PEOs can change the game for SMBs looking to reduce overhead, streamline operations, and access affordable small group health insurance. 

A PEO is a third-party organization that partners with businesses to manage specific administrative tasks primarily related to human resources. Understanding the PEO’s role and benefits allows you to make informed decisions about optimizing your resources and managing your HR responsibilities.

PEOs can provide SMBs with a comprehensive solution to various administrative challenges. To fully leverage their capabilities, it is crucial to recognize their role in the following key areas of your business operations:

Payroll

Managing payroll is one of the primary features of a PEO. This includes:

• Paying employees on time
• Handling tax withholdings
• Completing end-of-year tax forms

Benefits administration

PEOs help businesses design and manage employee benefits packages, which can include:

• Health insurance
• Retirement plans
• Wellness programs
• Employee assistance programs
• Service discounts
• Enrollments, changes, and terminations

Workers’ compensation

PEOs can process workers’ compensation claims for you. They can also help you get better rates for workers’ compensation insurance because they have collective bargaining power and industry knowledge.

Regulatory compliance

PEOs help you navigate employment laws and regulations. They use their expertise to help you stay compliant and avoid potential legal complications. This includes helping you adhere to labor laws and ensuring that employment practices are fair and nondiscriminatory.

Human resources management (HRM)

PEOs often also provide comprehensive HRM services, which include tasks such as:

• Creating and updating employee handbooks
• Managing onboarding and offboarding processes
• Handling employee complaints
• Helping with performance management

Risk management

Many PEOs have risk management experts who can help you identify potential risks and develop strategies to combat them. For example, they can help you create safety protocols or provide training sessions. They can also check for compliance with Occupational Safety and Health Administration (OSHA) regulations.

Employee training and development

PEOs may also offer training and development programs to help you invest in your employees. They give you access to training resources that you may not have access to otherwise, including:

• Technical training
• Soft skills development
• Compliance and regulatory training
• Cross-cultural training and language learning programs
• Personal development and wellness sessions

Recruitment and hiring

Some PEOs also help with recruitment efforts by:

• Posting job listings
• Screening applicants
• Conducting interviews
• Managing the end-to-end hiring process

Legal consultations and support

Last but not least, PEOs often provide legal expertise and consultation on employment-related issues, including:

• Handling disputes
• Understanding updated labor laws
• Drafting compliant employment contracts

This legal support can be invaluable for small businesses, as they often don’t have access to the same legal resources that larger corporations do.

Healthcare costs are rising and as a result, businesses are always seeking more efficient and cost-effective ways to provide quality health benefits to their employees. 

PEOs offer a streamlined approach to health insurance management. But like any solution, group health insurance through PEOs has pros and cons.

Pros

PEOs offer numerous advantages that can help your business access affordable health insurance and relieve administrative burdens.

Economies of scale

The term “economies of scale” refers to lowering the cost of a service or good by consolidating effort or volume. In health insurance, this means that the greater the number of businesses that pool together, the lower their healthcare costs will be. 

PEOs pool together employees from various small businesses, which increases their purchasing power when negotiating health insurance rates. The cost of benefits gets spread out across more employees, and can lower your cost per employee.

This means you can access more competitive premium rates and a wider variety of coverage options than you might secure on your own. You can offer your employees high-quality healthcare plans without breaking the bank.

Administrative relief

Managing health insurance can be time-consuming and labor-intensive, especially if your HR resources are limited. PEOs do all the heavy lifting of benefits administration, freeing up precious time for you to focus on other important areas of your business. They reduce your administrative burdens, minimizing the risk of health insurance management errors.

Compliance support

Staying compliant with ever-changing healthcare regulations can be a challenge for many small businesses. PEOs provide experts in the latest healthcare regulations and laws. They make sure the healthcare plans you offer align with current legal requirements. They also help you navigate the complexities of the Affordable Care Act (ACA) and other health insurance mandates — an invaluable resource.

Access to a wider range of benefits

While many PEOs offer basic health insurance, they also have relationships with providers that allow them to provide many additional benefits, such as:

• Dental benefits
• Vision plans
• Wellness programs

Partnering with a PEO allows you to offer robust, competitive benefits packages like those of larger corporations. Such diverse benefits packages can help you attract and retain top talent in a competitive market and increase job satisfaction.

Cons

While PEOs offer notable advantages, they also come with their own set of disadvantages.

Potential loss of control and flexibility

Since you hand over the reins of benefits administration when partnering with a PEO, you often have to give up some decision-making power regarding your benefits offerings. The PEO may predetermine specific health insurance plans, coverage options, and even providers. You may have limited flexibility to tailor your offerings to the unique needs of your business or workforce.

Cost of services

While PEOs can offer economies of scale, you do have to pay for their services. PEO fees can sometimes be substantial, especially if you’re a very small business. These fees can add up over time, and the cost savings from group rates might not always make up for the expense. In some cases, you may end up paying more overall to provide health benefits.

Group rate fluctuations

Because PEOs are rated based on a “pool” versus individually, your pooled group rates could go up even if your group’s claims are low. So depending on your group, pooling could hurt or help come time for renewal. Additionally, most PEO plans renew on 1/1 so depending on when your group joins the PEO, your first renewal could come quickly and be more pricey than you had anticipated.

Lack of personalization

Since PEOs serve multiple businesses and pool them together, your unique culture, values, and needs may get lost in the shuffle. PEOs are more efficient, but you may have to sacrifice personalized attention and customization in exchange. This can lead to a one-size-fits-all approach to benefits that may not meet the needs of every employee. 

Long-term commitment

Finally, many PEOs require businesses to enter into extended contracts. If you decide that the PEO isn’t the best fit for your business or find a better alternative, you may have to jump through hoops or pay a costly sum to break the contract.

Besides looking at the pros and cons of a PEO, you also need to make sure it’s the right fit for your business. Ask yourself a few questions to determine if a PEO is the answer to your administrative challenges and employee needs.

How much time is my business spending on HR tasks?

If you find that you’re spending many hours on administrative duties like benefits administration, payroll, or compliance, you may need external assistance from a PEO. If your business operates efficiently with your current HR processes and manages administrative tasks easily, a PEO may not be necessary.

Do we have the expertise and capability to offer competitive benefits packages?

A business that struggles with negotiating favorable terms with payers or lacks the knowledge and expertise to curate attractive benefits might benefit from a PEO’s bargaining power and expertise.

If you have strong relationships with insurance providers, can negotiate favorable terms on your own, and have internal experts who can create and offer competitive benefits packages, a PEO might not add enough value to justify the cost.

Are we equipped to handle compliance and regulatory changes?

A PEO can be a valuable asset if your business struggles to keep up with the ever-changing employment regulations or doesn’t have a dedicated legal team. Conversely, if you have someone who keeps up with the latest regulatory changes and keeps you compliant, you don’t really need external assistance.

Is our business growing rapidly?

If you anticipate or are experiencing rapid expansion, evaluate whether your current internal HR processes can keep up. If not, a PEO might be the solution that keeps growth from compromising operational efficiency.

You might not need a PEO if you have no issues with employee onboarding, process transitions, and HR tasks amid rapid expansion.

How well are we managing employee-related issues and concerns?

Frequent employee concerns and disputes or a high turnover rate may indicate gaps in your HR management. A PEO can fill in those gaps. If you have a strong internal HR team that fosters a positive work environment and addresses concerns promptly, you may not need a PEO’s intervention.

As a small business, you have access to a diverse variety of plan types, some of which work well with PEOs. Understanding how they interact with one another can help you decide if PEOs are right for your business and employees.

Fully insured plans

Traditional fully insured plans are the most common type of health insurance in which you pay a premium to the insurance carrier. PEOs typically have pre negotiated rates with insurance carriers for these plans. 

They also manage the relationship between you and the payer and handle all administrative tasks. This means you can access better premium rates and reduce administrative burden.

Self-funded plans

In self-funded plans — also known as self-insured plans — you take on the financial risk of providing health insurance to your employees and pay for medical claims out of pocket. A PEO provides invaluable support by providing third-party administrative services and offering risk management insights so you can set aside appropriate funds for anticipated claims.

Level-funded plans: How Sana works with PEOs

Sana is a level-funded plan that combines the cost savings of a self-funded plan with the financial stability of fully insured plans. You pay a set monthly premium to Sana, part of which goes into a claims fund. If your claims exceed the amount in the fund, stop-loss insurance covers the excess. And if your monthly premium is higher than the total of claims you paid, you get refunded based on a few factors including your total annual spend.

It’s easy to use Sana as your health benefits provider and keep your PEO to manage your payroll and administrative tasks. Sana can accept an automated file feed directly from your PEO or your plan administrator can manually update enrollments in the Sana portal. You can also enroll in Sana through the Sana portal and upload your benefits enrollment information into your PEO to align with your payroll. 

If you choose to leave your PEO, Sana can keep you covered with a full suite of benefits.

Related: Self-Funded vs. Level-Funded plans: What’s the Difference?

Health maintenance organizations (HMOs) and preferred provider organizations (PPOs)

In an HMO, members select a primary care physician (PCP) to receive services from, and the PCP provides referrals for specialists. PPOs are like a more flexible form of HMOs. They allow members to see any doctor or specialist they want without a referral, even if they’re out of network. But staying in-network typically keeps their out-of-pocket costs lower. 

When PPOs and HMOs partner with a PEO, they get access to the PEO’s established network of PCPs and specialists. The PEO also handles the administrative side and provides educational resources to employees.

The post Health insurance 101: Professional employer organization (PEO) appeared first on Sana Benefits.

This blog post focuses on one plan option: exclusive provider organization (EPO) plans. We’ll cover what they are, how they work, and their benefits and limitations to help you decide whether EPOs suit your small business and its employees.

An exclusive provider organization (EPO) insurance plan is a type of health insurance that offers its members a network of specified healthcare providers to choose from. They are a common option among businesses, and nearly a third of plans selected in the Affordable Care Act (ACA) Marketplace are EPO plans. 

You can think of EPO plans as a mix of two other types of health plans: a health maintenance organization (HMO) and a preferred provider organization (PPO). It tries to find a middle ground between them by managing costs while still giving you a degree of flexibility in where you get healthcare.

While there are similarities, several features distinguish EPO plans from other health insurance options. Before we dive into details, here’s a quick overview of the four most common types of health insurance plans and how they compare:

Let’s look closer at EPO plans and see how they compare to the other three:

Both EPO and health maintenance organization (HMO) plans limit coverage to in-network providers. However, an HMO requires a referral from a primary care physician (PCP) to see a specialist, while an EPO does not. Additionally, EPO premiums are higher than those of an HMO because of the added flexibility EPO plans offer.

An exclusive provider organization (EPO) is a type of health insurance plan where the coverage only pays for care provided within its network, except for life-threatening emergencies. If you use services outside the EPO’s approved network, you’ll have to pay the total cost of care. EPO plans typically do not require members to choose a primary care physician (PCP) or obtain referrals to see specialists, offering flexibility in direct access to specialty care. They tend to have comparatively lower premiums but restrict coverage to in-network providers.

Point-of-service (POS) plans are more flexible than EPOs regarding coverage and offer both in- and out-of-network coverage, albeit out-of-network services are usually covered at a higher cost. Unlike EPO plans, POS structures still require a designated primary care physician who can provide referrals to specialists. EPO plans typically have lower premiums than POS plans.

Preferred provider organization (PPO) plans are the most flexible and comprehensive options. While both PPO and EPO plans provide flexibility in accessing specialists, the key difference lies in the out-of-network coverage: PPO plans offer it, while EPO plans don’t. Also, EPO plans have lower premiums compared to PPO options due to their network restrictions. 

Find the most updated information about plans and prices through the government portal at healthcare.gov. 

There are benefits and drawbacks to offering EPO insurance plans. If you are serious about attracting top talent via enticing benefits packages, considering the pros and cons of EPO insurance options is critical in determining whether these plans are suitable.

Benefits of using an EPO

• Cost-effective: EPO plans are one of the most affordable options when providing health insurance. For small businesses with limited resources and insurance budgets, the affordability of EPO plans makes them an attractive choice. 
• No referrals required: With an EPO plan, members do not need to endure long wait times or jump through hoops to get a referral from their doctor. EPO plans allow you to contact and make an appointment with any specialist within your exclusive provider network.
• Large network: Similar to HMOs, EPO plans usually provide access to an extensive network of providers, giving members ample choices regarding physicians and specialists. 
• No need to choose a PCP: Since referrals from PCPs aren’t required, those with EPO insurance plans don’t have to choose a primary doctor to be eligible to enroll. 

Limitations of an EPO plan

• Network restrictions: Even though EPO plans grant access to a relatively large network of providers, the inability to go out-of-network is still a major drawback of these types of plans. Out-of-network services are sometimes necessary, and all medical expenses incurred outside the exclusive provider network would be out-of-pocket costs to those with an EPO plan. Medical expenses can quickly amount to tens of thousands of dollars without insurance coverage, exposing one of EPO plans’ most significant disadvantages. 
• Regional limitations: EPO plans are generally regional in nature, meaning their network and providers serve a specific geographic area. While this regional focus can be advantageous for those living within the plan’s designated region, it poses challenges for individuals with dependents residing outside of this area.
• Burden of responsibility: The details of which provider or medical procedure is covered under an EPO plan aren’t always apparent to those signing up. This means those choosing EPO plans have more responsibility to ensure they aren’t accidentally receiving services out-of-network or without pre-authorization. For example, if a member receives a medical service without realizing it requires pre-authorization, they would be liable for the entire cost of the procedure. 

You should do a thorough audit of your business’s needs and goals before deciding if an EPO plan is suitable. Remember, your employees’ needs are a key part of the conversation, so having an open, two-way dialogue with them is crucial for accurately evaluating whether an insurance plan is right for your business.

Here are some questions to ask to help determine whether an EPO is the best fit for your small business:

• How will employees react to being restricted to in-network providers?
• Do your employees have special, specific, or rare medical needs?
• Does the EPO network include a diverse range of specialists and facilities?
• Will employees find it convenient that they don’t need to choose a primary care provider? 
• How easy is it to get pre-authorization for certain procedures in the EPO plan?
• Does the EPO plan cover preventative care and wellness programs?
• How have other similar small businesses fared with EPO plans?
• What’s the reputation of the insurance provider offering the EPO plan?
• How do the costs of premiums, out-of-pocket-maximums, deductibles, copay, and coinsurance compare to other plans?

Comparing EPO plans with other health insurance options

Remember, the choice to offer health insurance is an investment, not just in the well-being of employees but also in your company’s long-term success. That’s why researching and comparing EPO plans with other options is essential. 

EPO plans are viable offerings within level- and self-funded structures, and small businesses should do their research to understand the differences. When looking at options, it’s critical to exercise due diligence and compare EPOs with other plans to find the one that best suits your business and employees’ needs.

Sana Benefits

Sana’s mission is to help small business owners offer their employees affordable, high-quality health insurance. With Sana, employees receive comprehensive health coverage at a fraction of traditional costs, flipping the script on the myth that small businesses can’t afford health insurance.

Our PPO plans and flexible network make health insurance radically more accessible and affordable than ever while maintaining a high standard and quality of care. To find out if Sana Benefits is right for your small business, contact us and get a quote today.

The post Health insurance 101: Exclusive provider organization (EPO) plans appeared first on Sana Benefits.

Group health insurance renewal basics

Understanding the fundamental aspects of a health insurance renewal is the first step towards a smoother, more efficient renewal process.

What does a health insurance renewal mean?

A health insurance renewal is the process of extending your current health insurance policy for another plan year. This typically involves:

• Reviewing your existing policy
• Assessing your current and future healthcare needs
• Deciding whether to continue with the same plan, switch to a different plan, or make changes to your current plan

When does the health insurance renewal process usually occur?

The health insurance renewal process usually occurs annually, typically at the end of the policy year. However, the exact timing can vary depending on the insurance company and policy terms.

Why do renewals happen on an annual basis?

Renewals happen on an annual basis to allow for adjustments based on changes in healthcare needs, insurance regulations, and market conditions. An annual review ensures that the health insurance plan continues to meet the needs of the employer and provides adequate coverage for employees.

Group health insurance renewal process

The group health insurance renewal process involves several steps. Each step is crucial in ensuring you end up with a health insurance plan that best suits your business and your employees. This process is cyclic and repeats every time your insurance policy is up for renewal.

1. Underwriting review

The insurance company does a thorough examination of the current policy, external factors, and risk scoring to determine any changes in cost to your current plan.

2. Renewal notice

The insurance company sends a renewal notice detailing the terms of the new policy, including any changes to coverage, benefits, and cost.

3. Internal review

The business assesses the healthcare needs of its employees to determine if the current plan still provides adequate coverage.

4. Market analysis

The business researches the health insurance market to understand current trends, offerings, and pricing.

5. Decision

The business makes a decision based on internal review and market analysis.

6. Communication and enrollment

The business communicates the changes to its employees and conducts the enrollment process.

7. Implementation and management

The business implements the renewed policy and manages it throughout the plan year.

Factors that affect group health insurance renewals

Several factors can influence the outcome of group health insurance renewals, leading to price changes. Understanding these factors can help you anticipate potential challenges and strategize effectively.

Premiums

Health insurance premiums are the amount you pay to the insurance company for your policy. They can increase at renewal due to factors such as:

• Higher healthcare costs
• Increased usage of benefits
• Changes in the risk profile of your group

Claims

The number and cost of claims made under your policy can significantly impact your renewal. A high number of expensive claims can lead to an increase in premiums as the insurer seeks to cover these costs.

Changes in group membership

When it comes to health insurance, insurers calculate premiums based on the risk profile of your group. As your team evolves, so does its risk profile. So, changes in your group membership can affect your rates because they influence the perceived risk and, consequently, the cost of your policy.

Size

Larger groups often have more predictable claim patterns. The larger the group, the lower the per-person cost of insurance. This is due to risk pooling, where the insurer can spread the risk of claims across a larger number of individuals.

If your workforce decreased in the previous year, you may have to pay a higher rate when the renewal period comes around. And, if you have a small group with a high number of claims, you will likely see a significant increase in premiums at renewal.

Age

If the average age of your group has risen since the last renewal, there’s a chance this might contribute to higher renewal rates.

Health status

Insurers assess the overall health of your group to predict potential healthcare costs. If members of your group have developed serious or chronic health conditions since the last renewal, it could lead to higher renewal rates.

However, the impact of health status on renewal rates can vary depending on the size of your group and the type of plan you have. In larger groups, the health status of individual members has less impact on the overall group rate because the risk is spread out over more people. For smaller groups, the health status of even one or two members can significantly affect the group’s renewal rates.

New dependents

Dependents — such as spouses and children — increase the number of individuals covered under your plan. Each dependent has their own health risks and needs that contribute to the overall cost of the plan, and this can potentially increase the overall risk from the insurance company’s perspective.

If the dependents are generally healthy, the impact on your renewal rates might be minimal. If the dependents have significant health issues or require frequent medical care, your renewal rates could increase because the insurer anticipates that these dependents will likely generate higher healthcare costs.

Industry trends

Several industry trends can significantly impact group health insurance renewal rates. Healthcare inflation — the increase in healthcare costs over time — is one key trend that affects even groups with low claims. As healthcare becomes more expensive, insurance companies may increase premiums to cover these higher costs.

Another trend is the shift towards value-based care, personalized medicine, and advanced treatment. These developments can lead to improved health outcomes and often lower costs.

Regulatory changes

Regulatory changes and reforms in the healthcare sector can also impact renewal rates. Changes in laws or regulations could affect coverage requirements or increase the pricing of health insurance plans.

How to navigate the renewal process for your business

Navigating the health insurance renewal process can be challenging, but it can be smooth and successful if you tackle it with the right knowledge and strategy. Consider these steps to guide you through the process.

Review your current plan

Start by reviewing your current plan to understand its:

• Coverage
• Benefits
• Costs
• Overall suitability for your group’s needs

This will help you identify what’s working and what needs to change.

Review the renewal offer

When you receive the renewal offer from your insurance company, assess it carefully. Compare the new terms with your current plan and consider how they align with your needs and budget.

Explore alternatives

Don’t limit yourself to the renewal offer. Explore alternatives from other insurance providers. Each type of plan comes with its own set of advantages and disadvantages, so you must consider your business’s specific needs and circumstances when exploring these alternatives, which include:

• Fully insured plans
• Self-insured plans
• Level-funded plans
• Pooled plans

Fully insured plans

These are traditional insurance plans where the insurance company assumes the risk of providing health coverage in exchange for premiums. They’re regulated by state laws and can be more expensive, but their costs are also more predictable.

Self-insured plans

With self-insured or self-funded health plans, you assume the risk of providing health coverage. While these plans can lead to cost savings in years with low claims, they also expose your businesses to potentially high costs in years with high claims.

Level-funded plans

Level-funded plans are a hybrid of fully insured and self-insured plans. They offer more flexibility and potential cost savings while limiting the risk to you. Modern insurance companies like Sana offer level-funded plans that can be a great fit for small and medium-sized businesses with five to 300 employees.

Pooled plans

You can also take advantage of Professional Employer Organization (PEO) plans and Association Health Plans (AHPs).

PEOs provide insurance by pooling together small businesses to get better rates. They share responsibilities with your business, acting as a co-employer to handle several aspects of the business:

• Benefits administration
• Human resources
• Payroll
• Administrative support

You retain managerial jurisdiction and make all decisions regarding your human capital.

AHPs allow small businesses and self-employed individuals to band together to create a group health plan. While both types of plans offer cost savings, they also limit your ability to customize your plan to your specific needs.

Make a decision

After assessing the renewal offer and exploring alternatives, make a decision. Choose the plan that best meets your needs and budget.

Communicate with your employees

Once you’ve made a decision, communicate the changes to your employees through a company-wide email or letter or your benefits administration platform. Make sure they understand the new plan and how it affects them.

Conduct the employee enrollment process

Conduct the enrollment process to get your employees signed up for the new plan. Make sure to provide support and answer any questions they may have.

Benefits administration software can make benefits administration as simple as filling out a few forms and clicking a few buttons. It can also include a knowledge base or chatbot that answers employee questions to streamline and simplify the entire enrollment process.

Implement the policy

Once enrollment is complete, implement the policy by setting up the necessary systems and processes.

Continue to manage your policy

Plan renewal doesn’t end with implementation. You must continue to manage your policy throughout the year. This includes handling claims, addressing issues, and ensuring the plan continues to meet your needs.

Stay compliant with regulations

Finally, ensure you stay compliant with all relevant health insurance regulations. This can help you avoid penalties and ensure your policy remains valid.

Health insurance renewal FAQs

The post Health insurance 101: Renewals appeared first on Sana Benefits.

What is stop loss insurance?

Stop loss insurance protects self-insured employers from unexpectedly high medical costs. The concept is simple: The insurance company agrees to reimburse the bills — thus “stopping the loss” — if a business’s employees have out-of-pocket healthcare costs that exceed a pre-established threshold. This insurance provides additional protection for small companies that want to minimize their financial risk without sacrificing their employees’ healthcare. 

Understanding stop loss insurance

At first glance, stop loss insurance may seem unnecessary, especially if you only have a handful of employees. Understanding the purpose of stop loss insurance can help you make an informed decision. 

Many small businesses consider this insurance a worthwhile investment because it can be challenging to accurately predict how much employees’ healthcare will cost in a given policy year. In an ideal world, your entire staff will stay healthy and only require routine healthcare, keeping expenses low. But unexpected medical issues can pop up anytime, and the costs can add up fast. 

Here are a few scenarios that could lead to an unanticipated surge in healthcare costs:

• An employee’s new baby requires an extended stay in the neonatal intensive care unit. 
• A staff member gets diagnosed with a rare form of cancer and needs treatment from specialists. 
• An employee needs emergency surgery after an accident. 
• A contagious disease infects most of the staff in your workplace. 

Any of these situations could result in significant claims, potentially leading to serious financial troubles for a small business. Stop loss insurance prevents this by putting a cap on the amount of money a self-insured employer needs to pay for medical costs. For example, if a business has an attachment point of $10,000, the loss insurance company will start reimbursing all claims beginning at $10,001. 

It’s important to note that stop loss insurance is a financial safeguard, not health insurance. That means loss insurance companies only reimburse employers for their expenses instead of paying the provider directly.

The pros and cons of a self-funded healthcare plan with stop loss insurance

An employer with a self-funded healthcare plan assumes financial responsibility for their employees’ healthcare. The business and covered members pay a set amount of money into a trust account, and these funds are used to pay claims for all employees. 

If the claims in a given year add up to less than the collected amount, the employer can invest the money or roll it over into the account for the next year. But if the claims exceed the trust account, the employer must cover the excess amount through stop loss insurance or with their own money. 

You may wonder why any small business would risk its financial security by selecting this type of plan. When paired with stop loss insurance, self-funded insurance is a safe option that has several advantages over traditional fully-funded plans, including: 

• Accurate pricing: Self-funded health plans typically cost less for groups with lower-than-average healthcare expenses since they are not subsidizing more expensive groups.
• Flexibility: Small businesses have more freedom to customize their health plans to suit their staff’s needs.  
• Potential rebates: The loss insurance company issues the employer a rebate if they have low claims. 
• Tax breaks: Self-insured plans qualify for tax deductions from the federal and state governments, providing additional savings for employers and members.

However, self–funded insurance does have a few drawbacks, even with stop loss insurance, such as: 

• Complexity: Putting together all the functions of a self-funded health plan can be time consuming. Luckily, some insurance companies have brought all the functions necessary — underwriting, plan administration, stop loss, network, and more — into a single offering.
• Accurate pricing: Groups with higher-than-average claims costs may pay more for self insurance than fully funded plans, since their rates are not being subsidized by less expensive groups.  

Weighing these factors can help you choose the best health plan for your small business.

How stop loss insurance works

You can choose two types of stop loss insurance: specific and aggregate. Your employee demographics and risk tolerance can help you determine the right options; many groups choose both types of coverage.

Specific stop loss coverage

Specific — or individual — stop loss insurance protects employers from significant claims for any given individual. The insurance carrier will set a specific attachment point per employee based on the number of covered individuals, pre-existing conditions, and other factors. 

Let’s say your company purchases specific stop loss coverage with a $50,000 attachment point per employee. Soon after, an employee gets seriously injured in a car accident and needs an expensive surgery and physical therapy. Their healthcare claims add up to $200,000. Your business must take responsibility for the first $50,000 in expenses, and the stop loss insurance company will refund you the additional $150,000. 

However, specific loss insurance only applies to the specific employee who exceeds the attachment point. Imagine that you have a second worker who needs a $45,000 emergency surgery during that same policy period. Their claim doesn’t exceed the individual attachment point, so your company is on the hook for the full bill.  

Specific stop loss insurance could be a strategic investment if you anticipate that only a few employees will have an unexpected health crisis during a policy year. For example, you may pick this coverage if you have a single older employee with pre-existing health conditions or a worker who plans to expand their family. 

Aggregate stop loss coverage

By contrast, aggregate stop loss insurance limits the employer’s maximum liability across all covered workers. Generally, insurance companies calculate the business’s expected claims and set the attachment point at 125% of this total. 

If an insurance company predicts that your business will have $1,000,000 in claims for the year, they could set your maximum claims liability at $1,250,000. That means you’re responsible for all claims up to that amount, and then the insurance company reimburses you any additional expenses — no matter which employees accrue them. 

Aggregate stop loss coverage is particularly beneficial for medium- to large-sized companies that have many employees with significant healthcare expenses. For example, if you have 50 employees each requiring $30,000 in care, the stop loss company will reimburse all eligible costs after the total claims exceed your attachment point. 

The benefit of stop loss insurance for small businesses

Stop loss insurance has many advantages for small businesses in particular, such as: 

• Risk management: Minimize your financial risk by shielding your company from surprisingly high claims. 
• Predictability: A set monthly fee makes it easy to plan your healthcare budget for the year because you always know the maximum amount of claims you’ll need to pay. 
• Prioritize employee health: Your employees can access the healthcare they need without worrying about negatively affecting the company’s financial health. 
• Customization: You can choose between specific and aggregate based on your business’s unique needs.

The role of Third-Party Administrators (TPAs) and stop loss insurance

A third-party administrator (TPA) is an external company that handles the daily operations of self-insured health plans. You can outsource most insurance-related tasks to a TPA, like creating custom health plans for your company and enrolling members. A TPA can also help you choose a stop loss plan and file claims with the insurance company. 

Benefits of utilizing a TPA

Sana is a leading TPA that provides full-service plan management and claims processing for small businesses with self-funded insurance. When you partner with Sana, you’ll enjoy advantages like: 

• Broker services for stop loss insurance 
• Effortless employee onboarding throughout the plan year
• Plan compliance with all relevant laws
• Year-round claims monitoring 
• Fair-value reimbursement to keep claims low 
• Free access to Mineral, an integrated management software for human resources professionals 
• Less time spent on tedious administrative tasks

You can learn more about how this service can improve your business’s operations and promote employee health by reading Sana’s comprehensive guide to TPAs. Or get in touch with Sana’s expert team to get personalized guidance as you weigh your insurance options. 

Related: View Sana Benefits health insurance plans

Stop loss insurance FAQs

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Keep reading to discover everything business leaders need to know about balance billing, relevant laws, and the role of insurance in balance billing disputes.

What is balance billing?

Balance billing occurs when an out-of-network provider receives less than the charged amount from an insurance company and charges the patient for the remaining cost. 

Say an ophthalmologist charges $3,000 to perform cataract surgery. The patient’s insurance doesn’t have a contract with the provider, so insurance pays $800 (120% of the Medicare rate) for the procedure. Several months later, the patient opens their mailbox to find an unexpected bill for the remaining $2,200.

People frequently don’t realize that a provider or service is outside their network, so surprise bills aren’t uncommon. For instance, several residents in Colorado were outraged when they received expensive balance bills for short ambulance rides not covered by their insurance.

A business’s covered employees may assume that their employer-sponsored health insurance fully covers their treatment and may feel shocked and upset when they get an unanticipated bill for hundreds or thousands of dollars. As a result, many people refer to balance billing as “surprise billing.”

It’s important to note that balance billing differs from other insurance-related charges employees may receive from their provider. Here’s a quick breakdown of standard health insurance terms that members often encounter.

Co-payment

Insurance companies typically require members to pay a fixed co-payment (co-pay) to cover a portion of each service. For instance, they may need to pay $15 every time they refill their blood pressure medication or have a dental cleaning. Co-pays never change during the annual duration of the plan, no matter how many times a patient receives a particular service.

All insurance companies state their co-payment fees up front, so these expenses aren’t unexpected or variable like a balance bill.

Deductible

A deductible is a set amount members pay for medical services each year before the insurance company picks up the tab. For example, people with a $1,500 deductible must pay the first $1,500 in qualifying healthcare expenses before their insurance company starts paying for covered services.

Out-of-network services charged through balance billing may not count as part of the member’s deductible. In other words, they could pay a $2,000 balance bill and still have to pay their entire deductible before triggering the insurer’s responsibility to pay claims.

Coinsurance

Coinsurance is the amount the insured must pay for covered services after they meet their deductible. For instance, the insurance company may pay 80% of covered expenses and require the member to pay 20%. Together, these payments cover the total cost of the bill.

Coinsurance payments can vary drastically based on the cost of the services. However, members never have to pay more than the set percentage. By contrast, balanced billing charges patients for any amount not covered by insurance, which could be a significant percentage of the bill.

Why does balance billing happen?

Balance billing occurs when a patient receives medical services from providers or organizations that don’t belong to their insurance company’s network. Providers want to get paid for the entire bill, so they target patients to make up the difference.

Here are a few common scenarios that may result in a balance bill:

• A person gets in a car accident and is transported to a nearby out-of-network hospital 
• An out-of-network resident assists an in-network cardiologist during a heart surgery 
• A member schedules an appointment at their usual in-network primary care clinic but receives treatment from a substitute out-of-network doctor

Additionally, balance billing can occur if a patient’s insurance company uses reference-based pricing (RBP). Under this model, insurers set benchmarks to determine how much they’ll pay providers for services. For instance, an insurance company may compensate doctors based on Medicare reimbursement rates or bundled payment rates. RBP can decrease healthcare costs and lead to greater transparency in medical billing. However, balance billing can occur under the RBP model because out-of-network providers haven’t agreed to the insurance company’s established rates.

Balance billing vs. out-of-network charges 

Understanding the differences between balancing billing, in-network charges, and out-of-network charges can help employees avoid costly surprises.

Balance billing laws

The federal government and some states have recently passed balance billing laws to regulate this practice.

No Surprises Act

On January 1, 2022, the federal government implemented the No Surprises Act to protect consumers from unanticipated medical expenses. This law makes it illegal for hospitals and providers to send patients balance bills for emergency care. Additionally, in-network hospitals can’t charge covered employees more money if they receive care from out-of-network providers.

The No Surprises Act applies to air ambulance services, emergency rooms, hospitals and other healthcare facilities, and physicians. However, the No Surprises Act doesn’t cover ground ambulances, so these services can still send patients balance bills. 

Also, patients can still receive surprise bills if they willingly choose an out-of-network provider during a nonemergency situation. For example, a person who makes an appointment with an out-of-network dermatologist for a routine skincare check may get a balance bill. 

Balance billings laws by state

Additionally, many — but not all — states regulate balance billing to varying extents. Business leaders who want to help protect their employees from this practice should research balance billing laws before selecting a health insurance plan. 

Medicare balance billing

The government prohibits balance billing by providers who have signed up to care for Medicare and Medicaid patients. These physicians and hospitals have agreed to accept the standard reimbursement rates established by Medicare and Medicaid. As a result, providers can’t ask patients for additional payment beyond their co-pay or coinsurance.

These restrictions apply in all states.

Balance billing and insurance

Some insurance companies can be helpful allies for patients who want to learn how to fight balance billing. 

People who receive a surprise bill should contact their insurance companies to see if they offer assistance. Insurers can sometimes persuade providers to match their in-network rates, significantly reducing the bill. And in exceptional circumstances, insurance companies may allow members to file an appeal to get the charges covered in-network. 

In many cases, though, insurance companies don’t step in to assist with balance billing, leaving members to resolve the matter on their own — often at a high cost. 

Sana’s approach to balance billing

Sana uses reference-based pricing to offer providers fair, data-driven reimbursement rates for healthcare services. In over 98% of cases, providers accept Sana’s rates without balance billing patients. 

In rare situations where covered employees receive surprise bills, Sana provides comprehensive support. Members should send their invoices to Sana so the company can work directly with the providers to find an agreeable solution. Currently, Sana has a 100% success rate at handling balance bills, and members have yet to pay more than their out-of-pocket limit. 

Balance billing FAQs

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Here’s what business leaders need to know to select the right coverage for their teams.

What is MEC?

The Affordable Care Act (ACA) requires all individuals in the U.S. to have a minimum level of health insurance each month. A MEC plan is health insurance that meets the federal government’s standard for coverage.  

As of 2018, individuals no longer face a federal tax penalty for not having coverage, but some state-level mandates still exist. There is also a federal mandate requiring certain employers to offer MEC plans to their employees.

MEC requirements for employers

In the U.S., 48.5% of individuals have health insurance through an employer — or a family member’s employer. Some of those employers are subject to a national mandate to offer a MEC plan, while others provide it voluntarily.

Are employers required to offer MEC to employees?

According to the Internal Revenue Service (IRS), a business must offer MEC plans if they are an applicable large employer (ALE), defined as an employer that had at least 50 full-time or full-time equivalent (FTE) employees in the previous calendar year. FTEs are typically part-time or seasonal employees whose work adds up to one full-time employee.

FTEs are staff hours, not individual people. The IRS defines one FTE as 2,080 hours of work per year — or 40 hours per week for 52 weeks. A business can calculate FTEs by adding up every employee’s total wage hours and dividing by 2,080, then rounding down to the nearest whole number.

For example, if a business has 20 employees working 20 hours per week each for 50 weeks a year, staff members work 20,000 hours that year. Therefore, even though the business has no full-time employees, they have nine FTEs.

However, because that business has fewer than 50 full-time or FTE employees, the IRS would not count them as an ALE. 

How much do ACA penalties cost?

The IRS explains the penalty breakdown in a document addressing employer shared responsibility provisions. According to question 53, if an ALE offers coverage to less than 95% of its full-time employees and their dependents, the employer owes a shared responsibility payment.

In total, businesses in this scenario will owe $2,880 per full-time employee — minus the first 30 — for the calendar year. For example, if an employer has 200 employees, they owe (200-30) * $2880, or $489,600.

This rule also applies to ALEs who offer no coverage. The IRS prorates penalties for employers who provide the required coverage for some months of the year.

If the employer owes shared responsibility payments because they did offer coverage, but an employee received a premium tax credit, the calculation happens separately per month.

To calculate the amount owed, multiply the number of employees receiving a premium tax credit for the month by 1/12 of the annual penalty, which is currently $4,320. See question 54 in the IRS’s provisions document for details.

Note that penalty amounts have increased annually since 2014 (according to question 55 of the IRS provisions document). The original per-employee penalties were $2,000 and $3,000 but have increased by 44%.

When do businesses incur ACA penalties?

According to the IRS, (question 43 of the provisions document), the ALE will owe a tax penalty if one of the following applies:

• The business doesn’t offer coverage or offers coverage to less than 95% of their employees
• The business offers coverage, but at least one full-time employee receives a premium tax credit to buy insurance via the Health Insurance Marketplace

The Health Insurance Marketplace is a government-run resource where Americans can shop for and enroll in medical coverage. The federal government runs a national Marketplace, but some states run their own.

A full-time employee might shop the Marketplace if their employer didn’t offer coverage to them. They may also use it if the provided coverage is unaffordable or doesn’t meet the minimum value standard.

What is the difference between minimum value and MEC?

Minimum value is a standard for employer-provided healthcare plans. It says that the plan should cover at least 60% of the total cost of services for a typical individual. Minimum value has a higher threshold for coverage than MEC.

In other words, a MEC plan can meet ACA requirements even if it doesn’t meet minimum value standards. However, if an employer’s offered plan doesn’t provide minimum value, the employee may qualify for a premium tax credit in the Marketplace. The premium tax credit is a refundable amount the federal government allocates to help low- and moderate-income taxpayers afford health insurance. If one or more full-time employees receive it, the business will owe a tax penalty.

Required coverage for a MEC plan

For an insurance plan to qualify as MEC, it must meet all essential requirements of the Public Health Service Act. Those requirements include:

• Fair insurance premiums
• No exclusions for pre-existing conditions
• No discrimination based on health status
• No lifetime or annual coverage limits
• Access to an appeals process for coverage decisions
• A yearly printed summary of benefits
• All essential health benefits

Essential health benefits include:

• Preventive services
• Outpatient care
• Emergency services
• Hospitalization
• Pregnancy and maternity care
• Mental and behavioral health treatment, including addiction therapies
• Prescription drugs
• Rehabilitative care
• Laboratory testing
• Pediatric care, including oral and vision care

New plans must undergo review to determine whether they provide MEC. Existing plans have MEC determinations that insurance companies can share with businesses.

Should non-ALEs offer MEC plans to their employees?

If a business has fewer than 50 full-time or FTE employees, they aren’t subject to employer shared responsibility rules. They won’t pay any penalties for not offering health insurance to full-time employees.

However, offering a high-quality plan is often in an employer’s best interests, regardless of requirements. For example, in a survey of job seekers choosing between a higher-paying job and a job with lower pay but better benefits, 88% considered health coverage in some way — making health insurance the most important factor for surveyed job candidates.

Offering a MEC plan to as many employees as possible can help a business attract and retain top talent. Quality benefits also promote a positive workplace culture by encouraging employees to prioritize their health and overall well-being. Healthy employees are happier, more productive, and more engaged with their jobs.

Choosing a MEC plan for employees

Choosing a plan means finding the right balance between the best offerings and what the business can financially sustain. Follow these critical steps for success.

Options for coverage

There are two basic types of employer-sponsored health coverage. With a fully-funded plan, a business pays a monthly premium to an insurance company. The insurer processes claims from employees and is on the hook to pay out valid claims. This is the best-known option and usually involves working with a large insurer such as UnitedHealthcare or Aetna.

The other option is to offer self-funded insurance. With a self-funded plan, the business sponsors the health plan, putting money into a claims fund that pays out its members’ claims. To protect against unexpectedly high claims, the employer can buy stop-loss insurance. Since the employer isn’t paying an insurer for health plan premiums, they are protected from arbitrary rate hikes.

Assess budget and needs

When businesses offer employer-sponsored health plans, they cover most of the premium, and employees cover the rest. On average, workers with individual plans pay 17% of their premiums, while those with family plans pay 28%.

To account for future growth, business owners should consider what they can afford overall and per employee. They should also think about what premium share employees would be willing to pay and what types and levels of coverage employees would expect. Formal and informal employee healthcare surveys are helpful in gathering such information.

Shop for plans

For businesses selecting MEC insurance for the first time, carrier websites are helpful for beginning research. Businesses with 50 or fewer employees can also shop via the Small Business Health Options Program (SHOP), a government initiative that makes group insurance more affordable for smaller businesses.

It’s important to compare benefits and get quotes, but business owners must also look beyond those basics to what the insurer can offer. For example, what consumer technologies can the insurer provide for the business and employees?

For many small businesses, the most versatile insurer will be the right choice. For example, Sana Benefits offers level-funded plans with flexible options to ensure each business has the coverage they need.

Related: How to Compare Small Business Health Plans

The post Health insurance 101: What is a MEC plan? appeared first on Sana Benefits.

A variety of factors have led to this worsening shortage. The high cost and time commitment required to become a doctor, an aging population outpacing the number of doctors entering the field, and burnout stemming from long hours and understaffed facilities rank high among them.

Amid the COVID-19 pandemic, telehealth grew exponentially for first-time consultations and follow-ups. Even with most lockdowns and social restrictions having ended, telehealth remains a viable option for outpatient consultations and pre-office evaluations largely because it’s easier and more convenient to access than having to commute to a doctor’s office.

In addition to telehealth, some areas offer programs designed to help fill the medical needs gap. According to the National Association of Community Health Centers, there has been a significant increase in mobile health clinics — clinics that travel into underserved communities to see patients —since 2019. Moreover, Congress’ passage of the MOBILE Healthcare Act in 2022 paves the way for even more mobile clinics by allowing qualified providers to use federal money to fund them. But despite this and other initiatives, some 99 million people live in areas — both rural and urban — where there is insufficient access to primary medical care. 

Sana compiled 2022 data from the Health Resources and Services Administration and Census Bureau to determine how many people in each state live in geographic Health Professional Shortage Areas (HPSAs) that specifically lack primary care facilities. States are ranked by the share of their total populations that live in geographic shortage areas and high-need geographic shortage areas — those with higher-than-average needs for care that have a doctor-to-patient ratio of 3000-to-1 or higher. Washington D.C., New Jersey, Delaware, Connecticut, and Vermont did not have reported shortage areas.

Read on to see where your state stands.

#46. Pennsylvania

– Share of state population living in primary care shortage areas: 0.18% (23,676 people)

— Share in high-need shortage areas: 0.14% (17,697 people)

— Share in other geographic shortage areas: 0.05% (5,979 people)

– Among shortage area populations, 38.98% live in rural communities

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#45. Rhode Island

– Share of state population living in primary care shortage areas: 0.35% (3,778 people)

— Share in high-need shortage areas: None

— Share in other geographic shortage areas: 0.35% (3,778 people)

– Among shortage area populations, 100.00% live in rural communities

#44. Kansas

– Share of state population living in primary care shortage areas: 1.08% (31,715 people)

— Share in high-need shortage areas: None

— Share in other geographic shortage areas: 1.08% (31,715 people)

– Among shortage area populations, 100.00% live in rural communities

#43. Massachusetts

– Share of state population living in primary care shortage areas: 1.55% (108,326 people)

— Share in high-need shortage areas: None

— Share in other geographic shortage areas: 1.55% (108,326 people)

– Among shortage area populations, 53.34% live in rural communities

#42. Florida

– Share of state population living in primary care shortage areas: 1.60% (355,091 people)

— Share in high-need shortage areas: 0.49% (109,510 people)

— Share in other geographic shortage areas: 1.10% (245,581 people)

– Among shortage area populations, 77.13% live in rural communities

#41. New York

– Share of state population living in primary care shortage areas: 1.67% (328,400 people)

— Share in high-need shortage areas: None

— Share in other geographic shortage areas: 1.67% (328,400 people)

– Among shortage area populations, 14.33% live in rural communities

#40. Maine

– Share of state population living in primary care shortage areas: 1.80% (24,921 people)

— Share in high-need shortage areas: 0.25% (3,492 people)

— Share in other geographic shortage areas: 1.55% (21,429 people)

– Among shortage area populations, 100.00% live in rural communities

#39. Oregon

– Share of state population living in primary care shortage areas: 1.94% (82,448 people)

— Share in high-need shortage areas: 0.11% (4,629 people)

— Share in other geographic shortage areas: 1.84% (77,819 people)

– Among shortage area populations, 34.08% live in rural communities

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#38. Nebraska

– Share of state population living in primary care shortage areas: 1.98% (38,914 people)

— Share in high-need shortage areas: None

— Share in other geographic shortage areas: 1.98% (38,914 people)

– Among shortage area populations, 35.06% live in rural communities

#37. Oklahoma

– Share of state population living in primary care shortage areas: 2.39% (96,144 people)

— Share in high-need shortage areas: 1.06% (42,705 people)

— Share in other geographic shortage areas: 1.33% (53,439 people)

– Among shortage area populations, 100.00% live in rural communities

#36. North Carolina

– Share of state population living in primary care shortage areas: 2.67% (285,785 people)

— Share in high-need shortage areas: 0.50% (53,884 people)

— Share in other geographic shortage areas: 2.17% (231,901 people)

– Among shortage area populations, 38.90% live in rural communities

#35. Colorado

– Share of state population living in primary care shortage areas: 3.15% (184,059 people)

— Share in high-need shortage areas: None

— Share in other geographic shortage areas: 3.15% (184,059 people)

– Among shortage area populations, 72.18% live in rural communities

#34. Idaho

– Share of state population living in primary care shortage areas: 3.87% (75,084 people)

— Share in high-need shortage areas: 0.59% (11,385 people)

— Share in other geographic shortage areas: 3.29% (63,699 people)

– Among shortage area populations, 100.00% live in rural communities

#33. Utah

– Share of state population living in primary care shortage areas: 3.96% (133,923 people)

— Share in high-need shortage areas: 0.05% (1,831 people)

— Share in other geographic shortage areas: 3.91% (132,092 people)

– Among shortage area populations, 100.00% live in rural communities

#32. Arkansas

– Share of state population living in primary care shortage areas: 4.19% (127,586 people)

— Share in high-need shortage areas: 2.33% (71,032 people)

— Share in other geographic shortage areas: 1.86% (56,554 people)

– Among shortage area populations, 100.00% live in rural communities

#31. Iowa

– Share of state population living in primary care shortage areas: 4.74% (151,588 people)

— Share in high-need shortage areas: None

— Share in other geographic shortage areas: 4.74% (151,588 people)

– Among shortage area populations, 94.32% live in rural communities

#30. South Carolina

– Share of state population living in primary care shortage areas: 4.95% (261,443 people)

— Share in high-need shortage areas: 4.60% (243,247 people)

— Share in other geographic shortage areas: 0.34% (18,196 people)

– Among shortage area populations, 91.47% live in rural communities

#29. Michigan

– Share of state population living in primary care shortage areas: 5.24% (525,446 people)

— Share in high-need shortage areas: 4.27% (428,708 people)

— Share in other geographic shortage areas: 0.96% (96,738 people)

– Among shortage area populations, 14.44% live in rural communities

#28. Tennessee

– Share of state population living in primary care shortage areas: 5.28% (372,150 people)

— Share in high-need shortage areas: 2.23% (157,013 people)

— Share in other geographic shortage areas: 3.05% (215,137 people)

– Among shortage area populations, 81.39% live in rural communities

#27. New Hampshire

– Share of state population living in primary care shortage areas: 5.52% (76,959 people)

— Share in high-need shortage areas: None

— Share in other geographic shortage areas: 5.52% (76,959 people)

– Among shortage area populations, 100.00% live in rural communities

#26. Wisconsin

– Share of state population living in primary care shortage areas: 6.38% (375,861 people)

— Share in high-need shortage areas: 4.12% (242,823 people)

— Share in other geographic shortage areas: 2.26% (133,038 people)

– Among shortage area populations, 25.50% live in rural communities

#25. California

– Share of state population living in primary care shortage areas: 6.51% (2,540,550 people)

— Share in high-need shortage areas: 4.34% (1,694,817 people)

— Share in other geographic shortage areas: 2.17% (845,733 people)

– Among shortage area populations, 44.79% live in rural communities

#24. Nevada

– Share of state population living in primary care shortage areas: 6.65% (211,406 people)

— Share in high-need shortage areas: None

— Share in other geographic shortage areas: 6.65% (211,406 people)

– Among shortage area populations, 74.89% live in rural communities

#23. Maryland

– Share of state population living in primary care shortage areas: 6.81% (419,597 people)

— Share in high-need shortage areas: 2.98% (183,657 people)

— Share in other geographic shortage areas: 3.83% (235,940 people)

– Among shortage area populations, 0.00% live in rural communities

#22. Missouri

– Share of state population living in primary care shortage areas: 7.17% (442,841 people)

— Share in high-need shortage areas: 0.16% (9,807 people)

— Share in other geographic shortage areas: 7.01% (433,034 people)

– Among shortage area populations, 49.52% live in rural communities

#21. Ohio

– Share of state population living in primary care shortage areas: 7.36% (865,695 people)

— Share in high-need shortage areas: 2.82% (331,403 people)

— Share in other geographic shortage areas: 4.54% (534,292 people)

– Among shortage area populations, 33.27% live in rural communities

#20. Georgia

– Share of state population living in primary care shortage areas: 7.48% (815,826 people)

— Share in high-need shortage areas: 5.44% (593,797 people)

— Share in other geographic shortage areas: 2.03% (222,029 people)

– Among shortage area populations, 53.85% live in rural communities

#19. Montana

– Share of state population living in primary care shortage areas: 8.23% (92,460 people)

— Share in high-need shortage areas: None

— Share in other geographic shortage areas: 8.23% (92,460 people)

– Among shortage area populations, 100.00% live in rural communities

#18. Kentucky

– Share of state population living in primary care shortage areas: 9.05% (408,210 people)

— Share in high-need shortage areas: 7.26% (327,631 people)

— Share in other geographic shortage areas: 1.79% (80,579 people)

– Among shortage area populations, 100.00% live in rural communities

#17. West Virginia

– Share of state population living in primary care shortage areas: 9.12% (161,967 people)

— Share in high-need shortage areas: 1.18% (21,026 people)

— Share in other geographic shortage areas: 7.94% (140,941 people)

– Among shortage area populations, 66.10% live in rural communities

#16. Illinois

– Share of state population living in primary care shortage areas: 9.46% (1,190,636 people)

— Share in high-need shortage areas: 0.51% (63,901 people)

— Share in other geographic shortage areas: 8.96% (1,126,735 people)

– Among shortage area populations, 32.40% live in rural communities

#15. Texas

– Share of state population living in primary care shortage areas: 10.10% (3,032,735 people)

— Share in high-need shortage areas: 2.41% (722,483 people)

— Share in other geographic shortage areas: 7.69% (2,310,252 people)

– Among shortage area populations, 51.84% live in rural communities

#14. Arizona

– Share of state population living in primary care shortage areas: 13.10% (964,071 people)

— Share in high-need shortage areas: 4.43% (326,068 people)

— Share in other geographic shortage areas: 8.67% (638,003 people)

– Among shortage area populations, 34.42% live in rural communities

#13. Virginia

– Share of state population living in primary care shortage areas: 13.16% (1,143,067 people)

— Share in high-need shortage areas: 1.11% (95,965 people)

— Share in other geographic shortage areas: 12.06% (1,047,102 people)

– Among shortage area populations, 82.62% live in rural communities

#12. Minnesota

– Share of state population living in primary care shortage areas: 13.44% (768,665 people)

— Share in high-need shortage areas: None

— Share in other geographic shortage areas: 13.44% (768,665 people)

– Among shortage area populations, 93.94% live in rural communities

#11. Indiana

– Share of state population living in primary care shortage areas: 13.46% (919,711 people)

— Share in high-need shortage areas: 2.16% (147,322 people)

— Share in other geographic shortage areas: 11.30% (772,389 people)

– Among shortage area populations, 72.10% live in rural communities

#10. Alaska

– Share of state population living in primary care shortage areas: 14.73% (108,051 people)

— Share in high-need shortage areas: None

— Share in other geographic shortage areas: 14.73% (108,051 people)

– Among shortage area populations, 100.00% live in rural communities

#9. Mississippi

– Share of state population living in primary care shortage areas: 15.13% (444,965 people)

— Share in high-need shortage areas: 14.24% (418,763 people)

— Share in other geographic shortage areas: 0.89% (26,202 people)

– Among shortage area populations, 100.00% live in rural communities

#8. Alabama

– Share of state population living in primary care shortage areas: 16.80% (852,409 people)

— Share in high-need shortage areas: 8.92% (452,443 people)

— Share in other geographic shortage areas: 7.88% (399,966 people)

– Among shortage area populations, 68.13% live in rural communities

#7. South Dakota

– Share of state population living in primary care shortage areas: 17.39% (158,226 people)

— Share in high-need shortage areas: 5.26% (47,887 people)

— Share in other geographic shortage areas: 12.13% (110,339 people)

– Among shortage area populations, 83.00% live in rural communities

#6. Louisiana

– Share of state population living in primary care shortage areas: 17.80% (816,925 people)

— Share in high-need shortage areas: 8.45% (387,854 people)

— Share in other geographic shortage areas: 9.35% (429,071 people)

– Among shortage area populations, 43.74% live in rural communities

#5. Washington

– Share of state population living in primary care shortage areas: 17.81% (1,386,696 people)

— Share in high-need shortage areas: None

— Share in other geographic shortage areas: 17.81% (1,386,696 people)

– Among shortage area populations, 19.22% live in rural communities

#4. North Dakota

– Share of state population living in primary care shortage areas: 21.32% (166,135 people)

— Share in high-need shortage areas: 0.86% (6,667 people)

— Share in other geographic shortage areas: 20.46% (159,468 people)

– Among shortage area populations, 100.00% live in rural communities

#3. New Mexico

– Share of state population living in primary care shortage areas: 26.61% (562,286 people)

— Share in high-need shortage areas: 16.65% (351,884 people)

— Share in other geographic shortage areas: 9.96% (210,402 people)

– Among shortage area populations, 67.36% live in rural communities

#2. Wyoming

– Share of state population living in primary care shortage areas: 27.35% (158,995 people)

— Share in high-need shortage areas: None

— Share in other geographic shortage areas: 27.35% (158,995 people)

– Among shortage area populations, 100.00% live in rural communities

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#1. Hawaii

– Share of state population living in primary care shortage areas: 35.64% (513,312 people)

— Share in high-need shortage areas: None

— Share in other geographic shortage areas: 35.64% (513,312 people)

– Among shortage area populations, 52.09% live in rural communities

The post Hawaii, Wyoming lead the country in share of population impacted by primary care doctor shortages appeared first on Sana Benefits.

Keep reading to learn how open enrollment works in the individual market vs. with group health insurance through an employer.

Open enrollment deadlines

Open enrollment deadlines in the individual market 

The annual open enrollment period for individual health insurance plans compliant with the Affordable Care Act (ACA) is November 1 to January 15 in most states. This means that individuals who have/are shopping for health plans on the online marketplace have 2.5 months each year to select or make changes to their coverage for the following year. 

Some states run their own exchanges as opposed to using the federally run marketplace (HealthCare.gov). Most of the state-run exchanges have the same open enrollment period as HealthCare.gov — November 1 to January 15 — but there are some exceptions:

States with an open enrollment period other than November 1, 2022 to January 15, 2023 for individual coverage in 2023

Note that those who are eligible can enroll in Medicaid and Children’s Health Insurance Program (CHIP) at any time of the year, and Native Americans and Alaska Natives can enroll year-round in ACA plans.

Open enrollment deadlines for employer-sponsored health insurance

Employer-sponsored health plans have different open enrollment periods that may not align with that of the ACA. Employees with job-based health insurance should always check with their company’s human resources (HR) department or leadership to find out when open enrollment is. 

Many employers choose to make their group health plan year align with the calendar year — meaning that open enrollment is during the fall, and all health plan changes take effect on January 1. But this is not always the case. For instance, some businesses may choose to do open enrollment in the spring for an effective date in summer. This is known as a mid-year, or off-cycle, open enrollment period. It may be appealing to businesses that are busiest at the end of the year and want to alleviate year-end stress by moving open enrollment to a less hectic season. 

The length of open enrollment will vary from one business to another, but it typically lasts a couple of weeks or more. To help employees make informed decisions regarding their health plan, employers should distribute health plan information and answer employees’ insurance questions during this time.

What is a special enrollment period?

A special enrollment period (SEP) is a 60-day period outside of the annual open enrollment period during which you can sign up for or adjust your health insurance. You can apply for a SEP if you experience a qualifying life event (QLE) — a life event that changes your health insurance needs or options, such as getting married or moving to a new state. Special enrollment periods help people avoid large gaps in health coverage when such life changes occur.  

Learn more about QLEs and SEPs. 

What happens if I miss open enrollment?

If you miss open enrollment, you have to wait until the next year’s open enrollment period to make changes to your coverage unless you:

• Are eligible for Medicaid or CHIP
• Experience a QLE
• Purchase short-term health insurance, which can provide you some level of coverage for up to a year — but is more expensive, less regulated, and less comprehensive than traditional health insurance 

Navigating open enrollment as an individual

If you are buying individual health insurance on the ACA marketplace, you should be aware of the ACA open enrollment period dates in your state (listed above). In most states, if you enroll in a plan by December 15, your coverage will begin on January 1. If you enroll after December 15 but before the end of the open enrollment period, your coverage will take effect on February 1. 

If you are an employee trying to decide which employer-sponsored health plan to enroll in, you will first need to familiarize yourself with your company’s open enrollment and effective dates. Then, you will need to carefully review the plan options available to you through your job. In order to decide which plan will be best for you and your family, it is important to weigh the flexibility of each plan with its cost. The least expensive plans typically offer the least flexibility in terms of which providers you can see, while the more costly plans usually give you more freedom to see the providers you choose. 

Learn more about what to consider when choosing from your employer’s health plans. 

Managing open enrollment as an employer

As an employer, you are in charge of making sure your employees have everything they need to make informed decisions about their healthcare coverage. This includes:

• Repeatedly communicating the open enrollment deadline to employees
• Distributing information about the health plans you offer in advance of the deadline
• Proactively educating employees on frequently used health benefits terminology
• Clearly flagging any changes to health plan offerings since the previous year
• Distributing information about additional benefits employees may want to add, change, or drop — such as vision, dental, life, and pet insurance
• Answering employees’ questions about health benefits
• Encouraging employees to consider these ten questions when choosing a health plan

Employers should also be aware that open enrollment is not the only time they will need to engage with health plan administration: Any time a new employee is hired, the employer must grant them a SEP of at least 30 days during which they can either enroll in a plan or decline employer-sponsored coverage. And any time an employee experiences a QLE, they have 30 days to apply for a 60-day SEP during which they can make changes to their plan. 

Related: Small but mighty: How to thrive as an HR department of 1

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In the United States, mental health support is more accessible than ever thanks to the expansion of telemedicine. Still, a survey of almost 54,000 Americans found that more than 1 in 10 respondents don’t receive the help they need. The barriers some people face in obtaining appropriate mental healthcare are overt — they’re financial, geographic, and socioeconomic. For others, their barriers are invisible, burdened by stigma and discrimination.

Despite greater, albeit unequal, access to care, America is facing a mental health crisis. Even in the best-case scenario, in which every American who needs support seeks it out, the U.S. healthcare system is understaffed and unable to meet that demand.

While the onset of the COVID-19 pandemic led to increased clinical depression and anxiety among Americans, reported cases and related symptoms decreased from peak pandemic levels as lockdowns and other restrictions eased. Those continuing to suffer from a lack of support today are historically marginalized communities like LGBTQ+ people and rural communities, or segments of the population assumed not to be at risk of mental illness, including young adults and children.

In December 2021, the U.S. surgeon general issued a public health advisory to specifically address the youth mental health crisis, citing a 40% increase in feelings of sadness and hopelessness among adolescents over the last decade. In 2022, the Preventive Service Task Force — an independent, volunteer panel of medical experts — recommended screening all children between the ages of 8 and 18 for anxiety. Nearly 8% of children and adolescents between the ages of 3 and 17 presented with an anxiety disorder, according to the 2020 National Survey of Children’s Health, released in 2021.

States of loneliness, anxiety, or hopelessness are, of course, not uniquely manifestations of youth. The World Health Organization found a 25% increase in anxiety and depression across the globe amid the restrictions brought on by the pandemic. A study conducted by insurance provider Cigna found that, post-pandemic, nearly 3 in 5 adult respondents (58%) actively experience loneliness; these findings are not far removed from the estimated 61% of adults that reported the same feelings before COVID-19’s onset. Further research published in October 2021 in the Lancet suggests that depression now affects about 1 in every 3 American adults.

To find out more about how adult populations are being affected, Sana cited data from the Census Household Pulse Survey weighted by the Centers for Disease Control and Prevention (CDC) to examine trends in who reports receiving the mental healthcare they need. The data used in this story was collected between April and May 2022. Although more recent surveys are available, they have not yet been processed to consider weighted sample sizes.

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U.S. average

Although a significant portion of the U.S. population is not currently receiving the mental healthcare they require, there have been blips of progress in recent years. The percentage of people seeking treatment during the pandemic increased from 19.2% to 21.6%, according to the CDC. But this increase in sought-after treatment was likely not happening across all demographics. When viewed through a racial lens, discrepancies between mental healthcare needs and treatment received highlight the significant cultural barriers many Americans face.

A further dissection of Census Household Pulse Survey data found that a greater percentage of Black and Hispanic or Latino Americans needed therapy but did not receive it. Hispanic/Latino culture is a broad, diverse community comprised of many languages and origins; both language and economic disparity can be barriers to gaining treatment. Moreover, Hispanic/Latino individuals diagnosed with mental illness may face cultural stigma within their communities. Many in Black communities have reported that mental health, particularly mental illness, can be viewed as something that should be discussed and dealt with privately. One factor contributing to this is a distrust of the medical establishment as a whole, stemming, in part, from a longstanding history of misdiagnosis and preferential consideration afforded to white, generally more affluent, patients.

As for Asian Americans and Pacific Islanders, the CHPS found that even though more of these individuals received treatment than did not, overall they represented less than half of those people seeking treatment in either the Black or Hispanic/Latino communities. AAPI is, like Hispanic/Latino, a very widespread designation. Social pressure and negative stigma are significant barriers for AAPI people to even seek therapy, let alone secure it.

Such attitudes among minority communities coalesce into even larger, more damaging stigmas that prevent people from getting the professional help they require. Finding a mental health professional who understands and can adapt treatment to one’s culture can be limiting, if not impossible, for some people.

Differences across states

The U.S. is contending with a shortage of mental healthcare professionals. More than 3 in 4 U.S. counties don’t have a mental healthcare provider, and patients face wait times of weeks or even months. Western and Southern states are among those with the greatest number of healthcare professional shortage areas, which are designated based on the number of mental health professionals relative to the population. To be considered a mental healthcare shortage area, the population-to-provider ratio must be at least 30,000 to 1 or 20,000 to 1 in high-needs communities. More than 4 in 5 rural counties in the U.S. lack adequate mental healthcare service compared to 36% of more populated metropolitan regions.

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LGBTQ+ people

LGBTQ+ people report discrimination as a primary reason for not seeking necessary mental and physical healthcare. Reports of discrimination and its adverse effects are often highest among transgender individuals.

Three in 5 transgender people report facing discrimination in their personal or professional lives — about twice the rate of the whole surveyed LGBTQ population — according to a 2020 study from the Center for American Progress. While 15% of LGBTQ+ people reported postponing medical care, including mental healthcare, to avoid discrimination, transgender Americans postpone at twice that rate. LGBTQ+ people face not only discrimination but a lack of access to professionals who are knowledgeable about LGBTQ+ issues.

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Younger generations

Young adults ages 18-29 were more likely than any other age group to experience high levels of psychological distress, according to a Pew Research Center analysis of CDC survey data collected between March 2020 and September 2022. Research has shown they are also the loneliest age group, with more than 3 in 5 (61%) saying they feel lonely frequently or all of the time. Loneliness can lead to serious physical and mental health issues, including depression, anxiety, substance use, and heart disease. And yet, they are the least likely to receive appropriate mental healthcare. Apathy is one of the biggest barriers young people face when accessing mental healthcare in the U.S.

Respondents who are older members of Gen Z — a cohort that ranges between the ages of 11 and 26 — are less likely than older generations to maintain their health proactively, according to a 2022 McKinsey survey. They were the generation least motivated to improve their health and the least comfortable talking about behavioral health with professionals, all while being more likely than any other generation to have a behavioral health condition, depression, and anxiety. Cost is another major barrier younger generations face when seeking mental health support, with roughly 1 in 4 Gen Z respondents saying they could not afford mental health services.

The post More than 11% of Americans may not be receiving the mental healthcare they need, data shows appeared first on Sana Benefits.

Sana analyzed differences in quit rates among various organizations, and found the largest companies in the private sector had the lowest quit rates, sometimes below even those in the public sector. While reasons for quitting vary, the data show a higher percentage of public sector employees sticking around, while a higher percentage of private sector employees cut ties and sought new opportunities elsewhere. The analysis used Job Openings and Labor Turnover Survey data from the Bureau of Labor Statistics as of August 2022, the most recent nonpreliminary data available.

COVID-19-related instability led to a massive spike in unemployment in early 2020, potentially encouraging job seekers to prioritize security at work. That shift may have contributed to what the analysis found: a higher quit rate among small private companies, which some perceive as less stable, and a lower quit rate among workplaces viewed as more stable, such as large companies and government employers.

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Private sector quit rates are higher and more volatile compared to the public sector

The Great Resignation affected private and public employers, though the effect was more pronounced in the private sector. In August 2022, 3% of non-government employees quit their jobs, while just 1% of government workers did so. 

Quit rates among private sector employees have long been well above those for government workers for more than 20 years. This also translates into worker longevity: BLS data shows the average government worker has been in their job for 6.8 years, as compared to 3.7 years for private sector employees.

Another factor in the quit rate difference could be age: About 60% of private sector workers in the U.S. are over 35 years old, while about 75% of public sector workers in the U.S. are over 35. Older workers are more likely to stay at their jobs: BLS reports that the typical employee between the ages of 25 and 35 has been at their job for 2.8 years, while the average for workers of all ages is nearly five years.

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The largest companies have the lowest quit rates

BLS data shows that enterprises with more than 5,000 employees had a quit rate of 1.1%, less than half that of any other size of company. Large companies employ just over one-third of all U.S. workers, and they’re found in all types of industries across the economy.

The next-smallest quit rate, at 2.3%, is actually for the tiniest companies, those with between 1 and 9 employees. Many of them are likely to have a very small staff — even just one or two people — who are partners in the operation. For them, quitting could mean closing the business rather than walking out the door of a business that would continue after their departure.

Companies with between 1,000 and 4,999 employees are next, with 2.6% of employees quitting in August 2022, followed by firms with 250 to 999 workers, at 2.9%. 

Smaller companies — but those large enough not to be staffed only by key partners — had higher rates. Those with 10 to 49 employees saw 3.2% of workers leave in August 2022. And the next-largest companies, with 50 to 249 workers, had the highest rate, at 3.6%.

Perhaps the key factor is sensitivity to risk. Large companies tend to attract risk-averse people who may be less interested in changing jobs in a time of economic uncertainty. And large companies may be better prepared to weather financial troubles. By contrast, more risk-tolerant people tend to work at smaller companies, where they may also know the owner and have a really solid view of how the business is really going.

In the August 2022 data, quit rates do seem to be returning to pre-pandemic levels. That could be a sign the Great Resignation is slowing down. But other factors may be at play, too: The Federal Reserve Bank of St. Louis says that quit rates decrease as threats of recession increase, meaning people could be staying put out of concerns that a recession is coming to the U.S. economy.

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