Group Health Insurance
Summary of Florida Group Health Insurance Coverage
In order to stay competitive in today’s working environment employers need to offer a health benefit package to their employees. Florida group health plans can be offered to companies with a minimum of 2 employees. Group coverage is sponsored by an employer and is offered to all eligible employees. In the state of Florida, an employer is required to pay 50% of the employee only portion of the premium. That means dependents can be added at the employee’s cost. Other benefits like dental, vision, life and disability can easily be added to complete the package.
Why employers in Florida should offer health coverage to employees?
Here is a list why all companies, no matter how small, should be providing employees a group health package.
- Great recruitment and retention tool
- #1 most important benefit to employees and their families
- Tax deductible to the business
- Employees portion can be deducted pretax off their paycheck, which makes it a more cost effective way for them to buy coverage
- Many plan designs with multiple provider networks to choose from
- Easy for employees to purchase vs going out on their own through gov’t exchanges
- It’s the law that all employers with greater then 50 employees provide the coverage
Different types of health insurance group plans
The following are the different types of group plans you will commonly see in Florida:
- PPO or Preferred Provider Organizations.
- POS or Point-Of-Service plans.
- Open Access HMOs or Health Maintenance Organizations; No referral needed.
- Gatekeeper HMO’s; Referral from the primary care is required.
No one type of health care plan is better than the other. It really depends on your needs and preferences. Some people enjoy the autonomy offered by fee-for-service plans, while others prefer the low costs associated with closed-panel HMOs. Also, as health insurers compete for business, distinctions among the types of plans may blur.
Preferred Provider Organizations (PPOs)
One step over the managed care border is the Preferred Provider Organization. PPOs have made arrangements for lower fees with a network of health care providers. PPOs give their policyholders a financial incentive to stay within that network.
For example, a visit to an in-network doctor might mean you’d have a $10 co-pay. If you wanted see an out-of-network doctor, you’d have to pay the entire bill up front and then submit the bill to your insurance company for an 80 percent reimbursement. In addition, you might have to pay a deductible if you choose to go outside the network, or pay the difference between what the in-network and out-of-network doctors charge.
With a PPO, you can refer yourself to a specialist without getting approval and, as long as it’s an in-network provider, enjoy the same co-pay. Staying within the network means less money coming out of your pocket and less paperwork. Preventive care services may not be covered under a PPO.
Point-of-service plans are similar to PPOs, but they are based on HMO networks. The best way to describe a POS plan is an HMO with out of network coverage.
As with the PPO, you can choose to go out of network and still get some kind of coverage. If your PCP refers you to a doctor who is out of the network, the plan should pick up most of the cost. But if you refer yourself out, then you’ll probably have to deal with more paperwork and a smaller reimbursement. You may also have to pay a deductible if you go outside the network.
Since POS plans run off the the HMO network, they typically have better negotiated costs with the provider than a PPO, leading to lower premiums. Therefore, the POS plan may be a cheaper way for employers to buy health coverage.
Health Maintenance Organizations (HMOs)
Now a days, when you talk about HMO plans for your company’s group health coverage, you’re really talking about open access HMOs — not the least expensive, but rather the most flexible type of HMO health plan. However with Affordable Care Act we have seen an increase of traditional HMO contracts where the primary care provider must be the gate keeper. This is especially true on the healthcare exchanges. Offering group HMO plans allows an employer to offer employees more flexible networks.
- Open Access– You can make your own referral to a specialist without visiting a primary care provider. You must stay within the network to receive the benefits of the plan. If the doctor falls out of network you’ll have to pay the full cost with no network negotiating the rates. Certain services like lab work or diagnostic testing may have to be done through an approved provider of the network.
- Gatekeeper-You must have an in network primary care provider (PCP) designated as your physician. This person will authorize a referral for you to see a specialist. Gatekeeper plans tend to have the lowest cost because the PCP can diagnosis important vs not so important medical conditions. In turn, this can help curb claim cost to the insurance carrier.