Group Dental

Oral health is often considered the runner up behind medical benefits since proper hygiene can help prevent medical complications.

Group dental policies provide employees immediate access to benefits since most exclude waiting periods for services if there are a minimum of 10+ employees.  If there are waiting periods for certain services, they may be waived with proof of prior coverage.

All preventive services such as oral exams, x-rays, and bi-annual cleanings are covered at 100%.  Pediatric dental is embedded in all medical policies, meaning minimum essential care is available to children age 18 and under within their medical policy.

Dental policies are defined by their annual maximum, copays, network, MAC vs. UCR coverage, age limits,  and additional riders such as orthodontic coverage.

  • Annual Maximum: This is the dollar amount that you are entitled to receive as a benefit in any calendar year. The benefit resets every January, and it would also reset should a group switch carrier’s mid-year.
  • Copays: This is the dollar amount associated with your dentist visit, and will vary between in-network and out-of-network.
  • Network: Each carrier is contracted with x number of dentists. If your dentist is contracted with the carrier, they have agreed to a predetermined cost structure and would be considered in-network.  If your dentist is not contracted with the carrier, your serves will be deemed out-of-network and will end up costing you more.
  • MAC – Maximum Allowable Charge. When visiting an out-of-network dentist, each service has a predetermined cost associated to it, you would be liable for anything above said cost.
  • UCR – Usual, Customary, and Reasonable. This coverage structure is accompanied by a percentage, typically ranging from 80-95% which means the allowable benefit is accepted by X% of dentists in your location.  It is still possible to find a dentist that charges more than what is UCR in your area, for which you will be liable for the difference.
  • Age Limits – This is typically associated with Orthodontic coverage. Some plans may only cover children up to the age of 19, whereas others may cover up to the age of 26.

While the information above covers most dental definitions in a nutshell, we look forward to simplifying the purchasing and claims process even further when the time comes.

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(HSA) Health Savings Account – Eligible Medical Policies

As insurance premiums continue to rise, you may find yourself exploring coverage options you may not have considered in the past.  One of which is an HSA eligible policy that has risen in popularity over the years for multiple reasons.    Health Savings Accounts are associated with high deductible health plans – a plan with an annual deductible no less than $1,300, and an annual out-of-pocket maximum not to exceed $6,550; the overall cost of an HSA eligible policy can be less than other plans, while it still provides you with the same catastrophic coverage. Health Savings Accounts allows the account holder to pay for current health care expenses and save for those in the future.  Payments towards qualified medical expenses are withdrawn tax-free, and interest earned on deposits also accrue tax deferred.  Funds roll-over each year, and the account belongs to the individual and follows the individual throughout his/her career.  An HSA eligible policy can be purchased on both the individual and group marketplace, providing full flexibility. Contributions are tax-deductible or are deducted directly from payroll pre-tax. Employers may also offer to contribute towards an HSA, and contributions are excludable from an employee’s income and are not subject to federal income tax, Social Security or Medicare taxes.  In addition, employer contributions are deductible as a business expense to the company.  Employers may choose to contribute a set amount or make ‘matching’ contributions.  The IRS sets annual limits on the amounts that may be contributed to the HSA.  If funded from both the employer and employee, it is important to ensure that the total contributions remain within the annual IRS...

Small Group 51-100 Transition

As of January 1st, 2016 the definition of small group has been expanded to include groups with 51-100 full time equivalent employees.  For groups that will be making the transition, the changes are significant and should be reviewed in detail with a small group specialist.  Since 70-80% of renewals will take effect in Q4 of 2016, it is imperative that you consider all options as soon as possible to familiarize yourself with the new ACA mandates. Rating Regions – Large group rating regions vary by each carrier. Small group consists of 19 regions that are standardized for all carriers. Rating Structure – Large group rates are composite (same rate for each member) and are generated based on the average of employee ages, tiers, genders, and zip codes. Small group rates are determined on a member level based on employer location, where employees and dependents are rated independently.  While age bands can vary by carrier, you will typically see the same rates for age 0-20, one band for each year between 21-63, and one band for age 64+.  Dependents under the age of 21 will be rated individually, up to 3 children. In addition, the ACA has imposed a 3:1 ratio for small group rates.  The rate difference between the youngest to oldest may not exceed a 3 to 1 ratio. The biggest rate increases will hit groups with good medical and SIC risk, and employees with dependents age 20+.  Conversely, young employees may experience rate decreases. Carriers release one set of rates and all groups receive the same standardized rates based on the enrollee’s age.  Rate negotiations are not...