Good News for Family-Owned Businesses. Family-owned businesses benefited from a big change during 2017’s Open Enrollment – and it’s likely to remain for the upcoming Open Enrollment for 2021. Before the 2017 Open Enrollment, group coverage was only available for employers with one or more employees. Allowing little or no wiggle room, carriers called for strict documentation that employer-employee relationships existed, requiring payroll reports from the Texas Workforce Commission. It was difficult to impossible for self-employed people with families, with no employees on their payroll, to meet the requirements for group coverage.
The Big Change. Since many family-owned businesses are Limited Liability Corporations (LLC), carriers are now designating officers or members of the LLC eligible for group coverage. Employer group coverage requires a minimum of two people, so a husband and wife who comprise an LLC can qualify for group coverage. If the family has dependents, their children can be insured under one parent’s group policy, so the whole family can be covered.
And importantly, group coverage through the LLC structure can allow a dependent 26 or older to remain covered under a group health insurance policy. Under current Affordable Care Act (ACA) rules dependents are required to “age off” a parent’s insurance policy when they turn 26. With an LLC group plan, corporate documents can be amended to reflect the dependent as a member of the LLC and eligible for group benefits sponsored by the LLC. Of course, other considerations such as tax reporting or distribution of profits from the LLC must be taken into account. But from a health insurance standpoint this type of corporate structure would allow dependents to remain covered.
Advantages of Family Group Coverage. Family group coverage provides access to a carrier’s Preferred Provider Organization (PPO) network, which is significantly broader than current Health Maintenance Organization (HMO) networks. In addition, PPOs have national provider networks and out-of-network benefits, which are not available with HMO plans. Employer group coverage offers several other advantages. First, families will have many more options to choose from. Group carriers offer hundreds of plans with varying levels of deductibles, out-of-pocket maximums and other benefits. With so many options, insured members can tailor coverage to their exact needs.
Whose Plan Works Best for LLCs? Humana’s! Humana has the most flexibility in issuing group coverage for two-person LLCs. Popularity of Humana’s group plans under a LLC corporate structure was due to people’s dissatisfaction with the skinnier networks provided by HMO plans, which were the most available plans in the individual market. Humana’s group plans offered exceptional coverage options and a PPO network national in scope.
In addition to flexibility, Humana has offered creative coverage solutions for the small business market. Humana’s Simplicity plans have been the most popular coverage because they offer zero-deductible coverage with a manageable $8,150 maximum out-of-pocket. Once the maximum has been met, Humana pays 100% for the remainder of the calendar year.
Haven’t Heard About Zero Deductible Plans? Here’s Why. Carriers have not marketed zero deductible plans heavily because the plan design promotes over utilization, which quickly drives up premiums and makes the coverage no longer competitive in the marketplace. Not so with Humana’s plan. Humana’s Simplicity plan protects against rapid premium increases because inpatient and outpatient services are charged on a co-pay basis outside of the zero deductible.
What About Humana’s Co-pays? With the Humana plan you pay a daily $2,300 co-pay for the first three days of inpatient or outpatient services. All inpatient and outpatient co-pays count toward the out-of-pocket maximum. Physician fees during a hospital stay are subject to the $0 deductible.
Advanced imaging – CAT scans, PET scans and MRIs – are billed at per-occurrence co-pay of $650. Imaging co-pays count toward the out-of-pocket maximum, but simple x-rays are subject to the $0 deductible.
Prescription benefits with Simplicity Gold plans are $5/$15/$75/$150/$500 for Tier 1 (preferred generic), Tier 2 (non-preferred brand), Tier 3 (preferred brand), Tier 4 (non-preferred brand) and Tier 5 (high technology/specialty drugs.
All Simplicity plans offer office visit co-pays. Gold plans offer primary care physician office visit co-pays at either $40 or $45 and $80 or to $90 for specialists. Silver plans offer primary care physician office visit co-pays at $55 and $100 for specialists.
STATESIDE CAN HELP!
Stateside Insurance Services, since 2003, has focused on providing comprehensive health insurance information, responsive customer service and expert industry knowledge for Texas consumers. Stateside has annually been recognized by health insurance carriers and the Health Insurance Marketplace as a Top Producer in Texas.
Whether the health insurance policy is for an individual, family, small business or supplemental Medicare coverage, Stateside dedicates the time, and our deep industry expertise, to ensure our clients have identified the best health insurance plan for their specific needs.
Stateside is available to answer any general questions regarding your coverage options, can provide a subsidy determination, and even assist in creating and submitting online applications for ACA compliant plans during an Open Enrollment or throughout Special Enrollment periods.
By using the Telephone Appointment System, clients can take advantage of scheduling a health insurance discussion when convenient for their schedule. During Open Enrollment phone appointment availability is expanded to include extended hours and weekends.