Considered one of the more traditional group health insurance options. Fully-Insured Plans mean the company pays
a fixed premium to the insurance carrier. The fixed-rate is based on the number of employees enrolled in the plan.
In this case, the covered persons (employees and dependents) are responsible for paying the deductibles or copays
required.
Glossary
Self-Funded Plans
Also referred to as self-insured plans, allow employers to have more control over the plan. These plans are
typical with employee populations of 250 or more. While self-funded plans can be more affordable since it allows
the employer to get the profit margin that would be added by the insurance company, it can expose the employer to
bigger risks.
Level-Funded Plans
These plans are NEW to the market and are now being implemented down to 5 enrolled employees. Once rates are
established based on underwriting guidelines those rates remain FIXED for the entire benefit plan year. Certain
factors that determine the monthly payments are claims allowances, fees, and stop-loss coverage premiums. At the
end
of the year, the insurance carrier will adjust the funding amount based on group performance. If the claims,
costs,
and expenses are less than the employer’s contributions, they get a refund. If those costs are more than the
employer’s contribution, the insurance carrier will cover the difference.
Health Maintenance Organization (HMO)
A setup where group coverage includes members paying for specific health services through monthly premiums.
With
this plan, you’ll have access to a network of healthcare providers. If you choose providers outside of the
network,
you’ll have to pay the bill.
Preferred Provider Organization (PPO)
Similar to HMO plans, but with more flexibility. PPO’s offer providers and facilities without you being
responsible for the entire bill. Instead, these visits may result in higher co-pays or additional service
costs.
High-Deductible Health Plan (HDHP)
HDHP are based on lower premiums and higher deductibles for their group members. This translates to more
out-of-pocket before the plan pays for it’s share. However, this does keep monthly premiums lower, making it
preferred
for those who don’t use their medical services frequently. These plans can also be paired with savings options
like a
health savings account (HSA). The funds in these accounts roll over every year, helping with retirement
savings
options. Health Reimbursement Accounts (HRAs) are another savings option that can be tied with an HDHP.
What are the differences between HMO, PPO, EPO, and POS plans?
Let's go over the plan types you may see offered depending on what's available in your area.There are different types of health plans that meet different needs.
An HMO (or “health maintenance organization”) requires you to select a primary care physician (PCP) who acts as a "gatekeeper." Think of your PCP as your personal health quarterback, strategically coordinating all of your care and providing for your basic healthcare needs. If you ever need to see a specialist or require a diagnostic service (such as a blood test), you will need a referral from your PCP. Your referral will always be to a provider within your HMO network. If you choose to see a doctor outside of the network or without a referral, you will generally have to pay all costs out-of-pocket unless it is a true medical emergency or you have no other options. With an HMO, your physician network is local.
A PPO (or “preferred provider organization”) is a health plan with a “preferred” network of providers in your area. You do not need to select a primary care physician and you do not need referrals to see a specialist. If you see a “preferred” (or “in-network”) provider, you will only be responsible for paying a portion of the bill (according to your plan's coverage structure). If you choose to see a doctor who is outside the preferred network, you will generally have to pay a larger portion of the bill than you would for an “in-network” provider, but most plans will still cover a portion of the bill. With a PPO, you will have access to out-of-state providers that are considered in-network.
An EPO (or “exclusive provider organization”) is a bit like a hybrid of an HMO and a PPO. EPOs generally offer a little more flexibility than an HMO and are generally a bit less pricey than a PPO. Like a PPO, you do not need a referral to get care from a specialist. But like an HMO, you are responsible for paying out-of-pocket if you seek care from a doctor outside your plan's network. An EPO is a good option if you want to see specialists without a PCP referral within your network.
A POS (or "point of service”) plan is also a hybrid of an HMO and PPO plan. Like an HMO, you will need a referral from your PCP in order to see a specialist. But, like a PPO plan, you will pay less if you use doctors, hospitals, and other healthcare providers in the plan’s network, and you will have access to out-of-network providers at an increased cost.
An HMO (or “health maintenance organization”) requires you to select a primary care physician (PCP) who acts as a "gatekeeper." Think of your PCP as your personal health quarterback, strategically coordinating all of your care and providing for your basic healthcare needs. If you ever need to see a specialist or require a diagnostic service (such as a blood test), you will need a referral from your PCP. Your referral will always be to a provider within your HMO network. If you choose to see a doctor outside of the network or without a referral, you will generally have to pay all costs out-of-pocket unless it is a true medical emergency or you have no other options. With an HMO, your physician network is local.
A PPO (or “preferred provider organization”) is a health plan with a “preferred” network of providers in your area. You do not need to select a primary care physician and you do not need referrals to see a specialist. If you see a “preferred” (or “in-network”) provider, you will only be responsible for paying a portion of the bill (according to your plan's coverage structure). If you choose to see a doctor who is outside the preferred network, you will generally have to pay a larger portion of the bill than you would for an “in-network” provider, but most plans will still cover a portion of the bill. With a PPO, you will have access to out-of-state providers that are considered in-network.
An EPO (or “exclusive provider organization”) is a bit like a hybrid of an HMO and a PPO. EPOs generally offer a little more flexibility than an HMO and are generally a bit less pricey than a PPO. Like a PPO, you do not need a referral to get care from a specialist. But like an HMO, you are responsible for paying out-of-pocket if you seek care from a doctor outside your plan's network. An EPO is a good option if you want to see specialists without a PCP referral within your network.
A POS (or "point of service”) plan is also a hybrid of an HMO and PPO plan. Like an HMO, you will need a referral from your PCP in order to see a specialist. But, like a PPO plan, you will pay less if you use doctors, hospitals, and other healthcare providers in the plan’s network, and you will have access to out-of-network providers at an increased cost.
Dental
Dental - often comes in the form of “100-80-50” meaning that the insurance provider pays for 100 percent of the cost of preventive care (such as cleanings and routine checkups), 80 percent of the cost of basic procedures (such as fillings), and 50 percent of the cost of more advanced procedures (such as bridges or crowns).
-
Preventive care - routine dental exams and cleanings (every 6 months) are covered.
-
Restorative care - Consists of any minor procedures to treat damaged or decayed teeth, like filings.
-
Endodontics - More advanced damage or decay will require more involved procedures like root canals.
-
Oral Surgery - Common oral surgeries include teeth removal, the drainage of infections, and gum tissue biopsies.
-
Orthodontics - Installation, maintenance, and removal of braces and retainers.
-
Periodontics - Involves the treatment of gum disease, infections, and lesions.
-
Prosthodontics - Fittings and installations of dentures and bridges can be expensive, you will need a quality insurance policy to help alleviate this cost.
Vision
Vision - helps with the cost of examinations, treatments, prescriptions, surgical procedures, and equipment. LASIK is generally not covered by insurance because it is deemed by many providers as elective or cosmetic surgery.
-
Eye Exams
-
Eyewear
-
Lens coatings & enhancements
-
Surgery
-
Cost of Service without & with insurance respectively:
-
Eye Exam - $154 vs. $15 (copay)
-
Eyeglass Frames - $159 vs. $9
-
Eyeglass Lenses - $86 vs. $25 (copay)
-
Lens Enhancements - $268 vs. $170
Disability
Disability insurance, also called Paycheck Protection, provides income if you are unable to work or earn money due to a sickness or accident.
Important Terms:
-
Short Term - offers the employee a portion of their salary if they are unable to work for a short period of time (3-6 months).
-
Long Term - offers the employee a portion of their salary if they are unable to work for a longer period of time (6+ months).
-
Elimination Period - the period of time in which the person must be disabled before receiving benefits.
-
Definition of Disability - an important distinction to be aware of. The language in the contract will either state the insured has to have a loss of income AND loss of material duties. Or, it will say the insured has to have a loss of income OR a loss of duties.
Life
3 Main Components:
Death Benefit
The death benefit or face value is the sum of money an insurance company
promises to the beneficiaries listed on the policy when the insured dies. The insured will choose the
desired
benefit amount based on estimated future needs for their beneficiaries. The insurance company will
determine
whether there is an insurable interest and if the proposed insured qualifies for the coverage based on the
company’s underwriting requirements related to age, health, and any hazardous activities in which the
proposed
insured participates.
Example: The insured might be a parent and the beneficiaries might be their children
Premium
These are what the policyholder pays for their insurance. The insurer is required
to pay the death benefit when the insured dies as long as the policyholder pays the premiums determined by
the
insurance company. The premiums are determined by factors like gender, age, medical history, and any
occupational
hazards. Premiums will be higher with those with larger death benefits, permanent policies that accumulate
cash
value, or those who are higher risk.
Cash Value
This serves two purposes; it is a savings account that the policyholder can
use during the life of the insured, and cash accumulates on a tax-deferred basis. Occasionally there will
be
restrictions on withdrawals, depending on the purpose of the withdrawal. For example, the policyholder
might take
out a loan against the policy’s cash value and have to pay interest on the principal. You can also use the
cash
value to purchase additional insurance or to pay premiums. The cash value remains with the insurance
company once
the insured dies. If there are any outstanding loans, the cash value will reduce the policy’s death
benefit.
Important Terms:
-
Accidental Death Benefit Rider - additional life insurance coverage in the event the insured’s death is accidental.
-
Waiver of Premium Rider - protects the policyholder in the event they become disabled or unable to work and can’t make their premium payments.
-
Disability Income Rider - pays monthly income if the policyholder is unable to work for several months or more due to a serious illness or injury.
-
Accelerated Death Benefit Rider - If the insured is diagnosed with a terminal illness, this rider allows them to collect a portion or all of the death benefit.
-
Long-Term Care Rider - a type of accelerated death benefit that can be appropriated for the payment of a nursing home, assisted living, or in-home care if the insured requires help with daily living activities.
-
Guaranteed Insurability Rider - allows the policyholder to purchase additional insurance at a later time without medical review.
Worksite Voluntary Benefits
Sometimes called supplemental insurance or employee-paid benefits, voluntary benefits are offered by an employer at the worksite. The most common voluntary benefits:
Accident Insurance
Accident Insurance helps offset any medical expenses as a result of a
covered accidental injury. Some expenses include initial care, surgery, transportation and lodging, as
well as
follow-up care.
Cancer Insurance
Provides coverage to protect against the non-medical related expenses
such as: experimental prescriptions, out of network treatment, lost earnings from a spouse, and much more.
Benefits are paid directly to the employee.
Critical Illness Insurance
Critical Illness Insurance provides a lump-sum benefit for an
employee diagnosed with a covered critical illness such as heart attack, stroke, coronary artery bypass,
end-stage
renal failure and more. Benefits are typically made out directly to the employee so they can choose
exactly how to
use it.
Hospital Indemnity Insurance
This type of insurance assists those with costs related to a
hospital visit. This may include outpatient surgery, diagnostic testing, doctor’s appointments and even
emergency
room visits.
Legal
Provides employees with access to qualified attorneys at a reduced cost. Typically
covers legal matters pertaining to family, vehicle, real estate, civil lawsuits and wills.
Identity Theft Protection
What this protection does is monitor public records and alert
the employee of any fraudulent use of their personal information . This includes loan or credit
applications.
Identity Theft Protection also covers the cost of repairing the employee’s credit history.