What Does Group Health Insurance Cover?

A group health insurance plan allows companies to offer employees a more cost-effective way to pay for health care expenses. The premiums employees will pay under a group plan are typically less expensive than those of individual plans, providing a cost-savings all around and an enticing employee benefit. When enrolled in a group plan, the insurance company pays a portion of the medical costs incurred. What services are covered and the percentage of the costs that the insurance company pays, however, vary from plan to plan. Here is an overview of group coverage basics.

What Group Coverage Includes

A group health plan covers a wide variety of medical services and equipment, including:

  • Check-ups
  • Wellness Services
  • Sick Visits
  • Outpatient Care
  • Emergency Services
  • Hospitalization
  • Surgery
  • Maternity and Newborn Care
  • Pediatric Services
  • Long Term Treatments
  • Mental Health Services
  • Substance Abuse Services
  • Rehabilitative Services
  • Laboratory Services
  • Many Preventive Screenings (blood pressure, diabetes testing, mammograms, cancer screenings)
  • Durable Medical Equipment (crutches, orthotics and diabetic supplies)

Group Coverage Limits

Under current federal law, lifetime and annual limits on most health care benefits are prohibited. Plans can, however, put an annual and lifetime limit on spending for health care services that are not deemed essential. In New Jersey, the lifetime limit is “unlimited”, meaning they will pay out, after the cost share deductibles and coinsurance, as much as is needed within and maximum.

There are also coverage limits based on the type and location of services. For example, the allowable coverage amount for a service or procedure in a hospital may vary from the same procedure or service performed in a doctor’s office, and can vary from provider to provider.

Group Limitations and Exclusions

Every health care plan has coverage limitations and exclusions. There are certain services and items for which the insurance company will limit the amount paid or simply not cover at all – regardless of open enrollment. Some of the most common limited or excluded areas include cosmetic surgeries, alternative medicine, home care and private nursing, in-patient rehabilitation, out-patient rehabilitation, chiropractic care, dental care, and vision care. It is important that you carefully review all limitations and exclusions when selecting your insurance plan so that you won’t be caught off-guard.

Prescription Coverage

There is a wide variation in terms of how insurance companies cover prescription drugs. Just because you have prescription coverage doesn’t mean that the prescription you wish to take is covered. Each insurance carrier has a formulary list of prescriptions unique to their products. These formulary lists are finite lists of medications they will cover, and health insurers are allowed to develop these lists and adjust them as needed. Prescription lists are typically divided into tiers based on price. There are also restrictions on how covered medications can be dispensed, such as prior authorization, dosage being consistent with FDA regulations, and step therapy which requires you try a less expensive drug before approving coverage for a more expensive option.

Combing through what is and is not covered in a group health insurance plan can be overwhelming. It is beneficial to speak with a health insurance broker who can guide you through and discuss plans tailored to your needs. We are here to help do just that.

What is Considered a Qualifying Event for Group Health Insurance

Every year millions of people sign up for health insurance plans during their employer’s open enrollment period. For workplace health insurance plans, the employer sets the enrollment window. This period is typically one month prior to the current plan’s renewal. Many companies hold open enrollment in the fall with coverage being effective for the upcoming calendar year. Most people don’t realize, however, that you can join a group health insurance policy, as well as add or subtract people on an existing policy, outside of the open enrollment period – provided you are experiencing a “qualifying event.”

Qualifying Life Events

There are several types of events that may make you eligible to change your current policy, or to enroll in a health insurance plan, without waiting for the next open enrollment period. Most of these “Special Enrollment” events are related to changes in job, family, or income status:

  • Marriage
  • Separation
  • Divorce
  • Birth of a Child
  • Adoption
  • Change in Dependents
  • New Hire
  • Court Orders
  • Change in Residence
  • Change in Spouse’s Benefits
  • Change in Spouse’s Employment Status
  • Change in Work Hours
  • Loss of Coverage
  • Loss of a Dependent
  • Change in Dependent Eligibility
  • Change in Living Location

Simply stating that these events occurred is not sufficient. You will need to supply proof of the qualifying event at the time of the change or enrollment application.

Qualifying Event Deadlines

Just as there is an open enrollment deadline, there is also a time limitation on special enrollment. If you have a qualifying event, you generally have 30 or 60 days from the date of the event to make changes to your health insurance policy. The time limit depends upon your plan’s requirements.

If you do not make the changes before the period expires, you will need to wait until the next open enrollment to do so. It is important to notify your insurer of your qualifying event as soon as possible. Different plans have different rules, so getting a jump on the changes is important.

If you are seeking a new plan that works best for your employees, Dawson Benefits is the skilled insurance concierge for you. We don’t leave you scrambling to figure out any of your insurance questions alone. Instead, we take care of individuals, businesses, and employees, assisting with everything from policy selection to claims issues.Call 201 258 4669 to set up a free consultation today!

Who is Eligible for Group Health Insurance?

one person away from group

First, a congratulations: that you are even asking questions about group health insurance shows a commitment to your employees, support for their healthcare, and a financially savvy decision to save when individual plans can be astronomically more expensive. And now, as another year begins, you have the opportunity to evaluate your insurance plans and needs to take proactive steps to secure group coverage.

But who is eligible for group health insurance? The easiest answer is full-time employees, but that term can be malleable depending on the company at hand. If you have a smaller company (one to 50 employees), full-time is defined as staff who work an average of 25 hours a week. For larger companies (51 or more employees), it is defined as an average of 30 hours a week.

This minimum number of hours might not be hard to reach: generally, full-time staff work 40-hour weeks. However you might ask what happens if an employee falls below this minimum number of hours. While that employee might not be offered your group health insurance, they must be offered an extension through COBRA, which benefits employees falling under this margin and, importantly, their dependents.

Are Freelancers and Independent Contractors Eligible?

Increasingly, more and more companies work with freelancers or independent contractors. A perk of working with groups such as these, like an outside marketing agency or press team, is that you needn’t offer them coverage. What is noteworthy, though, is that if an independent contractor receives 100% of their compensation from one source, they can be allowed to be added in to your group plan.

How Does Part-Time Staff Turning into Full Time Affect Group Eligibility?

It is also possible that your part-time staff will be promoted or take on more hours. If this is the case, such employees can be added into your company plan but need to satisfy the new-hire wait period first, which may vary business to business.

What this does illuminate are the many ways to offer coverage to entice diligent employees who want to work with and for your company. If you are seeking ways to offer coverage and thus legitimize your company, or are seeking a new plan that works best for your employees, Dawson Benefits is the skilled insurance concierge for you. We build plans around your health, life, dental, vision, and disability insurance needs.

Call 201 258 4669 to set up a free consultation today!

What Is The Difference Between Group and Individual Health Insurance?

Lots of myths swirl around group and individual health insurance, but the truth is the breakdown of each is rather predictable. Simply put, group coverage is offered through an employer while individual coverage is procured on a personal basis.

Group vs. Individual Coverage: Understanding the Differences

What gets complicated is preconceived notions about each type of health insurance plan. One might think that individual coverage is better: it lets you customize your package to your needs and on your own schedule. While this may be true, it can also be much more expensive. Since group coverage is provided by your company, premiums are paid through salary deferrals on a pre-tax basis. And despite what you may think, group health insurance offers a broader selection of carriers: a solid ten offer group plans to employers across New Jersey. These plans do offer prescription copays, and depending on the size of your company and thus its group, the rate can be negotiable. To instill security, rates are guaranteed for a full twelve-month period. COBRA — the Consolidated Omnibus Budget Reconciliation Act — is also offered, which, as a health insurance program, allows eligible employees and their dependents the continued benefits of coverage in case that employee loses their job or experiences a work cut.

But what about individual coverage?

The insured, in this case, work directly with the carrier for individual health insurance plans and premiums are paid post-tax. There is also a more limited selection of carriers; just three remain in New Jersey that offer plans to individuals. These types of coverage also do not come with prescription plans, and rates are filled with the State meaning they are sadly not negotiable. Additionally, rates can change as frequently as every three months, once a quarter, and COBRA is not offered since this type of plan won’t come from an employer. This can affect not only you but your dependents.

With group coverage, sharing really is caring

In a group health insurance plan, your company can play with various options and offer more employees the healthcare they need. In need of a group plan but unsure of which to work with? These are not decisions to make hastily: the mean age of your employees, the frequency of their doctors visit, and the specific needs they have will all influence which plan you should embrace. Dawson Benefits can help you find a plan and then also be your conduit between the insurance company and your own.

Call today for a free health insurance plan consultation and quote!

Why Group Health Insurance Rates Increase Annually (and How You Can Help Minimize Them)

Price increases are common across industries, and even though that’s an accepted fact it doesn’t make your wallet feel any better. When it comes to health insurance, what can help alleviate this pain is understanding why costs go up — and what you can try to do to minimize these price hikes. One of the dangers of cost increases to your insurance plans is blind acceptance: have your services changed? Are there new plans in place? Has there been an institutional shift at your insurance company, and does that change benefit you? Stay vigilant and don’t be afraid to ask questions.

Impact of Inflation and Medical Advancements

Unsurprisingly, health insurance premiums rise with inflation. But they also increase due to advancements in the medical field: expensive technology that can more quickly determine diagnostics and give patients firmer information faster also affect prices while benefiting the insured.

Detriment of Data Mining

Insurance companies also harvest data to determine the cost their users should pay. If your company is comprised of a certain demographic, your insurance plan may monitor usage and update costs accordingly. For example, if your company is made up of men ages 40-60 and men in that demographic are going to a certain doctor with greater frequency, your plan may note that and adjust.

How to Maximize Your Plan Coverage and Minimize the Rate Hikes

While rising group health insurance costs are often an inconvenient truth, it’s important to know what you can get out of your health plan so you can make the most of it. Learn how many eye, dental, and general practitioner visits you are allotted each year, what your co-pay is, and what your premiums are. And don’t let them go to waste! You are paying for a service, and your money goes straight to your insurance company if you do not make use of it.

Get to know your company’s habits — it’s advisable to distribute surveys, perhaps every other year, to get a sense of how often employees make use of certain insurance benefits and what services they need. By studying habits and group coverage needs, you can decrease your premiums. If you see your company is not in need of a particular service, considering switching to an alternative plan that might be cheaper without it. The more informed you are, the cheaper your costs can be.

Deciphering insurance plans and premiums can be difficult. If you want to work with an insurance broker to see if your plans are being maximally utilized for your company, speak with our insurance broker at Dawson over a free consultation call.

How many employees are required for group health insurance?

Companies of all sizes pride themselves on offering health insurance with their employees’ jobs. It is an enormous perk, one that can’t be underestimated, and something that those searching for full-time jobs have come to expect. But with small businesses and those that employ remote workers on the rise, it can be common to question how many employees are needed to qualify for a group health insurance plan.

To be eligible for group health insurance (which is often cheaper than individual plans), a company must have between one and 50 employees. This allows companies to apply for small group coverage, and those with more than 50 employees can only apply for large group coverage. But, there are other requirements.

Requirements Beyond the Number of Employees for Group Insurance

In addition to the right number of employees, you need to satisfy the following requirements:

Certified Office Space.

Another key necessity to qualifying for group health insurance is that you must have a certified office or workspace in the state in which you are applying for group coverage.

One of the Employees Cannot Be the Owner.

Additionally, the only covered member cannot be the owner of the company — they cannot also be the spouse of the owner or member of the owner’s family. If your company is one that you and a spouse run as the sole employees, you would need to apply for coverage through a MEWA plan until other workers unrelated to the owners join the staff. But once you have enough employees to qualify for group coverage, the market would open up.

Full Time Employees.

Employees must work on a full-time basis. Insurance cannot be offered to part-time workers, but it is not necessary to as they won’t count toward your minimum to qualify for group coverage. Your full-time employees are considered those who work at least 25 hours per week. Note that seasonal employees do not count, even if they are indeed working for 25 hours during their term of employment.

Enrollment Percentage.

Companies accepting group coverage are also required to enroll at least 75 percent of eligible employees. Those with differing insurance plans do not count toward this minimum rule, and know that enrollment happens annually usually in the month prior to the group’s renewal.

Wondering how you and your company can qualify for group health insurance, and curious about which plan you should go with? Let the experienced insurance broker of Dawson Benefits help you navigate this intricate course — call today for a free consultation.

Can I keep my doctor if I switch health insurance plans?

Switching health plans can bring about a lot of anxiety — it’s a major transition for some, and it is often a highly personal, medical, and financial decision. As such many dally in changing their plans, even if it is more beneficial to, as they say, rip the band-aid off.

But one principal concern in switching health insurance plans is defining whether or not you get to keep your doctors after you make the change. Patients establish trusted, healthy, and sometimes even lifelong relationships with their doctors, and leaving your medical professional can be difficult; they are the keepers of your entire clinical history and know how to communicate with and treat you. But changing insurance plans does not also necessarily mean losing your medical contact.

Obtain a List from Your Doctor of Participating Insurance Plans

When choosing a new insurance plan, there are lots of steps to take to see if this means going to a new doctor. To start, request from your doctors or their staff a list of networks they are contracted with. (This may also be on their website.) From there, you know exactly who you can switch to while still staying in-network. The work that follows, of course, entails finding out which plan is a good fit, financial and otherwise, but websites like healthcare.gov or using state or private exchanges can be helpful.

What to Do if Your Doctor Is Not in the Plan You Are Considering

But it’s also very possible that the new health insurance plan that you’ve been considering is not one your beloved doctor accepts. Fear not: this does not mean the end of the road. Talk to your doctor; perhaps some kind of an agreement can be arranged, or perhaps he or she has been getting requests from other patients about your chosen network and so the office may consider adding it to their plans.

However if it turns out that plan cannot be accepted, you may have to make a firmer decision. Without your insurance to cover key expenses, you’ll have to decide whether staying with your doctor and paying out-of-pocket is worth it, or perhaps your doctor can still be of use: mention the network you plan on switching to, ask your doctor if they know of any neighboring facilities that accept that plan, and see if your doctor recommends any other professionals who could be a good fit for your needs. They’ll know you best and can find someone for you to have a fruitful relationship with.

If you’re considering switching plans or are unsure about what that means for your medical future, speak with our insurance broker — we’ll happily guide you through and discuss plans tailored to your needs!