Benefits and Coverage of Health Insurance

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Employers in small, medium and large businesses face a challenge in putting together a healthcare compensation plan that meets the demands and desires of their workers while still meeting organizational capacity (Kongstvedt, 2012). There are several choices to choose from when it comes to health insurance. As a result, employers tend to select carefully, taking into account various aspects of and choice. From a business standpoint, it is clear that healthcare costs are continuing to grow, and companies should carefully choose suitable health insurance options while still attempting to keep prices low as premiums rise. This proposal includes detailed guidelines for medical insurance benefit coverage for small, medium, and large groups. Small Group Company Health Insurance Benefit Coverage
Small group company employees according to the law offer health insurance for their employees and their dependents working for 30 hours or more per week. Small group employers are required by most insurance companies to have 75% of their full-time employees to have an insurance plan, and they offer this cover for the whole year (Texas Department of Insurance, 2017). The following encompasses the various aspects that small group company employers should examine when considering health insurance benefits and coverage for its employees.
Selection of Health Insurance Plan
Employers for this organizational size should identify and examine the required plan which entails health benefits that are essential to cover specific services. The essential health insurance benefits may include outpatient care exclusive of hospital admission, surgery and hospitalization, emergency services, maternity care, laboratory services, vision and oral care as well as other pediatric services, prescription drugs (Texas Department of Insurance, 2017). Other plans include machines and services assisting persons with disabilities, injuries, recovery from physical and mental skills, services pertinent to substance abuse and mental health which constitute psychotherapy and counseling; disease management, wellness and preventive services (Kongstvedt, 2012). Employers should study laws and regulations under these plans for health insurance such as specific disease policies and indemnity to satisfy all the requirements.
It is important for employers to provide a more than a month period for new employees to register for health insurance plan.The enrollment of coverage notably depends on the time limits provided by the insurance companies. Employees may be required to consider a period of up to three months after enrolling in a plan for the commencement of the coverage. Insurance companies are at liberty to limit or deny coverage to employees with the current conditions (Texas Department of Insurance, 2017). Regarding continuing coverage, it is important for employers to determine whether to keep the coverage of employees after terminating their contracts.
Therefore, employees should be explained regarding their rights of coverage continuity. Employees wishing to continue their coverage should cover the full cost of their plans. On the payment of premiums, small group companies are not required to pay any portion of the employee health insurance premiums, but they may be needed to pay up to 50%.
Small-group Companies Employer Health Insurance Plan Premiums
Employers underlying this category should select insurance companies that consider pay for insurance based on benefits as well as cost-sharing levels. The recommendable insurance company for small-employers is those that have their rates not affected by the employees’ health status (Texas Department of Insurance, 2017). Suitable health insurance companies should have favorable terms on pertinent to the employee’s age, the tobacco use, and the geographical location of the organization.
Coverage Consideration
Smaller-group employers should have an in-depth understanding of the coverage which is essential for making a comparison of rates and plans. It is important to note that health insurance plans with higher copayments, the share of employee co-insurance and deductibles have lower premiums (Texas Department of Insurance, 2017). Therefore employees may be required to pay more to access the underlying services. Also, it is important for employers to understand the difference between the employee health coverage and the worker's compensation insurance. Workplace injuries and accidents are usually excluded by most medical insurance benefits coverage plans.
Medium Group Company Health Insurance Benefit Coverage
There are recommendations for medium size organization for controlling the increasing cost of healthcare. The first step is to analyze and review their employee benefits program to determine whether to reduce or eliminate some benefits offered to employees (Morrow, 2009). It is important to determine whether to split the costs of premium between the employees and employer, increase copayments or deductibles to ensure that the adopted health care insurance benefits and coverage plan are feasible to the organization (Iglehart, 2009, p. 32).
Employers should consider offering incentives for opt outs where they may offer rewards for employees who have health insurance plans through spouses plan and thus opting out of employer paid benefits. Employees are convinced to sign a waiver that assures the employer confirming that they have health coverage from other sources. Sharing the cost of the insurance premium is also recommended for medium-group companies where companies increase the monthly premiums proportion of employees thus increasing the deductibles (Morrow, 2009). This strategy will assist the employees to value their health insurance plans while reducing the cost of premium as deductible increases (Morrow, 2009). This option, however, requires the employers to notify their employees in advance in case there is additional cost required. Another recommendation pertinent to the medium-group companies is to establish health savings account for their employees. This saving account should be tax-free for medical expenses allowing employers to develop high-deductible insurance benefits and coverage. The accumulated amounts over the years may be used to reimburse tax-free at the same time qualifies for medical expenses (Morrow, 2009). The underlying savings account lowers the costs for medium-group organizations offering health insurance benefit and coverage for their employees. It also helps employees working in medium-group companies to acquire high-deductible insurance plans.
Another recommendation entails the provision of incentives for healthy behaviors to counter increased health insurance premiums due to increased utilization. Medium sized organizations can reduce health insurance and coverage benefits cost by promoting healthy living among their employees. This recommendation should be complimented with offering rewards to employees who are willing to undertake programs such as fitness programs, smoking cessation, and stress management (Kongstvedt, 2012). The final recommendation pertinent to medium sized companies’ employers regarding health insurance plans is periodical shopping of appropriate plans.
It is therefore important for companies to periodically to annually shop for an affordable health insurance plan to complement other options such as premium sharing, offering health saving accounts and purchase of higher deductible plan to lower the cost of health care (Morrow, 2009). Thus, companies and organizations should review their health insurance benefits and coverage plans annually. The underlying recommendation can be achieved through exploration of different quotes from various insurance companies to ensure that employees are given a price competitive and quality insurance plan.
Larger Group Company Health Insurance Benefit Coverage
It is evident that there are many health care insurance benefits and coverage options for employers and employees under this category. The most commonly preferred health care benefits and coverage include the preferred provider organizations and health maintenance organizations (BizFilings, 2017). The most recommended health care insurance options for larger groups include the following.
Health Maintenance Organizations
This health care plan is popular among the larger-groups attributed to its tendency of reducing costs and its broader health coverage. The insurance company contracts hospitals, doctors, and physicians to offer health care services to its insureds. The underlying health care insurance benefits and coverage option is suitable because it offers a broader coverage as a whole. It is also evident that it provides more comprehensive coverage of different levels of copayment and deductibles thus assists in striking an appropriate balance pertinent to co-sharing between the employer and the employees (BizFilings, 2017). This health insurance plan provides a cover for preventive health care thus facilitating affordability of the scheme among the employees. For employees preferring the choice of physicians then they can pay more for HMO.
Fee-for-service Health Insurance Plans
This health insurance benefits and coverage plan also referred to as indemnity plan allows the employees of a company to have freedom in selecting medical facilities as well as doctors and physicians. Regarding this scheme, it is evident that the insurance companies require that the employees pay an annual deductible, and after the payment of the deductible then the insurance company pay at a determine coinsurance rate. Mostly the coinsurance is 70%/30% or 80% / 20% in which the insurance company covers the higher percentage.
The underlying insurance plan is considered expensive but it is preferable for larger organizations who may want to allow employees to choose their medical services, and avoid the limitations of copayments and deductibles (Iglehart, 2009, p.1035).This option is suitable for employers’ who pay well their employees, have employees with chronic health conditions and they can afford to pay higher premium payments and deductibles.
Preferred Provider Organizations
This recommended type of health insurance plan for larger groups is suitable for employers who do not expensive prefer fee-for-fee plans but want more choices than those offered by HMO. Regarding this medical insurance plan, the insurance company contracts specific hospitals or physicians as well as preferred providers to provide health care services to the employees insured (BizFilings, 2017). This healthcare insurance plan is suitable for a larger group size of companies because health care costs can be easily controlled and management measures monitored thus benefiting both the employers and the insurance company.
This healthcare insurance plan requires the employees to pay for health care services with copayments, and they receive higher coinsurance amount (BizFilings, 2017). It is also recommended for employers and employees for larger organizations who may exceed the deductible amount hence making employees realize the value of the health care benefits and the cover plan they have purchased.
Major Medical Plans
This health insurance plan is preferable for larger organizations employees and employers in need of protection against catastrophic injuries, and long-term chronic diseases and illness. It is evident that this type of health insurance has a higher deductible as well as coinsurance requirements but has many benefits over other health insurance plans. There are two types of major medical plans which include the comprehensive plans and the supplemental plans. The comprehensive major medical plan offer cover for similar health care services as many other plans (BizFilings, 2017). The underlying recommended scheme is inclusive of deductibles and copayments requirements and in some policies may constitute full coverage with no deductible. The supplemental major medical plan is also recommended as it covers services such as inpatient and outpatient health care, outpatient psychiatric care, special nursing care, medical appliances and outpatient prescription drugs. This plan constitutes copayment requirements, set deductible and sometimes limitation of benefits. Other recommended health insurance plans for larger group organizations include dental and vision care plans.
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BizFilings. (2017). Health Care Insurance Plan Options for Employee Benefits. Retrieved August 17, 2017, from
Iglehart, J. K. (2009). Health Insurers and Medical-Imaging Policy — A Work in Progress. New England Journal of Medicine, 360(10), 1030-1037. doi:10.1056/nejmhpr0808703
Kongstvedt, P. R. (2012). Essentials of managed health care. Jones & Bartlett Publishers.
Morrow, S. (2009, December). Health Insurance for Your Employees: How can small to medium sized businesses offer health benefits to their employees without breaking the bank?| August 17, 2017, from small-to-medium-sized-businesses-offer-health
Texas Department of Insurance. (2017, June). Small Employer Health Insurance. Retrieved August 17, 2017, from

August 31, 2021

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