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Answering Clients’ Questions: Understanding the Differences Between Small Group and Large Group Health Insurance

March 11, 2022   |   by Alex Strautman
small-group-vs-large-group-health-insurance

 

If you have clients with 50-100 employees or more than 100 employees, they may not be aware of the options available to them when shopping for Group Health Insurance. In fact, California and Nevada have different standards when it comes to Large Group. In California, Small Group includes health insurance for groups of 1-100 employees. In Nevada, Small Group includes groups of 1-50 employees. A California Large Group has 101+ employees, while Large Group in Nevada begins at 51+ employees.

California is not the only state defining a small employer as having up to 100 employees. Colorado, New York, and Vermont have a 100-employee limit for Small Group, too.

Small Group vs Large Group Health Insurance

Roster of Partners

Word & Brown works with a diverse roster of partners for different market segments. The tables below show California and Nevada carriers and administrators offering Small Group and Large Group health insurance.

California Carriers and Administrators

Small Group Medical

(1-100 Employees)

Aetna
Anthem Blue Cross
Blue Shield of California
CalCPA
CaliforniaChoice
Chinese Community Health Plan
Cigna
Cigna + Oscar
Evolved Benefits
Health Net
Kaiser Permanente
MediExcel Health Plan
Nippon Life Benefits
Sharp Health Plan
SIMNSA
Sutter Health Plan
Total Benefit Solutions
UnitedHealthcare (UHC)
Western Health Advantage
California Carriers and Administrators Large Group Medical

(101+ Employees)

Aetna *
Anthem Blue Cross
Blue Shield of California
CalCPA
Cigna
E.D.I.S.
Evolved Benefits
Health Net
Kaiser Permanente
MediExcel Health Plan
Nippon Life Benefits
Sharp Health Plan *
Total Benefits Solutions
UnitedHealthcare (UHC) *
Western Health Advantage *

✓ Word & Brown has Large Group contract with carrier

* No Word & Brown Large Group contract with carrier; co-brokering required.

✓*Word & Brown writes groups up to 300 lives; possible co-brokering needed. Please contact your Word & Brown representative to discuss further.

Nevada Carriers and Administrators Small Group Medical

(1-50 Employees)

Aetna Funding Advantage
Anthem BCBS
Cigna
CalCPA
E.D.I.S.
Nippon Life Benefits
Prominence Health Plan
Seniors Choice
Total Benefit Solutions

✓ Word & Brown has Large Group contract with carrier

Nevada Carriers and Administrators Large Group Medical

(51+ Employees)

Aetna ✓++
Anthem BCBS
Cigna
E.D.I.S.
Nippon Life Benefits
Prominence Health Plan
Total Benefit Solutions

++Groups up to 100; larger groups need to be co-brokered.

✓ Word & Brown has Large Group contract with carrier

* No Word & Brown Large Group contract with carrier; co-brokering required.

 

It also is worth mentioning that MediExcel and SIMNSA coverage in California is cross-border health. Worksite Voluntary coverage is available through Aflac. Your Word & Brown representative can provide you with complete information.

The California Department of Insurance lists more than 35 insurers writing Group Health Insurance on its website. Six health insurers offer Small Business Health Options Program (SHOP) coverage through the Covered California exchange.

For information on the small employer health insurance market in Nevada, visit the Nevada Division of Insurance website.

Small Group vs Large Group Insurance Rates

Shelf Vs. Custom Premiums

Another thing that differentiates coverage for Small Groups and Large Groups is pricing. Small Group premiums are set by the insurer and are non-negotiable. They are what used to be described as book rates or shelf rates – because brokers looked them up in large binders on their bookshelf.

While the Affordable Care Act (ACA) does mandate that health plans with like benefits be priced similarly for Small Groups, premiums for larger groups are negotiated for each group specifically.

What goes into pricing for larger groups is the group’s claims experience for its insured employees and dependents, the insurance company’s profit, and the negotiated compensation for the selling broker or benefit consultant.

EHBs – Included or Not?

Essential Health Benefits (EHBs) are required under the ACA. EHBs include 10 specific categories of health services: ambulatory patient services (outpatient care without admission to a hospital); emergency services; hospitalization (like surgery and overnight stays); pregnancy, maternity, and newborn care; mental health and substance use disorder services; prescription drugs; rehabilitative and habilitative services and devices; lab services; preventive and wellness services; and pediatric services (including oral and vision care).

Large employer plans are not required to cover EHBs, although some do. Any health plan that covers EHBs must cover these benefits with no annual limits or lifetime maximums. This includes self-insured and Large Group plans.

Large Group health plans are not subject to state regulator scrutiny concerning rates, provider networks, or drug formularies. Additionally, while regulators do review large employer health plans for compliance under state and federal requirements, the U.S. Department of Labor is the regulating agency that determines whether a plan meets federal rules.

Association Health Plans – in Nevada

California prohibits Association Health Plan (AHP) coverage; however, it is available to Small Groups (of 2-50 employees) in Nevada.

Prominence Health Plan offers AHP coverage in seven locales throughout Nevada:

  • Carson City
  • Clark County
  • Douglas County
  • Lyon County
  • Nye County
  • Storey County
  • Washoe Country

Eligible Nevada employers must be affiliated with one of the following trade groups to qualify:

  • California Auto Wholesalers Association (CAWA)
  • Clark County Bar Association
  • Nevada Hotel & Lodging Association
  • Nevada Builders Alliance
  • Nevada Optometric Association
  • Northern Nevada Dental Society
  • Reno Chamber of Commerce
  • South Nevada Dental Society
  • Washoe County Bar Association
  • Washoe County Medical Society

Look at the Big Picture

If you’re working with clients reviewing their Group Health options, it is important to remind them health plans rates don’t always tell the whole story. Some health plans may offer “extras,” such as wellness services, digital health programs, wearable technology, or other differentiators. That could tip the scale one way or another when they are comparing plans.

As a Word & Brown broker, you’re able to offer a range of extras, too, including:

  • Side-by-side plan comparisons showing your client’s current plan, renewal, and suggested alternative options
  • Quote-integrated provider search tools to ensure your customers get their preferred medical groups, doctors, specialists, and Rx benefits in the plans being considered
  • Ease online enrollment access and API integration – making it easy to go from quote to online enrollment with just one click
  • Onsite enrollment experts to expedite enrollments, explain carrier perks, review completed applications, and finalize your case submissions

Your clients may be eligible for additional benefits like a Health Savings Account (HSA), Premium Only Plan (POP), or other services, too. Ask your Word & Brown representative for details. Or, if you are not already doing business with Word & Brown, call (800) 869-6989.

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