What do employers have to pay?
Is Insurance Required?
At this time, small employers (50 or fewer full-time or full time equavent employees) are not required to offer health insurance to employees. Many do so because they believe that health insurance coverage is a valued employee benefit that helps employers attract top employees and retain them. State and federal laws apply to varying degrees – again based on factors including the number of employees, the type of business and whether an insurance company is providing the coverage.
The Affordable Care Act requires that insured small group plans offer health plans that meet certain benchmarks. The benchmarks are represented by the metal levels of platinum, gold, silver and bronze. Each metal level tier plan is designed to provide the same average level of benefit to an enrollee.
The tiers are based on the percentage the plan pays of the average overall cost of providing essential health benefits to members:
- Platinum plans are the most generous and more expensive. These are designed to pay as much as 90% of medical expenses
- Gold plans are designed to pay 80% of medical expenses
- Silver plans are expected to pay 70% of medical expenses
- Bronze plans are expected to pay 60% of medical expenses.
It’s important to note that the metal tiers reflect what the plans will pay on average. These percentages are not the same as coinsurance, which calls for an individual to pay a specific percentage of the cost of a specific service.
Large group health insurance contracts also have to be offered on a guaranteed-issue basis, so a health insurance company cannot reject a large employer group based on its claims history. No individual employee who is eligible for benefits can be excluded from large group coverage based on medical history. Federal law mandates all group insurance contracts, including large group contracts, be renewed every year at the employer's discretion, unless there is non-payment of premium, the employer has committed fraud or intentional misrepresentation, or the employer has not complied with the terms of the health insurance contract.
Large group health insurance is medically underwritten at the time of purchase, with rates based on employee participation and prior claims experience, if available. In a large group employment situation, employees are not generally asked to fill out a medical questionnaire prior to obtaining coverage. The employees may be asked some limited medical questions depending on the employer size and whether the employer has a record of claims experience. The health insurance company bases annual premium changes for large employer groups primarily on the claims experience of the group in past years, as well as any overall increases in the cost of providing health insurance coverage. An example of such costs would be changes in laws that may impact operating expenses.