Benefits Consulting

Managing employee benefits takes extensive time and resources. Here at Health Insurance Consultants Inc., we take the guesswork out of cumbersome topics like COBRA Administration, health, dental, life, accidental death insurance and more.

Our benefits consulting team works alongside your internal management team to develop a customized and innovative strategy. We utilize our specialized partners and industry experts to meet the needs of your business and employees. Our consultants will provide:

  • Benchmarking
  • Employee Surveys
  • Market Analysis
  • Create a Benefit Strategy to Align with Company Mission and Values
  • Assist in Creating a Benefit Committee
  • Contract Review
  • Develop Mid-term to Long-term Benefit Goals
Benefits Consulting

Benefits

When it comes to health and dental insurance, there are hundreds of options for employers to choose between. A typical employer policy can cover costs for categories like medical expenses, prescription drugs, doctor’s visits, and much more.

As you can imagine, navigating the benefit world on your own can be complicated. With so many providers and offers, it’s not easy to find the right fit. We’ll work with you to identify criteria for your ideal health insurance plan and then bring together a set of competitively priced policies that match your company’s priorities.

Many employers consider their staff to be family. A great life insurance policy provides your employees with peace of mind knowing their loved ones are going to be taken care of.

At Health Insurance Consultants Inc., we strive to find group term life insurance solutions that cover your highest priorities – from strong death benefits to low premiums, and everything in between. With over two decades of experience and industry relationships, we negotiate with carriers to get the most competitive rates.

Short term disability assists employees by providing an insurance benefit that offers partial or full income compensation for non-job-related injuries or illnesses that may inhibit someone’s ability to work. This can be for things like a car accident or catching pneumonia. Our team has a lot of experience setting up and implementing these types of plans, so your business can rest assured that its employees’ best interests are safe.
Long term disability insurance is another protection that’s awarded to employees – Should a member of your team suffer from a loss of income because he or she is unable to work due to illness, injury, or accident for a long period of time, then long term disability protections kick in to do the heavy lifting.
Accidental death or dismemberment insurance is a must for any business that puts its employees into high-hazard situations. Usually structured as a rider to an existing health insurance or life insurance policy, AD&D covers the unintentional events on work premises that lead to the death or dismemberment of an insured employee. Handling such high-pressure coverage as this can exhaust even the most experienced HR teams. Our representatives are experts in their field and will ensure that your staff members are provided with the level of protection they need.
Funding-Concepts-3

Health Insurance
Funding Concepts

Small-group health insurance offers medical coverage for businesses with 50 or fewer full-time employees. It provides employers with the opportunity to buy directly from an insurance company by using either a broker, private exchange, or their state’s network. Small group premiums are set by the insurance company, and once set, premiums are non-negotiable and can’t be discounted. Small group plans are community rated which means everyone in a given area pays the same price for their health coverage regardless of the group’s claims experience.

Large group health plans cover employers with 51 or more full-time employees. What makes them different from small group plans is that premiums are negotiated between the employer and the insurance company, usually through a broker or benefit consultant.

This gives larger businesses a bit more flexibility, and can lead to more comprehensive plans at a lower cost. Large group health insurance is medically underwritten at the time of purchase, with rates based on employee participation and prior claims experience. Medical underwriting refers to the process by which a health insurer uses a group’s medical claims history, typically from the last year and in some cases two years, to determine the rates for the upcoming year. In a large group employment situation, employees are not generally asked to fill out a medical questionnaire prior to obtaining coverage.

With a fully-insured health plan, the employer pays a certain amount each month (the premium) to the health insurance company. In return, the insurance company covers the costs of the employees’ healthcare. With a fully-insured plan, there is no additional risk to the employer. The employer knows exactly what their plan is going to cost each year. The downside is if the employees are healthy and don’t use much health care, the employer has spent a significant sum and doesn’t get any of the money back.

Self insured means employers choose this model of funding to pay for health claims from company assets and employee premiums. Self-insurance allows employers to pay only for actual claims, instead of the fixed premiums of fully-insured plans.

There are a lot of different acronyms out there, but basically the below components and options make up a package that allows you to become self funded. 

  • Third Party Administrator (pays claim / runs plan): Basically you’re breaking apart the pieces and then bundling them back together.  A Third Party Administrator (TPA) is going to be the entity that will pay the claims and administer the plan.
  • Provider Network (physician, clinic and hospital discounts): You’re still going to need to have a network. When you go see a doctor or have an event at a hospital, you’re not going to want to pay billed charges. You’re going to want to pay discounted charges that come from having a network.  The network will also protect you from being balanced billed.
  • Pharmacy Benefit Manager (PBM) : You’re also going to want to have a PBM, i.e. a pharmacy benefit manager. PBMs are organizations that secure discounts on prescription drugs.
  • Stop Loss Protection: 
    • Specific Stop Loss (SSL)– 25K to 75K (Employer risk per member): Specific stop loss is basically the maximum risk that an employer takes per covered life under the plan. As an example, a self funded group with 150 lives and a $60,000 risk means the maximum they pay out of their own pocket the first $60,000 of any claim in a calendar year. Then the rest is covered by the insurance carrier. For some groups that are taking that first step into self funding, that may be too big a risk.  As a solution you can actually buy down the specific to $25,000.  This is simply an example of how you can control your risk on large claims.
    • Captive Stop Loss – SSL up to 250K (Captive risk per member): The second layer of stop loss is where the captive comes into play .  You have your company’s specific risk up to $25,000, and then the captive takes the risk from $25,000 up to $250,000. As a result if you have a claim that goes to $50,000, you pay the first $25,000 and the captive picks up the next $25,000.
    • Reinsurance Over 250K to Separate Insurance Carrier:  You want to pass any substantial large claims to an insurance carrier, and the captive as a whole buys protection. Then if you have a large claim, the first $25,000 is your responsibility, and the next $225,000 would be the captive’s responsibility. Anything above $250,000 is ceded to a reinsurance carrier.

A group captive is an insurance company owned and controlled by its shareholders. Typically the shareholders are of similar-sized companies that join together to form a “small insurance company.” The captive, (small insurance company), then buys insurance to protect against large losses and provide policy forms and the “A” rated insurance policy required by most companies. 100% of the underwriting profits and investment income of the captive are distributed to the shareholders/policy owners.
The captive concept is not new. Today, there are over 7,000 captives as more and more business owners exit the traditional insurance marketplace for an alternative to gain ownership and control of their insurance programs.

Who are Captive Candidates?

  • 75 – 300+ Employees
  • Stable Workforce
  • Good Demographics
  • Strategic Long Term Buyer: Moving into a captive or a self funded arrangement is not something that you just try out for a year. It is a commitment. It is something you need to go into with an understanding that you’re moving down this path because there are other things than just pure cost savings you are looking for, such as transparency, access to claims data, and more predictive modeling.
  • Fully Insured and Frustrated with Lack of Control and Lack of Access to Data
  • Historically Good, Stable Claims Experience and Rates
  • Focused on Risk Management with Wellness Intent: Lastly the employers that get into the captive are going to be focused on risk management, and they are good performing groups of individuals. Then we add a wellness program on top to make sure we’re controlling the risk on an on-going basis as well. 

Health Savings Accounts (HSA) are a type of savings account that lets individuals set aside part of their income in order to pay for qualified 213(d) expenses. All money added to this account is free of taxes, and caps out at $3,600 for self-only plans, and $7,200 for family coverage for the 2021 plan year. These limits are adjusted annually.

A Health Reimbursement Arrangement (HRA) is an employer-funded account that helps employees pay for qualified medical expenses not covered by their health plans. Your employer sets aside a fixed amount of money to your HRA each year for you to use. The money is available to you at the beginning of the year. And, based on your employer’s individual plan, funds may roll over each year. An HRA is funded by employer contributions only.

Flexible Spending Accounts (FSA) are special accounts where employees put money in each month, then use it towards the payment of certain out-of-pocket health care costs. This money is non-taxable, and employers may even make contributions, but aren’t required to.

Worksheet Benefits - HIC

Voluntary Worksite Benefits

Critical illness insurance provides employees with another source of support if they are diagnosed with one of the specific illnesses on a predetermined list as part of the carrier’s policy. Usually, once diagnosed, the insurer under contract is required to make a single lump sum payment to the insured individual. This money can go a long way, and is great for kickstarting treatment plans right away instead of pushing employees into debt or delaying treatment for falling under the impact of an unexpected illness.

Hospital Indemnity insurance essentially covers the nooks and crannies that regular health insurance plans may not cover. They are supplemental insurance plans that are purpose-built to assist policyholders with the costs of a hospital visit that may not necessarily be paid for by an existing health insurance plan.
Whole life insurance is an insurance policy that is guaranteed to stay in effect during the entire lifetime of the insured. Compared to term life insurance, whole life can often provide more comprehensive coverage, but usually at a higher premium – since that coverage isn’t temporary. Whole life insurance plans are a fantastic way to care for employees and their families by providing them with an economic safety net should they pass away.
Voluntary cancer coverage (VCC) can be a major worksite benefit that enriches the lives of your employees. Also known as cancer coverage insurance or supplemental cancer insurance, VCC provides additional coverage that’s often beyond what a typical health plan can provide, and is usually available for most types of cancer. Coverage provides qualifying employees with additional funds to help pay for expenses like procedures, doctor visits, and deductibles.
Pet insurance helps provide medical coverage for employee pets. Usually executed on a reimbursement-based model, covered individuals first pay a qualified bill (like taking their dog to the vet), and then submit a claim for reimbursement. Pet insurance helps to lessen the overall costs of veterinary bills – which can get quite expensive. It’s quite similar to human health insurance policies, and depending on the plan, can either partially or entirely cover veterinary expenditures.
COBRA

COBRA Administration

Health Insurance Consultants Inc., provides COBRA expertise paired with an innovative technology platform. Our goal is to ease your administrative burden, fully support your COBRA participants, and reduce employer risk of noncompliance.

Unparalleled COBRA and Regulatory
  • Expertise in handling all aspects of COBRA compliance and administration, including day-to-day implementation, regulatory and legislative changes, and Department of Labor rules and regulations
  • Total commitment to accurate and timely processing of all notifications to help prevent inadvertent extension of coverage, reducing the overall cost of claims
  • Ability to free up your benefits staff to focus on more important issues and avoid the potential. costs associated with noncompliance
Dedicated, Responsive Customer and Client
  • Customized support for unique COBRA administrative requirements in regard to severance, leave of absence, and eligibility reporting
  • Dedicated, experienced Account Managers
  • Dedicated COBRA Call Center for participants

Industry Glossary

A

An organization, made up of a network of healthcare providers that coordinate patient care and provide the full range of healthcare services for patients. Accumulation Period: A specified period during which a covered employee must accumulate eligible expenses to meet the plan’s deductible amount.
The percentage of benefit costs the health insurer expects to pay toward a health plan.  It is based on an average for a population or area, and may not necessarily reflect actual cost sharing
Maximum amount on which payment is based for covered health care services. This may be called “eligible expense,” “payment allowance” or “negotiated rate.” If your provider charges more than the allowed amount, you may have to pay the difference. (See Balance Billing.)
A request for your health insurer or plan to review a decision or a grievance again.

B

When a provider bills you for the difference between the provider’s charge and the allowed amount. For example, if the provider’s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider may not balance bill you for covered services.

C

 A corporate benefits plan where employees are permitted to choose among two or more benefits that consist of cash and certain qualified benefits. Cafeteria plans are also called flexible benefit plans, Flex plans or Section 125.
A plan on a calendar year runs from January 1 – December 31. Items like deductible, maximum out-of-pocket expense, etc. will reset every January 1.
Provision in major medical plans to avoid two deductibles applied to covered medical expenses when expenses are incurred toward the end of one calendar year and sickness or injury continues into the next year.
A health plan with limited benefits, a high deductible, and a generally lower premium.  Available to persons under 30, it provides coverage for unforeseen and expensive illness or injuries.
Consolidated Omnibus Budget Reconciliation Act of 1985. COBRA permits eligible employees and beneficiaries to continue their health coverage for a period of time after it would normally terminate. The continuation of coverage requires the individual to pay a premium.  COBRA applies to groups of 20 or more people.
Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay co-insurance plus any deductibles you owe. For example, if the health insurance or plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your co-insurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount.
A plan on a contract year (also called benefit year) runs for any 12-month period within the year. Items like deductible, maximum out-of-pocket expense, etc. will reset at the plan’s renewal date. For example, ABC Company renews on July 1 every year. The deductible would start July 1 and end on June 30. The deductible would reset every July 1 for ABC Company members.
A process if an individual has two group health plans, the amount payable is divided between the plans so that the combined coverage amounts to, but does not exceed, 100 percent of the charges.
A fixed amount (for example, $15) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service.
Stands for Current Procedural Terminology code and was designed by the American Medical Association as a method to communicate, by a five-digit number, specific medical care, and services. The numbering system covers the majority of recognized medical services a physician can provide and be reimbursed. The CPT code is used to report services on the claim form.

D

For persons with chronic conditions (diabetes, COPD, etc.) it is the coordination of care for the entire disease treatment process, including patient education, inpatient and outpatient care, preventive care, and acute care.
The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay. For example, if your deductible is $1000, your plan won’t pay anything until you’ve met your $1000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services.
Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.

E

Employers with 51 or more employees must offer affordable coverage to its full-time employees or pay a penalty.
An illness, injury, symptom or condition so serious that a reasonable person would seek care right away to avoid severe harm.
A set of 10 benefits including ambulatory patient services, emergency services, maternity and newborn care, hospitalization, mental health and substance use disorder services, prescription drugs, rehabilitative and habilitative services, laboratory services, pediatric services, and preventive care that must be included in a qualified health plan (QHP) for individuals and small groups.
General term for the online marketplace all states are required to have for individuals and small businesses. They serve as an Expedia or Orbitz for the health insurance market, where private insurers can offer health plans.  See also Health Insurance Marketplace and Small Business Health Options Program.

F

A list of prescription drugs covered by a prescription drug plan offering prescription drug benefits. Also called a drug list.
A tax-advantaged financial account that can be set up through a cafeteria plan of an employer that allows an employee to set aside a portion of earnings to pay for qualified medical expenses as established in the cafeteria plan. Money deducted from an employee’s pay into an FSA is not subject to payroll taxes.

G

A complaint that you communicate to your health insurer or plan.
A tax-advantaged financial account that can be set up through a cafeteria plan of an employer that allows an employee to set aside a portion of earnings to pay for qualified medical expenses as established in the cafeteria plan. Money deducted from an employee’s pay into an FSA is not subject to payroll taxes.

H

 A tax-advantaged medical savings account available to taxpayers enrolled in a high-deductible health plan (HDHP). The funds contributed to an account are not subject to federal income tax at the time of deposit.
A tax-advantaged financial account that can be set up through a cafeteria plan of an employer that allows an employee to set aside a portion of earnings to pay for qualified medical expenses as established in the cafeteria plan. Money deducted from an employee’s pay into an FSA is not subject to payroll taxes.
Services to provide comfort and support for persons in the last stages of a terminal illness and their families.
Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be outpatient care.
Care in a hospital that usually doesn’t require an overnight stay.

I

The percent (for example, 20%) you pay of the allowed amount for covered health care services to providers who contract with your health insurance or plan. In-network co-insurance usually costs you less than out-of-network co-insurance.

M

Health care services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.
Program administered by the state’s Department of Medical Assistance Services (DMAS) under The Centers for Medicare and Medicaid Services (CMS). Payments are made for approved healthcare services provided by hospitals, health agencies, and private practitioners for welfare recipients or persons whose income does not exceed maximum limits. Funds are derived on a state-federal shared basis.
A term used to describe the supplies and services provided to diagnose and treat a medical condition in accordance with the standards of good medical practice and the medical community.
Program administered by the state’s Department of Medical Assistance Services (DMAS) under The Centers for Medicare and Medicaid Services (CMS). Payments are made for approved healthcare services provided by hospitals, health agencies, and private practitioners for welfare recipients or persons whose income does not exceed maximum limits. Funds are derived on a state-federal shared basis.
The federally financed hospital insurance system (part A) and supplementary medical insurance (Part B) for the aged created by the 1965 amendment to the Social Security Act.
A person eligible to receive, or receiving, benefits from an HMO or insurance policy. Includes both those who have enrolled or “subscribed,” and their eligible dependents.

N

The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.
A provider who doesn’t have a contract with your health insurer or plan to provide services to you. You’ll pay more to see a non-preferred provider. Check your policy to see if you can go to all providers who have contracted with your health insurance or plan, or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers.

O

The period (usually once a year) during which subscribers in a health plan may have an opportunity to select an alternative plan being offered to them; or a period when uninsured employees and their dependents may obtain coverage.
The percent (for example, 40%) you pay of the allowed amount for covered health care services to providers who do not contract with your health insurance or plan. Out- of-network co-insurance usually costs you more than in- network co-insurance.
The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. This limit never includes your premium, balance-billed charges or health care your health insurance or plan doesn’t cover. Some health insurance or plans don’t count all of your co-payments, deductibles, co-insurance payments, out-of-network payments or other expenses toward this limit.

P

A law with a series of statues that go into effect beginning March 23, 2010 aimed at increasing access to affordable healthcare for most Americans.  Health insurers, healthcare facilities, physicians, individuals, small and large businesses, Medicare, and Medicaid are all impacted by the law.
A health condition (except pregnancy) that was diagnosed and/or treated within six months prior to enrolling in a health plan.
A benefit your employer, union or other group sponsor provides to you to pay for your health care services.
A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the cost.
A provider who has a contract with your health insurer or plan to provide services to you at a discount. Check your policy to see if you can see all preferred providers or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers. Your health insurance or plan may have preferred providers who are also “participating” providers. Participating providers also contract with your health insurer or plan, but the discount may not be as great, and you may have to pay more.
The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly.
The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. The UCR amount sometimes is used to determine the allowed amount.

R

Insurance obtained by a carrier from another company to protect itself against part or all the losses incurred in the process of honoring the claims of members or policyholders. Also referred to as “stop loss” insurance. The coverage may apply to an individual claim or to all claims during a specified period for an individual enrollee.
A financial arrangement that spreads the risk of utilization and cost among the participants generally the insurer, the hospitals, and the physicians. The pool may insure against unusually high utilization and costs. The pool may also provide incentives for controlling utilization and costs.
Deductibles paid under a previous plan that are applied to the deductibles of the current plan.

S

A completely non-insured or self-funded plan is one in which no insurance company or insurance plan collect premiums and assumes financial risk.  Employer groups use self-funded plans where they collect premiums from employees and pay the claims, but contract with an insurer to provide the administrative services.
The portion of the Exchange dedicated to small businesses with 2-50 employees. Businesses with 51-100 employees will be eligible to participate in the SHOP beginning January 1, 2016.

T

An organization that administers healthcare benefits, mostly for self-insured employers. Services may include claims review and claims processing.

U

The maximum amount an insurer will consider eligible for reimbursement under group health insurance plans. Charges are generally based on customary fees paid to providers with similar training and experience in a given geographic area.

V

Voluntary worksite benefits are one of the best ways to attract and retain high-quality employees in a competitive labor market. These are solutions that help employees in numerous ways, with very little (and in many cases zero) cost to the employer.

There are several types of voluntary worksite benefits than employers can offer, these include:

  • Accident insurance
  • Cancer insurance
  • Critical illness insurance
  • Hospital indemnity
  • Identity theft insurance
  • Legal services
  • Pet insurance
  • Retail discounts
  • Concierge services