Group Health Insurance

Group health insurance covers members of a natural group, such as employees of a business, union, association, or employer group. This coverage grants each employee benefits for hospital room and board, surgeon and physician fees, and miscellaneous medical expenses. Employees must pay a deductible and coinsurance requirement.

Businesses can choose from four fully-funded medical plans and one level-funded option:

Preferred Provider Organization (PPO)
You are allowed to self-refer to any provider in the network. When using the in-network providers, the higher level benefit is received. This may be as much as 90% after the deductible. The benefit level for providers out of the network is typically 70% to 80%. Pre-authorization requirements must be met in or out of network. Providers in and out of network usually have a doctor office copay.

Point of Service (POS)
Very similar to an HMO in-network plan. It uses a “gatekeeper” (Primary Care Physician, or PCP) to refer cases to other in-network providers. Deductibles usually only apply to out-of-network care. Coinsurance is either 90% or 100% for in-network providers. The plan typically covers 60% to 70% of the cost for out-of-network services. There are exceptions—typically, an emergency while away from network providers or treatment required from specialists not available in-network.

Health Maintenance Organization (HMO)
The HMO uses a Primary Care Physician to direct all health care. No benefits are available outside of the provider network except when there is an emergency. HMO plans focus on wellness and preventive medicine and is the highest level of managed care.

Indemnity Traditional Coverage
The insured individual is free to use the doctor, clinic, or hospital of their choice. Both a deductible and a coinsurance apply and there are normally no copays for doctor office visits.

Level-funded/Self-funded

Level funding offers the same coverage and protection as fully-funded insurance plans, while giving you the opportunity to earn a refund on unused claims dollars. How does that work? Just like fully-funded insurance plans, these policies place a large portion of your premium dollars into reserves to pay claims.With level-funding plans, if your group has a healthy year they keep the claims dollars at the end of the contract term. Level-funded plans pair easily with PPO, POS, and HMO service platforms.