Group plan options for employers

Network designs

Fully insured small-group coverage, and many large-group and self-funded plans, are issued in the network designs HealthCare.gov describes.

• A group PPO generally pays a higher share of costs in the plan's network and also covers out-of-network care, usually at a higher cost, without a referral.
• A group HMO generally covers care from doctors who work for or contract with the HMO, except in an emergency, and may require employees to live or work in a service area.
• A group EPO or POS plan sits between those designs: an EPO generally covers in-network care except in an emergency; a POS plan generally costs less in-network and requires a referral to see a specialist.

We will match the design to how and where your people actually get care, including on a multi-state workforce.

How costs are shared

• An HSA-qualified high-deductible health plan meets the IRS definition of an HDHP under Internal Revenue Code § 223 and can be paired with a health savings account. Contribution and deductible limits are published each year by the IRS.
• Small-group metal tiers — Bronze, Silver, Gold, and Platinum — are actuarial-value categories in the individual and small-group markets. They describe a design target for how the plan and the enrollee share expected allowed costs. They are not a quality rating.
• Minimum essential coverage and minimum value are the federal tests that matter most for applicable large employers, and for any employer that wants a clear reading of what a given medical plan actually is.

How the plan is funded or arranged

• A fully insured small-group plan is a group policy. The employer pays a premium and the carrier takes the claims risk.
• A level-funded plan typically combines expected claims, administration, and stop-loss into a fixed monthly amount.
• A self-funded plan, more often a fit as the group gets larger, is the employer's plan for paying covered claims, usually with stop-loss insurance.
• A defined contribution arrangement such as an ICHRA or a QSEHRA sets an employer allowance that employees use toward coverage they obtain, rather than a single group medical policy for every class.
• Some employers belong to a bona fide association that sponsors a plan, or they obtain coverage through a professional employer organization. Both are reviewed against current federal and state rules, not against the label on the brochure.
• Inside a self-funded structure, some groups look at reference-based pricing as a claims-payment method, or at a captive as a way to finance stop-loss. Those are design choices, not replacements for a medical plan.

SHOP is the ACA's Small Business Health Options Program. It is one path to a fully insured small-group plan, and it is generally the path to the Small Business Health Care Tax Credit for eligible employers.

Accounts and other benefits that sit beside the medical plan

• A Section 125 cafeteria plan, often a premium-only plan, is how employees pay their share of eligible premiums with pre-tax wages when the Code allows it.
• A health FSA or dependent-care FSA can be added to that cafeteria plan.
• An excepted benefit HRA can sit next to a traditional group medical plan, subject to an annual IRS cap. An integrated HRA reimburses additional medical expenses for employees enrolled in a group medical plan.
• Group dental and vision, group life and disability, and other voluntary benefits complete a typical package.
• Telehealth and direct primary care are additional ways employees can reach a clinician. Recent federal legislation also changed how those designs interact with an HSA.
• COBRA and, in Florida, the state's continuation statute, decide what happens when someone would otherwise lose group coverage.

Who the group is

Headcount and legal form change which products can be issued.

• Companies with 2, 5, or 10 employees are in the small-group market in most states, but SHOP and many carriers still look at who those people are — owners, family members, or common-law employees.
• An LLC or S corporation can sponsor a group plan. The tax treatment of owners is a separate question from whether the policy can be issued.
• A family business often has the same product menu, with extra attention to SHOP's "one employee who is not an owner or family member" rule and to cafeteria-plan nondiscrimination.
• Employers approaching or above 50 employees should also read mid-size and large-group coverage, and the employer coverage requirement page.

Comparing cost structures

Searches for the "cheapest" group plan are usually a request to compare structures. Premium, deductible, employer contribution, tax treatment, and — for some eligible small employers — the Small Business Health Care Tax Credit all move together. We will compare the structures that can actually be issued for your census. We will not publish a typical premium, and we will not describe one design as cheaper in the abstract.

How we help

You send a roster, work locations, what you offer today, and your renewal date if you have one. We confirm the market you sit in, compare the structures on this page that actually apply, and help you implement the one you choose, including Section 125 payroll pieces and any voluntary benefits that belong in the same package.

Named carriers and networks — including Florida Blue, UnitedHealthcare, and AvMed, plus funding and ancillary options — are on the carriers and networks hub.