Making Group Health Insurance Simple

By combining the localized knowledge of a neighborhood agent with the broad experience and comprehensive understanding of a national health insurance agency, we are able to offer our customers unparalleled service in the following areas:

Paying the highest premium does not equate to the best coverage, nor does choosing the lowest premium equate to getting the most for your dollar. Unfortunately, choosing the wrong coverage becomes painfully obvious when you need it most. Looking at hundreds of plans and benefit options can be quite daunting and if you are among the majority of businesses without an in-house risk manager, we can help save you money and give you a choice of plans to meet your needs.

Typically, a deductible is the amount of money you must pay each year before your health insurance plan starts to pay for covered medical expenses. For example, if you have a health plan with a $1,000 deductible, and have a surgery bill for $30,000, you would be responsible for paying the first $1,000. After this $1,000 deductible is met, the insurance company will pay a percentage of the bill, this sharing of expenses is called the coinsurance.

Coinsurance is a cost-sharing requirement where you are responsible for paying a certain percentage and the insurance company will pay the remaining percentage of the covered medical expenses after your deductible is met. For a health insurance plan with 20% coinsurance, once the deductible is met, the insurance company will pay 80% of the covered expenses while you pay the remaining 20% until your out-of-pocket limit is reached for the year.

A co-payment or copay is a specific flat fee you pay for each medical service, such as $30 for an office visit, after which the insurance company often pays the remainder of the covered medical charges. Let’s say you are not feeling well and went to see your doctor who charges $200 for the office visit. If your insurance plan has an office visit copay of $30, then you will only be responsible for the $30 copay and the insurance company will cover the remaining $170. It is important to understand that copays typically only apply when receiving in network care.

This is the amount of money one would pay out of their own pocket towards their medical expenses in any given year. This could be determined on either a calendar year, or a policy year, but varies based on your contract with the insurance carrier. Under the ACA, an network out of pocket maximum must include the deductible, any copay amounts, coinsurance, or per day deductibles Also, when the term annual out-of-pocket maximum is used, that is referring to how much the insured would have to pay for the whole year out of their pocket, excluding premiums. Out of pocket maximums have an inflationary adjustment each year, if the plan of benefits is ACA compliant. It does not mean the out of pocket maximum must be at that level, just that it cannot exceed that amount for a plan subject to the ACA laws.

The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) requires employers, with 20 or more employees, that offer certain group plans to extend the opportunity to continue temporarily their group health care coverage under their employer’s plan. Those eligible for COBRA continuation are those individuals that are enrolled in coverage(s) and it ceases due to termination, layoff, or other change in employment status (referred to as “qualifying events”).

The qualifying event requirement is satisfied if the event is the death of a covered employee; the termination (other than by reason of the employee’s gross misconduct), or a reduction of hours, of a covered employee’s employment; the divorce or legal separation of a covered employee from the employee’s spouse; a spouse and/or a child if a covered employee becomes entitled to Medicare benefits under Title XVIII of the Social Security Act; or a dependent child ceasing to be eligible under the generally applicable requirements of the plan and a loss of coverage occurs.