Groups & Businesses

The amount you typically pay for office visits, laboratory tests, X-rays and prescriptions. After you pay the copay for these services, the insurance company typically pays the remainder. There are different copays and limits for out of network care, so try to stay in network whenever possible.

What is an Out of Pocket Maximum (OOP)?

This is the maximum amount you could be required to pay out for claims incurred during any calendar year, provided that you are only using in-network services. The maximum is considerably higher if you use non-network services, so try to stay in the network.

What happens if use providers who are not in my network?

In some plans, these providers are not covered at all. In other plans, they are covered to a much lower level. It is highly recommended not to go out of network if at all possible. If you must see an out of network provider for an emergency issue, this would be paid as an in-network expense.

What happens if I don't have control over who treats me in an emergency situation? For example, an ambulance, anesthesiologist or an assisting surgeon in an emergency room?

These claims will often be declined or considered as out of network. Please use our services to help you attempt to get reimbursement on an in-network basis. We have a good track record with helping sort out claims problems, although we cannot guarantee this will always work out.

Why do I need to buy insurance, anyway?

There is a requirement under the Affordable Care Act, frequently referred to as Obamacare, that all legal residents of the USA have coverage compliant with the new plan requirements. There are tax penalties for deciding not to purchase insurance. For members with coverage starting in 2015, this is 2.0% of your overall income, or $295, whichever is larger. For coverage beginning in 2016, the penalty will be 2.5% of your overall income or $695, whichever is larger.

Does it matter if I have a pre-existing health condition?

No. Under the Affordable Care Act, there are no health questions asked and no effect on rates if you have a condition.

How much do I as the employer have to pay towards the costs of the insurance premiums for my employees?

If you choose to set up a company plan, you are typically required to contribute at least 50% of the lowest-cost plan you implement. You are free to put in multiple plans (the number of plans will vary depending on the size of your company) and allow staff to customize their plan choice and pay any difference in premium as pre-tax payroll deductions.