Help Center
What is the difference between large and small-group health insurance?
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 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 on our master policies.
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 small group health insurance?
Small group health insurance plans are accessible to companies smaller than a certain size, either 50 or 100 benefits-eligible 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 small-group insurance?
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. With small group open market plans, all companies enrolled in these plans receive the same premiums, meaning there is no company-specific variability.
What are the differences between large-group and small-group health insurance?
The plans and networks available on large group health insurance through the Justworks master policies and small group open market plans are comparable but may be offered through different carriers. There are some nuances between large-group and small-group 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. Small group 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’ master policy 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 employees on small group health insurance, members over the age of 65 will have Medicare operate as their primary insurance with their small group policy as a secondary payer.
Qualifying Life Events (QLEs)
On Justworks, employees using our large group master policies will submit any QLE to Justworks for approval. Groups using small group open market plans through Justworks will act as the plan administrator. This means 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 master policies will see their company premiums remitted to the carrier directly through Justworks. For companies using small group 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.
Deductibles
As with any move to a new health insurance carrier, employees can request a deductible credit directly from the carrier. This would be contingent on the carrier’s approval and their ability to provide deductible credits.
Which states have access to open market plans through Justworks?
- California: 100 or fewer employees
Anthem (Blue Cross Blue Shield), Kaiser, United Healthcare -
Colorado: 100 or fewer employees
Anthem (Blue Cross Blue Shield), Kaiser, United Healthcare -
Connecticut: 50 or fewer employees
Anthem (Blue Cross Blue Shield), Oxford (United Healthcare) -
Georgia: 50 or fewer employees
Anthem (Blue Cross Blue Shield), Kaiser, United Healthcare -
Illinois: 50 or fewer employees
HCSC (Blue Cross Blue Shield), United Healthcare - Maine: 50 or fewer employees
Anthem (Blue Cross Blue Shield), United Healthcare -
New York: 100 or fewer employees
Oxford (United Healthcare), Empire (Blue Cross Blue Shield) -
Texas: 50 or fewer employees
United Healthcare, HCSC (Blue Cross Blue Shield) -
Virginia: 50 or fewer employees
Anthem (Blue Cross Blue Shield), United Healthcare
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.