Selecting medical insurance options and providers


The legal landscape of employer-sponsored health coverage has been rapidly evolving. Selecting medical insurance plan coverage options and insurance providers generally is a daunting task. Below are three vital aspects to contemplate when reviewing your options for the upcoming plan yr.

Funding. The 2 basic varieties of employer-sponsored health plans are self-funded and fully insured. Small businesses generally select fully insured plans by which the employer pays a non-refundable premium
to a medical insurance provider that assumes the danger of paying health claims. Larger businesses, typically with 200 or more employees, generally decide to self-fund. In a self-funded plan, the employer assumes the danger of paying worker health claims and pays an administration fee to a medical insurance company to manage claims. Self-funded employers often purchase a stop-loss insurance policy to insure against large health claims above a set dollar amount.

By specializing in the funding, sort of plan and provider
network, and premiums and cost-sharing, businesses can hone in on plans that may fit their needs and budgets.

Employers with self-funded plans have more flexibility to design health coverage details, but in addition experience greater compliance risk and administrative complexity. Fully insured plans often limit or exclude coverage for certain high-cost treatments for conditions corresponding to autism and gender dysphoria. Nevertheless, they’re required to comply with state insurance requirements corresponding to mandatory autism treatments in children as much as a certain age. While self-funded employer plans usually are not subject to state insurance mandates and due to this fact have more freedom to exclude high-cost treatments, these coverage design selections still carry compliance risks because they’re subject to federal laws just like the Mental Health Parity and Addiction Equity Act of 2008. The Department of Labor’s Worker Advantages Security Administration has been increasing its investigation efforts with respect to mental health parity this yr and employers are ultimately responsible for any compliance failures.

Kind of plan and provider network. There are lots of basic varieties of plan design that employers can pick from. Most medical insurance plans utilize provider network agreements with the health insurer or administrator. The common varieties of provider network arrangements are:

  • Health Maintenance Organization (HMO): An HMO provides care inside the provider network. Participants must select a primary care provider and specialist visits often require a referral. Out-of-network care is usually limited to emergency services.
  • Preferred Provider Organization (PPO): A PPO offers a big provider network for the next monthly premium. Covered employees can select in-network or out-of-network care. Specialist referrals are generally not required.
  • Exclusive Provider Organization (EPO): With an EPO, employees have access to a smaller, local provider network. Premiums are generally lower than PPO premiums, and specialist referrals may or is probably not required.
  • Point of Service (POS) Plans: POS plans are a hybrid between HMO and PPO plans. Out-of-network coverage is restricted and sometimes comes with higher patient cost-sharing. Specialist visits require a primary care referral.

Less common plan design offerings which are marketed with an emphasis on cost savings to employers can include increased compliance risks. Two such designs are reference- or value-based plans and “skinny” plans designed to cover Inexpensive Care Act (ACA) essential health advantages.

Reference-based health plans don’t utilize provider networks. They reimburse claims as much as a certain allowed amount, which is usually a percentage of the Medicare reimbursement amount. Some employers have a standard network-based plan and limit the reference-based model to out-of-network emergency and laboratory claims. While these plans may lower employer costs without reducing the variety of covered services, they carry the next degree of administrative risk as a result of uncertainties regarding compliance with newer laws corresponding to the No Surprises Act, which prohibits balance billing in certain situations.

“Skinny” health plans are designed to cover emergency and preventive care as required to fulfill the “minimum essential coverage” requirement of the ACA, but often exclude most or all inpatient and outpatient care. Although these plans could also be marketed as being ACA-compliant, they often fail to offer ACA “minimum value” by covering such a small collection of medical services. Employers with 50 or more full-time employees or full-time equivalent employees mustn’t select skinny health plans as a result of the danger of Employer Shared Responsibility Payment penalty assessments.

Premiums and cost-sharing. One of the crucial vital considerations for all businesses in selecting health coverage is the associated fee to each the staff and the employer. Costs to employees are spread between premiums and cost-sharing features corresponding to copayments, co-insurance, deductibles and out-of-pocket maximums. Employers must rigorously compare all of those cost elements for every coverage tier (bronze, silver, etc.) and level (employee-only, family, etc.) when reviewing options to search out a plan that strikes a balance between inexpensive for the employer and competitive inside the business’s labor market.

Higher deductible plans typically have lower premiums and vice versa. Deductibles for family coverage may be embedded, by which a person deductible applies to every member of the family along with the general family deductible. With an aggregate or non-embedded deductible, only the family deductible amount applies before the plan begins paying claims. Deductibles for medical and prescription advantages could also be combined or separate. Copayment designs also must be given close attention, especially with respect to prescription drug advantages. Copay maximizer, accumulator or optimizer programs hunt down and apply drug manufacturer coupons for high-cost specialty drugs to a participant’s cost-sharing amounts. These programs can present compliance issues with federal guidance on ACA essential health advantages, high deductible health plans and Health Savings Accounts (HSAs), and mental health parity.

Choosing or renewing employer health coverage may be overwhelming, with many options and aspects to contemplate. Nevertheless, by specializing in the funding, sort of plan and provider network, and premiums and cost-sharing, businesses can hone in on plans that may fit their needs and budgets. Moreover, insurance brokers and other third-party advisors can assist employers with selecting a health plan that meets their criteria. Some states also offer helpful medical insurance resources for small businesses. 

Hillary Sizer is an attorney with Ogletree Deakins, Atlanta. The American Rental Association (ARA) has a partnership with Ogletree Deakins to offer human resources help and guidance to ARA members. Learn more at


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