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A Guide to.....

Health Insurance for Small Businesses

 

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A Guide for Employers With 50 or Fewer Employees

Published by:
The Maine Bureau of Insurance
September 2014

 

 

Paul R. LePage
Governor
Eric A. Cioppa
Superintendent

 

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A Guide for Employers With 50 or Fewer Employees

 

Small employer health insurance is available in Maine from several insurers, both on and off the federally facilitated Marketplace. This publication will help small employers understand their options.

Getting Started

It is a good idea to contact an independent insurance broker who represents more than one health insurance company to help you
shop. That broker can answer questions, evaluate your group’s coverage needs and budget, and provide quotes.

Compare benefits and premiums carefully when considering different plans. In addition to benefits and premiums, service is important to consider; a company providing superior service may be worth some additional cost.

If you need to find a broker, the National Association of Health Underwriters (NAHU) provides a member agent/broker search tool at www.nahu.org/consumer/findagent2.cfm. Another free online tool you can use specifically to find a Marketplace certified broker is
www.enroll207.com/locator/. (The Bureau of Insurance suggests these tools as resources, not endorsements.) Asking a colleague for a referral to a broker they have worked with and can recommend is another option.

Elibibility

A “small” employer has 50 or fewer eligible employees and at least one employee who is not the employer or spouse. Eligible employees are those who work 30 or more hours per week. Under certain circumstances, the employer may opt to consider employees working as few as 10 hours a week as eligible, as well as retired employees. By law, any insurer in the small employer health insurance market must provide coverage to any small employer who applies, as long as a sufficient percentage of eligible employees and dependents participate. The insurer cannot require partici-pation of more than 75% of eligible employees and dependents (if you choose to cover dependents).

Continued Coverage for Dependent Children up to age 26
Under the federal Affordable Care Act (ACA), if your business offers coverage for dependent children, that coverage must be available for adult children up to their 26th birthday. This coverage must be available even if he or she is a student, is married, has their own dependent(s), or files their own taxes. If the plan does not cover dependents, your company does not have to change the plan to cover adult dependents.

If you believe that you are eligible for small group health insurance but have been declined for a small group (or an individual) plan by any of the insurers shown in this brochure, please note the name of the person you spoke to at the insurance company and contact the Consumer Health Care Division of the Maine Bureau of Insurance at (207) 624-8475 or 800-300- 5000 (in Maine only).

Pre-Existing Conditions and Enrollment Periods

Starting January 1, 2014, the Affordable Care Act prohibits pre-existing condition exclusions for new health plans.

An employee or dependent may enroll in the employer’s plan after the employer’s waiting period is met; during the employer’s annual Open Enrollment period; or if and when their existing coverage terminates for one of several reasons specified by law. These reasons include loss of coverage through a spouse’s or parent’s plan (if younger than 26 years) due to death, divorce, termination of employment, or termination of the group plan. Also, when an employee gains a new dependent through marriage, birth or adoption, the employee has a 30 day special enrollment period in which to add the dependent to their plan.

Cost

Rates cannot differ based on gender, health status, claims experience, or policy duration. Rates can vary based on tobacco use, age, and geography. Each employee is rated individually, as are his or her dependents. Each dependent under the age of 21 is rated the same, regardless of their age. Costs for dependents younger than 21 are capped at three dependents. (In other words, providing coverage for more than three children under 21 does not cost any more than providing coverage for three.)

Plans of all types generally have an annual deductible that must be met and paid before benefits begin or before they are paid at the highest level. A coinsurance provision generally requires the insured to pay a percentage of the cost until an out-of-pocket limit is reached. Certain services may only require a co-payment at the time of service (such as a visit to the doctor’s office when sick or injured) while some preventative services will not require any payment by the insured, as outlined by the ACA.

To help cover the cost of premiums, deductibles, cost-sharing and copays, IRS Code Section 125 allows employers to offer their employees some pre-tax options.

  • Employees may make their health benefit plan premium contributions with pre-tax dollars (known as a Premium Only Plan).
  • The employer may choose to set up a fund to include a Health Care Reimbursement Account. Employees are then able to set aside pre-tax dollars to pay for medical expenses that are not covered or otherwise reimbursed. The employee decides each calendar year how much to set aside for that year and funds the account with a pre-tax contribution each pay period. The employee then makes a claim for reimbursement by submitting proof of incurring a qualifying expense. Any money left unclaimed at year end is forfeited. Anyone interested in these types of funds should contact a tax attorney, CPA, or other qualified professional.

The employer my elect to set up a Health Savings Account (HSA) which, unlike a Health Care Reimbursement Account, can carry over from year to year. These investment accounts are combined with high -deductible plans. The employee can withdraw money tax-free from the account for medical expenses. Otherwise, the money accumulates with tax free interest.

The investment account can be funded by the employer, by the employee, or both. The high-deductible health insurance policy must meet standards set in federal tax law. Policies are designed specifi-cally for this purpose. Other high-deductible policies may qualify, but you or your tax adviser should check the federal standards careful-ly to be sure.

What Types of Plans are Available?

Most insurers offer a variety of plans. Plans vary as to the level of benefits that are paid, the provider network that is part of the particular plan, and the extent of managed care provisions. The general types of available plans are:

  • HMO - A “pure” HMO plan requires enrollees to choose a primary care physician from participating doctors. Any non-emergency hospital or specialty care requires a referral from the primary care physician. With a few exceptions, no coverage is provided for doctors and hospitals that are not part of the HMO’s network.
  • Point-of-Service (POS) - This plan is similar to a “pure” HMO plan except that services from non-network doctors or hospitals, or services obtained without a referral from the primary care physician are covered, but at a lower benefit level than in-network care.
  • PPO - A PPO (preferred provider organization) plan is similar to a point -of-service plan. PPO plans usually do not require a referral from a primary care physician in order to receive the highest level of benefits for services received from an in-network specialist or hospital.
  • Indemnity - An “indemnity” or “fee-for-service” plan does not use a provider network. The same level of benefits apply to any doctor or hospital and is generally limited to the “usual and customary” charge for the service. If the doctor or hospital charges more than this amount, the patient is responsible for the extra charge (this is known as “balance billing”).

Companies Selling Small Business Health Insurance in Maine

Small business health insurance plans are currently offered in Maine by the companies listed in the table on the following page. You can compare plan types and rates using the Bureau’s comparison charts, found by clicking on the Small Group Health Insurance Options link on the Bureau’s home page at www.maine.gov/insurance.

For plan-specific questions and additional information please use the phone numbers or website addresses provided in the table. You may also want to contact a local independent broker or agent.

NOTE: Anthem and MCHO offer plans both on and off the federally facilitated Health Insurance Marketplace, so you may purchase them directly from the insurance company, from an insurance agent or broker, or through the Marketplace. For more information about buying Marketplace plans through the Small Business Health Options Program (SHOP) see the back page of this publication.

As always, the plans and rates offered by insurance companies in Maine are reviewed and approved by the Bureau of Insurance. You are welcome to call the Bureau at 800-300-5000 (in state only) or 207-624-8475 with any insurance-related questions. For TTY, please use Relay 711.

NOTE: 2015 offerings will be posted in October of this year.

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2014 Plans By Metal Level Offered By Each Carrier and Network Type

Insurance Carrier
Bronze
Silver
Gold
Platinum
Network Types
On Exchange
Off Exchange

Aetna Life Insurance Co.

(800) 694-3258

www.aetna.com

 

 

 

 

 

 

 

PPO

Indemnity

 

 

 

Anthem Blue Cross Blue Shield

800) 547-4317

www.anthem.com

 

 

 

 

 

 

 

Guided Access HMO (South)

Guided Access POS (North)

Direct Access

 

 

 

 

 

Harvard Pilgrim Health Care

(888) 333-4742

www.harvardpilgrim.org

 

 

 

 

 

 

 

HMO

PPO

 

 

 

Maine Community Health

Options (855) 624-6463

www.maineoptions.org

 

 

 

 

 

 

 

PPO

 

 

 

 

 

 

United Health Care Insurance

(866) 432-5992

www.uhc.com

 

 

 

 

 

 

 

 

POS

 

 

 

 

 

 

 

Last Updated: September 26, 2014