An Anthem Blue Cross Exclusive Provider Organization (EPO) Medical Plan offers you and your employees access to some of Stanislaus County’s foremost medical care providers: AllCare IPA, Doctor’s Medical Center, Memorial Medical (Sutter), and Sutter Gould. Ask your broker how much your business and employees could save with an Anthem EPO.
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If your Fresno County business is looking for an affordable health plan with outstanding doctors and hospitals, you’ll want to know about the Exclusive Provider Organization (EPO) Medical Plan from Anthem Blue Cross. It gives your employees access Santé Health, Saint Agnes Medical Center, Clovis Community, Fresco Surgical, and others. Ask your broker just how affordable Anthem’s EPO can be.
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If you’re looking to change your current health insurance benefits for employees – or you’re considering offering health insurance benefits to employees for the first time – there are some key questions you need to ask as you investigate options for your business.
How can I control my health care costs?
One reason employers like private health insurance exchanges is Defined Contribution, which gives you the ability to set the amount you want to spend on health benefits for your employees each year. You can choose to contribute either a fixed dollar amount or fixed percentage of the insurance premium for your employees – for example, 50% of the lowest-cost plan option. Whatever amount you choose to contribute, that dollar amount is locked in for 12 months, giving you complete control over what you’re spending. If an employee selects a health plan that costs more than your generous contribution, he or she simply pays the different.
What kind of benefits should I offer my employees?
Your employees are all different and have unique needs, which makes it difficult to find a single benefit type that everyone loves. Our recommendation is to find a program offering your employees a variety of different benefit types, like HMOs, PPOs, and Health Saving Account-compatible plans. This way your employees have a selection and can find a benefit plan that makes sense for their individual or family needs.
Can I offer multiple health insurance plans?
Similar to offering different benefit plan types, like HMO or PPO options, offering a selection of different health insurance plans can also be beneficial. As the employer, you have the option to offer a single health insurance plan or to work with a program like CaliforniaChoice, which packages seven different health insurance plans into one program. This means instead of having your employees choose from one option, they instead get to choose from:
- Anthem Blue Cross
- Kaiser Permanente
- Health Net
- Sharp Health Plan
- Sutter Health
- Western Health Advantage
Health Insurance only? Are there other benefits to consider?
As an employer, you can build an employee benefits portfolio that includes just health insurance or more; it’s up to you. Many businesses offer additional benefits like dental, vision, life – even chiropractic and acupuncture! It really depends on what you want to spend. It’s also important to take into consideration how you manage different types of options. For example, you can work with a health, dental, vision, and life carrier independently, or you can work with a private exchange like CaliforniaChoice where these types of options are available and bundled into one program, making it much easier to manage.
What about administration – will it be a lot of work for me or my staff?
When comparing carriers, ease of administration is important. Maybe you’re worried about how much time you’ll spend administering all of your employees’ coverage. If you offer multiple plans, or plans from different carriers, does that mean multiple bills to pay each month? It doesn’t with a multi-carrier private exchange. If your business has 10 employees, it’s possible to offer them a range of health plans and still get just one bill for all of their coverage. And making changes throughout the year is easy, too – with one phone number and one website for assistance.
One Final Consideration…
Choosing the right health insurance and benefits partner is important. If you don’t already have an employee benefits broker, we can help you find a CaliforniaChoice broker to speak with about health insurance for your business and your employees.
An Anthem Blue Cross Exclusive Provider Organization (EPO) Medical Plan offers you and your employees access to some of the region’s foremost medical groups and facilities: Palo Alto Medical Group, Physicians Medical, Stanford Health Care, Good Samaritan, O’Conner Hospital, Sutter Health, and others. You’ll appreciate the fact that there’s an Anthem Blue Cross EPO facility close by whenever you need health care.
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If you’re a small business owner or manager, you’re probably used to making important decisions. But when it comes to employee benefits and health insurance, you may not be an expert. That’s why it could be advantageous – to you and your business – to use a broker. Below are four reasons why engaging a broker when shopping for employee benefits is worthwhile.
Just like with an attorney or a CPA who provides you with professional counsel based on years of experience and training, a broker can provide you with guidance on employee benefits and health insurance. He or she will answer your questions and sort out all of the industry jargon which can be confusing and, perhaps, a little overwhelming. An independent broker is just that, independent, so you can expect that he or she will work to find you the best-available plan for your organization, your employees, and your budget. And, a broker can help you evaluate “extras” that might be available, such as optional coverage (like Dental or Vision), online enrollment, or other services (like a Flexible Spending Account, Premium Only/Section 125 Plan, COBRA services, etc.).
2. No Cost
Contrary to what you might think, using a health insurance broker doesn’t cost more. In fact, it may be less expensive because an experienced broker will have the expertise and the technology to help you find the most competitive benefits for your company, while also ensuring you and your employees have access to the doctors, hospitals, and other health care providers you want. (Brokers are paid a commission by the insurance companies or health insurance exchanges they represent, so you typically won’t pay an added fee for a broker’s services.)
Using a broker frees you up to focus on what you need to do: manage your business. A broker will have the knowledge, experience, and resources to quickly research the options available to your group and to present you with the “pluses and minuses” offered by each of the carriers and plans being presented. He or she may also offer online tools and resources, such as those available through California’s leading private health insurance exchange. The CaliforniaChoice exchange, for groups of up to 100 employees, delivers a “Smart Decision Technology” suite that includes an Automated Choice Profiler, which gives your employees the power to compare plans not just based on their premium, but also on doctor availability, affordability, and expected plan use. CaliforniaChoice also offers online enrollment, which reduces processing time, and online search tools for providers and prescription drugs – so enrolled or enrolling employees and dependents know who’s included and what’s covered before selecting a plan or visiting a health care provider.
4. Peace of Mind
When you shop and compare employee benefits plans with help from a broker, you can take significant comfort in knowing your broker will be working on your behalf – and in your best interests – to find the plan that best matches the needs of your business and your employees. It’s your broker’s responsibility to ensure you get the coverage you want at a price you can afford. Health insurance is – and likely will continue to be – a complicated topic, and it’s your broker’s role to understand it and help you and your employees get the most for your premium dollar. He or she will also work with you and the insurance company if there are claims-related issues that come about later – helping to ensure the best-possible outcome for you and your employees.
To learn more about all of the options available to you and your employees, talk with your health insurance or employee benefits broker. If you don’t already have a broker, we can help you find a CaliforniaChoice broker in your area.
Employers in the Sacramento Valley who select an Exclusive Provider Organization (EPO) Medical Plan from Anthem Blue Cross for their employees’ health care can get access to some of the region’s leading providers: Hill Physicians, Mercy Physicians (Sutter Health), Dignity Health/Mercy, NorthBay Healthcare, and UC Davis Medical Center. Ask your broker about the savings an EPO offers.
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An Anthem Blue Cross Exclusive Provider Organization (EPO) Medical Plan offers you and your employees access to some of the region’s foremost medical facilities: Brown & Toland, Mills-Peninsula, Palo Alto Medical Foundation, Alta Bates, El Camino, UCSF Benioff Children’s Hospital, and others. Wherever you are in the Bay Area, you’ll appreciate that there’s an Anthem Blue Cross EPO facility close by when looking for care.
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Health care is complicated – and it seems like it’s becoming more complicated every day. As you consider health insurance coverage options for your business (and yourself), it might be useful to have a glossary of frequently used insurance- and medical-related terms.
What follows is not a full list of the terms you and your employees might encounter; rather, it’s a list of frequently used words and phrases you may encounter in your health plan literature or your health insurance policy. Keep in mind, these are general definitions; your health plan or insurer may define something in a slightly different way. When in doubt, always check your policy or ask your health plan for information.
Affordable Care Act; also referred to as the Patient Protection and Affordable Care Act (PPACA); the federal health care reform law enacted by Congress in 2010 to establish creation of an American Health Benefits Exchange (AHBE) and Small Business Health Options Program (SHOP) Exchange. See related entries below.
Annual Enrollment Period; that time of the year when an annual enrollment takes place – for example, for 2017, the AEP for the ACA was November 1, 2016, through January 31, 2017. The expected open enrollment period for the ACA for 2018 is November 1, 2017, through December 15, 2017, based on an announcement from the Centers for Medicare & Medicaid Services in May 2017.
American Health Benefits Exchange; refers to the health care exchange established under the Affordable Care Act (ACA) enacted by Congress in 2010 (see related entry above), under which lower-income individuals earning between 133% and 400% of the Federal Poverty Level can access sliding-scale tax credits and cost-sharing subsidies toward the purchase of health insurance coverage.
Administrative services only. A relationship between an insurance company or other management entity and a self-funded insurance plan or group of providers in which the insurance company or management entity performs administrative services, such as billing, premium collection and submission, etc., and does not assume any of the risk with the insurance operation (the plan bears the financial risk for all claims).
This refers to the practice when a health care provider (like a doctor, hospital, or outpatient facility) bills a health plan member for the balance of the amount due on services provided. This amount is the difference between the actual amount billed and the amount allowed by the health plan. For example, if the provider charge is $200 and the amount allowed by the member’s health plan is $120, the provider may “balance bill” for the remaining $80. This often happens when a member visits an out-of-network (or non-preferred) provider.
This is a request for payment made in connection with a health care expense reimbursement. It can be made to the health plan/health insurer by a health plan member or a health care provider for services or items that are (or are expected to be) covered under the plan.
Refers to the Centers for Medicare & Medicaid Services, a federal agency responsible for Medicare, Medicaid, and children’s health, survey, certification, and quality improvement as well as implementation of the ACA; CMS is an agency within the U.S. Department of Health & Human Services (HHS), under the leadership of the Secretary of HHS, who serves as one of 15 members of the President’s Cabinet.
Consolidated Omnibus Budget Reconciliation Act; refers to the federal act that established a continuation of coverage option for employees (and their dependents) when group health insurance plan coverage ends (due to voluntary or involuntary termination); applies to employers with 20 or more employees; coverage for employees can be extended for up to 18 months, while coverage for dependents can be extended for up to 36 months; COBRA premiums are the sole responsibility of the insured person(s).
A Consumer Operated and Oriented Plan; a new type of private, nonprofit, consumer-governed health insurer offering access to qualified health plans through health insurance exchanges; established under the guidelines of ACA; CO-OP profits must be used to lower premiums, while improving health outcomes through quality of care and expanded coverage for members.
This refers to an insured member’s percentage share of the costs of health care services (ranging from 10% to 40%, depending on the metal tier of plan you select). Under the ACA, there are four tiers of coverage – Platinum, which pays 90% of the costs of covered health care services, while the member pays 10%; Gold, which pays 80% of the costs of covered services, while the member pays 20%; Silver, which pays 70% of covered services, while the member pays 30%; and Bronze, which pays 60% of covered services, while the member pays 40%.) You generally pay your coinsurance percentage plus any deductible. After your deductible is satisfied annually, you continue to pay your coinsurance amount for covered services throughout the plan year, up to your total out-of-pocket maximum.
A fixed amount (for example, $25) that you must pay when receiving covered health services. The amount can vary based on the type of covered services provided.
Your share of the costs for health care services; also referred to as your out-of-pocket costs, which includes your coinsurance amounts, annual deductible, and copayments.
This is the amount you must pay before your health plan begins to pay. An overall deductible applies to all – or almost all – covered services and items. Separate deductibles may also apply to some services. (As an example, if you have a $500 deductible, your health plan will not pay for any covered services until you have first paid your deductible.)
To learn more about the ABCs of health insurance, and what you need to know when considering health insurance for your business and employees, talk with your employee benefits broker. If you don’t already have a broker, we can help you find a CaliforniaChoice broker to speak with about the plans and choices available in your area.
As we mentioned in our prior post on this topic, health care is complicated. As you consider health insurance coverage options for your business (and yourself), it might be useful to have a glossary of frequently used insurance- and medical-related terms.
What follows is Part 2 of our glossary of health care and insurance terms. This is not a full list of what you and your employees might encounter; it is, instead, a list of frequently used words and phrases used in health plan literature and health insurance policies. Keep in mind, these are general definitions; your health plan or insurer may have a slightly different definition. When in doubt, always check your policy or ask your health plan for more information.
Elect Open Access; an HMO health plan with the added freedom to self-refer to any of the PPO providers in the insurance company’s network of doctors for exams, evaluations (perhaps for a second opinion), and other professional services for a slightly higher copayment.
Explanation of Benefits; sometimes also referred to an Evidence of Benefits or an Explanation of Coverage (EOC); a booklet or letter from the insurance carrier explaining to the insured person (or his covered dependent) the benefits under an insurance plan.
Evidence of Insurability; proof of a person’s physical condition that impacts their acceptability for health, life, or disability insurance.
Exclusive Provider Organization; similar to an HMO (see below), an EPO provides benefits only if care is rendered by a health care provider within a specific network (this exclusivity provision may be waived for emergency situations); some carriers/plans also use the “EPO” designation for their “Extended Provider Organization” and “Exclusive Panel Option” network participants.
Employee Retirement Income Security Act; this 1974 federal act requires persons involved with pension funds to have fiscal responsibility to ensure that investments are made with care and prudence, and that all investments are diversified to minimize risk. Self-funded medical plans are also covered under ERISA provisions. ERISA has strict rules on reporting and various notification requirements to participants. This act also created an insurance program to protect and guarantee benefits for individuals in the event their employer-sponsored fund fails or is terminated.
Each health insurer and plan has a drug formulary for covered prescription drugs. The formulary includes whether a drug is covered by the plan and the cost sharing for the drug, which may differ for generic and brand-name drugs.
Flexible Spending Account; established under the Internal Revenue Code, Section 105 (see related “Section 105” entry below); employee contributions to an FSA are intended for reimbursement of qualified health care-related expenses.
High deductible health plan; a health insurance plan with a lower premium and higher deductibles; coverage under an HDHP is a requirement for having a health savings account (see “HSA” definition below); some HDHPs also offer added “wellness” benefits, which may be subject to its own co-pay or deductible.
Short-hand reference to a health maintenance organization, a type of managed care organization providing health care through a network of physicians, hospitals, and other health care providers contracted directly with the HMO.
Health Reimbursement Account or Health Reimbursement Arrangement; established under the Internal Revenue Code, Section 105, an HRA is funded by an employer to reimburse employees for qualified medical expenses; it contrasts with a Health Savings Account (see below) and Flexible Spending Account (see above), which are both funded by employee contributions.
Health Savings Account; set up by employee to fund qualified health care-related expenses, HSAs were introduced in 2003 to help employees pay health-related expenses not covered under a high deductible health plan.
Shorthand for Health Care Service Plan, a HMO-like plan offered through select networks (such as Health Net’s PureCare HSP network) for individuals who want to be able to see any participating physician or health care professional without first obtaining a referral (as required with most HMOs).
Your co-insurance amount when you receive care in-network (such as through the HMO or PPO
Independent Practice Association (or Independent Practice Associate); an independent group of physicians and/or other health care providers who are under contract to provide services to members an HMO or PPO as well as other insurance plans, usually at a fixed fee per patient.
Maximum out-of-pocket limit
The amount set by your health plan or by the federal government for ACA plans offered through the federal marketplace, which is the most each insured individual is required to pay in annual cost sharing.
Medical Loss Ratio; mandated by the ACA (see above), this provision requires insurance companies to spend no more than 15% to 20% on administrative expenses such as executive salaries, overhead, and marketing, with the rest spent on patient care and/or quality improvement.
Premium Only Plan; a POP (also referred to a Section 125 plan) allows employers to deduct health plan premium dollars from employee paychecks on a pre-tax basis, thus reducing the employer’s FICA expense and the employee’s tax liability.
Preferred Provider Organization; refers to a participating medical group or other health care provider (e.g., hospital or specialty facility) in a managed care network contracted with an insurer or third-party administrator to provide medical services at a negotiated discount rate.
Pre-Existing Condition Insurance Plan
Also referred to as PCIP, this plan (implemented as part of ACA) is available to children and adults unable to secure group or individual insurance because of ill health, such as cancer, heart disease, diabetes, HIV/ AIDS, asthma, or some other pre-existing medical condition.
Rate Adjustment Factor; formerly used in quoting group insurance; prior to the ACA, insurance companies in California were allowed to increase or decrease a company’s group medical plan rates by up to 10% from the standard rate, based primarily on the health of the group; typically, the larger the group, the better the RAF because the bad health of some employees is expected to offset the better health of other employees; under the ACA, the RAF was eliminated.
State Children’s Health Insurance Program; also referred to as CHIP (for Children’s Health Insurance Program); administered by the Department of Health & Human Services (see “HHS” entry above), this program is designed to cover uninsured children in families with incomes that are modest, but too high to qualify for Medicaid. At the time it was established in 1997, S-CHIP was the largest expansion of taxpayer-funded health insurance coverage since Medicaid began in the 1960s.
Refers to Internal Revenue Code section allowing for the establishment of “cafeteria benefit plans” by employers (where employees can choose from a menu of benefit options); a Section 125/Premium Only Plan is the only means by which an employer can offer employees a choice between taxable and non-taxable benefits without the choice resulting in a benefits tax. A plan offering only a choice between taxable benefits is not a Section 125 plan.
Small Business Health Options Program (often used as “SHOP Exchange”); refers to one of two exchanges established under the Affordable Care Act, under which small businesses can offer a range of health insurance options to their employees through a multi-employer coverage exchange.
Third Party Administrator; the individual or firm responsible for the administration of a group insurance plan; this may include administration of accounting, sales, underwriting, certificate issue, claims, and marketing – all performed without financial responsibility for any of the risks associated with the insurance.
Insurance claim-related shorthand for Usual and Customary Rate (may also be referred to as “URC” for Usual, Reasonable, and Customary); the maximum amount an insurance company will consider eligible for reimbursement under a health insurance plan. The UCR or URC amount is determined based on a review of prevailing charges for a given service within a specific community or geographic area. Commonly, the UCR/URC is set in the 80th-90th percentile. The amount is separate and distinct from any applicable co-pay amount or deductible for covered health services.
To learn more about the ABCs of health insurance, talk with your employee benefits broker. If you don’t already have a broker, we can help you find a CaliforniaChoice broker to speak with about the options available to you and your employees.
An Anthem Blue Cross Exclusive Provider Organization (EPO) Medical Plan offers you and your employees access to some of the region’s foremost medical facilities in the Inland Empire. Whether you’re in Apple Valley, Loma Linda, the Palm Springs area, Riverside, San Bernardino, or Victorville, you’ll appreciate the fact that there’s an Anthem Blue Cross EPO facility close by when you need health care.