Health Insurance 101

We’ve assembled the most commonly asked questions for those new to group health insurance.

Can’t find the answer to your question? Call us at (888) 584-9220.

Small Group Health Insurance

What is group health insurance?

Group health insurance refers to a medical policy issued to a group (typically a business with W2 employees, although there are other kinds of groups that can get coverage) that covers all eligible employees and sometimes their dependents.

Am I eligible for small group health insurance?

Small groups are definitely eligible for group insurance if:

  1. There are at least two people in the company
  2. At least one of those two people is a W2 employee
  3. The group does NOT consistent of only a husband and wife.

If you are looking for a small business health plan for you and your spouse only, you may still be eligible if you live in the following states: Washington, California, Texas

You can start group insurance as long as you meet eligibility even if not all your employees need insurance.

What is the advantage of group insurance versus individual insurance plans?

Group insurance is pre-tax, which means you can offer this employee benefit and have it exempt from employer and employee taxes. This usually means a 30-40% tax benefit on the cost of insurance.

SimplyInsured will ensure you file all the proper forms to have group insurance premiums be tax-deductible.

Individual insurance, by contrast, provides no tax benefits and must be paid for with post-tax money.

I found a plan I want. How do I apply for group insurance?

Applying for group insurance is easy on SimplyInsured!

  1. Click "Start Application" on the plan you wish to purchase for your company
  2. Walk through the application steps on our website as directed. This should take about 10-15 minutes.
Is there any price difference between a spouse/child vs. employee?

Pricing for medical insurance is only based on age and is not based on whether the person is an employee/dependent/spouse.

For example, a 30 year old spouse on your plan would cost the same as a 30 year old employee. A 21 year old child would cost the same as a 21 year old employee.

Can the owner of the company who is not on payroll enroll?

Yes! Owners of small businesses can enroll as long as the group is eligible, and the owners can provide documentation proving they are owners of the company.

Appropriate documentation can include:

  1. Personal tax return forms showing profit/loss from the company
  2. If it is a new company with no tax returns, the company's legal formation documentation showing the person as an owner would suffice.
Do I have to offer my insurance to all employees?

You do not have to offer insurance to all employees, but if you do decide to offer insurance, you must treat all employees of the same type the same way.

  • Example 1: If you have part-time hourly employees, you may choose not to offer the company's insurance to them and only offer the insurance to your full time employees.
  • Example: 2: If you choose to offer insurance to your full time employees, you cannot exclude offering insurance to one of the full time employees for any reason.
How do I pay for group health insurance?

Insurance premiums are billed on a monthly basis.

Most insurance companies will use auto-debit/ACH for your monthly premium, but may require a physical check for the first month.

If your employees are paying for part of the insurance, you will set up your payroll to deduct their share from paychecks. SimplyInsured works with every major payroll provider and can help make sure the proper deductions take place.

Selecting A Plan

How do I get a quote on SimplyInsured?
  1. In the upper left hand corner of the quote page, there is a section that says "Get Precise Quote" where you'll put in the ages of your employees and optionally, their dependents by clicking "+Family"
  2. As you put in the ages, all the plan pricing will automatically update. Since age is the only factor in small group insurance pricing for small businesses, these are exact quotes.

The cost being shown is the TOTAL cost so you can choose to split that with the employees or pay for all of it as the employer. It's up to you.

What's the difference between an HMO, PPO, EPO, and POS?

HMO - Health Maintenance Organization

HMOs tend to have the lowest monthly premium, but they require referrals to see specialists from a primary care physician (PCP). There is no out-of-network coverage on this type of network.

PPO - Preferred Provider Organization

With a PPO network, you can choose any doctor on their preferred list of providers, no referrals are needed. You can also use an out-of-network provider (ie., not on the preferred list), but you will have to pay more out of pocket.  PPO networks are the broadest and most flexible, but will increase your monthly premium.

EPO - Exclusive Provider Organization

With an EPO, you must pick from the providers on the list, or the insurance company will not pay. An EPO is like a PPO, but without out-of-network benefits. You do not need to choose a PCP or get referrals.

POS - Point of Service plan

A POS plan is like a HMO, but in some cases you can get out-of-network coverage like with a PPO. Typically you are required to get referrals, with some exceptions (eg., Humana).

Do plans on SimplyInsured cover pre-existing conditions?

Yes, all of our plans cover pre-existing conditions. Having a pre-existing condition does not affect your price or ability to sign up for a plan at all.

When can the insurance start?

You can start your group insurance on the first of any month. You do not have to wait for an open enrollment period in November.

Can I offer multiple plans to my employees?

Usually yes, but it depends on three factors:

1. How many employees are signing up for coverage.

2. The insurance company you selected

3. The state in which your business is located.

Contact us at hello@simplyinsured.com and we can help you determine how many plans you may offer.

Are these plans compatible with the Affordable Care Act (ACA)?

Yes, all of our plans meet the requirements of the Affordable Care Act. Any employees enrolling on the plans on SimplyInsured would not face the individual penalties for being uninsured.

What is the cost that is displayed on the quote page?

The costs displayed on our quote page is the total monthly price that the insurance company would charge for all the employees and dependents you've entered for your company.

As the employer, you can split that total cost with your employees in any way you want.

On our quote page, you can:

  1. Click "See Employee Costs" on any plan to see the full quote with all your employees' pricing broken down by each person. You will also be able to use the contribution calculator there to play with how much each employee would pay out of their paychecks for their insurance.

  2. Click "Enter Ages" in the top right of the quote page to change/edit the ages of the employees, spouses, and children being quoted.

How much does it cost for a medical procedure on the plan?

Click on "More Details" on any of the plans on this quote page, and you will see two sections:

  1. Estimated Costs gives you an estimated cost of common medical procedures based on how the plan covers those procedures. These estimates are based on national averages so it may differ in your area.

  2. Plan Details below Estimated Costs gives you the exact descriptions of how the plan covers different categories of medical services. Some services may be subject to the deductible or some may be on copay with deductible waived. You can hover over any of the terms to get a more detailed description of what they mean.

Can I purchase dental and/or vision insurance?

Yes! Dental and/or vision insurance can be selected during the application process. You can also preview dental quotes by clicking on the menu at the top of our quote page where it says "Medical" and selecting “Dental” or “Vision.”

Health Insurance Terminology

Affordable Care Act (ACA)

The healthcare reform law enacted in 2010 by the federal government. The laws govern certain aspects of health insurance, what must be covered, and how insurance can be priced amongst other things. The Affordable Care Act is also often referred to as “Obamacare.”

Brand Name (Drugs)

Patent-protected drugs that are sold under a specific patented name by a specific company. These drugs can be either prescription or sold over-the-counter.

Bronze Health Plan

The federal health insurance marketplace divides health plans into four metal levels. The bronze health plan is one of those levels. These plans offer the lowest monthly premiums in exchange for higher levels of self-insurance. These plans best serve individuals who generally have few health care needs.

Claim

The payment requests health care providers or pharmacies submit to insurance companies, based on services or drugs provided to insured individuals.

Coinsurance

The portion or percentage of a health care cost that you are responsible for once your deductible is met. Under your health plan, you are responsible for both your deductible and coinsurance.

Copayment / Copay

A set amount you pay for various services under a health plan. The amount typically varies depending on the service received and the individual plan. Some copayments are only offered after you have met your deductible while other copayments can be used outside of your deductible. Read the plan's details for more information.

Deductible

The amount you are responsible for paying for covered services before the insurance company begins paying its portion.

Generic Drugs

Prescription drugs that are no longer patent-protected and are sold by drug manufacturers under a different name than the original brand name drug. These drugs have the same active ingredient formula as the brand name drug.

Gold Health Plan

The federal health insurance marketplace divides health plans into four metal levels. The gold health plan is one of those levels. These plans typically have higher monthly premiums, but the cost of care for the insured is less. These plans are generally more beneficial for individuals who need more medical care or for those who prefer to pay more on the front end.

Health Savings Account (HSA)

A savings accounts that allows you to contribute pre-tax money to cover qualified medical expenses. HSAs are only allowed in conjunction with a High Deductible Health Plan.

Funds contributed to a HSA roll over year to year.

High Deductible Health Plan (HDHP)

A plan that requires you to pay a higher deductible than most traditional insurance plans. In exchange for the higher deductible, you often pay a lower monthly premium. The cost of care before the insurance begins paying its portion is generally more expensive than that associated with traditional health plans. A HDHP can be combined with Health Savings Account to help covered qualified medical expenses.

 

According to the IRS, a HDHP is any plan where the deductible is at least $1,300 for an individual or $2,600 for a family. Total yearly out-of-pocket costs for a HDHP cannot exceed $6,550 for an individual or $13,100 for a family.

Individual Health Insurance Policy

A health insurance policy a person qualifies for and enrolls in that is not associated with an employer-sponsored group plan.

Non-preferred provider

Health insurers contract with various providers. A non-preferred provider is not contracted to provide services under your health plan. You will be required to pay more for services obtained through non-preferred providers.

Out-of-Network Coinsurance/copayment

The amount you are required to pay for covered services obtained through providers who do not contract with your insurer.

Out-of-Pocket Costs

The costs you pay for medical services that are not reimbursed by your health insurer. These costs include coinsurance, copayments, deductibles and the cost of non-covered services.

Out-of-pocket maximum/limit

The maximum amount you have to pay for covered medical services within a given plan year. Once you hit this threshold for deductibles, coinsurance and copayments, your health plan pays 100% for covered services. Premium payments are not included in your out-of-pocket maximum/limit.

Platinum Health Plan

The federal health insurance marketplace divides health plans into four metal levels. The platinum health plan is one of those levels. These plans typically have the highest monthly premiums of any of the four levels of health plans. The tradeoff is that platinum health plans pay the most when you need medical care.

Preauthorization

Some health plans require that you obtain preauthorization before seeking certain covered services. While preauthorization is not a guarantee from a health insurer to pay its portion of the cost for a covered medical service, it is a finding that the given service, treatment, prescription drug or device is medically necessary.

Preferred Provider

A provider who contracts with or works for your health insurance company. You can obtain services from preferred providers at a discounted rate.

Premium

The amount you pay your insurer for health insurance coverage. Premiums are typically paid on a monthly basis.

Silver Health Plan

The federal health insurance marketplace divides health plans into four metal levels. The silver health plan is one of those levels. These plans offer the lower monthly premium than Gold Health Plans, however the cost of copays and deductibles is higher. Silver Health Plans fall in the middle of the spectrum when it comes to costs, and are the most popular level selected.

Summary of Benefits and Coverage (SBC)

A short, easy-to-read and understand document which health insurers are required to provide. The SBC allows you to easily make comparisons between health plans.

Vision Coverage

Insurance coverage that helps pay for the cost of vision care services. All health plans must provide vision coverage for children. If your health plan does not include vision coverage for adults, you can purchase a standalone plan.  

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