HealthInsuranceFAQs Businesses under common ownership can be treated as a single employer. For the ACA, all employees of a commonly owned group are combined to test the 50 full-time-equivalent threshold for ALE status, though each company stays its own ALE member for penalties and reporting.
Union employees usually get coverage through a multiemployer, or Taft-Hartley, plan jointly run by unions and employers. Employers contribute to a trust fund at a rate set by the collective bargaining agreement, and eligibility is based on hours worked.
A Broker of Record (BOR) letter is a signed document naming the broker authorized to service your insurance with a carrier. It moves servicing and commissions to the new broker without changing your plan, carrier, premium, or benefits.
No. A properly structured group medical stop-loss captive is not a MEWA. Each participating employer keeps its own single-employer self-funded health plan, and the captive insures the employers through stop-loss, not the employees, so no single plan covers the workers of two or more unrelated employers. An Association Health Plan, by contrast, is a type of MEWA.
Eight jurisdictions ban tobacco rating entirely: California, Connecticut, the District of Columbia, Massachusetts, New Jersey, New York, Rhode Island, and Vermont. Elsewhere insurers may add up to a 1.5x surcharge.
Generally no. HMOs cover only in-network providers except for emergencies and pre-authorized referrals; routine out-of-network care is the member’s full responsibility.
In an HMO you pick a primary care physician who coordinates your care and must issue a referral before the plan will cover a visit to a specialist.
The ACA caps the oldest adult’s premium at three times the youngest adult’s for the same plan, so coverage is relatively cheaper for older workers and pricier for younger ones than raw cost would suggest.
An HMO is a managed-care plan that keeps costs low by requiring you to use in-network providers and choose a primary care physician who coordinates your care and refers you to specialists.
A POS plan is a hybrid: in network it works like an HMO (with a PCP and referrals), but it also covers out-of-network care like a PPO, at higher cost.
Pros: lower premiums, low predictable copays, and coordinated care. Cons: you must stay in network, need referrals for specialists, and have no out-of-network coverage except emergencies.
Pros: lower premiums than a PPO and usually no referrals. Cons: no out-of-network coverage except emergencies, so you must stay in network.
The network determines which doctors, hospitals, and pharmacies are covered at in-network rates. Narrow networks cost less but limit choice; broad PPO networks cost more but offer wider access and out-of-network benefits.
EPOs generally don’t cover out-of-network care except for emergencies, so non-emergency services outside the network are the member’s full responsibility.
Premium tax credits are ACA subsidies that lower the monthly premium for marketplace coverage. They’re based on income and are available to people who don’t have an affordable, minimum-value offer of employer or government coverage.
It depends on the leave. Under FMLA (employers with 50+ employees), coverage must continue on the same terms. For non-FMLA leave, it’s governed by the employer’s written policy and the carrier’s eligibility rules.
Compare the annual maximum, the coinsurance for preventive/basic/major services, any waiting periods, orthodontia coverage, the network, and how out-of-network claims are paid (MAC vs. R&C).
Look at the exam copay, the frame and contact-lens allowances, lens and lens-upgrade coverage, how often you can get new lenses or frames, and the provider network.
Any size employer can offer an ICHRA. Employees (and reimbursed dependents) must have qualifying individual coverage or Medicare, and the employer can’t offer the same class of employees both an ICHRA and a traditional group plan.
A QSEHRA is limited to employers with fewer than 50 full-time-equivalent employees that do NOT offer a group health plan, and it must be offered to all full-time employees on the same terms.
Yes. QSEHRA funds can reimburse individual-market premiums and other qualified medical expenses tax-free, as long as the employee has minimum essential coverage and substantiates the expense.
It depends on the HRA type. A traditional/integrated HRA covers employees enrolled in the group plan; ICHRAs can be offered to all employees or defined classes; and QSEHRAs must generally be offered to all full-time employees on the same terms.
No. ACA-compliant plans can’t deny coverage, charge more, or exclude benefits because of a pre-existing condition, in either the individual or small-group market.
They cap your monthly premium at a set percentage of household income. You can take the credit in advance to reduce each month’s bill or claim it on your tax return.
Because EHBs must be covered and the ACA bans health-based pricing and exclusions, people with pre-existing conditions get the same comprehensive coverage at the same rates as everyone else.