High Deductible Health Plans (HDHP) - high deductible insurance

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High Deductible Insurance: General Information
Benefit Booklet

Each insured employee receives a Benefit Booklet with a validation page indicating the coverage and effective date. Benefits, exclusions and limitations can be found in the Benefit Booklet.

Claims Payment

Claims are paid directly by our group claims office to the insured or a network provider. We do not allow claims to be assigned to a non-network provider.

Eligible Employees

All full-time employees who have completed the required waiting period, if any, are eligible to enroll. Full-time means working at least 30 hours per week, excluding time worked at home. Employees working 20- 29 hours per week can be included at the employer's discretion.

Employees must enroll within 30 days of becoming eligible, otherwise they may be considered a late enrollee. (Special exceptions apply. See the Special Enrollment Period section). Details on special enrollment procedures will be provided in the administration kit.

Late Enrollees

"Late enrollees," will be enrolled and subject to a 18 month pre-existing condition limitation. Late enrollees are individuals who declined coverage when it was first offered to them and are not enrolling during a Special Enrollment Period. (See the Special Enrollment Period section for more details.) Late enrollees will be given credit towards satisfaction of this pre-existing condition limitation for prior creditable coverage. However, the period of time between when the person was eligible to enroll, and when he or she actually enrolled as a late enrollee will not be counted as a waiting period, and therefore will not run concurrently with this pre-existing condition period.

Special Enrollment Period

An employee or dependent who is eligible for coverage under the Plan, and who declines coverage during the initial enrollment will be allowed to enroll during a Special Enrollment Period if he or she meets the following conditions:

The employee or dependent declined this coverage initially because they stated in writing at the time of enrollment that they had other coverage AND the other coverage:
- terminated as a result of loss of eligibility for that coverage (due to legal separation, divorce, death, termination of employment, or reduction in the number of hours of employment); or
- was COBRA continuation which exhausted, or
- terminated as a result of employer contributions towards such coverage ceasing.
In these cases, enrollment must be made no later than 30 days after the date such coverage in above terminated.
or
If an employee gains a dependent through marriage, birth, or adoption or placement for adoption, they may enroll themselves and their newly acquired dependent under this Special Enrollment provision no later than 30 days after the date the person is eligible for coverage. or
A court has ordered coverage to be provided for a spouse or minor or dependent child under a covered employee's health benefit plan and request for enrollment is made within 30 days after issuance of the court order. Individuals enrolling during a Special Enrollment Period will be given credit towards satisfaction of this pre-existing condition limitation for prior creditable coverage.

Effective Date

In general, employees are covered on the later of the plan's effective date or the first day of the month coinciding with or following the date of timely enrollment. New York is a Community Rated, Guaranteed Issue state for medical coverage for employers with 50 or less employees subject to Small Group Health Insurance Law. No individual will be denied enrollment in a group plan on the basis of any health status related factors.

Guarantee Renewability

All group medical plans are guarantee renewable. A carrier may not deny an employer continued participation or access to the same or different coverage under a plan except for the following reasons:

Non-payment of premium
Fraud or misrepresentation
Violation of participation or contribution requirements
Non-compliance with plan provisions
For network plans, when there is no longer any member working or living in the service area
When the carrier discontinues a particular product (subject to state and federal guidelines)
When a carrier discontinues all coverage in either the large group or small group market, or both, in a state (subject to particular state guidelines)

Plans Available

We offer PPO medical plans that are HSA-compatible. We also offer HDHP that are not HSA-compatible.

For additional information on High Deductible Insurance, fill out the form below or contact us.

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Type of Business: Corp. Sole Prop. Partnership

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