Insurance & Employee Benefits
Group health insurance is often the foundation employee benefit program. Often the most expensive component, it is becoming more common for organizations to change their insurance carriers periodically as people do with auto insurance. In response to this trend, the carriers are designing plans that shift more of the cost to the participants (cost-
We at Group Coverage, Inc. try to fulfill the needs of the group first, thus we recommend the plans that offer the greatest value to its members and the sponsoring organization.
If your organization is looking for a new plan to replace its current or have our agency service your existing account, our experienced staff will provide the support and tools needed to effectively manage these increasingly complex plans. We are paid by the carrier a servicing commission which usually remains at a fixed percentage rate for the life of the business, thus our goal is to provide the highest quality service long after the account is written. We have grown our business one client at a time, and realize how important each client is to us.
Choosing the Right Plan
There are many types of health insurance products such as HMO's, EPO's, Point-
We offer programs that can either be comprehensive in coverage or only offer catastrophic protection. Many of our carriers or associations that offer coverage will write groups down to one life. For larger companies we offer self funded, fully insured, or plans that combine the best of both. We can assist with the implementation and administration of complex cafeteria plans to simple premium only plans (Sec. 125). To understand the basics of some various types of plans, following is a list of the most popular types and a brief explanation of the coverage's:
An HMO is an organization that provides its members with comprehensive healthcare services through an established group of network providers including doctors, hospitals, pharmacies, labs, etc. HMO's are proactive in their approach to promote wellness and preventative medicine by encouraging physicals and by offering discounts to services such as gyms and other wellness facilities. In theory, early detection and prevention saves the carrier money before medical conditions worsen and costs escalate. Generally a primary care physician (PCP) is selected to oversee the medical management of the member and act as the 'gatekeeper'. The PCP may be the internist, pediatrician, or even a woman's gynecologist. One of their roles as the gatekeeper is to authorize the services beyond their scope of their expertise by way of a referral. The referral would often be required for specialist visits, scheduled surgeries, diagnostic tests, and hospitalizations. However 'open access' HMO's are becoming very popular and now allow the participants to self refer. With an HMO, your choice of doctors, hospitals, and other providers is restricted to a network except in the case of an emergency. In most cases, preauthorization by the carrier it is still required for treatment outside of the network. The network of providers is paid by the carrier on a predetermined basis for the services rendered. The cost to the member is usually limited to a small co-
POS is a type of managed care plan that offers in-
An EPO is an organization of providers which includes Physicians, Hospitals, Pharmacies, Labs, etc. that have agreed to charge a discounted rate in accordance to the allowable charges set by the insurance carrier. The structure is similar to the HMO without the need of a primary care physician (PCP). Since there is no PCP, there is no need for a referral.
Similar to an EPO, a PPO is an organization of providers which includes Physicians, Hospitals, Pharmacies, Labs, etc. that have agreed to charge a discounted rate in accordance to the allowable charges set by the insurance carrier. Unlike an EPO, the PPO allows the member to receive services outside of this network subject to the conditions of the policy. This structure is similar to the POS without the need of a primary care physician (PCP) for services received in network. Since there is no PCP, there is no need for a referral.
William F. Schaake, CIC, CRM
Group Health Insurance
Group Health & Medical Insurance Related Concepts