Benefit Plan Package
Eligibility
EMPLOYEE ELIGIBILITY
•Affordable Care Act requires that full time employees working 30 or more hours per week be eligible for health insurance
•New Hire Waiting Period (NHWP): The amount of time a new employee must be employed before they are eligible for coverage
•Cannot exceed 90 days for health insurance as required by the ACA
•Common NHWP’s include:
•Date of Hire
•First of the month following date of hire
•First of the month following X number of days (30 or 60)
•X number of days (30, 60, or 90)
DEPENDENT ELIGIBILITY
• You may also enroll eligible dependents for benefits coverage.
•A ‘dependent’ is defined as the legal spouse and/or ‘dependent child(ren)’ of the plan participant or the spouse.
•Domestic Partners – You can request the carrier to allow coverage for Domestic Partners
Dependent Children could include:
• Natural child & step- child
• Adopted child, child of which you have legal guardianship for
•Medical – dependent children are eligible until age 26 (26th birthday, end of the month of 26th birthday, or end of the year the child turns 26)
•Dental & Vision typically follow suit for dependent children, until age 26
•Voluntary coverages are typically age 19, or 25/26 if full-time student
QUALIFYING EVENTS
After an employee's opportunity to make an election as a new hire or at open enrollment, they cannot make changes to their elections unless they have a QUALIFYING EVENT. Common Qualifying Events listed below, please note, there are additional events that may allow for a mid-year election change.
Qualifying events discussed in this presentation are dependent on an Employer's plan design and what types of qualifying events are permitted.
Medical/Rx
Components of a Medical Plan
Funding Arrangements
Funding Arrangements – Fully Insured
Funding Arrangements – Self Funded
What is Stop-Loss Insurance?
What are Administration Costs?
Plan Types/Networks
Plan Flow
Traditional Plan
HDHP/HSA Plan
Dental
Dental Plan Example
EXAMPLE of a typical plan is shown – This indicates how much the insurance company will pay based on service
Variations can occur – What is considered Basic and Major can vary between plans.
This is not inclusive of all covered dental services. Coverages are subject to applicable Deductible and Annual Maximum.
Vision
Vision Plan Example
EXAMPLE of a typical plan is shown – This indicates how much the insurance company will pay based on service.
This is not inclusive of all covered vision services. Coverages are subject to applicable Deductible and Annual Maximum.
Life / AD&D
Life/AD&D Common Terms
Disability
Short Term Disability (STD)
Short-term disability insurance can provide monthly payments if you are too sick or injured to work. You can expect to receive about 40% to 70% of your monthly income until you are able to return to work or until the end of your benefit period — whichever comes first. Benefits typically last three to six months. Unlike health insurance, disability payments are paid directly to you, and you can use them however you like.
Long Term Disability (LTD)
Long-term disability insurance covers a portion of your income if you are too injured or ill to work for an extended period of time. Your benefits will typically last anywhere from five, 10 or 20 years or up until retirement age. The benefit amount could be anywhere from 60% to 80% of your monthly salary. The typical elimination or waiting period for long-term disability insurance is anywhere from 90 days to a year, depending on the insurer and the plan.
Sample Disability Timeline
Disability Insurance Common Terms
Worksite
Health Savings Account (HSA)
The Health Savings Account (HSA) allows you to set aside pre-tax dollars to pay for eligible expenses. By contributing to a HSA you reduce your taxable income, so you pay less in taxes — which saves you money.
Flexible Spending Accounts (FSA)
The Flexible Spending Account (FSA) allows you to set aside pre-tax dollars to pay for eligible medical and/or dental and vision expenses. The nice part about an FSA is you have access to the full annualized amount on day one!
The election you make cannot be changed throughout the year unless the change aligns with the qualifying event. For example, if you get married, you can increase your contribution, however, you cannot decrease or end your FSA for this type of life event.
There are three types of FSA options:
1. General Purpose FSA: To pay for qualifying medical, dental, and vision expenses. This type of FSA is only available if you do not have an HSA.
2. Limited Purpose FSA: To pay for qualifying dental, vision, and post-deductible medical expenses. This type of FSA is available for those who have an HSA.
3. Dependent Care FSA (Reimbursement Account): Allows you to set aside pre-tax dollars to pay for eligible dependent care expenses. Qualifying expenses include daycare, nursery & preschool tuition, summer day camps, and more! The election you make cannot be changed throughout the year unless the change aligns with the qualifying event. For example, you can increase your contribution if you add another member to your family through birth or adoption, however, you cannot decrease your contribution for this type of life event.
COBRA
The Consolidated Omnibus Budget Reconciliation Act (COBRA) gives workers and their families who lose their health benefits the right to choose to continue group health benefits provided by their group health plan for limited periods of time under certain circumstances such as voluntary or involuntary job loss, reduction in the hours worked, transition between jobs, death, divorce, and other life events. Qualified individuals may be required to pay the entire premium for coverage up to 102% of the cost to the plan.
COBRA generally requires that group health plans sponsored by employers with 20 or more employees in the prior year offer employees and their families the opportunity for a temporary extension of health coverage (called continuation coverage) in certain instances where coverage under the plan would otherwise end.