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Large Group vs. Open Market Health Insurance

Justworks
Justworks
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What is the difference between Large Group health plans and Small Group Open Market health plans? Check out our video explainer and information below to learn more about which option may be best for your team.

 

What is Large Group health insurance? 

Large Group health insurance plans are typically reserved for groups larger than a certain size, either 51 or 101 benefits-eligible U.S. based employees, depending on where a company is located. With that being said, Professional Employer Organizations (PEO) like Justworks allow smaller companies access to Large Group health insurance plans.

Justworks offers a range of Large Group health insurance plans, depending on where a company is sitused, through carriers such as Aetna, Kaiser, and UnitedHealthcare (UHC).

 

What is Open Market health insurance?

Small Group Open Market health insurance plans are accessible to companies smaller than a certain size, either 50 or 100 benefits-eligible U.S. based employees, depending on where the company is located.

For certain states* Justworks can provide direct access to Small Group health insurance through the Open Market. We work with a range of carriers such as Anthem, Health Care Service Corporation (HCSC), Empire, Blue Cross Blue Shield (BCBS), United Health Care (UHC), Oxford, and Kaiser.

 

How are rates different on Large Group and Open Market plans?

Large Group health insurance rates are determined by an underwriting evaluation that takes into account your company's specific demographics as well as past health insurance utilization. This provides the insurance company with a holistic view of your team’s needs and allows them to formulate a stable baseline for your cost of coverage. Factors related to both your specific company and the macroeconomic landscape will be taken into consideration at your annual renewal. You can read more about this here. 

Small Group Open Market health insurance is quoted a little differently, with the plans being either state or community-rated. For state and community-rated plans, a carrier charges groups covered by the same policy the same premium regardless of factors like gender, health status, occupation, or plan utilization. The carrier determines the premium based on the health and demographic profile of the entire geographic region or the total population covered under a particular policy that it insures. All companies enrolled in these Open Market plans receive the same premiums, meaning there is no company-specific variability.

 

What are the differences between Large Group and Open Market plans?

The plans and networks available on Large Group health insurance and Small Group Open Market plans are comparable but may be offered through different carriers. There are some nuances between Large Group and Open Market options that should be taken into account.

Eligibility Requirements

Large Group health insurance offerings must satisfy the carrier’s minimum eligibility requirements, which are reviewed upon enrollment and at the time of your renewals. Open Market health insurance offerings also have minimum eligibility requirements, but they tend to be less constraining, with some small market carriers only requiring one enrolled employee.

Medical Coverage

State-mandated treatments, like IVF, can sometimes only apply to Large Group insurance - but this is dependent on the state and where the policy is written out of. Justworks’ Large Group offering with Aetna is based in New York, a state where IVF coverage is required for Large Group health insurance. Though IVF is not covered in some states, there are often regulations requiring coverage for other reproductive treatments on Small and Large Group health insurance.

Medicare

For companies with less than 20 U.S. based employees on Small Group Open Market health plans, members over the age of 65 will have Medicare operate as their primary insurance with their Small Group policy as a secondary payer.

Creditable Coverage Notice Requirements 

If your company offers policies that include prescription drug coverage, as group sponsor for your Open Market Plan, your company will be responsible for complying with Creditable Coverage notice requirements under the Medicare Modernization Act (MMA). A group sponsor is providing creditable coverage if they are offering prescription drug coverage that is as good as that offered under the Medicare drug benefit. 

To comply with the disclosure requirements under the MMA, you will still need to do the following:

  1. Provide written notice to all Medicare-eligible employees covered under a sponsor’s prescription drug plan before October 15 each year and at various times as stated in the regulations, including when an employee joins the plan. The notice must also be provided to:
      • Medicare-eligible active working employees and their dependents
      • Medicare-eligible COBRA individuals and their dependents
      • Medicare eligible disabled individuals covered under your prescription drug plan and any retirees and dependents.
  1. Complete the Online Disclosure to CMS Form. This Disclosure form must be completed:
      • No later than 60 days from the beginning of a plan year (contract year, renewal year)
      • Within 30 days after termination of a prescription drug plan
      • Within 30 days after any change in creditable coverage status.

Qualifying Life Events (QLEs)

On Justworks, U.S. based employees using our Large Group plans will submit any QLE to Justworks for approval. Groups using Open Market plans through Justworks will act as the plan administrator. This means that as the employer, you will have the ability to review and approve QLEs directly, adhering to the documentation requirements outlined by the IRS.

Billing

Companies that are using our Large Group plans will see their company premiums remitted to the carrier directly through Justworks. For companies using Open Market plans, these premiums will be paid directly to the carrier rather than Justworks. We will assist with setting this up on your company’s behalf, and it will be set as auto payments via ACH.

 

Which states have access to Open Market plans through Justworks?

Open Market plans through Justworks are available in the following states where the threshold for Small Group health insurance is 100 or fewer benefits-eligible U.S. based employees:

  • California: Anthem (Blue Cross Blue Shield), Blue Cross Blue Shield, CalChoice (Blue Cross Blue Shield), Kaiser, United Healthcare
  • Colorado: Anthem (Blue Cross Blue Shield), Kaiser, United Healthcare
  • New York: Oxford (United Healthcare), Empire (Blue Cross Blue Shield)
  •  

Open Market plans through Justworks are available in the following states where the threshold for Small Group health insurance is 50 or fewer benefits-eligible employees: 

  • Alabama: UnitedHealthcare

  • Alaska: UnitedHealthcare

  • Arizona: AZBlue (Blue Cross Blue Shield), UnitedHealthcare

  • Arkansas: UnitedHealthcare

  • Connecticut: Anthem (Blue Cross Blue Shield), Oxford (UnitedHealthcare)

  • Delaware: UnitedHealthcare

  • Florida: UnitedHealthcare

  • Georgia: Anthem (Blue Cross Blue Shield), Kaiser, UnitedHealthcare

  • Hawaii: Kaiser

  • Idaho: UnitedHealthcare

  • Illinois: HCSC (Blue Cross Blue Shield), UnitedHealthcare

  • Indiana: Anthem (Blue Cross Blue Shield), UnitedHealthcare

  • Iowa: UnitedHealthcare

  • Kansas: UnitedHealthcare

  • Kentucky: UnitedHealthcare

  • Louisiana: UnitedHealthcare

  • Maine: UnitedHealthcare, Anthem (Blue Cross Blue Shield)

  • Maryland: UnitedHealthcare

  • Massachusetts: UnitedHealthcare

  • Michigan: UnitedHealthcare

  • Minnesota: UnitedHealthcare

  • Mississippi: UnitedHealthcare

  • Missouri: Anthem (Blue Cross Blue Shield), UnitedHealthcare

  • Montana: UnitedHealthcare

  • Nebraska: UnitedHealthcare

  • Nevada: UnitedHealthcare

  • New Hampshire: Anthem (Blue Cross Blue Shield), UnitedHealthcare

  • New Jersey: Horizon (Blue Cross Blue Shield), Oxford (UnitedHealthcare)

  • New Mexico: UnitedHealthcare

  • North Carolina: UnitedHealthcare

  • North Dakota: UnitedHealthcare

  • Ohio: Anthem (Blue Cross Blue Shield), UnitedHealthcare

  • Oklahoma: UnitedHealthcare

  • Oregon: UnitedHealthcare

  • Pennsylvania: UnitedHealthcare

  • Rhode Island: UnitedHealthcare

  • South Carolina: UnitedHealthcare

  • South Dakota: UnitedHealthcare

  • Tennessee: UnitedHealthcare

  • Texas: UnitedHealthcare, HCSC (Blue Cross Blue Shield)

  • Utah: UnitedHealthcare

  • Virginia: Anthem (Blue Cross Blue Shield), Kaiser, UnitedHealthcare

  • Washington: UnitedHealthcare

  • Wisconsin: Anthem (Blue Cross Blue Shield), UnitedHealthcare

  • West Virginia: UnitedHealthcare

  • Wyoming: UnitedHealthcare

Will my company be quoted on Large Group or Open Market plans with Justworks?

We’ll assess your needs and work to find the perfect fit—whether it's Large Group or Open Market plans that suit your company best. Our personalized approach ensures that your group’s coverage aligns with the size and unique requirements of your company.

Our commitment doesn't end with enrollment; each year, during the renewal process, we’ll reassess your needs to confirm that you have the best options for your group.


Disclaimer

This material has been prepared for informational purposes only and is not intended to provide, and should not be relied on for, legal or tax advice. If you have any legal or tax questions regarding this content or related issues, then you should consult with your professional legal or tax advisor. 

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