR). |
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Click here for our glossary of terms |
What is an EOB?
An EOB (or Explanation of Benefits) is what the PPO patient receives from the carrier each time they have a service rendered by a provider. It explains what the “Billed amount” is, then the “Allowed amount” (which is what the carrier’s negotiated rate is), then the “Amount NOT allowed” (or excluded), and finally the “Patient’s responsibility.” Click here for our glossary |
How do I know if I have a Federal COBRA group or a CAL COBRA group?
If your group was less than 20 employees 50% of LAST year, you are a CAL COBRA group. If you were more, then you are Federal. Click here for our glossary |
What is the difference between Co-pays and Co-insurance?
Co-pays are a set dollar amount that your employees pay (usually upfront) at the provider’s office (usually ranging from $10-40).
Co-insurance is the percentage amount that your employees pay (sometimes after a deductible) for certain services (hospital, etc). These range from 10%-50%. Their co-insurance ends at the “Out of pocket maximum” amount, and begins again each calendar year. Click here for our glossary |
