Clearing the Confusion:
What You Really Need To Know About Group Health Care Insurance
When you need guidance and direction with your health insurance we've got what you need!
Meet Our Specialist: Laura Mount
Laura holds an MBA in Risk Management and Insurance. With over fifteen years of experience, Laura specializes in individual and group health insurance. She is certified to assist and enroll individuals/companies for health insurance through the NJ Federally Facilitated Marketplace. Her certifications consist of the following:
- National Association of Health Underwriters Health Care Reform Certification for The Patient Protection and Affordable Care Act
- Individual Marketplace Certified for 2017 and 2018
Kathi is a licensed Health Insurance Agent in New Jersey. She has been working hard at NorthEast Insurance Services and in the insurance industry for two years. She specializes in Life and Health Insurance. For personal assistance with your health insurance needs please contact Kathi at 800.290.8120 x1100.
What you'll find in this section:
Group Eligibility Requirements:
Group Health Insurance is the most crucial part of a benefits package for obtaining and retaining the kind of employees you are relying on to help grow your business. It is no secret that in our current environment, it has become a challenge for small employers in New Jersey to maintain affordable health coverage for their employees due to ever increasing costs.
In order to be considered for group health coverage in New Jersey, a carrier will require that there be a minimum of one eligible employee but, no more than fifty eligible employees. In general, the eligible employee is one who works on a full time basis with a normal work week of twenty-five or more hours for compensation.
In December 2013, The New Jersey Department of Banking & Insurance issued an Advisory Bulletin that contained changes to the NJSEH regulations that would bring it in line with the requirements of the Affordable Care Act. A couple of these changes are the definitions of a small employer and eligible employee. The Patient Protection and Affordable Care Act (PPACA), required the elimination of a group that consists of a husband and wife only, partners only, sole-proprietor's only, and certain sub "S" Corps.These types of business must obtain their health insurance in the individual marketplace. However, if these businesses have at least one bona-fide employee enrolling with them, they will be qualified to obtain group health coverage. Each year an employer is required by the carrier to verify that their company still meets the eligibility requirements for group coverage. A health insurance carrier reviews the application for compliance during the initial enrollment and each year at renewal by requesting a certification form with proper tax documentation.
It is recommended that employers read through and understand the NJ Small Employer Health Benefits Program Buyer's Guide available on the NJ Department of Banking and Insurance website:
ACA Employer Notification Requirement
The Affordable Care Act (ACA) requires employers subject to the Fair Labor Standards Act (FLSA) to provide information to employees about the availability of the Health Insurance Marketplace. FAQ Notices should be provided at the time of hiring or within 14 days of an employee's start date.
Here, you can access the model notices, in English and Spanish, to inform employees of the Health Insurance Marketplace.
Notice for employers who offer a health plan
Notice for employers who do not offer a health plan
The notices inform the employee:
- Of the existence of the Health Insurance Marketplace, a description of available services and how to access the marketplace.
- That if the employer does not provide minimum essential coverage and/or "affordable" coverage, the employee may be eligible for a premium tax credit and/or cost-sharing subsidy.
- That if he/she purchases a Qualified Health Plan (QHP) from the Health Insurance Marketplace, the employee may lose any employer contribution to any health plan offered by the employer and that all or a portion of the contribution may be excludable from income for federal income tax purposes.
Type of Group Benefit Plans Available
Health Insurance -- Thanks to the forever changing world of health insurance there are many plans to choose from; HMO, EPO, HSA, POS & PPO plans that will accommodate your needs for health insurance, whether, you are just looking for a plan to cover you locally or have employees across the country.
Health insurance plans will have a metallic tier to show the actuarial value of the plan. Rates are based upon each enrolling member's age & geographical location:
- Platinum - 90%
- Gold - 80%
- Silver - 70%
- Bronze - 60%
- Dental Coverage -- May be purchased as a standalone plan or as a rider (an add-on depending on the carrier) to a group health plan.
- Vision Coverage -- May also be purchased as a standalone plan or as a rider (an add-on depending on the carrier) to group health plans.
- Pediatric Dental -- As of January 1, 2014, all groups must have a pediatric dental plan in place upon renewal regardless if there are dependents enrolled on the health plan or not. Groups are obligated to either purchase a Stand-Alone Pediatric Dental (SAPD) from the carrier plan or provide reasonable assurance that they have purchased Exchange-Certified SAPD from a different issuer. A few carriers have opted to include the pediatric dental in the medical plan.
- Pediatric Vision - Similar to the pediatric dental this is now a requirement for all health insurance plans, however the pediatric vision is built into your small group medical plan.
Essential Health Benefits
The Affordable Care Act ensures health plans offered in the individual and small group markets, both inside and outside of the Health Insurance Marketplace, offer a comprehensive package of items and services, known as Essential Health Benefits or EHB. They include the following:
- Ambulatory Patient Services - such as doctors' visits and out-patient services
- Emergency Services
- Maternity and Newborn Care
- Mental Health and Substance Abuse Disorder Services - including behavioral health treatment
- Prescription Drugs
- Rehabilitative and Habilitative Services
- Laboratory Services
- Preventative and Wellness Services - including chronic disease management
- Pediatric Services - including oral and vision care
- Office Visit Co-Payment -- A fixed amount ($20, for example) you pay for a covered health care service after you've paid your deductible.
- Referral -- When a plan requires a referral for you to see a specialist, you must first see your primary care doctor and they will electronically put in a request to give you authorization to see that specific specialist
- Deductibles -- An amount you must pay before your insurance carrier begins to pay/cover a specific benefit. Many plans have deductibles both in-network and/or out-of-network.
- Network of Participating Physicians -- Doctors who are contracted with the health insurance carrier for that specific plan. When you are enrolled on a plan with in-network benefits only, the health insurance carrier will NOT pay a claim for a doctor who does not participate in your plan. It is recommended that you verify they participate with the carrier or by calling the doctor's office directly.
- RX Coverage -- Coverage for prescribed medications. Many plans include 50% coverage. Tiered RX plans may be available for Generic/Name Brand/Non-Formulary Drugs (i.e. $10/25/50). The prescription plans are now built into the medical plan and cannot be changed.
- Guaranteed Issue -- In New Jersey, no one can be declined to enroll in a health insurance plan due to a pre-existing condition, age, claims history, or other risk factors.
For more insurance term definitions please click here or click here.
COBRA Or NJ State Continuation:
Notifications to an employee to continue their health insurance after employment ends is the responsibility of the employer as required by the Department of Labor and Department of Treasury. It is an employer law not an insurance law.
COBRA (Consolidate Omnibus Budget Reconciliation Act of 1985) requires businesses to extend their group health insurance coverage to an employee who leaves or is terminated. The employee must pay the premium to the employer, who in turn includes it with their monthly payment to the carrier. Please refer to the guide provided by the Department of Labor found here.
Model Cobra Notices can be found through the Department of Labor below:
This notice should be given to every new hire
This model notice should be sent to the employee once employment is terminated
In New Jersey, companies with under twenty employees fall under NJ State Continuation. Unlike COBRA where a former employee has 60 days to elect coverage, NJ State Continuation only gives them 30 days to enroll after the qualifying event.
Employers are now required to inform the former employee about the availability of the marketplace when they send a COBRA or NJ State Continuation Notice.
Additional Considerations For The Employer:
An employer must offer coverage to all eligible employees to avoid discrimination. In NJ, employers are required to contribute a minimum of 10% to the health insurance premium. Employers need to understand the requirements in offering a group plan as health insurance is becoming more complicated every day. The New Jersey Department of Banking and Insurance provides a Buyer's Guide for Small Employers to help them understand the requirements. At NorthEast Insurance Services, we are committed to educating employers and helping you to streamline your plans during these difficult times.
Large Group Mandate
Health Insurance Legislation requires large group employers to Pay or Play. All employers that employ at least 50 full-time employees or an equivalent combination of full-time and part-time employees are subject to the Employer Shared Responsibility Provisions. The determination of a large employer is made based on the following Internal Revenue Codes: IRC § 414 (b), (c), (M) or (o).
You can also use the Full-Time Equivalent Calculator on healthcare.gov or consult your accountant:
Large groups must offer affordable coverage that provides a minimum level of coverage to their full-time employees and their dependents or the employer may be subject to an Employer Shared Responsibility Penalty if at least one full-time employee receives a premium tax credit for purchasing individual health insurance through the marketplace. Please review the final regulations issued by the Treasury and IRS or contact your CPA regarding tax penalties.
For more information on Employer Shared Responsibility click here for IRS FAQ.
Small Group Health Insurance Carrier Websites
This information is for educational purposes only and is not intended, and should not be relied upon, as tax or legal advice. Recipients of this information should seek advice based on their particular circumstances from an independent tax adviser or legal counsel. The information on this page is valid up to our most recent website update on July 26, 2017. Rules, laws, and regulations are subject to change without notice.