Group Benefits - Frequently Asked Q's

How are rates for small groups determined?

Washington State has mandated that rates for “community pool groups” are to be determined by the average age of employees. Zip code factors may also be used which acknowledges that costs are somewhat higher in urban areas. 

What parameters must an employer establish for participation?

Waiting Period…. How soon after an employee is hired is he/she eligible to participate in the group benefit plan.  Three months is the norm, however, this does handicap an employer who may wish to enroll a highly skilled employee sooner.  Employers may determine a class system where hourly employees have a different waiting period than salaried or management.
Who is eligible…. Salaried only, hourly only, all employees?
What part of the cost is an employer required to pay?  See next question

Generally, what portion of the cost of insurance must be paid by the employer?

Most insurers require that employers pay at least 75% of the employee cost. (May be higher for small groups)  Since rates for small  groups are determined by the average age of employees, it is wise to encourage enrollment by younger employees who may not do so if their payroll deductions are significant.   Older employees are more likely to enroll since they are more aware of the potential costs of medical claims. The employer is not required (in most cases) to contribute toward dependent costs.

If an employee does not enroll when first eligible, (or does not enroll dependents) when can they enroll?

  1. At the open enrollment period which is typically the annual renewal date of the group contract.
  2. A qualifying event.  If the employee or dependent had similar group coverage elsewhere, they may enroll if those benefits are lost.
  3. Newly aquired dependents.

Once I am insured,  what if any medical expenses will I be responsible for?

Generally there are four ways that you participate in medical costs.

  1. copays for specific circumstances (office vists, emergency room, pharmacy)
  2. Deductible… this is your responsibility before the insurer participates.
  3. Co-Insurance.. once the deductible has been met, most insurers pay a specific percentage of the costs. (70/80/90) You would be responsible for the balance generally up to a specific out of pocket limit.
Uncovered expenses.  All insurers will provide you with an agreement, the insurance policy, which details what non-covered expenses are.

What about pre-existing health conditions?

Washington State has specific protection for consumers leaving one plan and transferring to another. Under most circumstances, if the coverage is like-kind, and there is not a prolonged break in coverage (more than 90 days) the waiting periods are waived.

What if I have been uninsured for an extended period?

There is a 9 month waiting period for existing health conditions.

How are my claims paid?

Most plans now are of the PPO variety. (Preferred provider Organization) When you seek the care from a member provider (hospital, chiropractor, physician, pharmacy) they will agree to bill your insurance company for you, AND agree to the fee schedule set by the insurer.

What is an explanation of benefits?

This is the statement that you receive from your insurer once a claim has been acted on. We refer to them as EOB’s. They will tell you how the claim was processed and what responsibility is yours.

Quick Links:
Washington Insurance Commissioner
Medicare Information
Lifewise Health Plan
Premera Blue Cross
Mutual of Omaha
Washington Health Insurance Pool
Washington Dental Service
Assocatiation of Wahington Business
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