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What is employer group health insurance coverage?

Group health insurance coverage is a policy that is purchased by an employer and is offered to eligible employees of the company (and often to the employees' family members) as a benefit of working for that company. A group health insurance plan is a key component of many employee benefits packages that employers provide for employees. The majority of Americans have group health insurance coverage through their employer or the employer of a family member. One of the advantages for employees in a group health plan is the contribution most employers make toward the cost of the health coverage premium—in many cases, employers pay one-half or more of the monthly premium for an employee.

Are all employer group health insurance policies the same?

Insurance is regulated in large measure by each state. Therefore, the laws regarding health insurance offered by the different types of employers can vary significantly from state to state. Also, different types of employers may offer different benefit plans. Millions of Americans work for small employers, which for health insurance purposes are generally those with 50 employees or less. Millions of other Americans get their health insurance coverage through large employers. Generally, those are businesses with more than 50 employees. The laws about how coverage can be issued to large groups are different than those for small groups, and the way that premium rates are determined is also different. The requirements for sole proprietors purchasing health insurance coverage also vary on a state-by-state basis.

What are the coverage requirements for small employer plans?

At this time, employers are not required to offer health insurance to employees. Many do so because they believe that health insurance coverage is a valued employee benefit that helps employers attract top employees and retain them. Each insurance company applies their own set of underwriting rules based on the number of employees and other factors. State and federal laws apply to varying degrees—again, based on factors including the number of employees, the type of business and whether an insurance company is providing the coverage. There are myriad requirements that apply to group health plans ranging from laws that address benefit communications (ERISA), claims appeals (ERISA) and portability of coverage (HIPAA) among others.

The federal HIPAA law mandates that no matter what pre-existing health conditions small employer group members may have, no small employer or an individual employee can be turned down by an insurance company for group coverage. This requirement is known in the insurance industry as "guaranteed issue." In addition, each insurance company must renew its small employer health plan contracts every year, at the employer's discretion, unless there is non-payment of premium, the employer has committed fraud or intentional misrepresentation, or the employer has not complied with the terms of the health insurance contract. In most states, small employer health insurance companies are allowed to look back at individual group applicants' medical histories for pre-existing conditions and may decide not to cover certain conditions for a specified period of time. This is known as an exclusionary, or a pre-existing condition, waiting period. Federal law states that small group health insurance companies may impose no more than a six-month look-back/12-month exclusionary period for pre-existing conditions, but individual states can reduce these time periods. Small group insurance companies are also required to give employees credit for prior coverage against any pre-existing condition waiting period that may be imposed, as long as the employee had other creditable health insurance coverage within 63 days of the application for new coverage. (Source: Nahu.org)

To learn more about group health insurance, call 415-512-2100 today.
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44 Second Street
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Phone: (415) 512-2100
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