Frequently Asked Questions

The best way for a small business to buy health insurance is through an independent agent, for the simple reason that an independent agent can shop among many insurance carriers to find the services that are the best fit and value for you and your employees.

An agent knows the ropes and the jargon. He or she knows carriers by reputation. The agent will get several quotes and can help your employees with enrollment and questions. Perhaps best of all, agents do all these things at no direct cost to their clients. They're paid on commission by the carriers.

Besides the obvious questions about premiums and deductibles, here are a number of other important questions to ask your insurance agent. Remember, it's your agent's job to see how a variety of carriers stack up against these questions. He or she will shop the market and provide an objective comparison. (That's why working with an independent agent is so helpful.)

What is the coinsurance limit? What is the total annual out-of-pocket cost for covered expenses?

Some managed care plans require their members to pay a small percentage of the charges beyond the deductible, up to a point. For example, you might pay a $500 deductible, plus 10 percent of the next $2,000. Your coinsurance limit plus your deductible is the point where your health plan takes care of all covered charges — in this case $2,500 — up to any policy limit. And your out-of-pocket maximum for any year is the deductible plus 10 percent of $2,000 — or a total of $700. Talk to your agent regarding how coinsurance and out-of-pocket expenses work.

What happens if I go to a doctor or hospital that's not on the "preferred" list?

If you're in a health maintenance organization (HMO), you probably have to pay on your own for any medical care from doctors or hospitals not on the list (or "panel") for your HMO. While you lose freedom in an HMO, you gain a lot more benefits for the money. Many other types of managed care health plans, however, provide some coverage for care from doctors and hospitals not on the preferred list.

Preferred provider organizations (PPO) do this, often requiring the member to pay a higher coinsurance percentage — say, 30 percent instead of the 10 percent in the above example — for out-of-plan care. This results in a higher out-of-pocket maximum for that year.

Another type of plan is an "elect provider organization," (EPO) in which, as with an HMO, members designate their primary care physician as a "gatekeeper." But unlike an HMO an EPO provides some coverage for out-of-plan care, in the same way a PPO does. An EPO is sometimes called a "point of service" (POS) plan.

Can employees pick a plan design?

These days, even the smallest of businesses can often get a health care plan in which individual employees can select from a menu of benefit options, including deductibles and coinsurance percentages. In many cases each employee can even pick for him or herself whether to go with an HMO, EPO or PPO.

What are the customer service hours?

Verify the customer service hours are convenient for you.

If I have a significant illness, will I get to talk to the same nurse every time I call the insurance company, or will I talk to someone who uses their computer to check what's been done up to that point?

As part of the utilization review process, many carriers employ "case managers." You'll want to be assigned to one case manager if your case gets complex and expensive. You'll come to appreciate this nurse's familiar voice, and the fact that she or he knows you, your situation and your local health care scene. If your assigned case manager is not available, verify if another case manager could assist.

Will I have to fill out claim forms?

Some carriers require members to fill out claim forms, while others simply have their members show an ID card that allows the clinic or hospital to take care of all the paperwork. We recommend the latter.

What is the carrier's A.M. Best rating?

An "A" ("excellent") rating from the independent insurance rating firm A.M. Best Co. is a positive indication that the insurer will have the money to meet its obligations into the foreseeable future.

Special concerns for employers:

How much experience does the carrier have dealing with small businesses (fewer than 10 employees)?

Small businesses have special needs because they generally don't have a personnel department or benefits managers. If you're in a small business, you need to think of your carrier as your benefits manager. Make sure their experience shows they're up to the task.

Do they handle all the employee benefits I need?

Dental plans are becoming a "must" to attract the very best segment of the labor pool. Now small businesses can easily set up flexible spending accounts (Section 125 plans) that allow employees to pay for things like uncovered medical costs, vision care and daycare using pre-tax dollars. This can often be done at no cost to employers. Group term life policies are becoming a very popular and very affordable employee benefit. Make sure your health carrier can provide all of these benefits — if not today, as your business grows.

Is the insurance carrier eEnabled?

The internet offers employers another way of doing business with their insurance carrier. Speak with your agent regarding what options the insurance carriers have available on the Internet.