Group Health Insurance
Let Erick Dodge Insurance Agency help you choose a policy that will fit your individual needs. Protecting your assets, whether personal, business, or both, is our goal. A well-chosen policy can lessen the impact of some of life’s most common, most states insurance law defines a small employer as a business with two to 100 employees, regardless of how much they work.
In general, insurance companies require at least 75 percent of a small employer’s eligible employees to participate in the health plan. Companies must always round down to the nearest whole number when calculating the number of participating eligible employees. For example, a business with five employees would achieve 75 percent participation if three eligible employees participate. Seventy-five percent of five is 3.75, and 3.75 rounded down is three.
Insurance companies that offer small-employer coverage must make it available to any employer who applies year round. However, if the employer doesn’t meet the minimum participation requirements, availability may be limited to the federal open enrollment period running from November 15 through December 15 of each year.
Types of Plans
The Patient Protection and Affordable Care Act (PPACA) requires all individual and small-employer group plans to cover a standardized package of services. These services are known as essential health benefits.
The essential health benefits include the following items and services:
ambulatory patient services (outpatient care you get without being admitted to a hospital)
- emergency services
- hospitalization (including surgery)
- maternity and newborn care
- mental health and substance use disorder services, including behavioral health treatment (including counseling and psychotherapy)
- prescription drugs
- rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
- laboratory services
- preventive and wellness services and chronic disease management pediatric services, including oral and vision care.
Grandfathered plans (those that an employer bought before March 23, 2010) aren’t required to contain the essential health benefits, but they do need to comply with State laws. Also, some types of insurance, such as indemnity policies, aren’t subject to the ACA and don’t count as minimum essential coverage for tax purposes.
Employers must give new employees at least 31 days from their start date to enroll in a health plan. After this time, employees may be required to wait up to one year for the next open enrollment period to join. Insurance companies must offer a 31-day open enrollment period annually.
Employers may require newly eligible employees to wait up to 90 days before being eligible for benefits. This is the maximum allowable waiting period for new hires by Federal standards. However, the insurance company may not charge a premium during this period.
Beginning in January 2014, insurance companies won’t be able to impose coverage limits, exclusions, or waiting periods for employees with preexisting conditions who had a gap in coverage.
State regulations and a federal law called COBRA (Consolidated Omnibus Budget Reconciliation Act) allow employees to maintain benefits for a time after leaving a job. COBRA doesn’t apply to all small employers with under 20 employees, but state continuation requirements do. Employers are required to tell employees about their rights to continue coverage. Former employees who choose to continue their coverage through COBRA or state continuation must pay the full cost of the plan. Employers aren’t required to contribute toward their premiums for former employees, even if they previously paid a share. Ask your carrier about your responsibilities regarding continuation notices.
Paying for Coverage
The law doesn’t require employers to contribute toward health benefit plan premiums. Many insurance companies, however, require employers to pay at least 50 percent of their employees’ plan premiums. Employers may choose to pay a higher percentage than the company requires.
Employers are usually not required to contribute toward the cost of dependent coverage.
Premiums may increase at each renewal term because of rising health care costs. State law also protects businesses who buy small-employer health insurance by prohibiting insurance companies from discontinuing coverage without a reason.
Businesses with 25 or fewer full-time equivalent employees that pay at least 50 percent of premiums and pay average annual wages below $50,000 may be eligible for a tax credit of up to 50 percent (35 percent for nonprofits) of the premiums the business pays if it buys coverage through the federal small-business health options program, called the Small Business Health Options Program (SHOP). For more information, visit www.healthcare.gov/will-i-qualify-for-small-business-health-care-tax-credits.
How Insurers Calculate Small-Employer Plan Premiums
Insurance companies base the amount employers pay for insurance on the specific benefits package and cost-sharing levels chosen by the employer. The health status of employees won’t impact rates. Insurance companies will consider the following factors:
- Age of employees. Older people usually have more expensive and more frequent health-related claims. Generally, the older your workforce, the more your plan will cost. However, federal law prevents insurers from charging more than three times more for older employees than they charge for younger employees.
- Tobacco use. Federal law allows health plans to charge tobacco users up to 50 percent more. Texas law requires that rating factors related to health status be spread across the employer group. A group with more tobacco users will pay higher rates than a group with fewer tobacco users.
- Geographic area. Health care costs vary by region because of differences in the cost of living and the number of providers in the area. Most plans use either the county or ZIP code of the employer’s business address to base rates.
Federal Health Care Reform Requirements
Small businesses with fewer than 100 full-time plus full-time equivalent employees won’t face a penalty if they don’t provide health insurance to their employees.
Federal law defines a full-time employee as one who works at least 30 hours during a typical week. The law counts each 120 hours worked by part-time employees in a month as one full-time equivalent employee.
Consider a company that employs 30 full-time employees who work at least 120 hours each per month and 24 part-time workers who average 80 hours each per month.
To convert the part-time employees’ hours to full-time equivalent employees, multiply the number of part-time workers by the average number of hours they work each month: 24 x 80 = 1,920. Then divide the total number of hours worked by 120: 1,920/120 = 16. To get the total number of full-time equivalent employees, add this number to the number of full-time employees: 30 + 16 = 46. Thus, the employer in this example has 46 full-time equivalent employees and qualifies as a small employer under the law.