Group Health - Technical questions for different states. Expert opinions sought.

newmindfashion · 09-28-2007, 10:41 AM

Greetings fellow pros,
I only do group health in my domiciled state of CT. However, I wanted to familiarize myself with group health rules in other states and was wondering what is HIPAA based and what is state-specific. For example, in CT, working 30 hours per week is considered a full-time employee. Is that specific to my state or is that HIPAA?

Other questions:
*In other states, is a 75% participation factor in the absence of spousal waivers pretty much standard practice or do some group carriers allow a lower participation percentage.

*Is there a minimum participation percentage established by HIPAA?

*In CT, the minimum premium an employer must contribute to an employee's plan is 25%. There is no participation minimum on dependents. Is that state specific or HIPAA?

*In a nutshell, what exactly is ERISA? Since I mainly do groups of 1 to 3, ERISA is never a factor according to my carriers when I ask them what to answer on the applications when ERISA is asked about.

*In CT, we have group of 1 options that are underwritten to a degree. Approvals can have their choice of the carrier's plan. Declines are reverted to a statutory plan that all group carriers must offer a legitimate group of 1. The statutory plan is actually a decent plan but with a capped pharmacy benefit. In NH, groups of 1 are guaranteed issue but have only two open enrollment periods throughout the year. How do the rest of the states work for groups of 1? All states seem to be different in this regard.

Newmindfashion (NMF)

newmindfashion · 10-02-2007, 09:37 AM

No takers?

somarco · 10-02-2007, 09:56 AM

Participation rules are carrier specific. I am not aware of any HIPAA rules regarding particpation or employer contribution. You do have other rules about non-discrimination at the federal level which flow down to the states.

ERISA (Employee Retirement Income Security Act) affects a wide variety of plans. Originally set up for retirement plans it has evolved and expanded to affect most (if not all) group plans.

Technically, ERISA group plans are 100+ lives and apply mostly to self funded plans. But fully insured plans must also comply with ERISA, particularly if you are dealing with 100+ lives.

Small group laws vary by state but most seem to have some level of uniformity. Any group plan must comply with HIPAA which addresses the portability issues.

GA dictates rules for groups of 2+ and only allows groups of 1 in a few situations. This "seems" to be carrier specific. Aetna for example will write a 1 life group as long as there are at least 2 eligible and the 2nd opts out due to other coverage. Other carriers may do it but are reluctant to admit it.

All the carriers who offer small group here are filed as 2+ lives.

James · 10-02-2007, 03:40 PM

http://www.nahu.org/consumer/healthcare/index.cfm

Your thread suggested expert opinion, I'm not an expert on group health, but I always find this site helpful.

newmindfashion · 10-02-2007, 04:16 PM

Bob and James,
Thanks for your input.

NMF

Consultant · 10-03-2007, 02:07 PM

Same as everyone said in other states.

CA - is pretty much carrier specific for most requirements.

Kaiser you can do a 1 person group but they don't tell you. I didn't know you could do an 1 life in Aenta but Aetna group is almost double here!

For the hourly requirement. I have a lot of groups that cover part-timers. So we set the hours crazy low - like 20.

planner · 12-22-2007, 06:12 PM

Quote:

Originally Posted by newmindfashion

Greetings fellow pros,
I only do group health in my domiciled state of CT. However, I wanted to familiarize myself with group health rules in other states and was wondering what is HIPAA based and what is state-specific. For example, in CT, working 30 hours per week is considered a full-time employee. Is that specific to my state or is that HIPAA?

Other questions:
*In other states, is a 75% participation factor in the absence of spousal waivers pretty much standard practice or do some group carriers allow a lower participation percentage.

*Is there a minimum participation percentage established by HIPAA?

These are either State specific or carrier specific requirements has nothing to do with HIPAA.

*In CT, the minimum premium an employer must contribute to an employee's plan is 25%. There is no participation minimum on dependents. Is that state specific or HIPAA?
These are either State specific or carrier specific requirements, has nothing to do with HIPAA.

*In a nutshell, what exactly is ERISA? Since I mainly do groups of 1 to 3, ERISA is never a factor according to my carriers when I ask them what to answer on the applications when ERISA is asked about.
The Carrier is in error since both COBRA and HIPAA are part of ERISA.

*In CT, we have group of 1 options that are underwritten to a degree. Approvals can have their choice of the carrier's plan. Declines are reverted to a statutory plan that all group carriers must offer a legitimate group of 1. The statutory plan is actually a decent plan but with a capped pharmacy benefit. In NH, groups of 1 are guaranteed issue but have only two open enrollment periods throughout the year. How do the rest of the states work for groups of 1? All states seem to be different in this regard.

Most States are not as crazy as CT or Florida permitting 1 man groups. Most states have either a guarantee issue law for these individual policies or they have a State risk pool. HIPAA allows the States to choose direction.

Newmindfashion (NMF)