by admin | Mar 26, 2024 | Health Insurance
Everyone needs health insurance but many people don’t fully understand it. One important concept to understand is your deductible. A deductible is the amount of money that must be paid for covered services before the health insurance company begins paying for expenses.
For an individual plan, the deductible is straightforward. But family plans are a bit more complex.
Embedded vs. Non-Embedded Deductibles
Family health insurance plans can have one of two types of deductibles:
- Embedded Deductible (includes an individual and family deductible)
- Non-Embedded (Aggregate) Deductible (includes only a family deductible)
Understanding the specific type in your plan and how it operates can help you prepare for out-of-pocket healthcare costs.
Embedded Deductible: Each family member has an individual deductible in addition to the overall family deductible. Meaning if an individual in the family reaches his or her deductible before the family deductible is reached, his or her services will be paid by the insurance company. However, these will be paid solely for that family member. Once multiple family members’ medical expenses add up and surpass the family deductible, the insurer would begin to pay covered medical expenses for all members of the family. This applies even if a member did not meet their individual deductible.
Typically, embedded deductibles are exactly half of the entire family deductible. For example, the family could have a deductible of $10,000 and individual deductibles of $5,000 for every covered member of the family.
Embedded Deductible Example
Ashley and Robert have a family health plan that covers them and their two children. Each family member has a $4,000 individual deductible, and they have a $8,000 family deductible. Ashley meets her $4,000 deductible after giving birth to their son in March who was in the hospital for an extra week. Their daughter, Emma, has surgery in May and meets her $4,000 individual deductible in April, which means the family deductible of $8,000 has now been met. Later in the year, when Robert needs shoulder surgery, he only owes a co-payment because the family deductive was already met.
Non-Embedded Deductible: There is no individual deductible. So, the overall family deductible must be reached, either by an individual or by the family, for the insurance company to pay for services. The non-embedded deductible is most common in high insurance health plans.
Non-Embedded (Aggregate) Deductible Example
Marc and his family have a health plan with a non-embedded deductible. The family deductible is $10,000. Son Ben dislocated his shoulder and medical care cost $700. Daughter Victoria had acute appendicitis that required surgery costing $3,300. Marc had an accident while working on his farm which resulted in a hospital stay costing over $6,000. The combined out-of-pocket expenses from Marc, Ben, and Victoria’s medical treatments met the family deductible. Any further medical care for anyone in the family will be covered by the insurance company according to the plan benefits.
No matter what type of deductible your health plan uses, keep in mind that you must personally cover that amount before your insurance kicks in. When you understand how deductibles work and how it impacts your family’s household budget, you can make wise, informed choices to set aside funds for your family’s medical expenses.
by admin | Aug 7, 2018 | Group Benefit Plans, Hot Topics
Q.For a high deductible health plan (HDHP) to qualify for health savings account (HSA) eligibility, what is the minimum amount that an embedded individual deductible can be?
A.For 2018, the embedded individual deductible must be at least $2,700. For an HDHP to qualify for HSA eligibility, an individual with family coverage would need to satisfy the required minimum annual deductible for family HDHP coverage (which is at least $2,700 for 2018) before any amounts are paid from the HDHP.
by admin | Jul 3, 2018 | ACA, Benefit Management, Compliance, Group Benefit Plans
On June 19, 2018, the U.S. Department of Labor released its Final Rule regarding Association Health Plans (AHPs). AHPs are not new, but they have not been widely available in the past and, in some cases, they have not been successful. The Final Rule is designed to make AHPs available to a greater number of small businesses as an alternative to standard ACA-compliant small group insurance policies.
This article answers common questions about AHPs under the current rules (which groups can continue to use) and the new rules.
Is group medical insurance the same for small and large employers?
Yes and no. Federal law imposes certain basic requirements on all group medical plans, regardless of the employer’s size. For instance, plans cannot exclude pre-existing conditions nor impose annual or lifetime dollar limits on basic benefits. If the plan is insured, it also is subject to the insurance laws of the state in which the policy is issued.
Small group policies, which are sold to employers with up to 50 or 100 employees, depending on the state, are subject to additional requirements. These policies must cover 10 categories of essential health benefits (EHBs), including hospitalization, maternity care, mental health and substance abuse treatment, and prescription drugs. (Some states allow certain grandfathered or grandmothered policy exceptions.) For most small employers, their options for group medical insurance are limited to small group policies that comply with the full scope of ACA requirements. On the other hand, the policies are subject to guaranteed issue and adjusted community rating rules, so carriers cannot refuse to insure a small employer nor use any past claims experience in setting rates.
Large group policies, which can only be sold to groups with at least 50 or 100 employees, depending on the state, are not required to cover all EHBs. Carriers have more flexibility in designing coverage options and developing premium rates in the large group market. This means larger employers have more options to choose from and may be able to purchase coverage at a lower cost than would apply to a small group policy. Note, however, that there is no guaranteed issue protection, so carriers can accept or reject each employer’s application or use the employer’s past claims experience in setting rates.
Lastly, self-funded plans are subject to the ACA and other federal laws, but generally are exempt from state laws. They typically are not feasible for small employers, however, due to the financial risk of uninsured programs.
What is an Association Health Plan (AHP)?
Group insurance covers the employees of an employer (or an employee organization such as a labor union). An AHP, as the name implies, covers the members of an association. Unrelated employers can obtain coverage for their employees through an AHP provided the employers form a bona fide association. Traditionally, this has meant that the employers had to have a “commonality of interest” and their primary interest had to be something other than an interest in providing benefits. For this reason, AHPs generally have been limited to associations formed by employers in the same trade, industry, or profession.
The Final Rule makes AHPs available to a wider range of businesses by expanding the meaning of “commonality of interest.” Once the Final Rule takes effect, an association may be formed by employers that are:
- In the same trade, industry, or profession, regardless of location; or
- In the same principal place of business; i.e., in the same state or in the same multi-state metropolitan area.
Under the new rules, the employer’s primary interest in associating may be benefits coverage, although they still will need to have at least one other substantial business purpose other than benefits. This is a key difference from the current rules.
When does the new Final Rule take effect?
The Final Rule expanding the definition of an association for purposes of an AHP will take effect on staggered dates:
- For fully insured AHPs: September 1, 2018
- For self-funded AHPs:
- If in existence on or before June 19, 2018: January 1, 2019
- If created after June 19, 2018: April 1, 2019
As noted, the new rules do not replace existing rules. Employers and associations may continue to follow the existing rules (which generally limit AHPs to employers in the same trade, industry, or profession). The new rules merely expand the opportunities for AHPs, such as making them available to employers in the same state or metropolitan area even if they are in different industries.
Are AHPs limited to employers with employees? What about sole proprietors?
Currently, sole proprietors, such as mom-and-pop shops without any W-2 employees, purchase medical insurance in the individual market. Individual policies often cost more than group policies or AHPs. The new rules will expand the availability of AHPs to include sole proprietors who work a minimum number of hours (so-called working owners).
What about state laws? Will AHPs be available nationwide?
Insurance products, including AHPs, are regulated by state law. Under both the existing and new rules, AHPs are multiple employer welfare arrangements (MEWAs). State laws on MEWAs are quite complicated. In some states, MEWAs are prohibited. In others, insured MEWAs are allowed but self-funded plans are prohibited. The laws vary from state to state, so different carriers will make different decisions about whether they want to design and market AHPs in various jurisdictions around the country.
A number of states are very concerned about AHPs and may prohibit them in their states or impose strict requirements to ensure they will provide reliable and effective coverage. Other states will view AHPs as cost-effective alternatives to ACA-compliant policies for small employers and look to encourage their expansion.
What’s next?
There is no clear answer to what’s next. Over the coming months, carriers across the country likely will review the reasons they have or have not offered AHPs in the past, and whether they want to consider new approaches in the future. Along with economic and market issues to consider, carriers also must consider the state insurance laws in different jurisdictions. At the same time, many state legislatures and insurance commissioners will be reviewing their existing rules and whether they want to promote or expand the availability of AHPs in their area.
Oh … and the lawsuits. Yes, that also is what’s next. As of this writing, attorneys general in different states are planning to join together in challenging the federal government’s Final Rule on AHPs. Their stated concern is that effective regulation is required to ensure that plans provide adequate coverage.
ThinkHR will continue to monitor developments in this area.
by Kathleen A. Berger
Originally posted on thinkhr.com
by admin | May 22, 2018 | Employee Benefits, Human Resources, Workplace
While there’s plenty of talk about work/life balance, many employees want to feel human while at work, too. Being able to bring their whole selves, according to “3 Ways to Create a More Human Workplace,” from Workforce, is an essential piece of a welcoming, inclusive workplace environment.
Putting employees first as a defined company value means helping team members feel connected, valued, and like their work is having an impact. Supporting employee well-being improves everything from engagement to loyalty.
Small changes, like building breaks into the day, as well as larger wellness initiatives are some of the best investments in resources, time, and money a company can make in both its people and its bottom line.
As companies think about the customer experience more and more, it’s also a smart idea to think about the employee experience. One-off opportunities or programs to check the wellness box, for example, are less powerful than a holistic experience. Employers should consider whether their employees would enthusiastically recommend a friend apply for a job, and craft a workplace experience that makes that a reality.
That whole person, whole experience approach also applies when building a diverse and inclusive workplace. Recruitment and hiring are often the talked about steps, but it’s as critical to think about the employee experience after the job starts.
Beyond the overall workplace environment, employers can strive to make the workplace a more inclusive space, according to “6 Steps for Building an Inclusive Workplace,” from the Society for Human Resource Management. After successfully hiring a diverse workforce, employers need to support and retain talented individuals.
It starts at the top, with education for leadership on topics ranging from inclusion to unconscious bias to training on how to best accommodate an employee with a disability. Creating a dedicated council or committee to act as intermediaries between executives and employees, clear employee goal setting, and regular reviews are just a few next steps.
Giving dedicated time, space, and opportunities (both organic and organized) to share about individuals’ background and opinions can help employees feel connected and seen in their workplace. Ensuring diversity is supported in both action and physical space—whether a meditation or prayer room or a space for nursing mothers—is essential. Likewise, celebrating culture and identity can also be a powerful connective tool.
Even the way day-to-day work happens showcases how inclusive a company is. Employers can learn what employees need and want by making time to listen part of the day. Rotating meeting times and checking on technology needs for remote workers are small choices a company can make to show it cares about its individuals.
And, ultimately, keeping inclusivity top-of-mind and visible for everyone helps foster a culture of expectations. Having leadership and management communicate goals and measure progress for an inclusive workplace ensures everyone knows inclusion is valued.
By Bill Olson, VP, Marketing & Communications at United Benefit Advisors
Originally posted on www.ubabenefits.com
by admin | May 16, 2018 | Benefit Management, Group Benefit Plans, Human Resources
Curious about when you should notify a participant about a change to their health care plan?
The answer is that it depends!
Notification must happen within one of three time frames: 60 days prior to the change, no later than 60 days after the change, or within 210 days after the end of the plan year.
For modifications to the summary plan description (SPD) that constitute a material reduction in covered services or benefits, notice is required within 60 days prior to or after the adoption of the material reduction in group health plan services or benefits. (For example, a decrease in employer contribution is a material reduction in covered services or benefits. So is a material modification in any plan terms affecting the content of the most recent summary of benefits and coverage (SBC).) While the rule here is flexible, the definite best practice is to give advance notice. For collective practical purposes, employees should be told prior to the first increased withholding.
However, if the change is part of open enrollment, and communicated during open enrollment, this is considered acceptable notice regardless of whether the SBC, SPD, or both are changing. Essentially, open enrollment is a safe harbor for all 60-day prior/60-day post notice requirements.
Finally, changes that do not affect the SBC and are not a material reduction in benefits must be communicated and summarized within 210 days after the end of the plan year.
By Danielle Capilla
Originally published by www.UBABenefits.com
