Market Overview

Small businesses in Florida can choose from many health insurance options – multiple carriers, tiered doctor networks, government exchange vs private market plans, etc. The large number of plans in the Florida market can make finding the right health insurance plan intimidating. SimplyInsured’s guide to the Florida market can help narrow the downs with guidance on the strength and value of the different insurance carriers.

Florida Health Insurance Carriers at a Glance

Florida Market Recommendations
Getting a small business health insurance plan in Florida can be a difficult decision given the multitude of options among carriers, networks, and plans. We’ve summarized the various options into a high level set of recommendations:
Florida Market Recommendations


Florida Health Insurance Carrier Overview

Aetna

Aetna is a national carrier offering medical, dental, and vision coverage. Aetna offers four tiers of networks in Florida, ranging from broad PPOs to smaller HMOs. Aetna’s HMO plans are among the least expensive plans in the market, however Aetna’s PPO options tend to be more expensive than similar plans from other carriers. Companies can mix and match up to 5 different plans to offer employees.

Network Overview

Aetna Network Overview

  • Open Choice PPO: Aetna’s largest network in Florida, with access to expansive network of doctors and hospitals. Offers nationwide coverage through Aetna’s national network
  • Open Access Managed Choice POS: Similar in size to the Open Choice PPO. Plans on the Managed Choice network places in-network doctors into preferred and non-preferred tiers, with greater savings when you utilize a preferred tier doctor.
  • Health Network Options (HNOptions): Slightly smaller POS network with fewer participating doctors and hospitals compared to the full network. Plans are ~20% less expensive than the Open Choice PPO, so the plan does offer quite a bit of premium savings.
  • Health Network Only (HNOnly): HMO network with fairly large network of doctors and hospitals, and is 25% less expensive compared to Open Choice PPO network.

 AvMed

AvMed is regional health insurance carrier that primarily operates in South Florida and Central Florida. AvMed plans have very good coverage within its geographic footprint, but doesn’t have as strong of a statewide or nationwide network. AvMed plans tends to be among the lowest cost plans in the market.

AvMed offers 3 different networks, including a PPO, POS, and HMO option.

Network Overview

AvMed Network Overview

  • Agility PPO: The Agility PPO network is the largest network available through AvMed, and provides national coverage through a partner network, the Private Healthcare Network. The Agility plan is a fairly good value in terms of cost, though will have more limitations on available doctors.
  • Empower POS: The Empower POS network has nearly the same size doctor network as the Agility plans, but does not have the same national network coverage.
  • Engage HMO: The Engage HMO network is the smallest network offered, and has substantially fewer in-network doctors and hospitals. The plan requires a Primary Care Physician to make referrals for specialist visits. The plan slightly less expensive than the Empower plans, so generally isn’t a very good value.

Florida Blue

Florida Blue is the largest carrier in Florida, and offers medical and dental coverage. Florida Blue offers 3 tiers of networks, two PPO networks and a HMO. PPO plans provide national coverage through the Blue Cross Blue Shield BlueCard network.

Florida Blue rates are among the more expensive plans available in most areas of Florida, but do provide access to a very strong network.

Network Overview

Florida Blue Network Overview

  • BlueOptions PPO: Full PPO network with access to the largest network in Florida, and nationwide coverage through the BlueCard network. Plans on the BlueOptions network tend to be among the more expensive options compared to similar full PPOs on other carriers.
  • BlueCare HMO: The BlueCare HMO network is a fairly broad HMO network, and about ~10% smaller than the full BlueOptions network. The plans are typically 18% less expensive than BlueOptions as well, and are most cost competitive with other carriers.
  • BlueSelect PPO: BlueSelect is a narrow network PPO, and includes ~50% of the doctors and hospitals as the BlueOptions PPO network. The plans are much less expensive, but typically still more costly than the PPO options with other carriers.

 

Humana

Humana offers a variety of medical, dental, and vision coverage. Humana offers four networks in Florida: two PPO networks and two HMO networks. Humana’s full PPO plans have an expansive network of doctors and hospitals, both statewide and nationwide coverage.

Humana is also very small business friendly, and covers many classes of small businesses that other insurance carriers do not, such owner-only companies and husband/wife-only companies.

Network Overview

Humana Florida Network Overview

  • ChoiceCare PPO: Full PPO network with access to a very large Florida doctor network and nationwide coverage on Humana’s national network.
  • NPOS – Open Access: Similar to the ChoiceCare PPO network in breadth, however the NPOS plan separates physicians into preferred vs non-preferred tiers. Going to physicians in the preferred tier will result in lower bills than a physician on the non-preferred tier. Plans on this network are ~5% less expensive than the full network.
  • HMO Premier: Humana’s full HMO network and includes a fairly broad network of participating doctors and hospitals. Plans are ~11% less expensive than the ChoiceCare PPO, and is among the lowest cost plans in the market.
  • HMO Select: Humana’s narrow HMO network and includes ~85% of the full HMO network. Plans on the Select tier are substantially less expensive, and are typically the lowest cost plans in the market.

UnitedHealthcare

United Healthcare is the largest carrier in the country, and offers medical, dental, and vision coverage in Florida. United Healthcare PPO plans provide access to the nationwide United Healthcare network. United Healthcare offers a combination of PPO and HMO plans, and allows companies to offer a mix of plans.

United Healthcare PPO plans are fairly competitive, especially for higher tier Gold and Platinum plans.

Network Overview

United Healthcare Florida Network Guide

  • Choice Plus PPO: Full PPO network with access to one of the largest network of doctors and hospitals in Florida and nationwide coverage through United Healthcare’s national network.
  • Choice EPO: Access to the same network of doctors and hospitals as Choice Plus, but plans do not include out of network coverage. Choice EPO plans are ~2% less expensive than the full PPO version.
  • Choice HMO: Same network as the Choice PPO, however plans on the HMO network require the use of a Primary Care Physician and specialist referrals. Plans are ~7% less expensive compared to the full Choice Plus network.
  • Neighborhood Health Plan (NHP): NHP is a narrow network with both HMO and POS plans. The network is much smaller than the Choice networks, and includes ~66% of the doctors and hospitals. NHP plans are substantially less expensive.

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Market Overview

The Texas small business health insurance market offers small businesses to multiple options across carriers, tiered doctor networks, government exchange vs private market plans, etc. The large number of options in the market can make looking for the right health insurance plan intimidating, but can also provide substantial savings opportunities by narrowing in on the most appropriate plan for specific needs.

Texas Carriers at a Glance

Texas Market Recommendations
Getting a small business health insurance plan in Texas can be a difficult decision given the multitude of options among carriers, networks, and plans. We’ve summarized the various options into a high level set of recommendations:
Texas Market Recommendations


Texas Health Insurance Carrier Overview

Aetna

Aetna is a national carrier offering medical, dental, and vision coverage. Aetna offers two main types of networks; (1) statewide EPO and HMO networks and (2) region specific networks called Aetna Whole Health. However, Aetna does not offer a PPO network with out-of-network coverage. Companies can mix and match up to 5 different plans to offer employees.

Statewide Network Overview

Aetna Statewide Network Overview

  • Elect Choice Open Access EPO: Aetna’s largest network in Texas, with access to expansive network of doctors and hospitals. Offers nationwide coverage through Aetna’s national network.
  • Savings Plus of Texas: Narrow EPO network comprised of medical providers with lower negotiated costs to Aetna. Plans are ~9% less expensive than the full network, but also is more restrictive as the plans are only available in major metropolitan markets and to in-state employees.
  • HealthNetwork Only (HNOnly): Statewide HMO network with fairly large network of doctors and hospitals, and substantially less expensive compared to full EPO network.

Aetna Whole Health Regional HMO Network Overview

Aetna Whole Health Regional HMO Network Overview

  • Aetna Whole Health Regional HMOs provide access to doctors and hospitals associated with specific medical systems in each major city (Houston, Dallas, San Antonio, and Austin).
  • Plans are typically 11-12% less expensive compared to the full network
  • However, these networks are region-specific, and do not provide statewide or nationwide coverage, except for emergency medical care

 BCBS TX

Blue Cross and Blue Shield of Texas is part of the Health Care Service Corporation, and is a regional network of Blue Cross Blue Shield plans, offering medical and dental coverage. BCBS TX offers only 2 tiers of networks, PPO and HMO. Companies can choose to offer up to 6 plans, 3 PPO plans and 3 HMO plans. PPO plans provide national coverage through the Blue Cross Blue Shield BlueCard network.

BCBS TX rates are among the most competitive in most areas of Texas. BCBS TX HMO plans are the lowest cost plans available in most of parts of Texas.

Network Overview

BCBS TX Network Overview

  • Blue Choice PPO: Full PPO network with access to the largest network in Texas, and nationwide coverage through the BlueCard network. The best doctor network available to small businesses in Texas.
  • Blue Advantage HMO: The HMO network includes ~50% of the doctors and ~63% of the hospitals on the PPO network. The HMO plans are often times the lowest cost plan available, and are a good option for low cost but effective coverage.

 


 

 

 

 

Humana

Humana offers a variety of medical, dental, and vision coverage. Humana offers two main types of networks; (1) statewide PPO and HMO networks and (2) region specific HMO networks. Humana’s full PPO plans have an expansive network of doctors and hospitals.

Humana is also very small business friendly, and covers many classes of small businesses that other insurance carriers do not, such owner-only companies and husband/wife-only companies.

Statewide Network Overview

Humana Statewide Network Overview

  • ChoiceCare PPO: Full PPO network with access to a very large Texas doctor network and nationwide coverage on Humana’s national network.
  • NPOS – Open Access: Similar to the ChoiceCare PPO network in breadth, however the NPOS plan separates physicians into preferred vs non-preferred tiers. Going to physicians in the preferred tier will result in lower bills than a physician on the non-preferred tier. Plans on this network are ~11% less expensive than the full network.
  • HMO Premier: Humana’s full HMO network is comparable in size to the BCBS HMO, however is similar in cost to the NPOS network.

Regional HMO Network Overview

Humana Regional HMO Network Overview

  • Humana has three region specific HMO plans for Austin, Houston, and San Antonio.
  • Only companies located within the network footprint can enroll in the plans, and only have access to doctors and hospitals within the regional network, and do not provide statewide or nationwide coverage, except for emergency medical care.
  • The rates for the narrow network plans can be up to ~30% less than the full network, so these plans can worthwhile for companies on a budget.

Memorial Hermann

Memorial Hermann Health Solutions is a health insurance plan offered through Memorial Hermann Health System. Memorial Hermann plans are designed primarily to serve the Houston area, with access Memorial Hermann’s facilities and doctors only. Coverage on Memorial Hermann plans does not include statewide or nationwide coverage, except for emergency care.

Memorial Hermann offers both a PPO and HMO network, with access to its hospitals and physician network in the greater Houston metro.

PPO/EPO Network Overview

Memorial Hermann Network Overview

  • Select PPO: PPO network with access to most of the doctors and all of the hospitals within the Memorial Hermann Health System. The plan also provides for out-of-network coverage, so patients can get care outside of the Memorial Hermann network if necessary.
  • Select HMO: The Select HMO network has nearly the doctor network as the PPO plans, but restricts the number of hospitals that can be utilized in-network. The HMO plans is actually more expensive compared to the PPO plans, so does not represent a good value.

 


 Scott & White

The Scott & White Health Plan is a non-profit insurance carrier part of BaylorScott&White Health, formed through a combination with the Baylor Health Care System. The Scott & White Health Plan provides coverage primarily on the Baylor Health Care System in Dallas, but also includes some providers in other parts of Texas.

Network Overview

Scott & White Network Overview

  • POS: The network includes the Baylor Health Care System, as well as access to hospitals in other areas of Texas.

UnitedHealthcare

United Healthcare is the largest carrier in the country, and offers medical, dental, and vision coverage in Texas. United Healthcare PPO plans provide access to the nationwide United Healthcare network. United Healthcare offers a combination of PPO, EPO, and two tiers of HMO plans, and allows any number of plans to be offered.

United Healthcare PPO plans tend to be more expensive than other carriers given the expansive doctor network, but are typically among the lower cost options for companies looking for higher coverage tiers and a wide network.

Network Overview

United Healthcare Network Overview

  • Choice Plus PPO: Full PPO network with access to one of the largest network of doctors and hospitals in Texas and nationwide coverage through United Healthcare’s national network.
  • Choice EPO: Access to the same network of doctors and hospitals as Choice Plus, but plans do not include out of network coverage. Choice EPO plans are ~4% less expensive than the full PPO version.
  • Navigate HMO: Fairly large HMO network with 75% of the doctors and 98% of the hospitals of the PPO network. One of the larger HMO networks in Texas, though plans are only ~10% less expensive than the full PPO.
  • Charter HMO: Narrow HMO network with ~40% the doctors of the full PPO network, though nearly the same number of hospitals. Charter plans are about the same cost as plans on the Navigate network, so are not a substantially better value.

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Market Overview

The California small business health insurance market is one of the most competitive and complex insurance markets in the country. For a small business, there are many health insurance options to choose from – multiple carriers, tiered doctor networks, government exchange vs private market plans, etc. The large number of options in the California market can make looking for the right health insurance plan intimidating, but can also provide substantial savings opportunities by narrowing in on the most appropriate plan for specific needs.

California Health Insurance Carriers at a Glance

San Francisco Market Recommendations
Getting a small business health insurance plan in San Francisco can be a difficult decision given the multitude of options among carriers, networks, and plans. We’ve summarized the various options into a high level set of recommendations:
San Francisco Market Recommendations


California Health Insurance Carrier Overview

Aetna

Aetna is a national carrier offering medical, dental, and vision coverage. Aetna has a wide variety of HMO and PPO network tiers, ranging from very narrow doctor groups to broad, statewide networks. One key benefit of Aetna is the ability to offer any number of plans and mix & match multiple tiers of coverage and networks to fit your company’s specific needs.

Aetna is currently most competitive in the Southern California market, and has very competitive rates in each tier of HMO plans.

PPO Network Overview

  • Managed Choice: Full PPO network with access to very large California doctor network and nationwide coverage through Aetna’s national network.
  • Savings Plus: Narrow PPO network comprised of medical providers with lower negotiated costs to Aetna. Plans are ~13% less expensive than the full network. Only available in major metropolitan markets and to in-state employees.
  • PrimeCare: Ultra-narrow PPO network only available in the Inland Empire, San Bernardino, and Riverside counties with access to the PrimeCare physician group. Plans are ~33% less expensive than the full network.

Aetna PPO Networks

HMO Network Overview

  • Full HMO: Full HMO network with comparable network to Aetna’s full PPO, with 90% of doctors and hospitals. Plans are ~18% less expensive than the full PPO plans.
  • HMO Deductible: Narrow network HMO that is one of the best value networks on Aetna. Network is 7% smaller but is ~20% less expensive than the full HMO network.
  • AVN HMO: Smaller HMO network and ~24% less expensive than full HMO network.
  • Basic HMO: Smallest HMO network with only 25% of the network size of full HMO network. Plans are ~31% less expensive than the full HMO network.
  • PrimeCare: Ultra-narrow HMO network only available in the Inland Empire, San Bernardino, and Riverside counties with access to the PrimeCare physician group. Plans are ~33% less expensive than the full HMO network.

Aetna HMO Networks


 Anthem

Anthem Blue Cross is part of Wellpoint and a regional network of Blue Cross Blue Shield plans, offering medical, dental, and vision coverage. Anthem has full and narrow network tiers, and allows only one tier to be selected and any number of plans within the tier. PPO plans provide national coverage through the Blue Cross Blue Shield BlueCard network.

Anthem rates are competitive in most areas of California, especially for lower cost PPO plans on the narrow Select network.

PPO Network Overview

  • Statewide/Prudent Buyer PPO: Full PPO network with access to a very large California doctor network and nationwide coverage through the BlueCard network.
  • Select PPO: Narrow PPO network comprised of medical providers with lower negotiated costs to Anthem, with 33% small network than the full PPO. The narrow network is only ~6% less expensive than the full PPO, so the full network tends to be the better value. The narrow network also provides nationwide coverage through the BlueCard network.

Anthem PPO Networks

HMO Network Overview

  • Full HMO: Full HMO network with ~70% of doctors and hospitals of the full PPO network, and comparable to the Select PPO network. Plans are fairly expensive and typically similar in cost to comparable plans on the full PPO network.
  • Select HMO: Narrow network HMO with substantially smaller doctor network than the full HMO. Plans are ~23% less expensive than the full HMO network.
  • Priority Select HMO: Ultra-narrow HMO network, with substantially fewer participating doctors and hospitals. The network is strongest in Southern California and is most suited to companies in that region. Plans are ~27% less expensive than the full HMO network.

Anthem HMO Networks


Blue Shield CA

Blue Shield of California is a non-profit company offering medical, dental, and vision coverage. Blue Shield has a full and narrow network tiers of HMO and PPO plans, and allows only one tier to be selected and any number of plans within the tier. The narrow network plans are through the Covered California SHOP exchange. Blue Shield PPO plans provide national coverage through the Blue Cross Blue Shield BlueCard network.

Blue Shield plans tend to be more expensive than other carriers in most California markets. Blue Shield is most competitive in Southern California and for high coverage gold/platinum plans.

PPO Network Overview

  • Off-Exchange/Full PPO: Full PPO network with access to a very large California doctor network and nationwide coverage through the BlueCard network.
  • Mirror/SHOP/Select PPO: Narrow PPO network with 75% the network size of the full PPO network. Blue Shield only offers 1 bronze plan on the narrow network and is ~10% less expensive than a comparable bronze plan on the full network.

Blue Shield PPO Networks

HMO Network Overview

  • Access+ HMO: Full HMO network with ~60% of doctors of the full PPO network and similar number of hospitals. Plans are ~5% less expensive than the full PPO plans.
  • Mirror HMO: Network used for SHOP exchange plans, and utilizes a mix of the Local Access+ HMO network and the Access+ HMO network. Mirror plans are ~3% less expensive than the full network.
  • Local Access+ HMO: Narrow HMO network with ~45% the network size of the full HMO network. Plans are ~6% less expensive than the full network.
  • Trio ACO HMO: Limited network HMO plan available in 16 counties organized under an Accountable Care Organization model, or a network of medical providers that share responsibility for coordinating care. Plans are ~8% less expensive than full network.

Blue Shield HMO Networks


HealthNet

HealthNet offers medical, dental, and vision coverage in California, and also has a strong network in Oregon and Arizona. HealthNet PPO plans provide nationwide coverage through the First Health network. HealthNet offers full PPO network, a lower cost EPO network, and several tiers of HMO plans. One key benefit of HealthNet is the ability to offer any number of plans and mix & match multiple tiers of coverage and networks to fit your company’s specific needs. HealthNet also offers some plans through Covered California SHOP exchange.

HealthNet rates tend to be competitive in most California regions, and have very cost effective plans in Northern California and the San Francisco Bay Area.

PPO/EPO Network Overview

  • PPO: HealthNet offers only one PPO network tier. HealthNet’s network is slightly smaller than other California carriers, but is still very large and covers most California doctors and hospitals. PPO plans provide coverage nationwide through the First Health network.
  • PureCare EPO: Narrow network with 60% of doctors and hospitals in the full network and no access to out-of-network coverage. Plans are ~8% less expensive than the full PPO network.

HealthNet PPO Networks

HMO Network Overview

  • WholeCare HMO: Full HMO network with ~46% of doctors and ~58% hospitals of the full PPO network. WholeCare network is one of the smaller full HMO networks in comparison to other carriers, though is also typically less expensive. Plans are ~20% less expensive than full PPO plans.
  • SmartCare HMO: Narrow HMO with ~42% the network size of the full HMO network.  Plans are ~10% less expensive than the full HMO network.

HealthNet HMO Networks


 Kaiser

Kaiser Permanente is non-profit HMO carrier that offers medical and vision coverage in California. Kaiser is unique among California carriers in that it both provides health insurance coverage and medical services through its own network of doctors and hospitals. Kaiser allows any numbers of plans to be offered, and can also be offered in conjunction with plans from another carrier to give employees choice of Kaiser and non-Kaiser options.

Kaiser primarily offers HMO plans, and Kaiser insurance can only be used at Kaiser medical facilities. Out of state employees have the option of enrolling on a PPO plan with access to the Private Healthcare Systems network. Kaiser plans are also available through the Covered California SHOP exchange.

Kaiser serves most areas of California, but has limited networks in certain parts of California given the size of its doctor network. Kaiser plans tend to be the most cost effective plans in most parts of California.

HMO Network Overview

  • Kaiser HMO: Kaiser operates a single HMO network in California. Plans directly purchased from Kaiser and the plans from the SHOP exchange provide access to the same network of doctors and hospitals.

Kaiser HMO Network


UnitedHealthcare

United Healthcare is the largest carrier in the country, and offers medical, dental, and vision coverage in California. United Healthcare PPO plans provide access to the nationwide United Healthcare network. United Healthcare offers two tiers of PPO networks and several tiers of HMO plans, and allows any number of plans to be offered within two portfolio of plans.

United Healthcare PPO plans tend to be more expensive than other carriers given the expansive doctor network, but HMO plans tend to be among the lowest cost options in many parts of California. United Healthcare HMO plans are most cost effective in Southern California.

PPO Network Overview

  • Select Plus PPO: Full PPO network with access to the largest network of doctors and hospitals in California and nationwide coverage through United Healthcare’s national network.
  • Core PPO: Narrow PPO network with ~45% the size of the full PPO network. Plans are ~11% less expensive than the full network.

UnitedHealthcare PPO Networks

HMO Network Overview

  • Signature HMO: Full HMO network with ~52% of doctors and ~65% of hospitals of the full PPO network. Plans are ~10% less expensive than the full PPO plans.
  • Advantage HMO: Narrow HMO network with 60% of the doctors of the full HMO network. Plans are ~14% less expensive than the full HMO network.
  • Alliance HMO: Very narrow HMO network primarily available in Southern California and with 40% of the doctors of the full HMO network. Plans are ~26% less expensive than the full HMO network.
  • Focus HMO: Limited network HMO available in select California counties. Plan features local providers and community hospitals that provide lower costs, with 25% of the network size of the full HMO network. Plans are ~28% less expensive than the full HMO network.

UnitedHealthcare HMO Networks

 

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Small Business Health Insurance 101

by Xiao Sun on August 17, 2016

Introduction

Getting health insurance for your company is an important decision for your company, both for yourself as a business owner and for your employees who will be covering themselves and their families. Making sure that you offer the most appropriate health insurance plan will ensure that your employees are properly covered without overspending on insurance premiums.

Finding the appropriate health insurance plan is easier than you think. This guide will provide you with the tools and knowledge you need to understand health insurance and how to select the appropriate plan for your business.


Health Insurance 101: How does health insurance work?

When you buy a health insurance plan, you are paying an insurance carrier a monthly fee (the monthly premium) to provide protection when medical bills come up. Having a health insurance plan protects you in 3 ways:

  1. Access to Quality Medical Care – Health insurance plans provide you with access to a network of doctors, hospitals, pharmacies, and other medical providers who will accept your insurance and provide treatment.
  2. Reduced Rates on Medical Procedures – Health insurance negotiate discounted rates with medical providers for medical services, and enables you to access services at a lower rate than if you did not have health insurance.
  3. Protection Against Catastrophic Medical Bills – In a worst case scenario, health insurance plans will cap the amount of medical bills that you personally are responsible for, and pay for 100% of bills that exceed the cap. This protects you from a potential medical bankruptcy when a major medical event occurs.

When comparing health insurance plans, the differences in plans will be mostly around these three dimensions. A more expensive health insurance plan will generally provide:

  • Access to a large network of doctors, hospitals, and other medical providers
  • Larger discounts on medical procedures
  • Lower cap on the amount on medical bills you are responsible for before health insurance pays for 100% of costs

When purchasing a health insurance plan, you will be deciding on whether it makes sense to pay a higher monthly premium in exchange for a larger doctor or lower future medical bills.


What does health insurance cover?

All health insurance plans are legally required to cover any legitimate medical condition. This includes situations as minor as a doctor visit when sick to major events like pregnancy or surgery. The Affordable Care Act also requires all health insurance plan to provide a standard set of benefits called minimum essential coverage.

  • Affordability – the plan must cover at least 60% of out of pocket expenses covered medical services
  • Can’t be denied for pre-existing conditions – you cannot be denied coverage based on your past health history
  • Ten Essential Benefits – medical plans must include coverage 10 core benefits (see below)
  • No lifetime dollar limits on coverage – insurance carriers cannot place a lifetime cap on medical bills

Essential Health Benefits

By law, all health insurance plans have to cover the 10 essential health benefits outlined in the Affordable Care Act.

  1. Preventive Care – Your annual physical, ob-gyn visits, immunizations, any screenings required to keep you healthy, and care for managing a chronic disease such as diabetes and asthma
  2. Ambulatory Patient Services – Care received outside of the hospital, such as going to a doctor’s office, emergency room, outpatient surgery centers, and home health services
  3. Emergency Services – Trips to the emergency room and ambulance rides
  4. Hospitalization – Care you receive in the hospital, including doctors, labs & tests, medication, and room & board. This covers anything that requires inpatient care, such as surgery, labor & delivery, transplants, etc.
  5. Maternity Care – Care received before and after your baby is born
  6. Prescription Drugs – Any medications prescribed by a doctor to treat an illness or condition
  7. Lab Tests – Any testing that helps a doctor diagnose illnesses or injuries or monitor the effectiveness of treatments.
  8. Mental Health and Substance Abuse Services – Covers both inpatient and outpatient evaluation and treatment of any mental health disorders or substance abuse disorders.
  9. Rehab Services – Care and equipment to help you recover from injuries, disabilities, or chronic conditions. This includes physical and occupational therapy, speech-language pathology, psychiatric rehabilitation, and more.
  10. Pediatric Services – Covers dental care and vision care for children under age 19. This includes at least 2 dental cleanings, 1 eye exam, and 1 set of correct lenses.

What does health insurance NOT cover?

While the list of excluded procedures can vary by health insurance companies, there are generally 3 types of services that insurance policies will not cover:

  • Cosmetic Surgery
  • Weight Loss Programs
  • Long Term Care

In addition, there are some procedures that typically are not covered, but occasionally will have limited coverage:

  • Infertility Treatments (limited)
  • Bariatric Surgery (limited)
  • Hearing Aids (limited)

Advantages of Small Business Health Insurance Coverage

As a small business owner, you have the option of getting coverage either through your business or as an individual through private and government exchanges. The health insurance plans available to small businesses have several advantages over those available to individuals, both in the quality of plans and costs of the plans.

  1. Tax Deductibility of Premiums – Health insurance premiums on small business plans are tax deductible for both the company and employees, and reduces the cost of coverage by 25-40%.
  2. Small Business Tax Credit – Small business with under 25 employees and payroll costs of under $50K per employee potentially qualify for tax credits of up to 50%.
  3. Larger selection of carriers & plans – There are substantially more plans and carriers available in the small business market (typically 2-3 times as many plans). This provides small businesses with a wider variety of plans in terms of costs and coverage levels.
  4. Larger doctor networks – most small business plans have larger networks of participation doctors and hospitals compared to individuals plans

Eligibility for Small Business Health Insurance Coverage

Because of the advantages that a small business plan provides over individual coverage, insurance carriers require that small businesses meet a several requirements to verify their eligibility for small business coverage. Most carriers look at 3 things to determine whether a small business is eligible for small business plans:

  1. Be registered as a business in your home state
  2. At least 2 employees working full-time at the company, with one W2 besides the owner
  3. Payroll history records for salaried employees & tax/ownership documents for owners

In general, most small businesses will easily meet the requirements to be eligible for health insurance coverage.

Eligible Employees for Small Business Health Insurance Coverage

Employees also have to meet a few eligibility requirements in order for them to be covered under a small business health insurance plan. The key eligibility criteria are:

  • Works full-time hours. Full-time hours is defined as working 30 hours per week or more. In some states, you are allowed to offer coverage to part-time workers who work as few as 20 hours per week.
  • Employed as a W2 employee or owner. In most states, 1099 contractors are not eligible to be covered under the company health insurance plan. There are some exceptions where 1099 contractors are eligible for company coverage if they work full-time hours.
  • Satisfied the company probationary period. Companies can choose to require up to a 60 day waiting period before new employees are eligible for insurance coverage.

Selecting Health Insurance for Your Business and Your Employees

When selecting a health insurance plan for your business and employees, there are 3 questions to ask to better understand what are the most appropriate plans to offer. These questions will help companies to narrow down the hundreds of available policies in the market to the best value plans for your business’ needs.

  1. What level of coverage do my employees need based on their medical profile?
  2. What type of doctor network does my employees want?
  3. How much am I looking to spend on health insurance benefits?

In general, most small businesses will easily meet the requirements to be eligible for health insurance coverage.

Question 1: What level of coverage do my employees need?

In general, there are 3 broad tiers of coverage available to a small businesses – Bronze, Silver, and Gold/Platinum. Each of these tiers are designed for a specific profile medical needs.

Bronze plans – low cost, high deductible plans for healthy employees

Bronze plans are best suited for healthy employees who have no recurring medical needs, typically only go to their annual check-up, and wants to be protected primarily against major medical events. The reason why the bronze plan works well for this type of person is because:

  • Lowest premium cost among all plans, so you aren’t paying extra monthly premiums for coverage the employee won’t utilize
  • Provides 100% free preventative care, such as annual physicals, ob-gyn visits, etc
  • Caps annual medical bills at $6600 at most if the employee experiences a major medical emergency (e.g. hospitalization, surgery, etc)
  • Often are eligible for health savings accounts (HSA), which allow employees to capture tax savings on medical bills

Silver plans – medium cost plans designed for recurring doctor visits and prescription users

Silver plans are designed for employees who have recurring doctor visits or prescription drug expenses, such as employees with diabetes, asthma, or have recurring doctor/therapy visits. Silver plans offers a low copay on doctor visits and brand name prescription drugs, and will save employees more on their out of pocket medical bills than the higher premium cost of the silver plans. However, the cost of major medical (such as hospitalization) are the same on silver and bronze plans.

  • Doctor visits will cost ~$30-50 out of pocket for each visits
  • Prescription drugs will cost ~$35-50 for brand name prescription re-fills
  • Provides 100% free preventative care, such as annual physicals, ob-gyn visits, etc
  • Caps annual medical bills at $6600 at most if the employee experiences a major medical emergency (e.g. hospitalization, surgery, etc)

Gold/Platinum plans – high cost plans with designed to cover major medical events

Gold and platinum plans are the highest cost plans available, and are best suited for employees who anticipate major medical expenses in the next 12 months, such as having a baby, surgery, or hospitalization. Given the high cost of these plans, it would only make sense to offer these plan if employees can save a substantial amount on medical bills.

  • Highest premium cost among all plans, so you are paying for lower bills
  • Lowest copays on doctor visits and prescriptions
  • Caps annual medical bills at around $2000-4000 for major medical emergency (e.g. hospitalization, surgery, etc)

One last thing to keep in mind is that companies are typically allowed to offer multiple plans to employees. So you don’t have to decide on a single plan to fit all of your employees’ health needs, but instead offer plans in each tier and allow employees to select the appropriate coverage level for their own situation.

Question 2: What type of doctor network does my employees want?

The type of doctor network available through your insurance plan has a pretty substantial impact on both your monthly premium costs and the availability of doctors and medical providers who will accept the insurance coverage. In general, insurance plans will the largest doctor networks will cost the most in premiums. The primary types of doctor networks are explained below.

Health Insurance Network Overview

Question 3: How much should I spend on health insurance benefits?

You should contribute enough to the cost of the health insurance plans to keep the cost of coverage affordable for employees and provide the appropriate level of coverage for each employee. Companies typically utilize one the following 3 strategies in deciding how much to contribute to the cost of the plans.

Fixed percentage contribution to plan costs – the company will pay for a fixed percentage (e.g. 60%) of each plan’s costs, and the employee pays for the remaining premium.

Paying for base plan + employee upgrade option – the company will pay for the all or most of a bronze plan’s cost, and then allow employees to pay the difference to upgrade to a higher cost silver or gold/platinum plan

Paying for a higher tier plan + employee downgrade option – the company will pay for all or most of a higher tier plan like silver and gold, and allow employees to downgrade to a lower cost plan if they don’t need the higher end coverage. The company then contributes the premium savings to an employee healthcare savings account like a Health Savings Account (HSA) or a Flexible Spending Account (FSA)


Starting a Plan and Getting Employees Enrolled

Once you’ve selected a health insurance plan or plans, SimplyInsured provides an easy, online process for getting a plan started. Insurance carriers allow small businesses to begin coverage on the 1st of every month, so there is no need to wait for an open enrollment period to get coverage. Insurance carriers just require applications to be submitted before the 1st of the month to get coverage.

Small businesses are guaranteed to be approved for coverage, and insurance carriers cannot decline coverage to the company or any individual employees for any pre-existing medical conditions.

The enrollment process consists of 4 steps, all completed online:

  1. Filling out a company application
  2. Filling out an enrollment form for each employee
  3. Uploading proof of payroll
  4. Making the 1st month premium payment

Additional Resources

Getting health insurance for your company is an important decision. While this guide provides a helpful overview to business owners looking at health insurance for the first time, we highly recommend the following resources to get additional information in helping you select the best possible health insurance benefits for your company and employees:

Plan Details & Rate Information: Available instantly online at www.SimplyInsured.com

Getting Further Help: Get free help and advice by speaking with a SimplyInsured benefits expert at 888.584.9220, emailing us at hello@simplyinsured.com, or chatting with us on our website.

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