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Tag Archive for: employee healthcare

Common Health Insurance Terms to Help You Understand Your Plan

March 12, 2023/in News

If you’re considering purchasing health insurance, you may feel overwhelmed by the variety of terminology associated with it. From coinsurance to deductibles, there are numerous health insurance terms you should know before you enroll. But don’t worry; we’ve got you covered. We have translated some of the confusing terminologies around health insurance into plain English to help you better understand your health insurance coverage.

Let’s dive in.

Coinsurance

Coinsurance is a health insurance term that refers to the percentage of the cost of a healthcare service that you are responsible for paying after you have met your health insurance plan’s deductible. 

For example, if your healthcare bill is $1,000 and you have already met your deductible, and your coinsurance is 20%, you will be responsible for paying $200 (20% of $1,000), while your insurance company will pay the remaining $800. Coinsurance is one of the ways in which health insurance companies share the cost of healthcare services with their policyholders.

Copay

Copay refers to a fixed amount of money that you may need to pay out-of-pocket for a covered healthcare service or supply. For example, your health plan may require a $20 copay for an office visit or a $10 copay for a generic prescription. After you pay the copay, your health insurance plan will cover the remaining cost of the healthcare service or supply. 

Copays are a way for health insurance companies to share the cost of healthcare services with their policyholders. Copay amounts may vary depending on the type of healthcare service or supply, and the specifics of your health insurance plan.

Deductible

A deductible is the amount of money that you need to pay out-of-pocket for healthcare services before your insurance plan starts covering those services. For example, if your plan has a $1,000 deductible, you will need to pay the first $1,000 of healthcare services you receive during the year before your plan starts contributing to the cost of covered services. Once you’ve met your deductible, your insurance plan will begin to share the cost of healthcare services with you. The amount of the deductible can vary depending on the specifics of your insurance plan and is an important factor to consider when choosing a plan, as it can significantly impact your out-of-pocket costs for healthcare.

Essential Health Benefits

Let’s talk about Essential Health Benefits – a set of healthcare services that must be covered by plans in the Health Insurance Marketplace, as required by the Affordable Care Act. These benefits include emergency services, hospitalization, maternity and newborn care, mental health, prescription drugs, preventive and wellness services, pediatric services, and more. 

In-Network Providers

Understanding the difference between in-network and out-of-network providers is critical. In-network providers are a group of doctors, hospitals, and other healthcare providers that your health insurance plan has partnered with to provide care to its members. 

Out-of-Network Providers

When you receive healthcare services from a provider that has not partnered with your insurance plan to provide care to its members, this is known as an out-of-network provider. It’s important to note that using an out-of-network provider may result in additional costs for you, so it’s crucial to know which providers are in-network before receiving care.

Another important term to be familiar with is out-of-pocket cost, which refers to the amount you pay for health care services. This may include your deductible, coinsurance, and co-pays.

The out-of-pocket maximum is the most you’ll pay in a policy period, usually one year, before your plan starts to pay 100% of the covered Essential Health Benefits you receive. This limit must include deductibles, coinsurance, and co-payments, but typically does not count premiums toward your out-of-pocket maximum.

Monthly Premiums

Monthly premiums refer to the regular payments that an individual pays to their health insurance company in exchange for coverage. This payment can be made on a monthly, quarterly, or yearly basis depending on the insurance plan. 

The amount of the premium varies based on a number of factors, such as the type of coverage, the individual’s age, location, and the level of benefits they choose. It’s important to understand the cost of the monthly premium when selecting a health insurance plan, as it can impact your budget and overall financial health.

Preventative Care

Preventive care is health care services focused on keeping you healthy before you may become sick. These include routine check-ups, patient counseling, screening tests, and immunizations. Plans must offer these services at no cost to you when the services are provided by in-network doctors. This means they can’t charge a copayment or coinsurance, even if you haven’t met your deductible for the year.

Provider

Lastly, it’s important to understand what a provider is. This refers to a person or place you go to receive health care services. Examples include doctors, hospitals, pharmacies, and more. Check with your health insurance plan to find out if a provider is in-network or out-of-network.

By familiarizing yourself with these health insurance terms, you can better understand your coverage and make an informed decision when choosing a health insurance plan.

Still Have Questions?

We serve employers who want to offer their employees affordable benefits. We simplify the complexity of providing those benefits and ensure compliance with the Affordable Care Act. We provide affordable benefits for the everyday person. We are different because of our personal service, speed of implementation, and innovative approach to providing benefits coverage.

Learn more about us and our services, here.

https://www.sbmabenefits.com/wp-content/uploads/2023/03/iStock-639494602.jpg 1414 2121 Nathan Ines https://www.sbmabenefits.com/wp-content/uploads/2021/12/SBMA_Website-Logo_250x150.png Nathan Ines2023-03-12 16:00:272023-03-10 16:13:36Common Health Insurance Terms to Help You Understand Your Plan

1094/1095 PCORI Compliance: What You Need to Know

June 5, 2022/in ACA Compliance, News

Businesses that provide health benefits for their employee workforce must submit the right forms proving that they offered the required benefits. Now that 1094/1095 filing is complete, it’s time to prepare for federally mandated annual PCORI fees. Are you prepared? Let’s discuss 1094, 1095, and PCORI compliance. 

How Can Applicable Large Employers Stay Compliant?

Applicable Large Employers (ALEs), employers with 50 or more full-time employees, must offer Affordable Care Act (ACA) compliant health benefits to at least 95% of their workforce. Failure to do so can result in hefty fines and penalties from the Internal Revenue Service (IRS). 

The IRS can issue ALEs Penalty A or Penalty B fines for ea

ch employee that is not offered correct or compliant benefit plans. Employers can avoid unnecessary fines and penalties by offering ACA Compliant Minimum Essential Coverage (MEC). MEC benefit plans allow employers to provide affordable benefits to their employees without compromising their bottom line. 

In order to verify employers are, in fact, offering ACA compliant benefits, the IRS requires employers to fill out form 1094 and 1095. 

Employers must complete Form 1094, which is used to determine their liability for payment under the employers’ shared responsibility provision. Form 1095, however, is used as a summary of healthcare information the ALE offers employees. 

What Can SBMA Do For You?

One of the many services we provide at SBMA Benefits is 1094 and 1095 Form processing. We simplify the complexity of providing employee benefits while simultaneously ensuring ACA compliance. 

What’s included in our 1094/1095 processing?

  • Electronic filing of 1094 and 1095 forms annually 
  • PDF soft copies of 1095 for employee distribution 
  • 1095 error corrections refiling (if applicable) 
  • Mail distribution

What Happens After I Submit Forms 1094 and 1095?

After submitting Forms 1094 and 1095 by their due date, March 31st, employers must pay fees to the Patient-Centered Research Institute (PCORI) by July 31st. This year, however, the due date has been extended to August 2nd since the previously mentioned due date lands on a Saturday. 

What is PCORI and Why Do I Have to Pay Their Fees?

PCORI was created to improve the quality, quantity, timeliness, and trustworthiness of health information for patients. 

According to the PCORI, its mission is to “help people make informed healthcare decisions, and improve healthcare delivery and outcomes, by producing and promoting high-integrity, evidence-based information that comes from research guided by patients, caregivers, and the broader healthcare community.”

Employers are responsible for paying PCORI trust fund fees annually. The amount employers owe depends on the number of people enrolled in their offered benefits program. 

The fee is calculated based on the average number of individuals covered in a benefits plan- including spouses, dependents, retirees, and COBRA participants. Currently, PCORI fees are $2.79 per enrollee. In 2021, PCORI fees cost $2.66 per enrollee. 

The fee was slated to end in 2019, but was extended via Trump’s Further Consolidated Appropriations Act of 2020. For now, PCORI fees are extended through 2029. 

For more information on Forms 1094 and 1095, read our article: What you need to know about 1094/1095 Filing. 

https://www.sbmabenefits.com/wp-content/uploads/2022/06/iStock-1313069986.jpg 1415 2119 maddie https://www.sbmabenefits.com/wp-content/uploads/2021/12/SBMA_Website-Logo_250x150.png maddie2022-06-05 07:00:402022-05-06 13:41:371094/1095 PCORI Compliance: What You Need to Know

HIPAA vs FERPA: What’s the Difference?

November 21, 2021/in ACA Compliance, HIPAA

HIPAA stands for Health Insurance Portability and Accountability Act of 1996. Under this federal law, patient health information is protected and kept secure unless the patient gives consent to disclose their information. The patient has control of who has access to their records.
Physical activity doesn’t always mean an intense hour-long workout at the gym every day. While this form of exercise has great benefits, it’s not for everyone.

Read more
https://www.sbmabenefits.com/wp-content/uploads/2021/10/SBMA-Open-Enrollment-Nov-1-copy-2.png 924 1640 Amanda Rogers https://www.sbmabenefits.com/wp-content/uploads/2021/12/SBMA_Website-Logo_250x150.png Amanda Rogers2021-11-21 21:39:002022-07-01 08:51:57HIPAA vs FERPA: What’s the Difference?

Reviewing The ACA Times “ACA EMPLOYER PENALTIES ARE REAL AND THE IRS WILL BE ISSUING MORE”

November 14, 2021/in ACA Compliance, News

All Applicable Large Employers (ALEs) are required to offer at least 95% of full-time employees Affordable Care Act (ACA)-compliant Minimum Essential Coverage (MEC) benefits.

ALEs are any business with over 50 full-time employees in a calendar year. Full-time equivalent employees (anyone who works at least 30 hours per week) also count towards the 50 full-time employee tally.

Read more
https://www.sbmabenefits.com/wp-content/uploads/2021/10/SBMA-Open-Enrollment-Nov-1-copy.png 924 1640 Amanda Rogers https://www.sbmabenefits.com/wp-content/uploads/2021/12/SBMA_Website-Logo_250x150.png Amanda Rogers2021-11-14 21:09:002022-01-11 10:11:40Reviewing The ACA Times “ACA EMPLOYER PENALTIES ARE REAL AND THE IRS WILL BE ISSUING MORE”

Open Enrollment 2022-2023: What You Need to Know

October 31, 2021/in MEC, Open Enrollment

Open enrollment is the one period of the year where employees can sign up for health insurance or change a health insurance plan provided by the employer. Remember that this period also allows employees to disenroll in health insurance if they no longer wish to have coverage.

The only exception to enrolling, changing a health insurance service, or disenrolling is through a qualifying event. Qualifying events can vary depending on the state the employee resides in.

Physical activity doesn’t always mean an intense hour-long workout at the gym every day. While this form of exercise has great benefits, it’s not for everyone.

Read more
https://www.sbmabenefits.com/wp-content/uploads/2021/10/SBMA-Open-Enrollment-Nov-1.png 924 1640 Amanda Rogers https://www.sbmabenefits.com/wp-content/uploads/2021/12/SBMA_Website-Logo_250x150.png Amanda Rogers2021-10-31 13:33:002022-11-18 09:39:43Open Enrollment 2022-2023: What You Need to Know

11 Minutes to a Longer Life

October 24, 2021/in Employee Engagement, Healthy Living

Living a longer, healthier life requires physical activity, eating healthy, and routine visits to the doctor. When these three factors work together, it allows you to stay your healthiest. In turn- your odds of living longer increase.
Physical activity doesn’t always mean an intense hour-long workout at the gym every day. While this form of exercise has great benefits, it’s not for everyone.

Read more
https://www.sbmabenefits.com/wp-content/uploads/2021/09/Oct-25-SBMA.png 924 1640 Amanda Rogers https://www.sbmabenefits.com/wp-content/uploads/2021/12/SBMA_Website-Logo_250x150.png Amanda Rogers2021-10-24 10:47:002021-11-30 17:03:4411 Minutes to a Longer Life

Opt-in vs Opt-out Health Insurance: What You Need to Know

October 17, 2021/in Employee Engagement, Employee Retention

Large employers offering employees health benefits need to choose between opting all employees in automatically, encouraging them to opt-in, or making them opt out of health benefits. When it comes to health insurance, opting in and out plays a key part in enrollment. Using the right strategy can help you as a large employer provides coverage for your employees.

Read more
https://www.sbmabenefits.com/wp-content/uploads/2021/10/opt-in-opt-out.png 924 1640 Amanda Rogers https://www.sbmabenefits.com/wp-content/uploads/2021/12/SBMA_Website-Logo_250x150.png Amanda Rogers2021-10-17 22:27:002021-11-30 17:02:25Opt-in vs Opt-out Health Insurance: What You Need to Know

How Do I Get My Employees to Sign Up for Health Insurance?

October 10, 2021/in Brokers, Employee Engagement, Employee Retention

All businesses with over 50 full-time employees are required to offer health insurance or be penalized $3,860 per uninsured employee. Our Affordable Care Act (ACA) compliant MEC benefits calculator breaks down the cost of remaining incompliant vs. annual costs with MEC here. Offering Minimum Essential Coverage benefits saves over $180,000,000 annually.

Read more
https://www.sbmabenefits.com/wp-content/uploads/2021/09/Oct-1121_Encourage-Employee-Health-Insurance_SBMA.png 924 1640 Amanda Rogers https://www.sbmabenefits.com/wp-content/uploads/2021/12/SBMA_Website-Logo_250x150.png Amanda Rogers2021-10-10 22:05:002021-11-30 17:02:04How Do I Get My Employees to Sign Up for Health Insurance?

What to do if your employee has COVID

September 14, 2020/in COVID-19

With companies beginning to return to work, there are a few procedures that employers need to put in place to keep their employees and customers safe. One thing employers need to put thought into is how they will handle what happens when an employee displays symptoms of COVID-19. Furthermore, when an employee is suspected or confirmed to have COVID-19, or if employees are exposed to COVID-19 but are not showing symptoms. Here is some guidance on what to do if your employee potentially has COVID-19.

Read more
https://www.sbmabenefits.com/wp-content/uploads/2020/08/pexels-marc-mueller-380768-scaled.jpg 1437 2560 Amanda Rogers https://www.sbmabenefits.com/wp-content/uploads/2021/12/SBMA_Website-Logo_250x150.png Amanda Rogers2020-09-14 07:00:002021-11-30 09:57:37What to do if your employee has COVID

How Have Your Employee Benefits Changed Since the Start of COVID?

September 7, 2020/in COVID-19, Voluntary Benefits

Before Coronavirus swept the world with high unemployment rates, a strain on healthcare resources, and economic strife, employers were thinking creatively about how to not only retain their existing employees but also attract the best employees with benefits. While some states have been more affected by the health concerns surrounding COVID-19, almost all have felt the effects of the economic downturn. How have your employee benefits changed since the start of COVID? Once you identify the changes, how can you begin to prepare your insurance plan for post-pandemic employee benefits to attract and retain the best employees?

Read more
https://www.sbmabenefits.com/wp-content/uploads/2020/08/national-cancer-institute-NFvdKIhxYlU-unsplash-1-scaled.jpg 1707 2560 Amanda Rogers https://www.sbmabenefits.com/wp-content/uploads/2021/12/SBMA_Website-Logo_250x150.png Amanda Rogers2020-09-07 07:00:002021-11-30 09:54:35How Have Your Employee Benefits Changed Since the Start of COVID?
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