Health Insurance

Group Health Insurance plans vary widely between insurance carriers based on jurisdiction, provider networks, benefit plan designs and pricing.  Horenberg Insurance assists our large and small business clients in determining which carrier and plan designs offer the best combination of price, benefits and services for their organization and plan participants.

Employees generally working 30 or more hours per week are considered full time employees and are eligible to participate in Employer sponsored Health Insurance Plans.  An employer may wish to offer part-time employees or retirees access to medical insurance plans.

Coverage effective dates for eligible participants typically range from date of hire to the first of the month following 90 days of employment.  Group Health Insurance plans are subject to certain participation requirements and employer premium contribution levels.  Understanding and complying with these requirements are critical to maintaining the availability of such plans.

In the state of Maryland, most employer groups with less than 51 participants are subject to Maryland Small Group Reform (MSGR).  In this market, rates are calculated using community claims experience and average group age, projected forward with a healthcare inflation factor.  In addition, factors such as prescription drug utilization, legislative mandates, and provider utilization play key roles in determining healthcare costs from community rated groups. MSGR plans are not individually medically underwritten.  For groups in Maryland with 51 or more participants and, in most other states, group rates are based on certain medical underwriting criteria which may include employer screening questionnaires and/ or employee screening questionnaires in addition to claims experience, average age, healthcare inflation factors, prescription drug utilization, legislative mandates and provider utilization.

Group Health Insurance Plans are generally offered in three forms:
     
Health Maintenance Organizations (HMO): An HMO plan offers participants access to a network of providers including doctors and hospitals which the insurance carrier has contracted with and has agreed to payment levels for services rendered. While an HMO is the least expensive plan design, it also has the least flexibility for plan participants.  In most HMOs participants choose an in-network primary care physician (PCP) and then get referrals form their PCP to in-network specialists.  Some HMO plans offer open access to avoid having to obtain specialist referrals.  HMO participants benefit from the lower fees providers have agreed to accept and are not responsible for amounts in excess of required deductibles, co-payments or co-insurance which are over the carrier/provider agreed upon fee schedule.  HMO plans do not offer any coverage for services rendered by out-of-network providers except for bona-fide emergency services.

Point of Service (POS): A POS plan offers the same benefits found in an HMO plan for in-network providers; however, benefits are also available when out-of-network providers are used.  These plans cost more than HMO plans, but allow the participant the choice to use in-network or out-of-network providers. Out-of-network benefit levels typically are subject to higher deductibles, co-insurance and co-payments levels for the participants, meaning more out-of-pocket costs.  When using out-of-network providers, participants may also be subject to “balance billing” where the participants may be responsible for paying the provider for amounts charged in excess of the allowed benefit amount determined by the carrier at the in-network benefit level.  These costs are in addition to deductibles, co-insurance and co-payments and do not count toward deductibles or out-of-pocket maximums.
 
Preferred Provider Organizations (PPO): The PPO plan design is the most flexible, providing in-network and out-of network benefits without requirements to obtain referrals to see in-network providers regardless if they are PCPs or Specialists.  Some services that HMO or POS plans require participants to go to a lab for certain tests can be performed in the in-network provider’s office. Typically, the provider networks for PPO are larger than for HMO or POS plans as providers are generally paid at a higher level for services rendered.  The PPO is the most costly of the three plan designs described here.  Services obtained through out-of network providers can be subject to “balance billing” similar to those in a POS plan.

In selecting which plan is right for any organization, in addition to premiums and benefit designs careful consideration must be given to the provider network coverage area and available participating providers.  Changing doctors is generally something a plan participant resists.  

Designing plans offering dual or triple options, where HMO, POS and/or PPO plans are available to eligible employees is an effective way to allow employees to choose the best benefit plan for them.

As Health Insurance brokers, Horenberg Insurance is committed to educating our clients and their employees on the options available to them and to assist with the evaluation, selection, implementation and on-going service requirements of plan administrators and plan participants.

Request a Quote for Group Health Insurance today.