Major Medical
What is Major Medical Insurance?
Major medical health insurance, commonly referred to as “real” health insurance, offers extensive coverage and protection against significant medical expenses. Unlike limited benefit plans, fixed indemnity plans, dental/vision plans, accident supplements, and critical illness plans, major medical health insurance is regulated under the Affordable Care Act (ACA).
Historically, the term “major medical health insurance” was used to describe comprehensive health plans covering a wide range of necessary medical care. With the introduction of the ACA, the term “minimum essential coverage” has become more prevalent. While not entirely interchangeable, all major medical health insurance plans, except for short-term health insurance, meet the requirements for minimum essential coverage under the ACA.
Key Features of Major Medical Health Insurance
- Deductible: Policyholders are required to pay a deductible—a predetermined amount—before the insurance coverage begins. This initial payment is the patient’s responsibility and must be met before the insurance starts to cover medical expenses.
- Coinsurance: After the deductible is met, the policyholder pays a percentage of the remaining medical costs, known as coinsurance. A common coinsurance rate is 20%, meaning the insurance company pays the remaining 80% of the costs.
- Maximum Out-of-Pocket Limit: Once the total in-network costs (including the deductible, coinsurance, and any applicable copays) reach the plan’s maximum out-of-pocket limit, the insurance covers 100% of the patient’s covered in-network care for the remainder of the year. This cap ensures that patients are protected from excessive medical expenses.
Major medical health insurance provides robust financial protection and comprehensive coverage, ensuring that individuals receive necessary medical care without facing overwhelming costs. Understanding the components of deductibles, coinsurance, and out-of-pocket limits can help policyholders make informed decisions about their healthcare coverage.
Major Medical for Small Business
How does small business health insurance work?
Coverage is generally guaranteed issue.
You need at least one employee to qualify.
You must contribute toward employee premiums.
And you can shop for coverage at any time of the year.
How much does small business health insurance cost?
An average small business plan covers 5 people and costs $1432 per month in premiums - or $286 per person.
How to choose the right small business health insurance plan
Assess your needs
First, determine what your small business needs in a health insurance plan. Consider the following:
Who will be covered?
Consider the needs of your employees and their dependents to find a plan that will suit the diverse medical and financial needs of the group.
How much cost sharing can you afford?
Premiums for small business health insurance are paid by the employees and the employer. Make sure consider how much cost sharing makes sense for your business.
What kinds of benefits are important for you and your employees?
While federal privacy laws prohibit employers from inquiring about employees medical history, it’s important to ask your employees which types of benefits are important to them.
Compare small business health insurance options
Monthly premiums:
Know what you and your employees will be able to pay on a monthly basis.
Deductibles, copayments and coinsurance:
Ensure these types of payments will be manageable for you and your employees when you receive medical care.
Medical provider networks:
If you already have a preferred doctor or facility, make sure they'll be included in your new coverage.
Prescription drug coverage:
Ultra Indemnity use prescription drug comparison tool to see which plans cover costs of certain prescriptions.
Coverage add-ons:
You can add things like vision and dental care through Ultra Indemnity to ensure your employees are fully covered.
Small business health insurance enrollment process
Enrollment is the process of getting your employees and their dependents signed up for your new health plan. Once you've selected a plan, an eHealth agent can walk you through the enrollment process.
During enrollment, be sure to answer all questions honestly and to the best of your knowledge. Though premiums may differ based on medical history of certain individuals, no employee will be declined coverage.
Compare Small Business Insurance Plans
Common types of health insurance plans for employers are:
Health Maintenance Organization (HMO):
Preferred Provider Organization (PPO):
Plans generally have higher premiums compared to HMO plans, but they offer larger networks and greater flexibility.
Members are not required to choose a Primary Care Physician (PCP) and do not need referrals to see specialists. You can visit any doctor or hospital, whether they are in-network or out-of-network, though out-of-network care may incur higher costs. Out-of-pocket expenses can include annual deductibles, co-payments, and coinsurance for covered services.
Understanding Point of Service (POS) Plans:
A Point of Service (POS) plan is a hybrid health plan that combines features of both PPOs and HMOs. The premiums for a POS plan typically fall in the mid-range between those of HMO and PPO plans, though the size of the provider network can vary by location.
Members generally need to choose an in-network Primary Care Physician (PCP), but they do not usually require a referral to see a specialist to receive POS plan benefits. The plan offers flexibility, allowing members to use in-network providers for some services and go outside the network for others. When staying within the POS network, members typically pay a small portion of the cost for covered services.
Self Funded
What is a self funded insurance plan?
A self-funded insurance plan, also referred to as self-insurance, represents a health coverage strategy where an employer assumes responsibility for funding healthcare benefits provided to their employees. Instead of purchasing insurance from a carrier, the employer directly collects premiums from participants and covers medical expenses incurred by employees and their dependents through direct payments to healthcare providers.
Employers have the option to self-administer the plan or engage a third-party administrator (TPA) to handle setup, administration, and ongoing management. TPAs offer services ranging from enrollment and claims processing to establishing provider networks, thereby facilitating smoother plan operation.
Self-funded plans promise advantages such as potential cost savings, greater flexibility, enhanced control over benefits design, and improved cash flow management. However, they also pose financial risks, administrative complexities, and resource demands. These include exposure to substantial financial liabilities from high-cost claims, regulatory compliance risks, and the need for increased oversight to ensure plan efficacy and regulatory adherence.
Voluntary
What are voluntary benefits
Voluntary benefits, also known as voluntary group insurance, are workplace plans crafted to enhance employee welfare by catering to diverse and evolving life circumstances. These benefits typically offer employees access to coverage at reduced rates compared to individual purchases, addressing expenses often overlooked by other insurance options.
Voluntary benefits allow you to:
• Pay for expenses out of pocket
• Get Income Protection
• Save you money on healthcare expenses
Get Insurance companies to pay your expenses
Voluntary benefits include supplemental health insurance plans, which are products that provide payouts to help offset expenses that medical insurance may not cover.
Accident insurance helps cover any extra, out-of-pocket expenses not covered by health insurance that you might face if you’re injured in an accident.
Critical illness insurance offers similar coverage if you become very ill or suffer a severe medical problem, like a heart attack or stroke.
Hospital indemnity insurance can help cover the costs associated with the stay. This insurance can be precious if your health plan has high deductibles and copays, you’ll need assistance with
childcare or you might need to travel far from home to receive medical care.
There are two main types of disability insurance: short-term and long term. Both plans are intended to help replace a portion of your income if you become too ill or injured to work. Shortterm disability insurance typically covers benefits for a period of up to three to six months, and long-term disability insurance may pay benefits for a period of five, 10, or 20 years — or even until you reach retirement age, depending on the plan.
Dental insurance typically covers some of the costs you pay every time you visit the dentist, such as cleanings or repairing cavities. It can help you pay less for extensive dental work or oral surgery.
Vision insurance helps cover routine visits to the optometrist for eye exams and the cost of glasses and contacts, which may not be covered under a typical health insurance plan. It can help
you care for your vision without racking up huge bills
What is Benefits Administration
Benefits administration refers to the management and oversight of an organization’s employee benefits program. This responsibility typically falls under the purview of the Human Resources (HR) department. It involves tasks such as deciding which benefits to offer employees (such as health insurance, retirement plans, and various types of leave), establishing eligibility criteria, communicating with benefit providers, selecting competitive benefit packages, educating employees about their benefits options, assisting with enrollment processes, maintaining and updating employee benefit information, and facilitating the transfer of data to insurance carriers or other service providers as needed. Essentially, benefits administration ensures that employees receive and understand the benefits provided by their employer, and that these benefits are managed effectively to support both the organization’s objectives and the well-being of its workforce
