Click on the state names to get state-specific rules or the carrier names to learn more about each carrier. Note: So far, Texas is the only state with any information and the only carrier pages with info are BCBSTX and some of the California plans. But more will be added…
FAQs
Is a 1094C required for each 1095C submitted?
No. It’s allowed, but definitely not required. An employer can send the 1095Cs to the IRS in batch. Each batch of 1095Cs must be accompanied by a 1094C and it needs to be noted on the 1094C how many 1095Cs are being submitted at the time and how many in…
Can a fully-insured small employer offer different plans or make different contributions for different classes of employees?
This is a hard one because different federal and state laws as well as different carrier rules might come into plan. HIPAA (1996) says that employers can offer different benefits/contributions as long as they treat similarly situated individuals the same and do not discriminate based on health status: See question…
Do small employers need to purchase Minimum Essential Coverage (MEC) plans?
Small employers, typically defined as businesses with fewer than 50 full-time equivalent (FTE) employees, are generally not required to purchase health coverage for their employees. The employer mandate applies to larger employers, and these companies sometimes purchase “MEC plans,” sometimes referred to as “skinny plans” because they cover only the…
What is meant by a “concentric” or “efficient” provider network in health insurance?
In health insurance, a “concentric” or “efficient” provider network is a strategically designed network of healthcare providers and facilities. The primary goal is to offer high-quality care while minimizing unnecessary costs. This is achieved by including providers who meet specific standards for quality and cost-effectiveness in patient care. Such networks…
What should employees consider when choosing a plan based on its provider network?
When choosing a health insurance plan, it’s important to consider the size and scope of its provider network. Look for a network that includes a sufficient number of local doctors and hospitals, especially those you prefer to use. Also, consider whether the plan allows for out-of-network care and at what…
How do provider networks affect access to healthcare services?
Provider networks can significantly impact access to healthcare services. If a healthcare provider is “in-network,” it means they have a contract with the insurance company, and plan members will typically pay less for their services. Conversely, receiving care from “out-of-network” providers generally results in higher out-of-pocket costs. Some plans, like…
How does a health insurance provider network work?
A provider network in health insurance is a group of healthcare providers that have contracted with an insurance company to provide services to plan members at negotiated rates. These networks can include a wide range of providers, such as doctors, specialists, hospitals, clinics, and pharmacies. The purpose of a provider…
Are referrals from a PCP always required to see a specialist in all health insurance plans?
No, referrals from a PCP are not always required in all health insurance plans. While HMOs and some POS plans require a PCP referral to see a specialist, PPOs and EPOs generally allow members to see specialists and receive other medical services without a referral. This provides greater flexibility for…
How does the referral system work in health insurance plans that require a PCP?
In health insurance plans that require a PCP, such as HMOs, the PCP must provide a referral before the patient can see a specialist or receive certain medical services. This system is designed to ensure that patients receive appropriate care and to control costs by avoiding unnecessary specialist visits. Once…
What is the role of a Primary Care Physician (PCP) in health insurance plans?
A Primary Care Physician (PCP) serves as the main healthcare provider and the first point of contact in many health insurance plans, particularly in HMOs and sometimes in POS plans. The PCP is responsible for providing general medical care, managing overall patient health, and making referrals to specialists when necessary….
Can an HDHP be paired with any network option (PPO, HMO, etc)?
Yes, HDHPs can be paired with various network options, including Preferred Provider Organizations (PPOs) and Health Maintenance Organizations (HMOs). The choice of network type will influence factors such as the availability of providers, the need for referrals to see specialists, and the costs associated with using out-of-network services.
Are copayments allowed after the deductible on a High Deductible Health Plan?
Yes, copayments are often required in HDHPs even after the deductible has been met. Once the deductible is met, the plan typically covers a significant portion of the costs, but the insured might still be responsible for copayments or coinsurance for covered services until they reach the out-of-pocket maximum.
What are the pros and cons of an HDHP compared with a copay plan?
Pros of an HDHP: Lower monthly premiums compared to many copay plans. Eligibility to contribute to an HSA, offering tax advantages. Potential for lower out-of-pocket maximums, providing better protection in catastrophic health situations. Cons of an HDHP: Higher deductibles leading to more out-of-pocket expenses before the insurance covers costs. The…
Is an HDHP required to set up and contribute to an HSA?
Yes, having a High Deductible Health Plan (HDHP) is a requirement to set up and contribute to a Health Savings Account (HSA). To be eligible for an HSA, you must be enrolled in a plan that meets the IRS’s definition of an HDHP, which typically includes a higher deductible and…
What is a High Deductible Health Plan (HDHP)?
A High Deductible Health Plan (HDHP) is a health insurance plan with a higher deductible than traditional health plans, but contrary to what the name might suggest, the deductible is not always significantly higher than those found in many copay plans. One of the key features of an HDHP is…
How do copay plans impact overall healthcare costs for the insured?
Copay plans can make budgeting for healthcare costs more predictable, as the insured knows the fixed amount they’ll pay for certain services. However, while copays can mitigate the cost of individual services, they do not count towards deductibles. As a result, individuals with frequent healthcare needs may end up paying…
Do copay amounts vary in health insurance plans?
Yes, copay amounts can vary widely among different health insurance plans. Some plans might have lower copays for primary care visits but higher copays for specialist visits or emergency room services. The structure of copays is often a key consideration when choosing a health insurance plan.
Are copays required for all services in a copay plan?
Not necessarily. The requirement and amount of a copay can vary depending on the type of service or treatment. For instance, a plan might have a copay for doctor’s visits and prescription drugs but not for preventive care or certain other services. The specifics of what services require a copay…
What’s the difference between a copayment and a deductible?
Copays and deductibles are both forms of cost-sharing in health insurance, but they function differently. A copay is a fixed amount paid for a specific service (like $25 for a doctor’s visit), regardless of the total cost of the service. A deductible, on the other hand, is the amount the…
What is a copay plan?
Copays and deductibles are both forms of cost-sharing in health insurance, but they function differently. A copay is a fixed amount paid for a specific service (like $25 for a doctor’s visit), regardless of the total cost of the service. A deductible, on the other hand, is the amount the…
What are the penalties for small group plans not complying with HIPAA regulations?
Non-compliance with HIPAA regulations can result in significant penalties for small group plans. Penalties can range from monetary fines for failing to safeguard protected health information to more severe penalties for willful neglect of HIPAA requirements. The severity of the penalty often correlates with the severity and nature of the…
How does HIPAA impact the portability of health coverage for small group plan members?
HIPAA improves the portability of health coverage by limiting exclusions for preexisting conditions in group health plans, including small group plans. It generally prohibits group health plans from imposing a preexisting condition exclusion of more than 12 months for any condition present before the start of coverage.
What are qualifying events and special enrollment periods (SEPs) under HIPAA for small group plans?
Under HIPAA, qualifying events for small group plans include life events such as marriage, birth, adoption, and loss of other health coverage. These events trigger a special enrollment period (SEP), allowing individuals affected by these events to enroll in or change their health insurance coverage outside the usual open enrollment…