888-765-5400Group Health Insurance
Group health insurance plans, such as Blue Options PPO, differ from individual/family health insurance plans, such as the Blue Advantage plan, in several ways. First of all, they are most often sponsored by an employer, who in NC, must contribute at least 50% of the cost of the employee portion of the premium. Groups must also have at least 75% of their eligible employees (full time working 30 hours or more per week) participating on the plan, less anyone who is on another group plan. Blue Advantage can be applied for by any resident of North Carolina who is under 65 and who is not on Medicare or Medicaid – there are no participation requirements.
Addtionally, the NC Department of Insurance regulates the rating and policy issuance of employer groups differently than individual plans. For example, BCBSNC group plans are guaranteed issue, meaning they cannot be denied because someone in the group has a serious health condition, such as cancer. In contrast, in 2009 the Blue Advantage plan will become a “decline” policy, meaning that an individual’s health can be a determining factor in obtaining coverage or not. Pregnancy cannot be considered a pre-existing condition for exclusionary purposes under a group plan, but you cannot add maternity coverage to a Blue Advantage plan if an applicant or their spouse is currently pregnant. You can add maternity to Blue Advantage if the applicant or spouse is not pregnant prior to the effective date of coverage (conception determined by physician). Prescription drug coverage on group plans is often richer with no limitations on brand name drugs, and vision (lens and frames) services can be added at an additional cost. Furthermore, under a group plan an employer has the option of offering ancillary products, such as life insurance, short and long term disability, and dental insurance. These options are not available under the Blue Advantage plan, with the exception of Dental Blue individual plans that can be purchased as a separate stand-alone policy. Finally, the application process for groups is different. In addition to each employee completing an individual application, there are a number of other documents that must be completed/provided for groups, including an Employer Risk Appraisal, NCUI 101 Employer Tax and Wage Report (groups of less than 10 eligible employees), business owner tax statements or employee W-4 forms (if the owner or employees is applying for coverage and is not on the Tax and Wage Report), Agent of Record Letters, and the most recent billing statement if the group currently has another group policy. With Blue Advantage, an applicant simply completes an application with health questions.
This comparison is not inclusive of all the differences between group and individual plans. If you are self-employed or with a small group that does not sponsor a health insurance plan, call Jerry Ballard at 888-756-5400 and he will be glad to go over more of the pros and cons of each type of plan to ensure you pick what is best for you and your family or company.