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What Your PPO Network Was Actually Designed to Do

Tue, 14 Apr 2026 15:18:12 GMT

When employers shop for health coverage, the conversation almost always begins with the same question: which network? The assumption embedded in that question is significant. It treats the network as the foundation of the benefits strategy—the starting point from which everything else is built. That assumption is worth examining.

Preferred provider organization (PPO) networks were introduced in the early 1980s to solve a specific problem: how to give employees access to a broad range of providers while creating some structure around how claims were paid. The original design was straightforward: a network of hospitals and physicians agreed to accept patients covered by a given plan, and in exchange those doctors and facilities received a predictable flow of patients. Employers and insurers got a defined group of providers they could direct their employees toward. In other words, networks were designed to manage access. That was the whole job. And for a long time, they did that job reasonably well.

But, somewhere along the way, the network became something more than infrastructure. It became the strategy.

Access and cost control are not the same thing

Managing access to providers and controlling the cost of care are two different problems. Networks were built to solve the first one. They were never designed to solve the second. This distinction matters because most employer health plan conversations conflate the two. When an advisor presents a network, the implicit message is that the network is doing the work of cost management. Employers are shown large provider counts, geographic coverage maps, and discount percentages—all signals of a network’s reach and negotiating position.

But broad access does not guarantee cost discipline. A network can include thousands of providers across every major city while doing nothing to address whether those providers are billing at rational prices. The size of the network and the quality of its pricing are separate questions entirely.

Research consistently confirms this gap. A 2024 analysis published in Health Affairs Scholar found that hospital prices have risen steadily for nearly two decades—faster than insurance premiums or professional services—suggesting that network contracting has not been sufficient to contain the primary driver of healthcare costs.

Meanwhile, Mercer’s 2025 National Survey of Employer-Sponsored Health Plans found that the average cost of employer-sponsored health insurance reached $17,496 per employee—a 6% increase over the prior year, and part of a sustained period of elevated growth. Employers operating within traditional PPO network structures have largely absorbed these increases year after year. The network did not prevent those increases. It was not designed to.

The access promise is shakier than it appears

Even on its own terms—pure access—the network model has significant limitations that are not always visible to employers. Provider directories, the tool employers and employees rely on to understand who is in their network, are frequently inaccurate. This problem is widespread enough that researchers and regulators have given it a name: ghost networks. These are providers listed as in-network who are, in practice, unavailable. They are either not accepting new patients, no longer listed at the location, or no longer contracted with the plan at all.

A study published by JAMA Open Network found that 81% of entries across provider directories of five large insurers contained inaccuracies. A secret shopper study conducted by the US Senate Finance Committee found that appointments could only be secured 18% of the time when contacting providers listed in network directories.

The practical implication here is significant. Employers may believe their workforce has access to a robust network of providers. In many cases, that access exists on paper more than in practice. When directory data cannot be trusted, the access argument for networks weakens considerably. Employees encounter friction when seeking care, face unexpected out-of-network costs, or simply give up on finding a listed provider. Ultimately, the network that was supposed to simplify access often complicates it.

The default became the strategy

None of this means PPO networks have no value. For many employers, particularly those with geographically dispersed workforces, a broad network still serves an important administrative function. Networks are not the enemy. But they are also not a strategy on their own.

The problem is how networks came to be treated. Over decades, the PPO became the default option in employer benefits. Advisors presented it. Carriers promoted it. Employers accepted it. And with repetition, the default became indistinguishable from the strategy. Choosing a network felt like making a strategic decision because it was the most visible decision available. But selecting a network is an infrastructure choice, not a strategic one. It determines which providers are covered. It does not determine whether those providers are delivering care at fair prices, whether the funding structure makes sense for the employer, or whether the plan design is aligned with the actual health needs of the workforce.

Strategy happens before the network selection. It starts with questions about employer goals, cost tolerance, workforce demographics, and risk appetite. The network is one tool that may or may not be the right fit depending on the answers to those questions. When that sequence gets reversed—when the network comes first and everything else is built around it—the strategy is inherited, not designed.

What employers are beginning to ask

The sustained rise in healthcare costs is pushing more employers to examine the assumptions behind their benefit strategies. Many are starting to ask not just which network, but whether a traditional network structure is the right foundation at all.

This shift is producing real interest in approaches that start from different premises: direct provider contracting, reference-based pricing, self-funded structures, and alternative funding models that prioritize pricing transparency over network discounts. These are not fringe ideas. They represent a growing segment of employer benefits strategy, particularly among mid-size and smaller employers who have more flexibility and more urgency to find approaches that actually control cost.

The common thread in all of them is that they treat the network as one possible tool rather than the automatic starting point. They begin with strategy and work toward structure—not the other way around.

The bottom line

Networks were built to manage access. In many cases, they still do that. But the industry’s habit of treating network selection as a proxy for benefits strategy has produced a generation of plans that are designed around infrastructure rather than outcomes.

When employers begin to separate the access question from the cost question, the conversation about benefits changes. The network stops being the default answer and starts being one option among several—evaluated on its actual merits rather than its institutional familiarity.

That shift in thinking is where smarter benefit design begins. And it raises a question that goes beyond the network entirely: if the annual renewal cycle has been built around a structure that was never designed to control costs, what does it mean to actually design a benefits strategy from scratch?
Look for a discussion on designing benefits strategy in our next blog.

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The Myth of PPO Savings

Tue, 31 Mar 2026 16:24:28 GMT

When discounts are calculated from inflated list prices, they can create the illusion of savings without addressing the underlying cost of care. Understanding how these pricing mechanics work is an important first step for employers trying to manage healthcare spending more effectively.

Why discounts aren’t always the same as savings

For decades, PPO networks have been positioned as the cornerstone of employer health plans. Advisors, carriers, and plan reports often highlight negotiated discounts as evidence that the system is working. A hospital may bill $10,000 for a procedure, a PPO contract reduces the allowed amount to $6,000, and the plan reports a 40% savings.

On paper, that sounds like a powerful cost-control mechanism, and employers understandably assume the network is successfully negotiating lower prices on their behalf. But if those discounts truly produced meaningful savings, employers would expect healthcare costs to stabilize—or at least grow more slowly. Instead, premiums have continued to rise year after year. That disconnect raises an important question: If PPO discounts are so effective, why do costs keep climbing?
The answer lies in how those discounts are calculated and in the starting prices they’re measured against.

The discount percentage alone tells us very little about the price that ultimately matters: the actual price of the care.

The starting price was never real

Hospitals maintain a comprehensive internal price list for services known as a chargemaster. These lists assign a price to every procedure, test, supply, and service a hospital provides. Research from KFF notes that these list prices can differ dramatically from the amounts insurers and patients ultimately pay. Rather than reflecting the actual cost of providing care, chargemaster prices function primarily as an anchor for negotiations between hospitals and insurers.

Because PPO discounts are calculated from these list prices, the starting number significantly shapes the size of the reported discount. If the list price is high enough, even a steep discount can still leave the final price well above what the service might cost in a more transparent market. This is why the percentage itself can be misleading.

In other words, a large discount does not necessarily mean a fair price.

Why discount percentages can be misleading

In most industries, discounts reduce a price that is reasonably close to the market value of a product or service. Healthcare pricing works differently. When hospitals establish list prices primarily to anchor negotiations, the resulting discounts can appear substantial even when the final negotiated rate remains high.
For employers reviewing plan reports, this creates a distorted signal of value. A report may highlight a 50% or 60% negotiated discount, suggesting the network is delivering meaningful savings. But the percentage alone tells us very little about the price that ultimately matters: the actual price of the care.
Consider two scenarios. A hospital bills $10,000 for a service and the PPO rate reduces it to $6,000 (a 40% discount). Another provider prices the same service transparently at $4,000 with no discount. The first scenario produces a larger reported discount, while the second produces the lower cost. But, most importantly, from the employer’s perspective, only one of those outcomes represents genuine savings.

What independent research shows

Research into hospital pricing has revealed just how wide the gap between list prices and negotiated rates can be.

A national study conducted by the RAND Corporation found that employers and private insurers paid an average of 254% of Medicare rates for hospital services across the United States. The RAND researchers also found that prices for the same services can vary dramatically across hospitals and regions, even within the same insurance networks.

These findings illustrate a straightforward point: a large discount does not guarantee the lowest price. Without visibility into the underlying pricing structure, the percentage alone can create a false sense of cost control.

A better question for employers

For years, employers evaluating health plans have been guided by one primary question: “How large is the network discount?” But focusing on discount size can distract from the metric that matters most.

A more useful question is: “What is the actual price being paid for care?” When employers shift their focus from discounts to real prices, the conversation about healthcare strategy begins to change. Advisors and plan sponsors begin evaluating whether the plan is truly delivering value—or simply reporting large discounts measured against inflated starting prices.

The bottom line

PPO networks were designed to expand access to providers and negotiate pricing agreements with hospitals and physicians. In many cases, they still serve that role. But the industry’s long-standing emphasis on discount percentages can obscure what employers ultimately care about most: the real price of care.
When employers look beyond the reported discounts and examine the mechanics behind pricing, they often discover that those savings are measured against inflated starting numbers. And that realization changes the conversation. Instead of asking: “How big is the discount?” Employers begin asking a more important question: “What should the price have been to begin with?” That question challenges the math behind PPO savings. It also opens the door to a broader conversation about how healthcare benefits are designed and, more importantly, how they might be designed differently.

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How Health Insurance Alternatives Can Save Your Small Business Money

Wed, 28 Jan 2026 16:00:01 GMT

Small businesses don’t have to accept rising premiums as the cost of offering benefits. Health insurance alternatives are giving employers a smarter, more sustainable way to support their teams.

As health insurance continues to siphon resources and provide little strategic return, it has become one of the most burdensome aspects of running a small business. Premiums climb year over year, plan designs remain inflexible, and every renewal seems to come with an unwelcome surprise. According to the 2025 Employer Health Benefits Survey from the Kaiser Family Foundation, the average annual premium for employer-sponsored family coverage has reached $26,933, with single coverage averaging $9,325. These costs continue to rise faster than both wages and general inflation, placing outsized pressure on small employers and offering little in return but administrative complexity and employee dissatisfaction. What was once considered a competitive advantage has now become a financial gamble that many employers feel forced to take just to stay viable in a competitive labor market.

But continuing to absorb these costs isn’t sustainable—or necessary. The traditional group insurance model was built for large, centralized workforces in a different era and simply wasn’t designed to serve today’s small businesses. Modern businesses are lean, nimble, geographically dispersed, and composed of employees with a wide range of healthcare needs. Trying to fit modern teams into yesterday’s benefits framework leads to waste, frustration, and a growing sense that the system is rigged against small employers. Fortunately, there are alternatives that allow small businesses to regain control over both their budgets and their benefit offerings.

Why traditional group insurance no longer fits

Group insurance is, by design, one-size-fits-most, and small businesses are rarely the size or structure it was built for. These plans typically require a minimum percentage of employee participation, which forces employers to subsidize coverage that many workers may not want or need. Traditional plans remain geographically anchored, leaving remote, or out-of-state workers with limited access to care. Premiums rise annually, often with little transparency or rationale, leaving small business owners unable to forecast or contain benefit-related costs. According to a longstanding survey of small business owners by the National Federation of Independent Business (NFIB) , the cost of health insurance consistently ranks as one of the top problems facing employers, especially in the face of unpredictable increases.

The issue isn’t that small businesses misunderstand how benefits should work, it’s that the traditional model was never built to serve them in the first place

The issue isn’t that small businesses misunderstand how benefits should work, it’s that the traditional model was never built to serve them in the first place. Employees may be left with high out-of-pocket expenses and narrow provider networks, while employers face ballooning premiums that don’t correlate with measurable plan performance or satisfaction. The end result is a system that frustrates everyone it touches, with neither side feeling they’re receiving real value.

A flexible model that reflects today’s workforce

Health insurance alternatives can offer a different path—one that acknowledges the reality of modern labor markets and evolving employee expectations. Instead of funneling all employees into a single, rigid group plan with unpredictable annual rate hikes, alternative strategies allow businesses to define their financial contribution and benefit structure up front. This might take the form of monthly stipends, health reimbursement arrangements (HRAs), defined contribution strategies (such as ICHRAs), direct primary care memberships, or health cost sharing programs (such as HealthShare membership). Each of these approaches offers a more tailored and controllable framework that aligns contributions with organizational capability rather than carrier pricing models.

In contrast to traditional employer-sponsored plans, which lock businesses into multi-year contracts and annual negotiations, nontraditional alternatives often provide month-to-month predictability, fewer administrative hurdles, and more control over how funds are used. For employees, this can translate to greater autonomy in selecting the providers and plans that make sense for their individual healthcare needs—often at a lower overall cost.

Rather than relying on a single solution, many employers combine strategies. For example, pairing a HealthShare with an HSA-qualified minimum essential coverage plan, offering stipends alongside virtual care, or integrating direct primary care membership with other health benefits. This isn’t just about savings. It’s about designing benefits that match how teams actually live and work while reducing waste and administrative friction.

HealthShares: A practical cost-sharing option

Among the growing array of health insurance alternatives, HealthShares (also known as health care sharing ministries or medical cost sharing communities) offer a compelling middle ground between traditional insurance and self-funded models. These programs are not insurance in the regulatory sense. Instead, members contribute a monthly amount to a shared pool, which is then used to help cover eligible medical expenses within the community. Unlike traditional insurance, HealthShares generally do not guarantee payment of claims, nor are they subject to the Affordable Care Act (ACA) coverage mandates, but they can provide meaningful financial support in a more transparent structure.

For small businesses that are priced out of traditional insurance—or that want to provide meaningful healthcare support without absorbing the full administrative and financial burden of a group plan—HealthShares offer an attractive option. Monthly contributions tend to be significantly lower than traditional premiums, and most HealthShares avoid restrictive provider networks entirely, allowing members to choose their clinicians and facilities. While formal surveys on HealthShare satisfaction are limited, member feedback consistently highlights high satisfaction with provider choice and transparency, even if participation requires a more proactive role in managing care.

That said, HealthShares are not right for every situation. They may have coverage limitations or eligibility guidelines that don’t match every employee’s healthcare needs. Still, for many individuals and families—especially those who want lower cost exposure and greater control over care decisions—HealthShares represent a viable alternative.

For small businesses that are priced out of traditional insurance—or that want to provide meaningful healthcare support without absorbing the full administrative and financial burden of a group plan—HealthShares offer an attractive option.

Rethinking the role of the employer

What makes these models transformative isn’t just that they reduce costs, it’s that they redefine the employer’s role. Traditional benefits ask small business owners to become de facto insurance administrators, absorbing risk, managing compliance, and navigating carrier bureaucracy. That structure makes little sense for businesses with fewer than 50 employees —and it’s a major reason many employers avoid offering benefits altogether.

In contrast, health insurance alternatives allow business owners to serve as benefit strategists rather than administrators. You provide structure, support, and investment—but you don’t carry the full burden of managing a failing system. You guide employees to options that make sense for them, while protecting your business from unsustainable commitments.

Choosing the right path

There is no single “best” solution for every small business. The right mix depends on your budget, the composition of your workforce, and your long-term goals. Some businesses thrive with a HealthShare-first approach. Others prefer to give employees a set amount to spend on the benefits they choose, or mix strategies to fit their needs. What matters most is partnering with a guide who understands the possible options, helps you avoid costly missteps, and builds a benefits strategy that reflects the reality of your business.

How Planstin helps

At Planstin, we don’t push one-size-fits-all plans or lock you into inflexible insurance contracts. We help employers navigate the full spectrum of benefits strategies, from traditional insurance to HealthShares and everything in between, so you can build a benefits approach that actually works for your people and your business.

We provide clarity on options, support on compliance and administration, and guidance on how to structure benefits in a way that aligns with your financial goals and your workforce needs.

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Why Telemedicine Is the Next Big Step for HSAs

Wed, 14 Jan 2026 01:27:25 GMT

Over 32 million people will benefit from HSA-compatible telemedicine under the new OBBBA law. Here’s why this change matters—and how it reshapes access to care.

As we get rolling into 2026, recent changes to Health Savings Account (HSA) rules are changing how people receive and pay for care. The One Big Beautiful Bill Act (OBBBA) expanded HSA flexibility to make direct primary care (DPC) arrangements compatible with HSA’s . But DPC wasn’t the only beneficiary of the new legislation; the new laws also include telemedical care and qualify it as HSA-compatible.

In the years since the pandemic, telemedicine has shifted from an emergency workaround to a mainstream mode of healthcare. Virtual visits with providers are now a regular option for primary care, mental health, and chronic condition management. But, unlike many of the temporary pandemic allowances, telemedicine hasn’t gone away. In fact, experts predict that its role in routine care will continue to expand in the coming years. Before 2020, fewer than 1% of all outpatient visits were conducted virtually in the US, whereas in 2024, 41% of US adults surveyed by Doximity reported receiving care virtually in the past year.

Out with the old: How Telemedicine fit into HSA rules before the new law

Before the OBBBA, how HSA’s interacted with nontraditional services like telemedical care was unclear. Under standard HSA rules, first-dollar coverage for non-preventive services, like virtual care visits, could disqualify someone from contributing to an HSA entirely. However, this changed with the CARES Act, which created a temporary safe harbor that allowed pre-deductible telemedicine visits without affecting eligibility. The problem was that this change was intended to be a temporary solution that expired.

Employers quickly adopted this change. A 2022 survey found that 96% of employers offered pre-deductible telemedicine access, with 76% supporting making this change permanent. This widespread adoption makes it clear that both employers and employees value the flexibility and convenience of virtual care.

In with the new: Telemedicine is now clearly HSA-Compatible

Now, with the OBBBA, Congress has permanently extended the telemedicine safe harbor for HSA’s and high-deductible health plans. Section 71306 of the bill clarifies that telemedicine and other remote care services can be used before the deductible is met without disqualifying a person from HSA eligibility.

This means that if your high-deductible health plan includes telemedicine (like virtual visits or remote consultations), you can use those services before your deductible has been met, and still contribute pre-tax dollars to your HSA, something that was not possible prior to the pandemic.

Industry trackers like the Alliance for Connected Care estimate that over 32 million people will benefit from telemedicine’s compatibility with HSA’s under the new law.

What this means for patients

With telemedicine’s eligibility now clarified under the new law, patients face fewer barriers to care than ever before. Telemedicine can make it easier to get help early, especially for situations that benefit from being seen by a provider promptly. This means an increase in early intervention for serious illnesses and conditions, and a reduction in costly delays that might otherwise result in a visit to the emergency room or extended hospitalization. For example, research shows that telemedicine can cut emergency room visits by about 28% when patients can access virtual care soon after the onset of symptoms.

Aside from fundamental access to care, however, this shift in HSA eligibility will also mean an improvement in affordability and convenience. Patients generally report higher satisfaction with virtual care, which has a positive influence on follow-ups and chronic condition management (both of which are key drivers of long-term health outcomes). Studies of telemedical applications have found notable cost savings for patients, including reduced travel time and lower overall healthcare spending.

Combined with access to alternative models like direct primary care, telemedicine helps create a more accessible and affordable healthcare environment for HSA holders by reducing costs, allowing tax-free funds to be used, and easing logistical concerns for routine healthcare needs. This means patients can feel freer in making choices about when and how they seek care.

What's next?

It looks like nontraditional models of care like DPC and telemedicine are here to stay. In 2025, 91% of large employers reported offering virtual health or telemedicine services in some capacity, with many employers expanding their offerings beyond basic primary care.

Employees and individuals can now benefit from easier access, lower logistical barriers, and more predictable costs resulting from the new law. A 2024 KFF survey showed that 28% of employers see telemedicine as “very important” for future care delivery, with an additional 33% rating it as “important.” The more barriers that get knocked down, the more we can expect these nontraditional methods of healthcare to become fully integrated into standard care environments across the country.

There will always be a need for in-person care, but these alternative services like telemedicine serve as a convenient and affordable complement. But for those needs that are more routine and not urgent, such as preventive visits, chronic condition management, and primary care, we predict that telemedicine will become a permanent fixture in modern healthcare.

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Benefits Trends for 2026

Tue, 09 Dec 2025 17:41:50 GMT

Benefits are getting more expensive, and traditional models are cracking under the pressure. In 2026, businesses will need smarter, more flexible ways to care for their teams.

The outlook for employee benefits in 2026 doesn’t look overly optimistic. Health insurance costs are going up, as are employee expectations, and employers are left in the middle trying to juggle budgets and values. But finding solutions in the coming year may take some creativity in how businesses choose to design and deliver benefits to their workers. Traditional insurance models may not work for small- and medium-sized businesses facing tough decisions.

In this article, we’ll take a look at the top trends affecting benefits in 2026. Some are related to costs of insurance, and others are tied to employee needs for flexible or optional programs. We at Planstin see the future in alternative solutions and innovations in plan design, so we’ll also be spotlighting one of our newest plans that’s just entered the market: Care+ Direct, a non-insurance approach that makes care more affordable and accessible for your employees.

Trend #1: Health insurance premiums are increasing

There doesn’t seem to be any way around it: premiums are going up.

According to a 2025 Mercer survey , employers are expecting their per-employee cost of benefits to increase by an average of 6.5% in 2026, while recent KFF data shows that premiums for family coverage have almost reached $27,000 per year.

If you’re running a small- or medium-sized business, ask yourself this: Are you expecting your budget to increase by 6.5% in 2026? Many are not, and it’s a real concern. Without comparable budget growth, these businesses are going to feel pressure to reduce benefits or shift more costs to the employee.

Trend #2: Employers are shifting more costs to employees

With costs going up, employers are preparing to pass more of the costs to their workers. In 2026, employees can expect their deductibles, copays, and coinsurance costs to all go up as their employers manage the increased expenses. Some smaller companies have already cut back their offerings to only high-deductible health plans, per KFF . And while these types of plans do keep premiums lower, they don’t always make healthcare easier to access. In fact, KFF has found that 28% of insured adults delayed or skipped medical care due to cost in the past year.

So, while the coverage may be there, the worker’s situation or access isn’t necessarily relieved by it.

Trend #3: A focus on access to primary care

One of the more visible shifts already in effect and expected to continue into 2026 is the push to improve how quickly and easily workers can get primary care. Employers are already in the know: better access to primary care leads to earlier intervention, lower costs, and better health outcomes. A report by the Primary Care Collaborative found that organizations investing in primary care models see reductions in emergency visits and improved management of chronic conditions.

To make this possible, many companies are redesigning their health plans to guarantee faster and easier access through new and innovative solutions. Direct Primary Care (DPC) memberships and Virtual DPC options are increasingly being included in benefit offerings, giving employees access to relationship-based care without the traditional barriers of waiting rooms or ever-increasing copays.

Trend #4: A focus on mental wellness and voluntary benefits

Another trend that has been building for some time and doesn’t look to slow down in 2026 is the growing support for mental health in benefits offerings. SHRM’s 2024 employee benefits survey found that the number of employers offering some form of mental health program has grown immensely since the pandemic years, with over 90% of employers now offering such benefits.

In tandem with this, other voluntary benefits are also becoming an increasingly important part of benefits packages. These are the add-on style options that allow employees to customize their coverage to their circumstances, including supplemental health coverage, financial wellness tools, or other lifestyle-focused programs. These types of opt-in benefits are proving a practical solution for small- and medium-sized businesses trying to add real value without multiplying costs for themselves.

Trend #5: More employers are using alternative plans and models

Traditional health insurance plans are becoming more expensive each year, and as discussed above, employers and employees are starting to opt out entirely. But, they aren’t all simply choosing to go without! There are alternative solutions out there that are starting to gain traction.

One such solution is level-funded plans . KFF’s 2025 survey reports that 51% of insured workers in companies with 10-199 workers are enrolled in a level-funded plan, up from 19% in 2018.

Employers are also increasingly offering benefits like telemedicine, standalone prescription programs, and other cost-saving tools that give employees better care without significant effects to premiums.

The future in alternatives and innovations

One thing seems clear from this list: both employers and employees want options that aren’t subject to constantly rising premiums and constrained access to the care they’re paying for. That’s why alternative options are starting to get more attention. And it’s why Planstin is constantly refining and innovating its non-traditional packages, like our new Care+ Direct plan.

Care+ Direct gives your employees more care with fewer costs. By using an included primary care membership and coordinated care pathway, your employees can get access to care and have their typical out-of-pocket costs waived. That means no deductibles, no copays, no coinsurance. In short, no surprises.

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Strategies for Effective Health Plan Renewals

Tue, 02 Dec 2025 21:53:34 GMT

Renewal season rarely waits for a quiet calendar. As projects stack up, so do the questions. What do our people need most? Where are we paying too much? Mercer projects a 6.5 percent increase in employer health benefit costs in 2026 , which can make open enrollment feel daunting.

The good news is that a business health plan renewal is not just an annual chore. It is a strategic opportunity to protect employees from financial stress and to strengthen recruiting. When out-of-pocket costs like deductibles, coinsurance, and prescriptions rise, reliable and affordable benefits matter even more.

With the right preparation, renewal season can convert renewal pressure into clear decisions. In the sections below, we walk through five practical steps for a business health plan renewal that controls costs, supports employees, and keeps you compliant.

1. Start early and stay ahead

One of the best things that you can do for yourself, and your business, is to start planning early. Give yourself about 90 days before your effective date so you have space to compare options, negotiate, and communicate.

90-Day Blueprint:

Phase 1: Set direction. Review renewal rates and projected costs. Confirm leadership goals and budget.
Phase 2: Shape the plan. Discuss claims-fund activity, plan offerings, and employer contributions. Outline your open enrollment strategy.
Phase 3: Build and prep. Configure plan changes in the enrollment system. Draft communications, FAQs, and a simple timeline.
Phase 4: Educate and refine. Share materials. Hold presentations and one-on-one meetings. Capture questions and adjust messaging.
Phase 5: Execute and confirm. Open enrollment, finalize elections, and queue payroll deductions and eligibility files. Spot-check for accuracy.

Similar to tax planning, the sooner you start, the more time you have to make smart adjustments. Starting early gives you breathing room, better conversations, and a smoother business health plan renewal for everyone.

2. Use data to drive smarter decisions

Data is the difference between guessing and making confident, defensible choices. If you don't already have access to claims data, request the data so that you can see where your dollars are going. This will help you understand and make projections for the year.

What to look for

When you review the data, start with the big drivers of cost like pharmacy, imaging, emergency room visits, and specialty care. Look at what employees are actually using so you can see which benefits are well loved and which benefits are barely touched. Then, step back and check for trends to understand whether this year is an outlier or part of a pattern. This data can help you better understand how to move forward with renewal strategies that keep costs in check and align with employee needs.

How to act on what you see

High utilization, such as 160%. Consider ways to make everyday care easier to reach and less expensive. Direct primary care, virtual visits, and clearer care navigation can all lower downstream costs while giving employees quicker support.

Low utilization, such as 60%. You may be overfunding the plan. At renewal, you could lighten contributions, simplify plan choices, or reinvest savings into benefits people are asking for, such as mental health resources or primary care access.

Bring employees into the picture

Numbers can show you where the dollars went, but employees can tell you which dollars actually mattered. Once you understand the cost drivers and underused benefits, reach out to employees to learn what was most valuable to them and where they may have felt gaps. A short survey or a quick feedback session is often enough to surface the benefits people rely on, the ones they find confusing, and the areas they would like to see improved.

When you pair utilization data with employee feedback, you can fine-tune your benefits strategy, so it supports the people who use it most, eliminates spending that isn’t serving them, and positions your business health plan renewal as both financially responsible and people centered.

3. Drive employee participation through communication

Great benefits only work when people use them. Many teams struggle to get employees to enroll or waive coverage, so make participation a priority and keep the process simple and supportive.

Key Drivers of Employee Participation

Participation increases when three things are clear: how much of the premium you cover, what the plan options and costs mean in plain language, and where employees can get personal help.

The more you contribute, the more affordable coverage becomes, which drives broader enrollment, creates a healthier risk pool that stabilizes costs year over year, and strengthens your edge in retention. Clarity matters just as much as contribution. When employees understand what is included and how to access it, they actually use their benefits. Offer live meetings and easy one-on-one support so people can ask questions, get personalized guidance, and choose with confidence.

Make Education Your Anchor

For many, benefits feel too complicated to attempt to understand. Start by making sure you fully understand the plan you offer, then share the essentials in a way that is easy to skim and easy to act on.

Be upfront about what is changing and why.
Spell out employee costs and employer contributions with simple examples.
Show how to enroll or waive, where to get help, and the key dates.
Highlight any nontraditional options that may be unfamiliar, like direct primary care or fair-priced healthcare. A quick explanation and a simple “how it works” goes a long way.

Clear, consistent communication builds confidence. Presentations and brief one-on-ones help employees choose the right option and actually use it. The more informed and supported your team feels, the smoother open enrollment will be, and the more stable your participation will remain throughout the year.

4. Optimize costs without sacrificing value

A well-planned business health plan renewal can control spending and improve the member experience at the same time. The goal is not to cut benefits. The goal is to invest in the options that deliver the most value for your team.

Proven Strategies to Consider:

Direct Primary Care (DPC) : Predictable access to primary care and fewer downstream high-cost claims.
Care Coordination : Guides members to quality providers at fair, transparent rates, helps avoid surprise bills, and lowers total spending.
Plan Design Adjustments : Offer tiered options to fit different needs. Align employer contributions to nudge smart choices.
Preventive Care : Promote screenings and routine visits to catch issues early and reduce catastrophic claims later.
Telehealth and Virtual Care : Convenient for common needs at a fraction of emergency room or urgent care costs.

One of our clients recently boosted plan participation from 41% to 61% by combining clear employee communication with more cost-efficient plan options. This shows that smart strategies can cut costs and boost satisfaction at the same time.

5. Ensure compliance and smooth operations

Small compliance misses and oversights can quickly turn into big headaches. But when compliance and operations are mapped out clearly, you can focus on running the business instead of fixing paperwork.

Compliance Must Haves

Compliance is a must-have during every business health plan renewal. At a basic level, you’ll want to make sure employees in the same class are being offered the same benefits, that Employer Shared Responsibility requirements (for both Part A and Part B of Section 4980H) are met where applicable, and that Section 125 paperwork is current for any pre-tax deductions. It’s also important to keep plan documents and notices updated each year so that employees always have accurate information to rely on. Taking the time to double-check these details helps you stay ahead of potential issues and protects your organization from penalties or employee frustration down the road.

Operations that Keep Things Smooth

Smooth operations are just as critical as compliance. Payroll deduction reports should be prepared and shared before the first payroll run to avoid surprises for both employees and accounting. Enrollments also need to sync correctly into your Human Resources information system (HRIS) or customer relationship manager (CRM) so that eligibility and deductions line up without manual fixes later. Once the plan year begins, reviewing the first invoice is a simple way to catch errors early. Beyond that, consider scheduling new-hire orientation and offering a quick “how to use your benefits” refresher for existing employees. These touchpoints give employees confidence and reduce the number of last-minute questions HR has to field. Finally, monthly or quarterly check-ins are a helpful way to keep tabs on new hires, terminations, and claims fund activity, while also gathering feedback to guide future improvements.

A structured business health plan renewal should bake-in compliance checks and operational guardrails. If your current process leaves you spending time chasing files or fixing invoices, tighten the handoffs. The right administrator will make these steps feel routine and low-effort.

Turning renewal into opportunity

Like any core process, benefits communication should be reviewed and refined. Track engagement across channels, measure which resources employees use most, and survey what was helpful or confusing. These insights allow you to adapt your strategy year after year.

Metrics like portal logins, video views, and email open rates reveal what captures attention. If engagement drops after open enrollment, consider adding lighter touchpoints throughout the year. Over time, you’ll discover the cadence and formats that resonate best with your workforce.

Need help with your benefits renewal? Have other benefits questions? Let’s talk.

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How to Communicate Your Benefits Package Effectively to Your Employees

Fri, 21 Nov 2025 01:38:33 GMT

When communication works well, trust grows, engagement rises, and people feel confident that the benefits you provide are truly for them. That sense of value makes all the difference.

You have worked hard to design a benefits package that supports your team. But, even a thoughtful program will not reach its full potential unless employees understand it and feel confident using it. Clear, thoughtful communication turns a list of offerings into meaningful support that people act on.

When communication works well, trust grows, engagement rises, and people feel confident that the benefits you provide are truly for them. That sense of value makes all the difference.

Start with clarity

The starting point is clarity. Many employees do not speak insurance or premium tiers as a second language. Jargon creates friction and increases the odds they opt out, forget, or misuse benefits. The simpler your message, the more confident they can feel.

Replace technical terms with familiar ones. Instead of saying “dependent premium contributions,” say “how much you pay to add a spouse or child to your plan.” That small shift can build trust and understanding.

You can also vary how you deliver information. A short video, a visual comparison chart, or a quick “top five things to know” list can help people remember. Employees appreciate when you respect their time and make information easy to digest.

Meet employees where they are

Even the best message can miss the mark if it lives in the wrong place. Teams, departments, and generations absorb information differently. Some employees prefer an email newsletter, while others are more likely to watch a short video or glance at a poster in the breakroom.

A multi-channel strategy helps reach everyone. Share updates through your intranet, HR portal, team meetings, or even text notifications for quick reminders. Consistency matters more than volume. Seeing the same, clear message in familiar places helps employees absorb and retain information.

Benefits communication is most effective when it continues all year, not just during open enrollment. Ongoing reminders show that your company’s support is consistent, not seasonal.

Lead with what matters to them

Every employee silently asks, “How does this help me?” Your communication should answer that question right away. Lead with what impacts real life: saving money, simplifying care, and supporting family needs.

Employees care about convenience. For example, highlight that telehealth means talking to a provider after hours, or that preventive screenings are covered at no extra cost. Stories make benefits tangible.

Different age groups and life stages value different things. Young professionals may want student loan help or wellness perks. Parents may prioritize family coverage and flexible scheduling. Near retirees may focus on long-term savings and supplemental plans. Tailoring the message helps each person see what matters most to them.

A recent Aon piece outlines approaches for a multigenerational workforce: Improving Benefit Communication for a Multigenerational U.S. Workforce

Roll out changes with purpose

When new benefits are introduced or existing ones change, clarity and transparency are key. Start with the reason behind the change. If an update lowers costs, expands access, or adds a new resource, lead with that message. Employees are more open to change when they understand its purpose.

Follow up with a simple outline of what’s new, what employees need to do, and where they can get help. Use FAQs, quick guides, and short walkthroughs to reduce confusion. Avoid overwhelming employees with all the details at once; focus on what directly affects them first.

Make enrollment feel simple

Enrollment can be a stressful process. Too many choices or unclear instructions can cause frustration. Simplify the process with a guided experience and clear next steps.

Provide side-by-side comparisons, short summaries, and examples of who might benefit from each option. A simple checklist and one online hub for all resources can make a big difference. When employees feel guided and supported, enrollment becomes an opportunity to engage, not a chore.

Keep the conversation going

Benefits are not a once-a-year topic. Regular reminders and ongoing communication keep employees aware and engaged. A quarterly or monthly benefits theme helps maintain visibility without overwhelming your audience.

For example, one month could highlight preventive care and checkups, while another might focus on financial wellness or telehealth options. Link messages to timely events, such as back to school for family plans or flu season for preventive care. This shows that benefits communication is woven into the rhythm of work life, not separate from it.

Invite dialogue and listen

Strong communication goes both ways. Give employees space to ask questions, share feedback, or express what they find confusing. Open dialogue builds trust and allows HR teams to identify pain points early.

A dedicated inbox, anonymous feedback form, or monthly office hours can make this process easy. Involving leadership also helps. When managers reinforce messages and share their own experiences, employees listen. This effort toward alignment shows that benefits are part of your workplace culture, not just an HR function.

Measure, learn, improve

For additional insights, explore SHRM’s report here: Efforts to Communicate Benefits Are Underwhelming, Report Finds

Final thoughts

Effective benefits communication is not a single campaign but a continuous cycle. Start with clarity, use channels employees trust, lead with value, roll out change with purpose, make action simple, and keep the dialogue alive. When employees understand and use their benefits, your investment becomes part of your culture and your people feel supported year round.

Need help building a benefits plan or communication strategy? Let’s talk.

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Why Supplemental Health Insurance Is a Smart Investment for Employers

Tue, 28 Oct 2025 20:04:09 GMT

When health costs rise, employee stress follows—and so does employer frustration. Discover how supplemental health insurance can bridge the gaps and boost loyalty without busting the budget.

Every year, healthcare costs seem to climb higher, and every renewal season, employers face the same challenge: how do you keep offering great benefits without breaking the budget? A good health plan is the foundation, but even the best ones have blind spots. Deductibles, coinsurance, and hospital bills can still hit hard.

When employees are stressed about paying those bills, it does not just stay at home. It often shows up at work too. That is where supplemental health insurance comes in. It does not replace your main plan. Instead, it works alongside it, giving people extra protection when life throws something unexpected their way.

What supplemental health insurance actually is

Think of supplemental health insurance as the “plus” in your benefits package. It is a set of optional protections that fill the gaps your main plan leaves behind. Accident insurance pays out if someone gets hurt. Critical illness coverage gives a lump sum after diagnoses like cancer or a heart attack. Hospital indemnity plans help with the extra costs that come with a hospital stay.

Then there are the everyday needs such as dental and vision care that can be surprisingly expensive without coverage. Supplemental benefits can take care of those too.

The point is that these plans are designed to complement your main coverage, not duplicate it. If an employee ends up in the hospital for a week, the primary plan might take care of most medical bills, but there can still be thousands left to pay. Supplemental coverage steps in to close that gap.

It is no surprise that in Voya’s 2024 survey, most workers said they would be more likely to choose an employer offering options like accident, hospital indemnity, and critical illness insurance

Why employers should care

When people are worried about medical bills, it affects everything from how focused they are at work to how often they call in sick and even whether they stay in their job. Studies show financial stress is linked to lower productivity and higher turnover.

Offering supplemental benefits can ease that stress. It is a way of saying, “We know unexpected things happen, and we have your back.” That message matters. Employees who feel supported are more engaged, more loyal, and less likely to look elsewhere.

It is also smart financially. For companies using high-deductible health plans to keep premiums down, supplemental options help employees manage those out-of-pocket costs.

T he Kaiser Family Foundation reports that in 2024 the total annual premium for employer-sponsored family coverage averaged $25,572. On average, workers contributed $6,296 toward that premium and employers covered the remaining amount, about $19,276. This reflects a 7% increase year over year, which is why many employers are looking for ways to keep plans affordable without reducing value.

How It Might Work in Practice

It is one thing to talk about the benefits. It is another to see them in action. Let’s take a look at some hypothetical scenarios.

Scenario 1: At a 20-person professional services firm, leadership wants to keep premiums low without making employees shoulder more costs. They add accident and hospital indemnity coverage. In the same year, two employees end up needing those benefits, one after a sports injury and another after an unexpected hospital stay. The payouts help them cover bills quickly and reduced time away from work.

Scenario 2: A mid-sized manufacturer takes a different route, offering voluntary critical illness coverage. When one employee is diagnosed with cancer, the lump sum helps cover travel to a treatment center and extra childcare at home. That story spreads, and the next year, enrollment jumps.

Scenario 3: Even in larger organizations, supplemental benefits make a difference. At a tech company with over 500 employees, a young engineer suffers a heart attack. His critical illness plan pays a lump sum that allows him to take a longer leave to recover without worrying about missed mortgage payments. His manager later shares that knowing the company offered that kind of help made the whole team feel more secure.

Clearing up supplemental insurance myths

One of the biggest myths is that supplemental health insurance is redundant. It is not. It is built to cover things your primary plan does not and to do it in a way that is simple and quick.

Another myth is that it is just for big companies. In reality, small businesses can see huge value because they can add these protections without overhauling their entire health plan.

And while cost is always a concern, many supplemental options are surprisingly affordable, especially when offered as voluntary benefits. Employees get to pick what works for them, and employers do not have to foot the entire bill.

Making it work for your team

Rolling out supplemental health insurance does not have to be complicated. Start by asking employees where they feel most exposed such as hospital stays, accidents, or serious illnesses. Then choose a few options that address those needs.

Focus on communication. Skip the jargon and provide examples of how the coverage works in real life. Instead of saying, “Hospital indemnity plans pay a per-day benefit for inpatient care,” say, “If you are in the hospital for five days after surgery, this plan helps pay for those extra costs your main insurance does not cover.”

Use short videos, simple one-pagers, and live Q&A sessions during enrollment. After launch, check in to see how many people are signing up and whether they feel more secure with the benefits in place.

Measuring the difference

You will know it is working if enrollment is healthy, employees give positive feedback, and you start to see fewer cases of delayed care. Over time, these programs can even reduce absenteeism and turnover.

Research shows that organizations offering well-communicated health strategies often improve employee health without increasing costs and sometimes even lower overall spending.

Final though t s

Supplemental health insurance is not about replacing what you already have. It is about strengthening it. It is an affordable way to show employees you care about what happens when life does not go as planned.

In a competitive job market, benefits like these can set you apart. Start small, explain them clearly, and let the results speak for themselves. The trust and loyalty you build might be the biggest return on investment of all.

Have questions about HSAs or direct primary care? Let’s talk.

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ACA 2026 Update: Reporting and Penalty Adjustments

Tue, 21 Oct 2025 17:45:45 GMT

The compliance landscape for employers continues to evolve in 2026, with updates affecting Employer Shared Responsibility Payments (ESRP) under the Affordable Care Act (ACA) and IRS reporting penalties.

After a brief and unexpected dip in 2025, the IRS is once again raising the Employer Shared Responsibility Payment (ESRP) penalties in 2026. Since the Affordable Care Act (ACA) first took effect, these penalties—outlined under Section 4980H—have generally climbed each year to account for inflation. The temporary reduction in 2025 caught many employers' attention, but it appears to have been a one-year anomaly.

For 2026, both the "A" and "B" penalty amounts are increasing, reversing last year's decline and reinforcing the IRS's ongoing commitment to ACA compliance enforcement. Employers, especially those close to the Applicable Large Employer (ALE) threshold, should take note of these new figures and ensure their health coverage offering remains compliant to avoid financial consequences.

A quick ESRP (Section 4980H) penalty refresher

If your company has 50 or more full-time (or full-time equivalent) employees, the ACA requires you to offer affordable, minimum-value health coverage to your full-time employees and their dependents. If you don’t, there are two potential penalties, of which you will pay one or the other.

Penalty A: No coverage offered

This penalty is triggered if you offer nothing, or don’t offer coverage to at least 95% of your full-time employees.

Penalty B: Insufficient coverage offered

This penalty is triggered if one of your full-time employees gets a premium tax credit because the coverage you’ve offered is either unaffordable or doesn’t meet the ACA’s minimum value standards.

2026 ACA penalty updates

Employer Shared Responsibility

As stated earlier, the Section 4980H penalty amounts are going up this year. If you are an ALE, this shift represents an opportunity to reassess your healthcare strategy and make sure you’re complying with the law—without unnecessary penalties eating at your bottom line.

4980H-A - $3,340 per full-time employee (up from $2,900)
4980H-B - $5,010 per full-time employee receiving a tax credit (up from $4,350)

Reporting

Just like the 4980H penalties this tax year, some of the reporting penalties under sections 6055 and 6056 have increased.

Failure to report -> $340 per return (up $10)
Corrections to a filed report
made within 30 days -> $60
made after 30 days -> $140 per return (up $10)
Intentional disregard -> $680 or 10% of the total reported amount (up $20)

2026 Reporting Deadlines

The deadline to provide individual, 1095-C statements to your employees is February 2, 2026.

The deadline to file forms 1095 and 1094 with the IRS is March 2 by mail, or March 31 for electronic submission.

Impact on you

Both the employer shared responsibility penalties and penalties for intentional disregard are going up. For now, it’s critical for you to understand if you are an ALE with a responsibility to report. If you are, you should review your health plan offering and make sure you are meeting the ACAs minimum requirements. This includes evaluating your health plan’s affordability and the extent of plan coverage. Additionally, you will want to verify that you have indeed made offers of coverage to all eligible employees.

Verify your ALE status
Review your plan offering
Confirm you’ve made offers of coverage
Report to the IRS

Planstin can help you navigate these changes whether that means auditing compliance, optimizing benefit design, or implementing cost-effective health plans so your organization stays compliant and competitive. We’re here to help you handle the finer points of compliance and navigate the benefits maze without the stress.

For detailed information from the IRS about penalties and deadlines, read this .

To learn more about your responsibilities as an ALE, read this .

Want to make sure your business is protected from penalties in 2026? Let’s talk.

Give us a call at 888-920-7526 or click the link below to speak with a Benefit Guide.

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Don't Wait: Open Enrollment Is the Time to Reevaluate Your Needs

Thu, 09 Oct 2025 22:38:11 GMT

With premiums rising, out-of-pocket limits climbing, and new rules on the horizon, this year’s Open Enrollment isn’t just routine—it’s a turning point. Here’s what employers need to know (and do) to stay ahead.

Open Enrollment is coming fast

Open Enrollment is a designated period of time each year in which employers and employees can review their current benefits and make changes to insurance coverage, add or remove dependents, or change plans completely. For 2026 coverage, the Open Enrollment period starts on November 1 ^st . That’s only a few days away, so HR teams and business owners should already be preparing for it! And because the window is short, your employees should be familiarizing themselves with their current benefits, changes to their plans, and any new options that they might benefit from. That way, when Open Enrollment actually starts, they can take full advantage of your benefits package!

Open Enrollment timeline

October 15, 2025 – Medicare Annual Enrollment Begins
November 1, 2025 – Marketplace (ACA Individual & Family Plans) Open Enrollment Begins
December 7, 2025 – Medicare Annual Enrollment Ends
January 15, 2025 – Marketplace (ACA Individual & Family Plans) Open Enrollment Ends

What’s new in 2026

Each Open Enrollment season brings with it some new dynamics and challenges, and 2026 is no exception. This year, small business employers and HR teams will be dealing with rising health insurance premiums, higher out-of-pocket limits, and policy changes that will soon shorten the Open Enrollment window itself. For many, the effect these types of changes have on employees’ budgets are front of mind, so let’s take a look at how your employees might be impacted.

Premiums Are Going Up

Health insurance costs are set to climb in 2026, and employers and employees will both feel it. According to a Kaiser Family Foundation report , ACA Marketplace insurance carriers are forecasting a median premium increase of 18%, which will be the highest single-year jump since 2018. As the employer, this could have a bigger effect on your operation than you realize.

For example, let’s say your business has 40 employees, each enrolled in a family plan that costs $20,000 annually. An 18% increase means $3,600 more per employee per year, or an extra $144,000 per year in employer premiums if the company covers the full amount. Even if employees contribute 25% toward premiums, each worker would still see their portion increase by $900 per year.

With substantial premium increases coming down the pike, it’s that much more important to make sure your employees are prepared ahead of time and understand the plans available to them.

Out-of-Pocket Maximums Are Going Up

Premiums aren’t the only expense that’s climbing. The out-of-pocket maximum, the most an individual or family must spend before their plan covers 100% of the costs, has been on the rise for years. For single coverage under ACA-compliant plans, this maximum has increased from $6,350 in 2014 to $9,100 in 2023, a 43% increase . For 2025, this maximum has risen to $9,200, and projections for 2026 suggest it could reach $10,600 for individuals and more than $21,000 for families.

For employers, rising out-of-pocket limits mean that even though your company may help cover premiums, employees may still face steep costs in seeking healthcare. This can lead to delayed treatments, financial strain, lower satisfaction with your benefits, and less desirable health outcomes.

Shortening Open Enrollment Window

One development that is less urgent but should warrant your attention, nonetheless, is the upcoming shortening of the Open Enrollment window, beginning with coverage for 2027. This means that the shortened Open Enrollment period won’t take effect until Open Enrollment time toward the end of 2026. This Open Enrollment cycle will stay the same, but employers should be paying attention because their employees next year will have less time to do research, review their plan options, and make decisions.

Forward-thinking employers should start thinking about and planning now how they will help prepare their employees ahead of time.

The costs of inaction

When businesses stick with the same benefit plans year after year without reevaluating, they certainly avoid short-term hassle, but they and their employees will pay for it in the long term. Given how fast premiums, deductibles, and out-of-pocket maximums are rising, inaction isn’t likely to provide a net-neutral result. It will likely mean overpaying and missed savings for both you and your employees. For small-and medium-sized businesses, choosing to not explore alternatives or negotiate better plans can eat into your margins and eventually wear away employee goodwill.

According to a report by Becker’s and JP Morgan, businesses with fewer than 50 employees saw premiums rise by 33% from 2018-2023, while total payroll increased by 42% over the same period. This should tell us just how much health insurance is becoming a larger portion of business costs, particularly for smaller companies.

That means that if you simply auto-renew your current benefits package each year, you are likely leaving money on the table. Taking the time to research and weigh your options usually translates into healthy savings for your business.

Questions to ask before renewing your plan

Here are three questions every business owner or decision maker should ask before reviewing benefits:

1. Are there alternative products that could lower costs while keeping similar benefits? Don’t assume last year’s carrier or plan tier is still the best value for you. Request quotes and compare designs!

2. What is the total cost of coverage, including premiums and employee out-of-pocket exposure? Lower premiums often shift more burden to the employees in the form of deductibles, coinsurance, or limits/caps. Understanding the total exposure can help avoid surprises for you and your employees.

3. When was the last time you benchmarked your benefits against similar competing businesses in your area/industry? Market rates, regulations, and provider networks can shift. What was competitive five years ago may be overpriced today!

Exploring alternatives

As traditional insurance costs keep going up and Open Enrollment windows start to tighten, small businesses can benefit from more flexible and cost-effective benefit options. Gone are the days where nontraditional alternatives are just backup plans. They have now become viable primary benefits that often align better with both employer and employee budgets. Planstin helps businesses explore these options, combining both traditional insurance with nontraditional alternatives to create solutions that don’t sacrifice affordability for value, or vise-versa.

Small businesses just getting their foot into the benefits door might consider:

Direct Primary Care (DPC) Membership

Where members pay a flat fee to have access to a primary care provider. This alternative arrangement helps bypass copays and restrictions found in traditional insurance networks.

HealthShare Membership

Where members contribute to a community fund that is used to assist with eligible healthcare expenses. These tend to have lower monthly costs than traditional health insurance and aren’t bound to Open Enrollment windows.

Virtual Care Membership

Where subscribers similarly pay flat fees to have virtual (either over the phone or online) access to healthcare providers. This is increasingly becoming an affordable way to manage routine healthcare needs while avoiding high premiums and out-of-pocket costs.

It’s worth noting that in another big upcoming change, starting in 2026 HSA funds can now be used to pay for certain nontraditional healthcare services, like DPC and Telemedicine. You can read more about this development here .

Next steps with Planstin

Planstin is here to help businesses like yours handle daunting changes like increasing costs and tighter deadlines. Our expert team works to build benefits packages that play to the unique strengths and needs of companies of all sizes. You get traditional coverage where it counts, and innovative alternatives, like direct primary care, where they make the most sense.

And this doesn’t just save money. It makes you a more appealing employer, helping you recruit and retain employees. According to a recent survey , 82% of workers say health benefits are a top factor in deciding whether to accept a job offer.

Letting your benefits stagnate doesn’t just risk higher premiums. It can drive up turnover, cost you talent, and hurt your employee morale and productivity.

Reach out to Planstin today to schedule a benefits review before Open Enrollment. Together, we can make sure your employees have access to the most cost-effective solutions that fit your budget and their needs.

Have questions about Open Enrollment or looking to explore alternatives? Let’s talk.

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2026 HSA Contribution Limit Increase

Wed, 01 Oct 2025 23:09:08 GMT

Offering a High-Deductible Health Plan (HDHP) with a Health Savings Account (HSA) remains one of the most effective ways to support your employees’ financial and health goals. With the 2026 updates to HSA contribution limits and HDHP requirements, there are new opportunities to enhance these benefits while maximizing tax advantages.

What’s new for 2026

Each year, the IRS updates HSA contribution limits and HDHP requirements. For 2026, both the contribution amounts and the qualifying deductible/out-of-pocket requirements have changed .

Individual Coverage

Contribute up to $4,400 – up $100 from 2025

Minimum deductible of $1,700 – up $50 from 2025

Maximum out-of-pocket limit: $8,500 – up $200 from 2025

Family Coverage

Contribute up to $8,750 – up $200 from 2025

Minimum deductible of $3,400 – up $100 from 2025

Maximum out-of-pocket limit: $17,000 – up $100 from 2025

What these changes mean for your business

Higher contribution limits give employees more room to save tax-free dollars for healthcare and retirement. While employers are not required to increase their contributions, many choose to support their employees’ well-being to align with the new limits.

Employer contributions are also fully tax-deductible, reducing your company’s taxable income while boosting morale and retention. Happy employees foster satisfied customers!

It’s equally important to verify that your HDHP complies with the 2026 minimum deductible and out-of-pocket maximum requirements. Plans that do not meet these requirements do not qualify as HSA-eligible. This means you cannot be enrolled in Medicare, a general purpose healthcare flexible spending account (FSA), or be claimed as a dependent on another person’s tax return.

How OBBBA impacts HSAs

The One Big Beautiful Bill Act (OBBBA) brings broad changes to employee benefits. While HSAs are still governed by IRS rules, the law creates new considerations for both employers and employees that are important to educate on.

HSA Eligibility Still Depends on HDHPs

Even with new flexibility under OBBBA, employees must remain enrolled in a qualified high deductible health plan (HDHP) to contribute to an HSA. If an employee changes their plan to one that doesn’t meet HDHP requirements under OBBBA, they become ineligible.

New Accounts Require Careful Design

The new law encourages additional benefit accounts, such as wellness or supplemental spending programs. However, if these accounts overlap too much with traditional medical coverage (similar to a full health FSA), they could disqualify employees from contributing to HSAs. Employers need to review plan design to confirm compatibility .

Risk of Employee Confusion

With more options available, employees may assume they can combine all accounts without issue. Missteps such as over-contributing or enrolling in conflicting account s can lead to IRS penalties and unexpected taxes. Clear communication is critical to help employees make the right choices.

Strategic Use of Employer Dollars

For now, HSAs remain fully tax-deductible for employers. Under OBBBA, businesses should decide whether to keep focusing contributions on HSAs or spread funds across multiple new account types. Aligning contributions with long-term employee financial wellness is key.

Why It Matters

Though OBBBA adds complexity, HSAs continue to provide significant advantages on pre-tax contributions, tax-free growth, and tax-free withdrawals for qualified medical expenses. Employers should be aware of the new benefit options introduced under OBBBA, structure plans carefully, and maintain compliance while reinforcing HSAs as a cornerstone of employee financial health.

Communicate with your employees

Employees rely on employers to help them understand how to maximize their benefits. When you share the 2026 updates, it’s crucial to emphasize important details about how they can maximize their HSAs.

Staying Within the Limit

While the new limits allow for greater savings, contributions that exceed the IRS maximums can trigger penalties and additional taxes. If employees over-contribute, they should contact their HSA provider to fix it as soon as possible.

Maximizing the Benefits

Encourage employees to take advantage of the higher limits by fully funding their HSAs. Contributions will lower taxable income, grow tax-free, and roll over year to year, building a safety net for both healthcare expenses and long-term retirement savings. That’s a triple tax savings advantage and a win-win for employers and employees.

How to Contribute

Remind employees of how they can contribute to their HSA:

Payroll Deductions: The easiest and most tax-efficient method.
Online Contributions: Direct transfers from other accounts, though less streamlined for tax purposes.

2025 Contribution Deadline Reminder

Employees still have until April 15, 2026 (the federal tax filing deadline) to make contributions for the 2025 tax year: $4,300 for individuals and $8,550 for families.

Note: For employees 55 and older, an additional $1,000 catch-up contribution is allowed each year. If both spouses are over 55, each can open an individual HSA and make their own catch-up contributions.

The bottom line

Now is the time to support your team by informing them of relevant changes and how they can continue to build their HSAs tax free and benefit from valuable savings each year.

Communicating these changes clearly and early positions your company as a top choice employer in a competitive job market. This is your opportunity to foster a healthier, more financially secure workforce while also benefiting from valuable tax savings.

Have questions?

We are ready to help.

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5 Tips for Designing a Comprehensive Health Plan for Your Employees

Thu, 18 Sep 2025 15:38:20 GMT

Designing a comprehensive benefits plan can feel overwhelming, with so many choices to make and regulations to follow. But at its core, a strong plan simply answers one question: How can we best support our employees’ health while protecting the business?

By understanding your workforce, selecting the right funding strategy and structure, and staying on top of compliance, you can build a benefits strategy that delivers real value to both your people and your bottom line.

Here’s how to get started.

Tip 1: Ask employees what they actually need

It's easy to make assumptions about what employees want from their benefits, but the best way to know for sure is to ask. Simple, well-crafted anonymous surveys allow you to gather real data directly from your team, helping you understand which benefits would truly make a difference in their lives. Tools like online survey platforms can make this process easy and confidential.

A key part of employee benefits planning is asking broad questions that dig deeper, not about personal medical conditions, but about overall priorities and what they would actually use and value day-to-day. For example, would they prioritize mental health support, family coverage, virtual care, or lower out-of-pocket costs? And, as an employer, if you can’t afford everything, knowing what matters most to employees will help you invest wisely.

It’s also important to recognize the diversity within your workforce. Employees’ needs often vary by age, family status, job type, and even location. For example, younger team members may place a higher value on telemedicine and flexibility, while older employees might prioritize chronic condition management and comprehensive in-person care. Striking the right balance can be challenging, but understanding these unique needs is the first step to building a plan that supports everyone.

Tip 2: Choose a funding strategy that fits your goals

One of the most important steps in designing a comprehensive health plan is choosing a funding strategy that fits your company’s goals and budget. The right choice can help you manage costs effectively while still providing great coverage to your team.

Fully Insured

Fully insured health plans are the traditional option many employers are familiar with. In this arrangement, employers pay a fixed monthly premium to a health insurance company, who then assumes the financial risk, handles all claims and administration.

Pros: Predictable monthly costs, minimal administrative burden, and protection from large, unexpected claims.

Cons: Generally higher long-term costs, less flexibility to customize your plan, and limited access to detailed claims data , since carriers typically own the data and share only summary reports.

Self-Insured

On the other hand, self-insured (or self-funded plans) mean your business takes on the financial risk and pays employee claims directly, often with the help of a third-party administrator (TPA).

Pros: Greater flexibility to design benefits, potential cost savings if claims are lower than expected, and more transparent healthcare spending.

Cons: Higher financial risk, potentially unpredictable costs, and the need for stronger administrative support and stop-loss insurance for protection.*

*However, options like level-funded plans and stop-loss insurance can help mitigate some of this financial risk by providing more predictable monthly costs and protection against large, unexpected claims.

Learn more about self-funded plans: https://resources.planstin.com/blog/self-fundedbenefits

Consumer-Directed Health Plans

Consumer-directed health plan (CDHP) options are another approach that can work with either funding model. These plans are designed to encourage employees to take a more active role in their healthcare choices and spending. CDHPs usually feature a high-deductible health plan (HDHP) combined with tax-advantaged accounts, such as:

Health Savings Accounts (HSAs): Allow employees to set aside pre-tax dollars for qualified medical expenses. HSAs can only be paired with HDHPs and offer the added benefit of funds rolling over year to year.

Health Reimbursement Arrangements (HRAs): Employer-funded accounts that reimburse employees for certain medical expenses.

Flexible Spending Accounts (FSAs): Let employees use pre-tax dollars for healthcare costs but typically have a “use it or lose it” rule each year.

By giving employees more control over their healthcare dollars, CDHPs can encourage smarter spending and promote a stronger sense of ownership over health decisions.

 Tip Takeaway:

Whether you choose a fully- insured, self-insured, or a hybrid approach, understanding your funding strategy helps you balance financial risk, offer competitive benefits, and build a plan that supports your team.

Tip 3: Structure the plan to support how employees want to access care

Plan structure has a major impact on how employees experience their benefits, from flexibility and provider choice to what services are covered and how easily they can access care. Designing a structure that supports your employees’ goals makes a big difference in satisfaction and utilization. Here’s a quick breakdown of the most common options:

Preferred Provider Organization (PPO)

Offers the most flexibility, allowing employees to see any healthcare provider — including out-of-network — without needing referrals.

Pros: Flexible provider choice, no referrals needed, large networks.

Cons: Higher premiums and higher out-of-pocket costs when using out-of-network providers.

Health Maintenance Organization (HMO)

Requires employees to select a primary care physician (PCP) and get referrals to see specialists; typically only covers in-network care.

Pros: Lower premiums and out-of-pocket costs, strong focus on guided care and preventive services.

Cons: Less flexibility, limited network, requires referrals.

High Deductible Health Plan (HDHP)

Offers lower premiums and higher deductibles, often paired with Health Savings Accounts (HSAs) to help employees cover out-of-pocket expenses.

Pros: Lower premiums, potential tax advantages with HSA, encourages cost-conscious care decisions.

Cons: Higher upfront out-of-pocket costs before coverage starts, may deter employees from seeking care early.

Hybrid Structures

Some employers choose to combine traditional plan features with direct primary care (DPC) or other integrated options. These hybrid structures provide comprehensive coverage of a major medical plan along with the convenience and personalized attention of DPC, giving employees easier access to primary care while controlling overall costs.

Check out Planstin’s Care+ Direct plan , a hybrid solution that brings together the best of both approaches.

In addition to the types listed above, there are other important structural elements to consider:

Level-funded plans: Offer predictive costs with more flexibility than fully-insured plans.

On-site clinics and telehealth programs: Convenient access that reduces absenteeism and supports early care.

Wellness programs and preventive care initiatives: Gym memberships, mental health resources, and wellness coaching help employees stay healthier and more engaged.

Tip takeaway: By matching your plan structure to how your employees want to access care, you create a plan they’ll actually use — and appreciate.

Tip 4: Build compliance and eligibility into your plan from the start

Compliance is a big part of employee benefits, and it’s crucial to consider legal requirements early when designing your plan — so you don’t face surprises (or penalties) later on.

Start by determining what laws apply to your business. Review Affordable Care Act (ACA) requirements and employer shared responsibility provisions to understand what coverage you must offer and to whom. If you’re an Applicable Large Employer (ALE), you’ll need to provide affordable coverage to full-time employees and their dependents or risk facing penalties.

Next, clarify eligibility rules to protect your business and help you communicate clearly with employees and prospective hires. This includes defining waiting periods before coverage starts, as well as who qualifies for coverage, such as spouses, domestic partners, and children.

If you have a self-funded or level-funded plan governed by ERISA (Employee Retirement Income Security Act), make sure you understand federal standards and how ERISA preempts most state laws. If you have a traditional fully insured plan, you’ll still need to follow state insurance mandates, which may include requirements to cover services like autism treatment, infertility care, or specific preventive services.

Tip takeaway: Addressing compliance and eligibility upfront protects your business, sets clear expectations, and lays a strong foundation for a plan that lasts as part of your employee benefits strategy.

Click to learn more about 5 Benefits Laws Every ALE Must Comply With .

Tip 5: Find a partner who makes benefits simple

While many employers think they have to tackle benefit planning alone, the truth is that finding the right partner can make your life easier and help you save both time and money. In fact, HR professionals spend an estimated 40-60% of their time on administrative tasks like compliance and benefits management.

Working with a trusted advisor, broker, or third-party administrator (like Planstin) can help you stay compliant, manage costs, and design a plan tailored to your workforce’s needs. The right partners also support ongoing administration and can help you educate employees about their benefits — ensuring they understand and actually use the resources available to them.

Tip takeaway: The right team behind you allows you to focus on other critical parts of your business, knowing your benefits strategy is in expert hands.

Ready to design your plan?

Designing a comprehensive benefits plan doesn’t have to feel daunting. With the right approach, you can create a plan that supports your employees, protects your business, and shows your team that you truly care.

At Planstin, we specialize in making benefits simple and effective. From designing and administering plans to helping you stay compliant and educating your employees, our team is here to help every step of the way — so you can focus on what you do best.

Start with these five tips to learn how to design an employee benefits program that your team will value and your business will be proud of. And if you’re ready for extra support, we’re happy to guide you.

Our Benefit Guides are here to help. Click below to get started.

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New Law Benefits Health Savings Account Holders

Tue, 09 Sep 2025 20:48:28 GMT

The rules just changed. A major new law is opening doors for patient-friendly healthcare access. Here’s what it means for anyone using HSAs or Direct Primary Care.

In July 2025, Congress passed the One Big Beautiful Bill Act , a comprehensive bill that seems to touch on all reaches of the economy. While the media and online chatter may be more focused on certain controversial parts of the new law, some patient-friendly changes are coming to the healthcare industry that may make life much easier for those using insurance alternatives for their access to affordable healthcare.

The effects of this bill won’t just be small changes to the already exhausting red-tape but paving the way for innovative healthcare access using more modern tools and provider models. The big change highlighted here is that under the new law, Direct Primary Care providers can now be used and paid for with Health Savings Accounts funds.

What is direct primary care?

Direct primary care (DPC) is a growing healthcare service provider model that acts as an alternative to traditional health insurance. Under this model, patients pay a flat monthly fee, that gives them direct access to a doctor or healthcare provider. It is a type of lower-cost membership or subscription that gives the patient easier access to their personal physician, while also typically enjoying same-day or next-day appointments, longer visits, and the freedom to reach out to their provider without extra bills coming in later.

For those that pay for DPC membership, the model feels more personal and less transactional, and because it operates outside the traditional insurance system, it’s a popular alternative for patients and even employers looking for affordable access to primary care. But because it’s a newer innovation, the broader medical industry hasn’t always known exactly what space it should occupy. Is it insurance? Is it technically a “medical expense”?

This grey area in categorizing this newer type of care has previously meant that more traditional funding vehicles like Health Savings Accounts (HSAs) could not interact with it, precluding many HSA holders from being DPC members at all. The new law helps clear this up and create an easy path for those who want to use both.

What is a health savings account?

A health savings account is one of the most practical tools available for managing healthcare expenses. It is a special type of savings account where you set aside money intended solely for medical expenses before taxes. Because the money goes into the account tax-free and comes out tax-free, when used for healthcare, your HSA dollars should stretch farther than money in your typical checking account.

An HSA is paired with high-deductible health plans, meaning to have an HSA typically also means having a traditional health insurance plan in place. These tax-advantaged funds can be used for healthcare expenses like doctor visits, prescriptions, procedures, and even medical equipment. But, due to the way the medical industry has categorized more modern healthcare tools and models, HSA funds have not been allowed for use with DPC services, until now. Under the new bill DPC services are considered a “qualified medical expense,” and DPC members can use their HSA monies to pay for their monthly membership fees.

More access to direct primary care

Previously, the relationship between DPC and HSAs has been frustrating for many trying to take advantage of easier access to care. Direct primary care practices clearly provide healthcare, but their services were not technically considered to be qualifying medical expenses. Instead, they were treated more like a type of insurance, which caused a conflict with HSA rules, which expressly state that HSA funds cannot be used to pay for insurance premiums.

This mismatch between DPC and HSA rules created two issues:

You couldn’t use your HSA funds to pay for your DPC membership fees.
Simply having a DPC membership could disqualify you from using an HSA entirely.

For those who value the convenience and affordability of DPC services, this was a tough tradeoff. You could either contribute tax-free money to an HSA or enjoy lower-cost access to healthcare, but not both.

The new law makes the whole dilemma moot by clearly categorizing regular DPC membership fees as qualified medical expenses.

How the new law is changing things

The One Big Beautiful Bill Act marks a considerable shift in how DPC fits within the larger medical industry and should help cement it as a fixture in modern healthcare options. For the first time, patients will be able to pay for their DPC membership directly with HSA funds, but like most complex issues, there are a couple caveats:

1. There are limits on how much HSA money can be applied to DPC expenses. Membership fees are capped at $150 per month for an individual, or $300 per month for a family membership (any membership that includes more than one person). If your DPC provider charges more than that, you’ll have to cover the difference out of pocket.

2. The law specifies that the DPC arrangement must provide “primary care services.” This phrase isn’t fully defined yet, but the legislation does make clear what doesn’t count (as of writing): procedures requiring general anesthesia, most prescription drugs—excluding vaccines and certain laboratory services—fall outside this definition. The main issue isn’t with standard primary care services themselves, but that bundling in additional services may disqualify a DPC practice from HSA eligibility.

Generally, most standard DPC providers should be HSA-eligible, but because it is still a relatively new model, and some DPCs offer services that others do not, you may want to make sure yours falls within the guidelines. Even with these caveats, though, this change makes DPC an accessible option for millions of people who already rely on their HSAs.

What's next?

This change introduced in the One Big Beautiful Bill Act should make DPC services accessible to many more people than before. A 2024 report by Devenir counted 39-40 million HSA holders nationwide, holding $147-155 billion in assets. These are account holders who previously couldn’t apply their tax-free money designated for medical expenses to DPC services. Now, starting on January 1, 2026, the way is clear.

Direct primary care was already gaining traction as an innovative healthcare model, with over 2,600 practices currently operating across the country. With HSA compatibility set up by the new law, that number is likely to grow even faster as both patients and providers recognize the advantages.

The effects won’t stop there. When large pieces of legislation make this many changes to entire systems, it will inevitably have wider impacts that are hard to predict. Employers may rethink benefit structures, insurers may adapt their offerings, and providers may continue to innovate how they deliver care. Many of these potential changes haven’t even been unpacked yet, by policymakers nor industry analysts.

One area we expect to see affected, and one we’ll explore in a later article, is how these new laws interact with telemedicine. Just like DPC, telehealth is now more clearly categorized and eligible for HSA funds, making modern healthcare more affordable and accessible.

Have questions about HSAs or direct primary care? Let’s talk.

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The Benefits of Telemedicine

Tue, 02 Sep 2025 15:27:05 GMT

Telemedicine is no longer an emerging trend; it's a fundamental part of modern healthcare. As virtual care technology evolves, patients, providers, and employers are seeing the advantages of remote healthcare access.

For years, access to healthcare remained stagnant and limited by technology or location. People in remote areas couldn’t receive the care they needed; or wasted time and money driving to a doctor’s office for something that turned out to be minor. On the flipside, many suffered from not prioritizing their health, leading to greater issues down the road.

Businesses didn’t have a way to offer a remote option, costing them and their employees more money than it should when providing benefits that are supposed to help them. They needed another option. The solution? Telemedicine.

At Planstin Administration, we understand the need for flexible, compliant health benefits that work for both employers and employees. Telemedicine is a strategic, long-term solution that enhances accessibility, lowers healthcare expenses, and promotes healthier populations.

How telemedicine works and why it’s effective

Telemedicine isn’t just a convenient way to access healthcare; it’s a healthcare tool that, when used correctly, can give businesses a competitive advantage as well as an effective way to protect their budget and people. It utilizes video, phone, or secure messaging to deliver healthcare services anywhere, so people can get the care they need on their time.

In recent years, its ongoing success has solidified it as a permanent and strategic part of modern care.

Unlike traditional office visits, telemedicine connects patients with providers from anywhere. This flexibility makes it especially valuable for individuals in rural areas, patients with mobility limitations, chronic conditions, and anyone with a demanding schedule.

Improved Access and Convenience

Patients don’t need to take hours off work, find childcare, or drive long distances unless their situation requires immediate attention. It's accessible for everyone with an internet connection. Meet with a doctor in the comfort of your home.

Continuous and Preventive Care

In addition to in-person visits, telemedicine supports follow-ups, remote monitoring, and early detection. This ensures managing chronic conditions and reduces the risk of more serious complications.

Cost-Effective Healthcare

Virtual care significantly reduces direct and indirect costs . It benefits both patients and payers by preventing costly, unforeseen issues that could arise. Patients avoid lost wages, travel, and time off. It's a practical solution to modern healthcare challenges.

Mental Health Support

Virtual healthcare platforms expand access to therapists and counselors especially in underserved areas. Making it easier for people to seek the support they need when they need it. This approach helps transition healthcare from a reactive model to a proactive one focusing on early detection, ongoing support, and reduced long-term risk.

Appointments are easier to schedule and attend.
Remote monitoring allows earlier intervention.
Regular check-ins reinforce treatment adherence.
Mental health care becomes more accessible.

Advantages for employers and employees

Telemedicine delivers significant value across the board, boosting employee satisfaction and productivity while reducing overall healthcare costs for employers.

Employees

Work-Life Balance
Appointments can be scheduled before work, during a break, or after-hours saving time and money.

Reduced Exposure Risk
Virtual care helps minimize contact with contagious environments, especially important for vulnerable individuals.

Avoiding Presenteeism
What’s presenteeism? It’s when employees work while sick and their productivity suffers. With telemedicine, they can access care quickly and return to work healthier, reducing the risk of errors.

Improved Access to Mental Health
In areas with provider shortages, telemedicine fills gaps in behavioral healthcare availability and removes barriers to entry.

Employers

Hiring and Retention
Offering modern, flexible health options makes your benefits package more attractive in competitive hiring markets.

Productivity Gains
Employees can address health issues without needing to take extended time off and can then decide their next steps.

Cost Reduction
Virtual visits are typically more affordable and help reduce claims tied to avoidable ER or urgent care visits.

Employee Loyalty
Providing easy, affordable access to care builds trust and long-term engagement with your team.

Limitations of telemedicine

While telemedicine offers considerable benefits, it’s not a perfect solution. Certain clinical needs and patient circumstances still require in-person care, and virtual care comes with a few challenges.

Required In-Person Care

Some health conditions demand physical exams, diagnostic testing, or hands-on procedures that can’t be done remotely. Telemedicine should be viewed as a complement, not a replacement for traditional care.

Technology and Access Barriers

Virtual care relies on internet access and connected devices. Which may present difficulties for rural communities, older populations, or low-income households.

Data Security and Privacy

Even though telehealth platforms are required to comply with HIPAA, protecting sensitive patient data in digital environments requires robust security protocols and constant vigilance to protect patients’ private information.

Face-to-Face Interaction

Although effective, virtual interactions may feel less personal or miss specific non-verbal cues that would be easier to detect in person.

Telemedicine works best when strategically integrated into a broader care strategy. It's most powerful when used to expand access and enhance continued care without attempting to replace every aspect of in-person healthcare.

Planstin’s strategic telemedicine implementation

At Planstin, we help employers easily integrate telemedicine into their health benefit offerings. Whether as a single option or part of a comprehensive benefits plan, our platform provides everything needed to offer modern, and cost-effective care.

Our Virtual Care Integration Includes:

24/7 access to board-certified providers
Mental and behavioral health services
Chronic condition support and remote monitoring
Transparent pricing

We also offer flexible plan design, allowing you to build healthcare packages that work for your team’s specific needs without unnecessary complexity or cost.

Redefining access, affordability, and outcomes

Telemedicine is reshaping healthcare by increasing access, lowering costs, and improving outcomes. Employers win by offering a healthcare solution to their employees that can cut costs on urgent care, office appointments, and emergency visits. Employees benefit from being offered a solution that can save them money and time while getting the care they need.

By embracing telehealth, you're not just offering convenience; you're being more strategic with how healthcare is delivered, managed, and experienced. Paving the way forward for better outcomes.

We're committed to helping employers lead the way with smart, scalable solutions that make a real difference in people’s lives. Click below to get started today.

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Do You Need a TPA?

Thu, 28 Aug 2025 21:49:54 GMT

If managing employee benefits feels overwhelming, you’re not alone. Between rising costs, complex regulations, and endless questions from employees, many businesses are stuck in survival mode—struggling to keep up or opting out entirely. That’s part of the reason nearly half of U.S. employers still don’t offer benefits.

Between navigating compliance regulations, processing claims, and designing cost-effective plans, employee benefits can feel overwhelming, especially as healthcare continues to evolve. But benefits don’t have to be that hard.

Third-party administrators (TPAs) like Planstin help businesses simplify and streamline their benefits strategy. We take on the busywork—processing claims, managing eligibility, handling compliance—so you can focus on growing your business, not drowning in paperwork.

Working with a TPA doesn’t just reduce stress. It can open the door to better plan design, lower costs, and more flexible benefit options. TPAs often support self-funded plans and alternative models that make offering benefits more realistic for small and mid-sized businesses.

So, what exactly does a TPA do—and does your business really need one?

What is a TPA?

Like the name suggests, a third-party benefits administrator primarily handles the administrative side of employee benefits. That means taking responsibility for important tasks like claims processing, compliance management, and benefits plan design. Benefits administrators become the crucial link between employers, employees, and healthcare providers. Their role is indispensable in creating efficient, cost-effective benefits programs.

Claims Processing : involves handling the entire lifecycle of claims to ensure they are managed efficiently and accurately, which allows employees to access care without unnecessary and frustrating delays.

Compliance Management : involves helping businesses navigate complex healthcare laws to minimize the risk of penalties.

Benefits Plan Design : allows benefit administrators to work with businesses to create tailored plans that align with company goals, and possible budgetary constraints.

One of the primary distinctions between TPAs and insurance companies is their independence. Benefit administrators are not tied to a single provider or carrier, which means they have the flexibility to help businesses create customized plans. It’s important to note that a TPA is not an insurance carrier, and they do not directly provide coverage. Rather, a benefits administrator works with their clients to build and manage their healthcare benefits plans.

The growing need for benefits administrators

Managing employee benefits has become increasingly complex due to rising healthcare costs and ever-evolving regulations. For many businesses, particularly small and medium-sized companies, handling these challenges in-house is not practical. Benefits administrators provide the expertise, flexibility and affordability necessary to navigate this while offering significant advantages to employers by allowing them to build self-funded benefits plans.

Affordability

Providing benefits the conventional way is expensive, especially for small businesses. Insurance premiums continue to rise, making it harder for companies to even afford benefits let alone something that’s market competitive. Benefits administrators can help lower costs by working with self-funded plans and other cost-saving solutions that keep their claims fund as stable as possible. And when it comes to preparing for the unexpected, a TPA can enable an employer to manage the financial risk of offering a health plan by adding stop-loss coverage, which protects against high-cost claims.

Self-Funded Plans

Unlike fully-insured plans, which require purchasing health insurance from an insurance provider that then assumes the risk, self-funded plans allow businesses to take control of their benefits programs. The higher costs associated with fully insured plans can make them a less feasible—or less desirable—option, leading many employers to explore alternative approaches such as partnering with a TPA.

Flexible Plan Options

Traditional insurance options often come with set structures that just don’t work for every business. Benefits administrators allow employers to customize benefits by offering flexible options that don’t take the cookie-cutter approach. Employers can provide employees with more choices for their healthcare benefits which improves access to care and overall satisfaction.

This flexibility helps businesses avoid paying for coverage they don’t need while still offering benefits that their employees want.

Guidance from the Experts

Healthcare regulations and compliance requirements are constantly changing, making it difficult for businesses to stay up-to-date. This is where a TPA’s experience in managing benefits programs and ensuring compliance with complex federal regulations comes in handy. Instead of tackling these challenges alone, businesses can rely on their benefits administrator to manage those important details, reducing the constant administrative strain and lowering their risk of mistakes.

Without a TPA, businesses would be stuck with minimal options that are unaffordable and impossible to understand. By working with a TPA, businesses can take a more practical approach to benefits administration—offering self-funded plans, gaining expert guidance, customizing plan options, and keeping costs under control while still providing quality healthcare options for their valued employees.

How Planstin stands out as a TPA

At Planstin, we're not just another third-party administrator—we redefine what benefits administration can be. With a mix of user-friendly technology, personalized support, and flexible solutions, we make managing employee benefits simple and stress-free.

In-House Support & Technology

Our job is to make life easier for our clients and ensure their employees feel supported- whether it’s through our easy-to-use technology, 1:1 guidance, or our hands-on care coordination services. At Planstin, we provide these services at no extra cost for our clients, in addition to the flexibility, affordability, and expert guidance expected from a TPA. Plus, our in-house support, customized solutions, and wide range of benefit options ensures businesses, and their employees, get the care they need.

We know that managing employee benefits can be overwhelming. That’s why we offer more than just average administrative support. Unlike TPAs that simply process paperwork, we take a hands-on approach with benefit advocacy, streamlined enrollment, educational resources, and compliance support.

Planstin makes open enrollment and benefits management stress-free with our Enrollment Manager, a tool designed to simplify the process for employers, HR teams, and employees alike.

This user-friendly platform helps businesses stay organized and gives employees the clarity they need to make informed decisions about their healthcare. At the end of the day, our goal is to take the hassle out of benefits so businesses can focus on what they do best.

Benefits Solutions

Planstin specializes in creating benefits programs tailored to the needs of businesses rather than forcing them to fit into predetermined, one-size-fits-all insurance models. We offer the kinds of things you’d expect: dental, vision, comprehensive care. But we also offer the kinds of things you might not, such as Direct Primary Care (DPC) memberships and HealthShare memberships. This unique approach—combining traditional and nontraditional solutions, is what separates Planstin from other TPAs.

Preventive care and wellness are also key components of what we offer. We can help your employees gain access to mental health resources, wellness management and other tools that support long-term health and well-being. With simplified processes and personalized care coordination, employees can feel confident navigating their benefits.

The employee advantage

A great benefits program isn’t just about checking a box, it’s about making life easier for employers and employees. Depending on the TPA, they can provide significant value to employees, transforming the employee experience by offering benefits that actually work for them. When employees have the freedom to choose their healthcare providers and customize their benefits options they feel more in control of their healthcare decisions.

When you partner with a TPA it tells your employees that you take their benefits plan seriously. Showing your employees that you care can win you favor with your team and boost morale. When employees feel supported and valued, it leads to increased productivity and a more engaged workforce. A win for everyone. Employees also benefit from better access to care, education resources, and a sense of security knowing their healthcare needs are covered. These advantages translate into a healthier, happier workforce and contribute to the overall success of the business.

“I highly recommend considering Planstin Administration as a way of approaching healthcare benefits for a wide range of coverage needs, with minimal out-of-pocket costs for your employees and business budget.”

Ashlee Hogancamp - Founder, Herban Market

Beyond benefits: The right TPA makes all the difference

There’s no denying that employee benefits are necessary for attracting and retaining top talent. As businesses try to accomplish this, the need for benefits administrators continues to grow. Unfortunately, not all TPAs are created equal, and finding the right one might seem overwhelming. Fortunately, you’ve found your way to this blog, and Planstin’s Administration.

While most TPAs provide guidance, flexibility, and affordability, Planstin goes beyond just handling the basics and takes a hands-on approach in empowering clients with adaptable options, dedicated support services, and easy-to-use technology. We also understand that a truly great benefits administration partner helps businesses take care of their employees while keeping costs under control, creating a win for both employers and their teams. At the end of the day, we’re here to make your life easier and help you succeed—like a trusted TPA should.

With Planstin by your side, offering benefits is within your reach.

Book a free meeting with one of our Benefit Guides to learn how you can make benefits available to your team.

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ACA Q&A: What Every ALE Needs to Know

Wed, 20 Aug 2025 17:44:57 GMT

If you're an Applicable Large Employer (ALE), navigating the Affordable Care Act (ACA) can feel like decoding a foreign language. With evolving rules, complex forms, and hefty penalties, it's easy to feel overwhelmed. But don't worry, we're here to break it down in plain English.

You don’t need a law degree or an in-house team to understand ACA compliance implications for your business. This guide breaks down the ACA from an ALE’s perspective (and defines ALE just in case this is your first run-in with that abbreviation). We’ll walk you through the essentials, define key terms, and explain the penalties in plain English. Whether you’re reviewing your strategy for the year or just figuring out if you qualify as an ALE, this is a great place to start.

What is the ACA?

The Affordable Care Act is a federal law that was enacted in 2010 to make health insurance more accessible and affordable. For employers, it introduced new responsibilities, especially for those classified as ALEs.

What is an ALE?

An Applicable Large Employer is a business that had an average of at least 50 full-time employees (including full-time equivalents) during the previous calendar year. If you're an ALE, you're subject to specific ACA requirements, including offering health coverage to your full-time employees and reporting to the IRS.

Note : You don’t need 50 FTEs at all times to be an ALE. But if you have 50 FTEs on average throughout the year the IRS will consider you an ALE.

Am I an ALE?

What is the employer mandate?

The ACA's Employer Mandate requires ALEs to offer health insurance that is both affordable and provides minimum value to at least 95% of their full-time employees and their dependents. Failing to meet this requirement can result in significant penalties.

What are ALE reporting requirements?

ALEs must file IRS Forms 1094-C and 1095-C annually. Form 1094-C is like a cover page that summarizes the employer's information, while Form 1095-C provides details about the health coverage offered to each full-time employee. These forms help the IRS determine compliance with the ACA Employer Mandate.

What are essential health benefits?

Essential Health Benefits (EHBs) are a set of 10 categories of services that health insurance plans must cover under the ACA. These include:

Ambulatory patient services
Emergency services
Hospitalization
Maternity and newborn care
Mental health and substance use disorder services
Prescription drugs
Rehabilitative and habilitative services
Laboratory services
Preventive and wellness services
Pediatric services

While large group plans aren't required to cover all EHBs, understanding them helps in designing comprehensive coverage.

What is minimum essential coverage?

Minimum Essential Coverage (MEC) refers to health insurance that meets the ACA's basic requirements. This includes most employer-sponsored plans, individual market plans, Medicare, Medicaid, and other government-sponsored programs. Offering MEC is the first step in ACA compliance for ALEs.

What is qualifying healthcare coverage?

Qualifying healthcare coverage is another term for Minimum Essential Coverage. It's the type of coverage that satisfies the ACA's individual mandate, ensuring individuals have access to basic healthcare services.

What is the minimum value standard?

The Minimum Value Standard requires that a health plan covers at least 60% of the total allowed costs of benefits. This means the plan should pay for 60% of covered healthcare expenses, with employees covering the remaining 40% through deductibles, copayments, and coinsurance.

In addition to this standard, plans that are ACA compliant must provide “ substantial coverage ” for inpatient and physician services.

What is a premium tax credit?

A Premium Tax Credit is a subsidy that helps individuals and families afford health insurance purchased through the Health Insurance Marketplace. If an ALE fails to offer affordable, minimum value coverage, and an employee receives a Premium Tax Credit, the employer may face penalties.

What penalties might an ALE face for non-compliance with ACA regulations?

There are two main tax penalties an ALE may be at risk for under the ACA employer mandate.

4980H(a) Penalty

If an ALE fails to offer MEC to at least 95% of full-time employees and their dependents, the employer faces a penalty. For 2026, this penalty is $3,340 per full-time employee, excluding the first 30 employees.

4980H(b) Penalty

If an ALE offers coverage, but it's either unaffordable or doesn't provide minimum value, and at least one full-time employee receives a Premium Tax Credit, the employer faces a penalty. For 2025, this penalty is $5,010 per affected employee.

What are ACA affordability standards?

For 2026, coverage is considered affordable if the employee's share of the premium for self-only coverage does not exceed 9.96% of their household income.

Since employers often don't know employees' household incomes, the IRS provides three safe harbors to determine affordability.

(See What are Safe Harbors? below)

Affordable Coverage Example (2026)

What are safe harbors?

Safe harbors are methods provided by the IRS to help employers determine if the coverage they offer is affordable. Using these safe harbors protects employers from penalties, even if the coverage turns out to be unaffordable based on an employee's actual household income.

W-2 Safe Harbor: Based on the employee's W-2 wages.
Rate of Pay Safe Harbor: Based on the employee's hourly rate multiplied by 130 hours per month.
Federal Poverty Line Safe Harbor: Based on the federal poverty level for a single individual.

Do ALEs have to offer dependent coverage?

Yes, ALEs must offer coverage to full-time employees and their dependents up to age 26. This includes any child who has been legally adopted. While ALEs are required to offer coverage to dependent children, spouses are not considered dependents under the ACA's rules for this mandate

Has the One Big Beautiful Bill Act (OBBBA) changed ACA rules for ALEs?

No. While the OBBBA introduced sweeping reforms to Medicaid, Medicare, ACA premium tax credits, and work requirements, it doesn't directly alter the ACA's Employer Mandate or ALE definitions. These remain governed by existing ACA regulations.

Do ACA regulations ever change?

Yes, ACA regulations are subject to change. For instance, in 2026, the affordability percentage increased from 9.02% to 9.96%. Staying informed about these changes is crucial for compliance.

Final thoughts

ACA compliance is one of those things that can either feel like a looming liability or a manageable task. The difference? Having the right tools, the right strategy, and the right support.

At Planstin, we know benefits can feel like a burden. But we believe they shouldn’t. We help employers cut through red tape, simplify compliance, and deliver coverage that works. Whether you are trying to avoid penalties, understand reporting rules, or build a smarter health plan, we’re here to make it easier. No jargon. No guesswork. Just smart benefits that keep your business protected and your people supported.

Tools & Resources

Ready to take control of your benefits? Talk to a Benefit Guide today—we'll walk you through it.

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Preventive Healthcare: A Win-Win for Employers and Employees

Wed, 16 Jul 2025 21:05:02 GMT

Most employees have access to preventive care—but far fewer actually use it. That disconnect can quietly cost businesses in the form of missed workdays, rising claims, and long-term health complications. The solution? Making preventive healthcare not just available, but a benefit that employees feel empowered to use.

It’s easy to brush off preventive services as optional, but the impact is significant. According to the World Health Organization, 30-50% of cancer cases are preventable through lifestyle changes and early detection. And yet, only 8% of Americans receive all recommended preventive services each year. Employers are in a unique position to change that.

By making preventive care a core part of your benefits package, you not only support better outcomes for employees—you also gain a healthier, more productive team and a more cost-efficient business.

What is preventive care?

Preventive care refers to services and strategies designed to detect, prevent, and reduce the risk of illness before symptoms appear. It’s typically included in health plans as a set of covered services or offered as a dedicated benefit that helps employees manage their health proactively.

Examples include:

Annual physical exams
Cancer screenings (e.g., mammograms, colonoscopies)
Immunizations (e.g., flu shots, COVID-19 vaccines)
Screenings for chronic conditions (e.g., diabetes, hypertension)
Mental health assessments
Reproductive health services

Under the Affordable Care Act (ACA) , many preventive care services must be covered at no cost when delivered by an in-network provider. This includes services for adults, women, and children.

However, not all plans offer the same level of preventive access. Some may bury services in the fine print or limit access through provider networks. That’s why choosing the right preventive care plan matters.

For more details on ACA preventive care services, visit: https://www.kff.org/aca-preventive-services-tracker/

Why offering preventive care is a win-win

For employers, investing in employees isn't just the right thing to do. It actually makes solid business sense.

For Employers

Lower healthcare costs: Catching issues early often avoids high-cost treatments later.
Fewer sick days: Proactive care helps reduce long-term illness and absenteeism.
Boosted productivity: Healthier employees are more present, focused, and energized.
Improved retention: Employees value benefits that truly support their well-being.
Compliance with ACA regulations: For large employers, offering preventive services is required.

Preventive care can positively impact and even transform the way employees experience their health benefits.

For Employees:

Less stress, more stability: Earlier detection reduces uncertainty and disruption.
Improved outcomes: Catching chronic conditions or serious illnesses early can save lives.
Better Access: No cost-services lowers financial barriers to care.
Increased Trust: Offering meaningful benefits builds goodwill and loyalty.

Required or not, here’s why offering preventive care matters

For Large Employers (Subject to ACA Requirements)

Many group health plans include preventive services, but they’re often underused simply because employees don’t fully understand them. Without clear communication, support, or a user-friendly experience, these benefits can go unnoticed, and employers can miss out on the long-term value.

To change that, preventive care needs to be visible, accessible, and easy to engage with. Try to choose benefits that go beyond the ACA minimum, offering features like virtual care and fewer restrictions. Just meeting compliance standards isn't always enough to meet employees’ needs. When preventive care is well supported and clearly promoted, it becomes a natural part of your workplace wellness strategy and becomes a simple, effective way to support your team.

For Small Businesses (Not Required to Offer Benefits)

Small employers may not be legally required to provide healthcare benefits, but offering preventive care is one of the most affordable and high-impact ways to support your team.

Preventive care doesn’t have to mean a full insurance plan. It can be as simple as providing membership to a Direct Primary Care (DPC) clinic, offering a telemedicine subscription or virtual care access, or introducing a preventive health plan with low or no-cost screenings and services.

Even a small investment in preventive care can make a big difference for your team and your business.

How to choose a better preventive plan

Preventive care might be included in your plan, but that doesn’t mean it’s easy to use. The best plans remove barriers and offer features that actually help people stay healthy.

Look for plans that:

Remove network restrictions
Include virtual or same-day care options
Offer simple access to mental health and chronic condition screenings
Provide transparency around what’s included and the costs
Make benefits easy to understand and use

Implementing preventive care benefits

Choosing the right plan is just the beginning. Turning it into a strategy that actually works requires thoughtful implementation, communication, and ongoing support.

Assess Your Current Benefits Package

Start by reviewing your current benefits package. Identify what’s already offered, what employees are using (or not using), and where gaps exist. If available, use tools like claims data, employee surveys, and feedback sessions to uncover opportunities for improvement and areas where preventive care can add the most value.

Offer Clear, Accessible Options

With those insights, choose benefits that align with your team’s needs and make care easy to access.

If you’re a large employer, ensure that your offerings meet ACA standards –- but don’t stop there. Look for plans that go beyond the minimum and offer services that will actually benefit employees, like flexible access and fewer restrictions.

To take it a step further, pair your preventive plan with wellness-focused benefits that support long-term healthy habits. These don’t have to be costly, but they show a commitment to more than just bare minimum coverage.

Consider enhancements like:

A wellness program that supports physical, mental, or financial health
A monthly stipend employees can use for fitness, apps, or self-care
Gym memberships or fitness reimbursements
A Direct Primary Care (DPC) membership for ongoing, relationship-based care
Onsite or virtual coaching on nutrition, mindfulness, or goal-setting

Communicate with Employees

Even the best plans won’t work if no one knows about them or understands how to use them. Start by educating your team on what preventive care is and how it supports their health. Then, clearly communicate what’s in their plan, how to schedule care, and where to go for help.

Build awareness into onboarding, reinforce it with email campaigns, and keep the momentum going through wellness challenges or occasional reminders. Making preventive care easy to understand and use is one of the most effective ways to boost utilization of benefits and create long-term value.

Ready to take the next step?

While preventive care is easy to overlook, making it a benefit employees feel confident using is one of the simplest ways to support a healthier, more resilient team. When care is easy to access and clearly communicated, your employees are more likely to use it, helping them stay focused, present, and better equipped to do their best work.

Whether your goal is reducing absenteeism, improving retention, or building long-term trust, preventive care delivers real value. It shows your organization is committed to wellness, invests in its people, and understands how everyday health impacts overall performance–making it a win-win for employees and employers.

At Planstin, we make it easy to put those values into action. With customizable preventive care plans and hands-on support, we help you implement solutions that work for your business and the people behind it.

Let’s build you a benefits strategy that supports prevention, performance, and people. Click below to get started today.

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What HR Teams Should Know About COBRA

Thu, 26 Jun 2025 17:53:06 GMT

When someone leaves your company, whether they quit or get laid off, one of the last things on either of your minds might be health insurance. But for HR and benefits teams, this is when COBRA continuing coverage responsibilities kick in—it's a test of how well your processes really work under pressure.

We work with COBRA every day, so we know it’s not the most exciting part of employee benefits. Nevertheless, managing continuing coverage is necessary, and when done properly, it gives former employees and their families a much-needed sense of stability during uncertain times. In this post, we’ll break down what COBRA is, why it matters, and what your team needs to do to stay compliant.

What is COBRA?

The acronym COBRA stands for the Consolidated Omnibus Budget Reconciliation Act. It’s a federal law passed in the 1980s that allows employees and their families to continue using their group health insurance after something happens that would normally cause them to lose it.

Think of it as a safety net. If an employee gets laid off, has their hours cut, gets divorced, or passes away, COBRA ensures that they (or their family members) can keep the same health plan for a while—at their own cost. It doesn’t create new coverage. It just lets them stay on what they had.

When does COBRA apply?

Continuing coverage through COBRA kicks in after what's called a qualifying event. These are life changes that would normally cause someone to lose their health insurance. The most common ones we see are when an employee leaves the company (either voluntarily or involuntarily), has their hours reduced, or experiences a divorce or death in the family. Even kids aging out of a parent’s plan can trigger COBRA rights.

If the employee was covered under your group health plan the day before the event happened, they’re probably eligible to continue it under COBRA.

How long does coverage last?

For most employees who lose coverage because of termination or reduced hours, COBRA lasts up to 18 months. In some cases—like when a second qualifying event happens or someone becomes disabled—that period can be extended to 29 or even 36 months , especially for spouses and dependents.

The timeframes are set by law, and it’s important to track them carefully so that people aren’t dropped too early (or kept on longer than allowed).

Who pays for COBRA?

This one surprises a lot of people. COBRA isn’t free. The individual who elects to continue their coverage has to pay the full cost of the health plan—including the portion the employer used to pay. On top of that, there’s usually a small administrative fee, bringing the total cost to about 102% of the premium.

That might seem expensive, but for someone going through a tough time—like a job loss—it often beats going without insurance altogether. It gives them time to figure out their next move while still having access to care.

What does HR need to do?

Here’s where it gets a bit more detailed. Employers (or whoever is handling continuing coverage for them) are responsible for making sure everything happens on time.

Once a qualifying event occurs, you’ll have 30 days to report it to your COBRA administrator (or handle it internally if you don’t use one). Then, you must ensure the eligible individual receives a COBRA election notice within 14 days. That notice gives them the option to keep their benefits and explains the cost and how long it lasts.

The individual has a 60-day window to decide. If they choose to keep coverage, they’ll have 45 days to pay their first premium. That premium will have to cover the time between losing coverage and electing COBRA, so the first payment is usually for several weeks or even months of coverage.

These timelines are strict, and missing a deadline could mean non-compliance, fines, or unhappy ex-employees. That’s why it’s so important to keep clear records and follow through quickly after someone leaves.

Why COBRA trips companies up

Even though COBRA has been around for decades, it’s still one of those benefits tasks that tends to cause headaches. That’s because it involves multiple steps, firm deadlines, and detailed communication. It’s easy for things to slip through the cracks—especially if there’s no system in place to manage it.

Some of the common issues we see include missing the notification window, using old or incorrect notice templates, forgetting about dependents, or not tracking how long someone’s been on COBRA. These may be honest mistakes, but they can result in real consequences if the IRS or Department of Labor comes knocking.

Do you have to handle COBRA alone?

The short answer is: no. Many companies choose to work with a third-party administrator (TPA) to handle COBRA. That’s wh ere we come in. A TPA can track deadlines, send out the right notices, collect premiums, and answer questions from former employees so your team doesn’t have to.

It’s not just about offloading the work—it’s about protecting your company and making sure you’re doing right by your people, even after they’ve left.

Why COBRA still matters

It might feel like a formality, especially when someone is no longer with your company, but COBRA matters. For many, it’s the difference between staying insured or going without coverage. For employers, it’s not just about wrapping up benefits, it’s about avoiding penalties that can reach $100–$110 per day per violation and reducing legal risk. Even a small oversight can turn into a costly compliance issue, making accurate and timely COBRA administration essential.

Additionally, the way you handle COBRA reflects how your company treats people. If the process is confusing, delayed, or poorly communicated, it can leave a bad impression. But if it’s smooth, timely, and supportive, it shows that your company takes its responsibilities seriously—both legally and personally.

For more information about COBRA, visit dol.gov .

Ready to take COBRA off your plate?

Managing continuing coverage responsibilities may not be the most exciting part of your benefits offering, but it’s one of the most important pieces to get right. It’s detailed, time-sensitive, and easy to mishandle if you’re not careful. That’s why having a reliable processor a dependable partner—or both—makes all the difference.

At Planstin, we manage COBRA for clients of all sizes, and we know how to take the stress off your team. Whether you need full-service administration or just some guidance on how to improve your current process, we’re here to help you stay on track and in compliance.

If you’re unsure about your COBRA setup or you’ve had issues in the past, let’s talk.

We’ll help you make it simple, clear, and most importantly, done right.

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5 Benefits Laws Every ALE Must Comply With

Thu, 05 Jun 2025 23:32:32 GMT

Once your business reaches 50 full-time employees, you’re officially recognized as an Applicable Large Employer (ALE) under federal law. It’s an exciting milestone that reflects your company’s growth—and it comes with new responsibilities to protect your team and your business.

As an ALE, you are required to comply with a set of federal laws designed to protect your business and ensure employees have access to important protections and resources. Compliance is critical, but it’s not just about avoiding penalties—it’s about building trust, strengthening your workforce, and positioning your company for long-term success.

Let's take a look at five key benefits laws every ALE needs to know:

1. The Affordable Care Act (ACA)

Signed into law in 2010, the ACA expanded access to affordable healthcare and introduced new requirements for large employers.

ALE Requirements

Offer minimum essential coverage (MEC ) , which includes basic plans that cover at least basic preventive services.
Ensure the plan qualifies as a minimum value plan (MVP) , which means broader care that covers at least 60% of total medical costs.
Make sure the employee-only premium is affordable: It cannot exceed 9.96% ( 9.02% for 2025) of the employee’s income.
Report coverage to the IRS: File forms 1094-C and 1095-C each year.

Penalties for Non-Compliance (2026)

If your business does not meet the ACA’s requirements, there are two potential penalties, of which you will pay one or the other.

To learn more about the ACA, click here.

Why it Matters

Being compliant with the ACA helps you avoid large IRS fines, but just as important, it strengthens your ability to attract and retain top talent.

Healthcare benefits remain one of the biggest reasons employees choose (and stay) with an employer.

2. The Family and Medical Leave Act (FMLA)

Passed in 1993, FMLA protects employees who need extended time off for personal or family health reasons, without the fear of losing their job or health benefits.

ALE Requirements

Provide up to 12 weeks of unpaid, job protected leave for qualifying reasons.
Maintain group health benefits during leave.
Reinstate employees to the same or an equivalent job after leave.
Post FMLA notices and inform employees of their rights.

Who Qualifies

Employees who have worked for you for at least 12 months, 1,250 hours, and work at a location with 50+ employees within 75 miles to qualify for FMLA. Additionally, employees who work remotely are considered main office employees and qualify for FMLA under the 50/75 rule.

Penalties for Non-Compliance

While there are no automatic fines, violations can lead to:

Employee lawsuits seeking backpay, lost benefits, and legal fees.
Department of Labor (DOL) investigations.
Liquidated damages (double the amount owed if the violation is deemed willful).

Why it Matters

FMLA compliance shows employees that you support them through critical life events, from welcoming a new child to caring for a loved one. It also provides employers with a structured, legally protected way to manage extended absences fairly and consistently.

3. Consolidated Omnibus Budget Reconciliation Act (COBRA)

Enacted in 1985, COBRA gives employees and their families the option to temporarily continue health insurance after certain life events.

ALE Requirements

Offer COBRA continuation coverage after qualifying events (i.e. termination, reduced hours, divorce, death, a dependent aging out).
Send timely COBRA notices to employees.
Administer coverage for 18–36 months, depending on the situation.

Who Pays

The employee usually pays the full premium plus a 2% administrative fee. While the employer is responsible for offering the continuation but not for subsidizing the cost.

Why it Matters

COBRA protects employees during vulnerable transitions while giving employers a clear process to avoid legal and IRS penalties. Handling COBRA correctly also shows employees that you support them through major life changes.

4. Employee Retirement Income Security Act (ERISA)

Passed in 1974, ERISA was created to protect employees' interests in employer-sponsored benefits plans, including health and retirement plans by setting minimum standards for the management of employer-sponsored benefits plans.

ALE Requirements

Clearly explain the benefits offered by
Maintaining a written plan document outlining plan rules.
Providing a Summary of Benefits Coverage (SBC) to employees.
Providing a Summary Plan Description (SPD) to employee s .
Disclose plan changes or important notices in a timely manner.

Act as a fiduciary
Always act in employees' best interest when managing the plan.

Create a fair and transparent claims and appeals process.

Potential Penalties

For more ERISA penalty information visit dol.gov or click here .

Why it Matters

ERISA ensures employees understand their benefits and have a process to challenge benefit denials. For employers, ERISA compliance minimizes the risk of Department of Labor audits and costly lawsuits while reinforcing transparency and trust in your organization.

5. Health Insurance Portability and Accountability Act (HIPAA)

Established in 1996, HIPAA sets national standards to protect sensitive health information and ensure employees can maintain health coverage between jobs.

ALE Responsibilities

PRIVACY

Safeguard employees' Protected Health Information (PHI).
Limit who can access or share employee health data.
Ensures employees health details are kept confidential

SECURITY

Protect electronic health information (ePHI) with safeguards like encryption, passwords, and secure storage.

PORTABILITY RIGHTS

Allow employees special enrollment rights if they lose other health coverage (e.g., through a spouse’s job loss).
Do not impose pre-existing condition exclusions.
Provide HIPAA Privacy Notices if you self-administer any part of your health plan.

Why it Matters

HIPAA compliance protects sensitive employee data, builds trust with your workforce, and helps you avoid serious financial and reputational risks.

Note: HIPAA doesn’t prevent you from asking employees about health issues when necessary (for sick leave, accommodations, or safety) — but any health information you receive must stay confidential.

Compliance isn’t optional, it's strategic

For applicable large employers, laws like ACA, FMLA, COBRA, HIPAA, and ERISA are non-negotiable. And for smaller businesses, many similar requirements may apply at the state level — especially as your team grows. But these five laws are just the beginning.

From state-specific mandates to evolving federal guidance, your business may face additional compliance considerations tied to how you offer, administer, and manage employee benefits.That’s why it’s so important to have a trusted partner in your corner.

At Planstin, we believe compliance shouldn’t feel like a burden. When you work with a team that understands the regulations and the people behind them, you gain more than peace of mind — you gain clarity, confidence, and time to focus on growing your business.

Have questions about your company's compliance with these or other benefits laws?

Let us help you handle the details, so you can stay focused on what matters most: leading your team and building what’s next.

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How do I find my benefit documents?

Thu, 05 Jun 2025 19:49:03 GMT

It depends on how you enrolled.

If you enrolled through Enrollment Manager, your benefit documents will be available there. Simply login using the same credentials you used when you enrolled.

Access Plan Documents in Enrollment Manager

1. Login to Enrollment Manager

2. Click on “Documents”

3. Select the plan document you wish to view

Need Help Finding Your Documents?

If you have trouble finding your plan documents, or if you have questions, please reach out to Member Services at 888-920-7526.

Learn More

Click here to login to Enrollment Manager .

Contact Member Services for help understanding your plan details at 888-920-7526 .

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Access Matters: Mental Health Benefits for the Real World

Tue, 20 May 2025 23:35:22 GMT

Offering mental health coverage is no longer optional. But offering coverage that goes unused, unmentioned, or misunderstood? That’s no better than offering nothing at all. When employees know support is available and how to use it, they’ll show up more focused and more likely to stick around.

May is Mental Health Awareness Month, and across the country, businesses are sharing reminders, posting infographics, and putting up green ribbons. That’s a good start. But while the national conversation grows louder, the actual support people receive often lags far behind. We are getting to the point where awareness isn’t the issue—it’s access

According to the American Psychological Association , 67% of U.S. workers report having access to mental health care through their job. But only 28% say that care includes telehealth or virtual counseling. That’s a huge gap for a workforce that’s busier, more remote, and more digitally integrated than ever.

Shockingly, just 29% say their employer offers an Employee Assistance Program, a tool that should be basic by now.

While benefits might technically exist, they’re often invisible. Research by SHRM found that 67% of employees are either totally unaware or only vaguely aware of what their mental health options are. That’s a problem, especially when nearly a third of workers say they’ve considered leaving a job due to mental health concerns.

Meanwhile, 92% of workers say it’s important to them to work for a company that values emotional and psychological well-being. Something is not adding up. At Planstin, we believe benefits should actually benefit people. And when it comes to mental health, that starts with building support systems that people can reach, afford, and rely on.

The case for rethinking mental health access

Traditional mental health care often means finding a provider, waiting weeks for an appointment, taking time off work to attend, and hoping insurance covers most of it. For many employees, those steps alone are enough to delay or avoid care altogether.

Unfortunately, people are not likely to avoid feeling overwhelmed or wait to fit it into their schedule. They need options that fit into their actual, messy lives. This is when virtual care becomes much more than a convenience.

Remote-first mental health tools have evolved far beyond simple chat support or downloadable PDFs. The most effective platforms offer structured, science-backed courses tailored to common issues like anxiety, stress, parenting challenges, and relationship strain. Employees can explore these programs at their own pace, on their own time, without needing a formal diagnosis or a time slot they can’t spare.

Additional tools—like daily journaling, progress assessments, and weekly group sessions with licensed therapists—help turn casual engagement into meaningful growth. And all of it can happen from a phone, a laptop, or wherever someone feels comfortable.

This kind of design removes friction. It reduces stigma. And it helps more people take that first step, because it’s right there when they need it.

Building a culture that supports participation

Offering benefits is only half the job. The other half is encouraging people to use them or helping them remove the hesitation that might keep them from doing so.

Workplaces that reward participation send a clear message: mental health matters here. That could mean providing small incentives for engaging with mental health programs, giving employees time during the workday to attend sessions, or simply celebrating when people take steps toward well-being.

When support becomes visible and valued, it becomes part of the culture. And that culture pays off. Employees who feel emotionally supported are more focused, more inspired, and more present. They miss fewer days, collaborate better, and stay longer. Teams that feel safe addressing mental health bring more energy, empathy, and resilience to their work.

That’s not just good for people, it’s good for business (including yours).

What meaningful mental health benefits should include

When we talk about mental health benefits, we’re not talking about vague promises. A meaningful offering gives employees access to:

Talk therapy and counseling options, in person or online
Mental health medications when needed
Digital tools that help with managing stress, emotions, and work-life balance

When these components work together—and when they’re easy to find and use—they create a supportive care system that’s flexible, effective, and far more likely to make a difference.

Planstin’s approach: Make it simple, make it work

At Planstin, we work with employers who are done playing by outdated rules. They want to offer real support, and they’re looking for smarter ways to do it.

We believe mental health care should be:

Easy to access
Designed for real life
Communicated clearly
Built into benefits in a way people actually notice

That’s why we focus on virtual-first tools that give people options—whether they want to talk to a professional, explore a program on their own, or check in every day with something as simple as a journal prompt.

Let’s build mental health support that makes a difference

So, here’s the bottom line: Your people matter. Their mental health matters. And how you design your benefits—including how easy they are to use, how clearly they’re communicated, how genuinely they’re supported—matters more than ever.

We've seen how flexible tools, virtual access, and a culture that values well-being can change how employees show up—not just at work, but in their lives. So, the question is no longer, “should we rethink mental health support?” It’s. “what are we waiting for?”

Now is the time to ask hard questions about your current offerings. To dig into what’s actually being used. To make space for tools that meet people where they are. Whether you’re starting from scratch or fine-tuning what you’ve built, this is your chance to move from intention to impact.

Want to rethink your approach to mental health benefits?

Talk to a Planstin Benefit Guide. We’ll help you build a plan that makes care clear, approachable, and actually accessible (without the jargon and without the guesswork).

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Maximizing Employee Satisfaction with Dental and Vision Benefits

Wed, 14 May 2025 20:47:00 GMT

Real benefits that address daily health needs impact focus, loyalty, and long-term success. When your benefits plan covers dental and vision needs, it shows you're thinking beyond what you have to offer and considering your employees' everyday life.

Dental and vision benefits have shifted from being optional perks to expected parts of a comprehensive benefits package. According to SHRM , 80% of employers now offer dental benefits and 71% offer vision coverage, reflecting how these services have moved into standard offerings. Employees increasingly rank dental and vision care among the top non-medical benefits that influence their satisfaction and loyalty. Including these benefits is a relatively low-cost way for employers to strengthen workforce stability, reduce preventable absences, and stay competitive in today’s labor market.

Why vision and dental benefits matter

Major medical coverage addresses serious health conditions, but everyday health needs often start elsewhere. Preventive services like dental cleanings, cavity checks, eye exams, and updated vision prescriptions make a noticeable difference in an employee’s day-to-day comfort and ability to work effectively.

Left untreated, minor issues like toothaches or blurred vision can escalate, leading to more serious health concerns, emergency visits, or extended time away from work. Even without major incidents, discomfort caused by dental or vision issues can lead to loss of focus, lower productivity, and increased workplace errors.

Dental and vision benefits allow employees to handle these issues proactively, improving both individual health outcomes and the company’s bottom line. Preventive care also tends to be more affordable for both employers and employees compared to reactive or emergency care.

When employees can easily access routine services, it reduces the need for urgent interventions and the associated costs.

Benefits that support retention and productivity

Access to dental and vision care has become an important benchmark for how employees evaluate the strength of a benefits package. These services address everyday health needs that directly impact an employee’s ability to work effectively.

Offering dental and vision benefits shows that a company is focused on maintaining long-term employee health, not just providing coverage for emergencies. As more employers make these services standard, businesses that overlook them risk falling behind in employee expectations—and in attracting and retaining top talent.

A 2023 survey by MetLife found that 68% of employees say having a broader range of non-medical benefits, including dental and vision, would increase their loyalty to their employer. In industries facing worker shortages or high turnover, offering a benefits package that includes these options can create a meaningful competitive advantage.

When employees feel that their everyday needs are supported, they are more likely to stay with a company long-term. This, in turn, reduces hiring and training costs while strengthening institutional knowledge and team cohesion.

Additionally, employees who can easily access vision correction and dental care tend to have better health outcomes overall, resulting in fewer absences, fewer short-term disabilities, and higher on-the-job performance.

Flexible options for small businesses

One common misconception is that only large companies can afford to offer comprehensive benefits packages. In reality, flexible dental and vision plans make it possible for businesses of all sizes to provide meaningful coverage without overwhelming their budgets.

Another smart strategy is pairing benefits with a Health Savings Account (HSA). HSAs allow employees to save pre-tax dollars for eligible expenses, including dental and vision care. Employers benefit too, with reduced payroll taxes and the ability to offer a valuable, flexible tool that empowers employees to manage their healthcare spending more effectively.

Together, flexible benefit structures and HSAs offer small businesses a way to provide a high-value, cost-controlled benefits experience.

Why dental and vision benefits are a win-win for employers

One of the reasons dental and vision coverage has gained traction is that it offers a high return on a relatively low investment. Compared to major medical insurance, dental and vision plans are significantly less expensive to provide. Yet they offer benefits that virtually every employee can access and appreciate.

While not every employee will experience a major medical event each year, nearly all will use their dental or vision benefits. Cleanings, exams, cavity treatments, glasses, and contact lenses are everyday needs. Utilization rates for dental and vision plans often exceed those for major medical plans, particularly among younger and healthier employees.

By offering affordable access to preventive care, employers help reduce the risk of more serious—and more costly—health issues over time. Routine dental exams can catch early signs of systemic conditions such as diabetes or heart disease, while regular vision screenings can detect early health changes that might otherwise go unnoticed.

What employees want in dental & vision plans

When evaluating dental and vision benefits, employees typically focus on three main factors.

1. Affordability

Lower out-of-pocket costs for services like routine cleanings, exams, glasses, and contacts. Employees want to know that using their benefits will not cause financial stress.

2. Provider Choice

Access to a broad network or the freedom to visit preferred providers ranks highly when employees consider their satisfaction with a plan.

3. Simplicity

Clear communication about what is covered, transparent pricing, and an easy-to-understand processes. Complicated claims, fine print, or surprise costs can quickly erode confidence in the overall benefits package.

By focusing on these factors when designing and communicating benefits, employers can better meet employee expectations and improve overall satisfaction with their offerings.

A smarter approach to benefits

Dental and vision benefits are sometimes overlooked in strategic planning, but they play a critical role in employee wellness, satisfaction, and business success. Offering access to preventive services, supporting health maintenance, and giving employees flexible options for managing healthcare costs shows a proactive, modern approach to workforce management.

The return on investment is clear: healthier employees, lower turnover, stronger recruitment, and fewer productivity losses due to untreated health issues.

Planstin works with businesses of all sizes to design smart, affordable benefits strategies including dental and vision coverage options that strengthen teams and support long-term growth.

Looking to explore dental and vision options for your team? Give us a call at 888-920-7526 or click the link below to speak with a Benefit Guide.

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A Plain-English Guide to Common Benefits Terms

Tue, 29 Apr 2025 01:05:13 GMT

The world of employee benefits is littered with acronyms, jargon, and unfamiliar concepts—especially for companies new to offering benefits. This guide can help you get to know the language so you can be more confident in your role.

Understanding healthcare and ACA compliance shouldn’t feel like decoding a secret language. Abbreviation lingo like “MVP,” “ALE,” and “QSEHRA” can quickly turn routine benefits conversations into overwhelming ones. That’s why we created this straightforward glossary. It’s designed for employers, like you, who want more clarity when it comes to health benefits and compliance. In it, we try to simplify the most common—and most confusing—terms related to healthcare, the Affordable Care Act (ACA), and employee benefits.

ACA compliance terms

If you're a large employer, ACA compliance is non-negotiable. But the terminology can be overwhelming, especially if you have just recently become an ALE (definition below). This section breaks down the foundational terms for understanding whether you're subject to ACA rules, what kind of coverage you’re expected to offer, and how health plan affordability is measured.

ALE

An Applicable Large Employer, or ALE, is an employer with 50 or more full-time employees * on average during the prior year. ALEs are subject to ACA requirements like offering affordable health insurance.

* For more details about how the ACA defines full-time employee and other terms like full-time equivalents read this blog dedicated to understanding ALE roles and responsibilities.

ESRP

Through the Employer Shared Responsibility Payment (ESRP), the ACA requires ALEs to offer minimum essential coverage (MEC) that is affordable and provides minimum value (MV). If ALEs don’t comply, tax penalties are assessed. *

* Click here for more information on ESRP rules and penalty amounts .

MEC

Minimum essential coverage (MEC) refers to the most basic level of health coverage required by the ACA. Most employer-sponsored health plans qualify, as do individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage types.

MV (MVP)

Minimum value refers to a standard set by the ACA for healthcare coverage. A health plan provides minimum value (and may be considered a minimum value plan or MVP) if it covers at least 60% of the total allowed costs and substantial coverage of inpatient hospitalization and physician services.

Affordable / Safe Harbor

ALEs must offer health coverage that the ACA considers affordable. For 2025, affordable means that the employee’s share of the premium does not exceed 9.02% of their household income. This standard, like the ESRP penalties changes each year.

Because employers don’t typically know an employee's household income, they may use one of the following safe harbors:

W-2 Safe Harbor
Rate of Pay Safe Harbor
Federal Poverty Line (FPL) Safe Harbor

Click here for more information about affordability safe harbors .

Form 1095-C

This is the form that ALEs must provide to each employee (and the IRS). It details the employer’s offer of healthcare coverage and if it met ACA standards.

Form 1094-C

This is a summary form that ALEs send to the IRS with all the 1095-C forms. It is what the IRS uses to determine if the ALE has complied with the ACA.

FAQs

How do I know if I’m an ALE?

The answer to this can get tricky depending on your employee population. Generally, if you had an average of 50+ full-time employees in the previous calendar year, you’re an ALE for ACA purposes.

We created this handy tool to quickly determine if you are an ALE.

Read this for more information on what the ACA considers “full-time” and ALE responsibilities.

What’s the difference between MEC and MVP?

Minimum essential coverage (MEC) is the most basic coverage acceptable under the ACA (think preventive care services). Offering MEC helps ALEs avoid a very costly tax penalty. Minimum value plans go a bit further, covering a wider range of services and paying for at least 60% of total costs. Offering an MVP helps ALEs avoid a second, more selective penalty.

Read this for more information on the differences and the impact of offering or not offering one or both.

Health plan & benefits strategy terms

From traditional insurance policies to self-funding and reference-based pricing, there are more options for benefits than ever before. But all of these choices come with more jargon that might hold you back from exploring possibilities that could work really well for your business. This section defines the different types of plan structures and cost-containment strategies you have access to, so you can feel more confident exploring strategies that balance coverage, flexibility, and cost.

Fully Insured

A traditional insurance plan where the employer pays a fixed premium to an insurance carrier, which takes on the financial risk for covered claims.

Self-Funded

A plan where the employer assumes the direct risk for paying healthcare claims. These plans, popular with larger employers but available to employers of all sizes, are often paired with stop-loss insurance to limit liability.

Read this for more information on the differences between self-funding and fully-insured.

Level-Funded

A hybrid between fully insured and self-funded. Employers pay a fixed monthly rate (like a premium), but claims are paid from a funding account (also called a claims fund). Surplus funds may or may not be refunded at year-end.

RBP

Reference-based pricing is a cost-containment strategy that health plans may use to reimburse medical providers based on reference points like Medicare rates instead of relying on a provider network.

FPHC

Fair-priced healthcare is a no-network, proactive pricing strategy that determines the most fair price for a service in any given area by leaning into existing cash prices, transparent and reflective of actual costs. Fair-priced healthcare relies on a care coordination team to match members with providers.

TPA

A third-party administrator is a company hired by an employer to manage their health plan administration, such as enrollment, claims processing, and compliance. A TPA is commonly used when employers choose self-funded or level-funded plans.

Do you need a TPA?

Stop-Loss Insurance

This is insurance that protects self-funded employers from catastrophic claims by covering costs that exceed a specified threshold (e.g., $50,000 per individual per year; or 110% of the claims fund.).

FAQs

What’s the advantage of level-funded for an ALE?

Level-funding combines the predictability of fully insured premiums with the flexibility and potential savings of self-funding. It’s good for growing employers trying to balance risk and cost.

What are the pros and cons of reference-based pricing?

Reference-based pricing pays providers based on a fixed formula which can lower employer healthcare costs but may lead to balance billing if providers don’t accept the RBP payment as full.

Tax-advantaged account terms

Tax-favored accounts like HSAs, FSAs, and HRAs can add value to your benefits package, that is, if you understand how they work. The terms in this section outline the options available to you as an employer and what they mean for your team’s health and financial well-being.

HSA

A health savings account is a triple tax-advantage account available to people with high-deductible health plans (also known as HDHPs). Contributions, growth, and qualified withdrawals are all tax-free.

FSA

An employer can set up a flexible spending account to allow employees to set aside pre-tax dollars for qualified medical expenses. Funds are typically "use it or lose it" by year-end.

HRA

A health reimbursement account is also employer-funded. It is set up to reimburse employees for eligible out-of-pocket medical expenses and premiums. Unlike an FSA, only employers can contribute to an HRA.

ICHRA

An individual coverage health reimbursement arrangement is a type of HRA introduced in 2020. It allows employers to reimburse employees tax-free for individual Marketplace health insurance premiums and qualified medical expenses. An ICHRA acts as a replacement for traditional group coverage.

QSEHRA

A qualified small employer health reimbursement arrangement is available to employers with fewer than 50 full-time employees who do not offer group health plans. It allows reimbursement for premiums and expenses, similar to an ICHRA.

FAQs

Can an employee have both an HSA and FSA?

Yes, but only if the FSA is a “limited purpose” FSA (e.g., dental & vision only). Otherwise, having both can disqualify HSA eligibility.

What’s the difference between HRA and ICHRA?

A traditional HRA reimburses employees for medical costs. An ICHRA goes further by allowing employers to reimburse employees for individual health insurance premiums. Additionally, an HRA does not replace group health coverage, but an ICHRA can.

Regulatory & reporting terms

Behind every compliant health plan is a set of rules, forms, and deadlines. Whether you're preparing IRS filings, drafting plan documents, or calculating fees, this section gives you a preview of the regulatory terms you’re likely to encounter—and how they impact your day-to-day responsibilities.

ERISA

The Employee Retirement and Income Security Act is a law that sets standards for private-sector employee benefit plans, including health insurance. This act established a federal standard for plan documents, fiduciary responsibility, and participant rights.

PCORI

The Patient-Centered Outcomes Research Institute assess annual fees on self-insured (self-funded or level-funded) health plans to fund health research.

Learn more about PCORI fees .

COBRA

The Consolidated Omnibus Budget Reconciliation Act requires group health plans to offer continuation coverage to employees and dependents after certain qualifying events (e.g., termination).

Section 125

A plan that lets employees pay for certain benefits (like health insurance premiums) with pre-tax dollars. A Section 125 plan helps reduce payroll and income tax liabilities.

Learn more about Section 125 plans .

SPD

The summary plan description is a document that employers are legally required to provide under ERISA. It explains the health plan’s benefits, claims procedures, and participant rights in plain language.

FAQs

Who pays PCORI fees and how often?

Employers with self-funded plans must pay PCORI fees every year via IRS Form 720. If you offer a self-funded or level-funded health plan, you’ll likely need to pay PCORI fees each year.

Is an SPD the only document ERISA requires?

No. The SPD is a document for employees that explains their benefits, rights, and how the plan works. ERISA also requires an official, legal plan document that outlines how your health plan works behind the scenes.

More clarity. Better decisions.

With a clearer understanding of the key concepts—like what qualifies as affordable coverage, how different reimbursement accounts work, or why terms like “minimum value” matter—you can make smarter decisions that support both compliance and cost control, while offering meaningful coverage to your team.

At Planstin, we believe healthcare administration doesn’t have to be complicated. We’re here to help you simplify the process, support your people, and move forward with confidence.

Bookmark this guide to keep these definitions close at hand. And if you ever need help tailoring your benefits strategy or interpreting new regulatory changes, our team is here to help.

Did we miss a term you’d like to know more about? Need support understanding how all the pieces fit together or optimizing your plan design?

Give us a call at 888-920-7526 or click the link below to speak with a Benefit Guide.

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What Is an HSA? And How Does It Work?

Thu, 17 Apr 2025 20:27:16 GMT

Whether you’re an individual looking for tax savings, a self-employed professional exploring flexible benefits, or an employer seeking sustainable options for your team, understanding HSAs can unlock major value.

If you’ve ever opened a medical bill and felt your stomach drop, you’re not alone. Between rising premiums, confusing networks, and unexpected out-of-pocket costs, managing healthcare can feel at best, overwhelming. And yet, most people don’t realize there’s a smarter way to approach it: one that puts you back in control and helps your money work harder for your health.

What is an HSA?

So, what exactly is an HSA? An HSA is a practical savings account that puts you in control when it comes to managing medical expenses. It allows you to set aside money specifically for healthcare needs and do it in a way that’s tax-efficient and completely yours to manage. Whether you're covering everyday visits or planning ahead for long-term care, an HSA gives you the freedom to choose how and when to use your funds. And this flexibility only expands when you understand who qualifies and how to get started.

It’s also portable. Your HSA isn’t tied to your job. Whether you switch employers, go freelance, or take time off, your money stays with you, and it never expires.

Who can open an HSA?

To open an HSA, you need to be enrolled in a qualifying high deductible health plan (HDHP). For 2025, that means a plan with at least a $1,650 deductible for individuals or $3,300 for families. You also can’t have other comprehensive health coverage, be enrolled in Medicare, or be claimed as someone else’s dependent.

If you qualify, you can contribute up to $4,300 as an individual or $8,550 as a family in 2025. Those 55 and older can add an extra $1,000. Contributions can come from you, your employer, or both and you can change your contribution amount anytime during the year.

It’s important to understand what makes this account such a smart choice especially when it comes to taxes.

The triple tax advantage

What makes HSAs such a standout? It's the trifecta of tax perks. First, the money you contribute goes in before taxes, reducing your taxable income. Then, any interest or investment earnings in the account grow tax-free. Finally, when you use those funds for qualified medical expenses, you don’t pay a cent in taxes on the withdrawals.

This combination is what makes HSAs more than a savings account. They're one of the most tax-efficient financial tools available.

More than just a savings account

Sure, the tax perks are great but that’s just the beginning. The real power of an HSA is in how it combines short-term flexibility with long-term strategy. You can use it now for medical bills, or let it grow for the future. You can spend it on a dentist appointment this month or invest it for healthcare needs decades from now. It’s both a cushion and a launchpad giving you financial room to breathe today and plan smartly for tomorrow.

What you can use an HSA for

HSAs aren’t just for emergencies. You can use them for everyday medical expenses like doctor visits, prescriptions, dental and vision care, and mental health services. They also cover things like chiropractic care, acupuncture, over-the-counter medications, and menstrual products.

Using Your HSA Day to Day

Using your HSA is simple. You can swipe your HSA debit card at the pharmacy or doctor’s office, or pay out-of-pocket and reimburse yourself later. Just remember to save your receipts especially if you choose to delay reimbursement. There’s no deadline to use the money, and it rolls over every year.

Using Your HSA if You Also Have a HealthShare

If you're part of a HealthShare program, your HSA can be especially helpful. HealthShares often require members to pay an Initial Unshareable Amount (IUA) before any sharing begins—similar to a deductible in traditional insurance. HSA funds can be used to cover that IUA, along with any other eligible medical expenses you’re responsible for under your HealthShare guidelines. This makes the HSA a natural fit for those using nontraditional models of care, offering a tax-efficient way to plan and pay for out-of-pocket costs.

For a full list of eligible expenses, check out IRS Publication 502 .

Your HSA as an investment tool

Many HSA providers let you invest your balance in mutual funds or ETFs once you’ve reached a certain threshold. That means your HSA isn’t just a short-term savings tool; rather, it can be a long-term asset.

If you’re able to cover smaller medical costs out of pocket, leaving your HSA funds untouched can allow them to grow significantly over time. And after age 65, you can use the funds for anything—not just healthcare. You’ll pay taxes on non-medical withdrawals, but no penalties.

What If You Use It for Non-Medical Expenses Early?

If you’re under 65 and use your HSA for non-medical expenses, you’ll owe income tax and a 20% penalty. But once you turn 65, that penalty disappears. You’ll still owe taxes on non-qualified withdrawals, but you’ll have the same flexibility as you would with any traditional retirement account.

Avoiding common HSA mistakes

HSAs are easy to operate, swipe a card, pay for medical expenses, track receipts, but their full potential is often miscalculated. Many people use them only for basic spending without realizing how much they can save or grow over time.

Common Mistake #1 — Not contributing regularly . Even small, consistent contributions help you build up savings over time and lower your taxable income.

Common Mistake #2 — Using your HSA only for immediate spending. While that’s totally valid, you may be missing out on long-term growth. If your provider allows investing, you can let part of your balance grow over time.

Common Mistake #3 — Forgetting to name a beneficiary. This can create tax headaches down the line. And skipping receipts? Not worth the risk. You don’t need to submit them to the IRS, but you do need to keep them in case of an audit.

Common Mistake #4 — Not knowing what qualifies. Spending HSA funds on non-eligible expenses can result in penalties and taxes. When in doubt, check with your HSA provider or refer to IRS Publication 502 .

How does an HSA work for my business?

Since HSAs are such effective healthcare tools, you might want to offer one as part of your company’s benefits package. If your business offers a HDHP, pairing it with an HSA gives employees a powerful way to save money for medical expenses while enjoying tax advantages. You can support your team’s financial well-being without breaking the bank.

You can also choose to contribute to your employees’ HSAs either as a flat amount or through contribution matching. It’s a simple, cost-effective gesture that goes a long way. Your contributions are tax-deductible and exempt from payroll taxes, which benefits your business financially too.

For small and midsize companies especially, HSAs are a thoughtful way to offer meaningful coverage without the steep costs of low-deductible plans. They’re easy to manage, scale as your business grows, and show employees that you're invested in their long-term well-being.

HSA FAQs

Can self-employed people have an HSA? Yes, if you’re on an eligible HDHP.

What happens if I switch jobs? Your HSA goes with you. It’s not tied to your employer.

Can I keep my HSA if I switch to a non-HDHP? You can’t contribute anymore, but you can still use or invest the funds.

How is it different from an FSA? FSAs often have use-it-or-lose-it rules. HSA funds roll over every year.

Can both spouses contribute? Yes. If you have family coverage, you share the annual family contribution limit.

Is an HSA Right for You?

An HSA offers clarity in a space that often feels confusing and overwhelming. It’s one of the few financial tools that balances immediate benefits with long-term potential all in one. With the ability to reduce taxable income, pay for real-life healthcare costs, and invest for the future, it brings practical relief and smart planning together in one account. It’s not flashy but it works.

Ready to take control of your healthcare spending? Start with your HSA.

Give us a call at 888-920-7526 or click the link below to speak with a Benefit Guide.

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How Offering Benefits (and Providing More Choices) Can Help Recruiting and Retention

Fri, 04 Apr 2025 20:05:01 GMT

In today’s hiring market, companies are doing everything they can to stand out. But the secret to attracting and keeping great employees may not be flashy perks or trendy office spaces — it’s your benefits package, and more importantly, the choices you offer within it.

Recently, the unemployment rate has dropped to 4%, meaning that most people who want jobs already have them. While that’s good news for workers, it creates a tight labor market, leaving fewer available candidates for employers to recruit. As a result, three out of four companies face significant challenges when it comes to recruiting.

With fewer candidates actively looking and job seekers having more options, companies must compete more aggressively to attract and retain employees. That competition goes far beyond pay—today's candidates are placing increasing value on benefits and workplace culture.

However, as employee expectations continue to shift, benefits alone aren’t enough. Today's workforce also expects choices—flexibility to select benefits that fit their needs and lifestyle. This personalized approach not only helps employers stand out in the hiring process but also empowers employees, leading to higher satisfaction and stronger long-term loyalty.

Benefits matter more than ever in recruiting

Finding qualified candidates with the right skills and experience remains a top challenge for 60% of talent acquisition professionals . With the hiring process becoming more competitive and expensive, companies are relying on benefits as a key differentiator—and it’s easy to see why.

Candidates Are Looking for Total Compensation, Not Just Salary

While pay remains the number one priority, employees are increasingly factoring well-being and work-life balance into their decisions when accepting a job. According to a Gallup study , 61% of employees now rate work-life balance and wellbeing as "very important," a notable increase from 53% in 2015. This shift reflects a growing demand for more than just basic health insurance, but for nontraditional benefits such as wellness programs and mental health support.

Candidates Prioritize Benefits Almost as Much as Pay

More than two-thirds of surveyed employees ranked healthcare benefits just behind salary in importance when weighing job offers. Even more telling, 78% said they would look for a new job if their benefits package didn’t meet their needs. In a competitive market, benefits often become the deciding factor when candidates compare multiple offers. A strong, flexible benefits package can be what tips the scales in your favor.

Flexibility in Benefits Is Highly Valued

Workplace flexibility is about more than just remote versus in-office work. While most companies are reporting an even split between remote and in-office workers , the real challenge is making sure employees have flexibility in how they can access and customize their benefits. Employees want options that fit their personal circumstances, health needs, and lifestyles, which makes flexibility in benefits just as important as flexibility in the workplace.

Your benefits package could be the reason top talent joins — or leaves — your company.

Employer retention and the role of benefits

Recruiting is only half the battle and keeping great employees is just as important. With the average cost to hire a new employee sitting at $4,700 , companies that invest in retention strategies can save significantly in the long run. One of the most effective ways to retain talent? You guessed it: offering strong, customizable benefits.

Matching Benefits to Employee Needs Enhances Job Satisfaction

Employees' needs vary—from single workers focused on preventive care, to parents needing dependent coverage, to older employees prioritizing retirement planning. Employees are far more likely to stay with companies that offer benefits that fit their specific personal and family needs. Offering customizable options from traditional health plans, to wellness perks, and family-friendly benefits shows employees you value their whole life, not just their work output. It’s a smart strategy: 73% of employees say they would stay with their employer longer if offered more benefits options.

Benefits Contribute to Overall Employee Well-Being and Reduce Stress

Comprehensive benefits cover medical bills, provide financial security, support mental health, and promote work-life balance. When employees feel secure physically, financially, and emotionally, they’re more focused, engaged, and far less likely to look for a new job.

Benefits that address life stressors — from mental health services to student loan assistance to financial wellness programs — allow employees to focus on their work, which improves productivity and morale.

Benefits Show Employees They Are Valued and Support Long-Term Loyalty

Benefits packages reflect your company’s values and culture. Offering nontraditional benefits like mental health apps, pet insurance, or wellness stipends sends a clear message: your company is adaptable, forward-thinking, and committed to supporting employees beyond the basics.

When employees see their employer investing in benefits that grow with them — like expanded family leave, fertility support, or elder care benefits — it builds trust, loyalty, and deeper connection to your organization. Employees who feel their employer cares about their long-term wellbeing and not just their productivity are more likely to stay and grow with your company.

Choice matters—Why flexibility in benefits is key

The best benefits are the ones that employees actually use and value. Offering choices allows employees to personalize their benefits to fit their health, family, and lifestyle needs.

It’s also a practical strategy for employers. Employee Satisfaction with benefits fell to 61% in 2023, down from 64% in 2022 — a clear sign that employers need to adapt to changing expectations. Giving employees a menu of options helps ensure they’re getting the benefits they actually want — not just the ones you assume they need.

Examples of Benefit Choices That Matter

Medical Care: Offer both traditional health plans and nontraditional options like HealthShares, which often come with lower monthly costs and greater flexibility.

Telehealth: Virtual care options allow employees to connect with doctors and specialists from anywhere, saving time and providing convenient access to care.

Mental Health: Go beyond a limited number of counseling sessions by including specialized therapy, stress management programs, and digital wellness tools to support ongoing mental health.

Wellness Perks: Offer options that fit different lifestyles, such as gym stipends, wellness apps, or general wellness stipends employees can apply to what matters most to them.

Health Savings Accounts (HSAs): Allow employees to set aside pre-tax dollars for medical expenses, helping them save while taking control of their healthcare costs.

Offering choices sends a clear message to both employees and candidates: you care about their individual needs. That message builds goodwill, improves job satisfaction, and boosts long-term retention.

It also benefits employers directly, allowing you to focus your benefits budget on offerings employees actually use, instead of paying for programs that go unused.

Your competitive advantage

As an employer, you’re juggling budgets, processes, and people management — all while trying to build a positive, productive culture. Offering flexible, customizable benefits is crucial and a strategic advantage that helps you attract great candidates, retain your top performers, and build a reputation as an employer that truly values your people.

When you offer benefits that employees actually want, and give them the power to choose, you’re not just building a better benefits package. You’re building a better workplace.

Want to learn how Planstin can help you create flexible, affordable benefits options tailored to your workforce? Let’s talk.

Book a free meeting with one of our Benefit Guides to learn how you can make benefits available to your team.

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ACA 2025 Update: Reporting and Penalty Adjustments

Mon, 24 Feb 2025 20:30:04 GMT

The IRS decision to lower employer shared responsibility penalties in 2025 is a rare move. However, it comes alongside increased penalties for missed reporting deadlines. Take this opportunity to optimize your benefits strategy and make sure you are avoiding the penalties altogether.

Since the Affordable Care Act passed, the Section 4980H penalty amounts have been steadily rising, going from $2,080 in 2015 to $2,970 in 2024. However, in late 2024, the IRS did something unexpected: for the first time ever, they lowered the ACA’s Employer Shared Responsibility Payment (ESRP) penalties.

The choice to decrease the larger penalty amounts for the 2025 tax year is surprising and should not be taken as an indication that these penalties will continue to be reduced. In fact, along with this decrease in the larger penalty amounts, the IRS has increased some of the reporting penalties—effective for those reporting for the 2024 tax year.

A quick ESRP (Section 4980H) penalty refresher

If your company has 50 or more full-time (or full-time equivalent) employees, the ACA requires you to offer affordable, minimum-value health coverage to your full-time employees and their dependents. If you don’t there are two potential penalties, of which you will pay one or the other.

Penalty A: No coverage offered

This penalty is triggered if you offer nothing, or don’t offer coverage to at least 95% of your full-time employees.

Penalty B: Insufficient coverage offered

2025 ACA penalty updates

Employer Shared Responsibility

As stated earlier, the Section 4980H penalty amounts are going down this year . If you are an ALE, this shift represents an opportunity to reassess your healthcare strategy and make sure you’re complying with the law—without unnecessary penalties eating at your bottom line.

4980H-A - $2,900 per full-time employee (down from $2,970)
4980H-B - $4,350 per full-time employee receiving a tax credit (down from $4,460)

Reporting

While the 4980H penalties have been reduced for this tax year, some of the reporting penalties under sections 6055 and 6056 have increased.

Failure to report -> $330 per return (up $20)
Corrections to a filed report
made within 30 days -> $60
made after 30 days, but before 8/1/25 -> $130 per return (up $10)
Intentional disregard -> $660 or 10% of the total reported amount (up $30)

2025 Reporting Deadlines

The deadline to provide individual, 1095-C statements to your employees is also unique this year. Typically the deadline is January 31st, but this year, the deadline is March 3, 2025 .

Also unique to this year, thanks to new legislation , employers may opt to provide employees with a clear notice that their forms are available upon request, rather than providing each individual with a 1095-C form automatically.

The deadline to file forms 1095 and 1094 with the IRS is February 28 by mail, or March 31 for electronic submission.

Impact on you

Though the penalties are dropping slightly, compliance is still the smartest move—especially since penalties for intentional disregard are going up. For now, it’s critical for you to understand if you are an ALE with a responsibility to report. If you are, you should review your health plan offering and make sure you are meeting the ACAs minimum requirements. This includes evaluating your health plan’s affordability and the extent of plan coverage. Additionally, you will want to verify that you have indeed made offers of coverage to all eligible employees.

Verify your ALE status
Review your plan offering
Confirm you’ve made offers of coverage
Report to the IRS

We’re here to help you handle the finer points of compliance and navigate the benefits maze without the stress. Whether you need a full compliance checkup or a more cost-effective benefits solution, we’ve got you covered.

For detailed information from the IRS about penalties and deadlines, read this .

To learn more about your responsibilities as an ALE, read this .

Want to make sure your business is protected from penalties in 2025? Let’s talk.

Give us a call at 888-920-7526 or click the link below to speak with a Benefit Guide.

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What provider network does my plan use?

Wed, 29 Jan 2025 00:55:59 GMT

Most Planstin-managed health plans do not use a provider network . That means you are free to work with any provider with out fear of any out-of-network penalties.

Very few Planstin-managed health plans still use a provider network. In this case, your health plan uses the PHCS network of providers.

Fair-priced healthcare & care coordination

The majority of Planstin-managed health plans use an innovative healthcare pricing strategy called fair-priced healthcare. This strategy does not require the use of a provider network, and instead relies on a care coordination team to help you work with your provider, make appointments, and locate providers that work well with your benefits.

To learn more about fair-priced healthcare, click here .

To learn more about care coordination click here .

Learn More

Does your health plan require you to use a provider network? Find your plan documents here . Or call Member Services for help understanding your plan details 888-920-7526 .

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What do I need to know about Preventive Core?

Wed, 29 Jan 2025 00:29:47 GMT

Preventive Core is a health plan that focuses on preventive care. This health plan meets ACA requirements for minimum essential coverage (otherwise known as MEC).

Fair-priced healthcare

This health plan uses an innovative healthcare pricing strategy called fair-priced healthcare. To learn more about fair-priced healthcare, click here .

Care coordination

Preventive Core health plans have no network restrictions and include care coordination services to help you make appointments and locate providers that work well with your benefits. To learn more about care coordination click here .

To view information about your Preventive Core health plan, click here and select your specific plan name.

Learn More

Call Planstin’s Member Services team at 888-920-7526 for further assistance.

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What is care coordination?

Fri, 24 Jan 2025 02:26:40 GMT

All Planstin-managed health plans now feature care coordination services as a part of a fair-price healthcare strategy. The Planstin Care Coordination team will help match members with providers that work best with their plan.

How to use care coordination

Before you make an appointment or visit your provider, contact the Care Coordination team. They will help make sure your provider will work with your benefits, or help you find one who will.

Care coordinators can also

help you find a fair-price provider, and
make appointments.

Call: 435-275-4492

Email: coordination@planstin.com

What else does fair-priced healthcare involve?

Download the fair-priced healthcare flyer below to learn more about how it works with Planstin-managed health benefits.

Download the Spanish version here.

Care coordination with Primestin Care

Members who do not have a Planstin-managed health plan, may still have access to care coordination services through a Primestin Care membership. Additionally, some members may have access to care coordination through either Primestin Care or the Planstin Care Coordination team.

If you are uncertain what benefits you have, or if you have access to care coordination assistance, contact Member Services at 888-920-7526 .

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Are Health Share Plans the Future of Employee Benefits?

Thu, 23 Jan 2025 23:17:13 GMT

With healthcare costs rising every year, employers are seeking innovative ways to provide benefits that strike a balance between affordability and quality care. Could health share plans be the solution that businesses need?

Healthcare costs are at an all-time high, pushing businesses to seek creative solutions that address both employee needs and their bottom line. In 2023, the National Health Expenditure (NHE) grew by 7.5%, highlighting the increasing financial strain traditional insurance places on everyone.

Health share plans, often referred to as "HealthShare memberships," are emerging as a cost-effective insurance alternative. These memberships offer flexible care options and financial protection for medical expenses, making them a viable choice for businesses aiming to escape the high costs and administrative burdens of traditional insurance.

For businesses looking to move beyond complex and expensive benefit models, health share plans represent a fresh approach to healthcare—one that prioritizes affordability, simplicity, and flexibility.

What are health share plans?

Health share plans are a modern alternative to traditional health insurance that takes a community-focused approach to managing medical expenses. Instead of being insured by a company, members join a group that collectively contributes to a shared fund.

These funds are then used to assist with eligible medical bills. Members pay a monthly contribution, and when they have a medical need, they pay an initial portion out-of-pocket (similar to a deductible). The remaining qualifying expenses are shared by the community, providing financial support and peace of mind.

Unlike insurance, HealthShare memberships are not bound by legal guarantees or contracts. Instead, they rely on established guidelines and shared responsibility to manage costs collaboratively. This approach allows for greater flexibility, affordability, and clarity for members.

Click Here to learn more about HealthShare Memberships.

The challenges of traditional employee benefits

The rising cost of healthcare makes traditional benefits a growing challenge for employers and employees alike. In 2024, the average annual premiums for employer-sponsored insurance reached $8,951 for single coverage and $25,572 for family coverage . These escalating costs highlight the need for more affordable healthcare solutions. For many businesses, the financial burden of traditional benefits is prompting employers to rethink how they can support their team’s needs without overextending their budgets.

But the challenges go beyond the financial strain. Traditional employee benefits are often complicated and difficult to navigate, leaving both employers and employees feeling overwhelmed. Some of the most common frustrations include:

High premiums and deductibles: Employees often feel like they pay a lot but get little in return, especially if they don’t meet high deductibles.

Limited provider networks: Employees want the freedom to choose their own providers, but traditional plans often limit their options.

Administrative complexity: For HR teams, managing enrollment, claims, and compliance can be time consuming and overwhelming.

Lack of flexibility for small businesses: Smaller employers often find it challenging to offer affordable plans that meet the unique needs of their teams.

These challenges make it difficult for employers to offer competitive benefits that truly support their employees, and they leave employees unsure how to make the most of their benefits. It’s no wonder many employers are searching for solutions that better align with the needs of today's workforce.

Health share plans as an employee benefit

Health share plans can address many of the frustrations associated with traditional insurance, offering advantages to both employers and employees. With more than 1.7 million Americans * relying on medical-cost sharing plans, it’s clear that medical-cost sharing is gaining popularity. By focusing on affordability, flexibility, and transparency, HealthShare memberships are providing businesses with a better way to support their teams while managing healthcare costs.

Affordability: Affordable monthly membership fee, allowing employees to save on premiums and take control of their healthcare dollars.

Flexibility: Members can choose any provider without being tied to a network.

Transparency: Clear guidelines outline what is eligible for sharing, reducing confusion.

Simplified Processes: Instead of complex claims, members pay an initial unshareable amount (IUA) and submit a sharing request for eligible expenses.

Community-Based Support: Members feel connected through a shared commitment to managing healthcare costs collaboratively.

Scalable Solutions: Adaptable as businesses grow, making them a sustainable option for growing businesses.

By offering HealthShare memberships, employers—including small and medium-sized businesses—can provide their employees with high-quality, flexible healthcare while staying within budget. It’s a sound solution for businesses looking to attract and retain top talent without the heavy financial burden of traditional insurance.

Why health share plans could be the future

The world of employee benefits is shifting, driven by rising healthcare costs, evolving workforce expectations, and the need for more flexible solutions. HealthShare memberships are emerging as an innovative way to support employees while addressing employers' financial concerns.

Rising Healthcare Costs

In 2024, employers contributed an average of $19,276 annually per employee toward family health coverage—a cost that adds up quickly and puts significant pressure on business budgets.

A HealthShare membership offers a solution that provides employees with financial flexibility while ensuring access to essential care. With lower monthly costs and a community-focused approach, they make healthcare more sustainable for both employers and employees.

Demand for Flexibility

While some CEOs are pushing for a return to the office, many executives acknowledge that remote work is here to stay, with fully remote employees projected to grow from 10.2% to 11.2% of the American workforce by 2028. This continued shift highlights the need for benefits that align with employees’ increasingly flexible lifestyles. HealthShare membership addresses this demand by eliminating network restrictions and empowering employees to choose their preferred providers—no matter where they live or work.

Meeting Employee Expectations

Modern employees value benefits that are simple, flexible, and cost-effective. Studies show that 56% of employees consider health coverage satisfaction a key factor in deciding whether to stay with a job. HealthShare memberships meet these needs with affordability, transparency, and a collaborative, community-driven approach.

By solving the challenges of rising costs and changing workforce needs, health share plans are paving the way for a new era in employee benefits—flexible, affordable, and built for the modern employee.

The next step in employee benefits

Health share plans are changing the game for employee benefits, offering a cost-effective, flexible alternative to traditional insurance. As healthcare costs rise and employee’s needs evolve, these memberships provide a new way to support your team while staying mindful of your budget and resources.

By offering health share plans, you can empower employees with more choice, simplify benefits administration, and create a benefits package that shows you truly care. It's a modern approach that helps attract great talent, retain loyal employees, and set your business up for success.

Now is the time to explore a solution that works for everyone. With health share plans, you can offer meaningful benefits that make a real difference.

* For a number of reasons, it is difficult to pin down exactly how many HealthShare members there are. However, reports like this one provide some insight on the growing number of HealthShare members nationwide.

Offering benefits is within your reach.

Book a free meeting with one of our Benefit Guides to learn how you can make benefits—including a health share plan—available to your team.

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What is Primestin Care?

Thu, 23 Jan 2025 00:58:24 GMT

Primestin Care is a complete primary care solution with membership options that include virtual and in-person care. Their mission is to deliver compassionate, patient-centered healthcare that can be seamlessly integrated and tailored for individual patients.

Primestin Care Memberships

Primestin offers three membership options as outlined below.

Virtual Care

Unlimited access to virtual primary and mental health resources, along with care coordination.

Primary Care

Personalized care with unlimited office and virtual visits, along with care coordination. Designed for patients in the Saint George, Utah area.

Advanced Care

Comprehensive services, including virtual care, in-office primary care, mental health resources, specialist visits, urgent care visits, and care coordination.

Need help getting started with Primestin Care?

Visit: primestin.care/how-it-works

Call: 435-281-2273

Email: support@primestin.care

Learn More

Visit www.primestin.care .

Download the Primestin Care App for Android here.

Download the Primestin Care App for Apple here.

Not sure you have a Primestin Care membership? Contact Member Services at 888-920-7526 .

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What is fair-priced healthcare?

Tue, 21 Jan 2025 23:58:25 GMT

Fair-price healthcare is a no-network, proactive pricing strategy that relies on a care coordination team to match members with providers that work best with their plan.

If your health plan uses fair-priced healthcare, it will try to determine the actual costs for a service in any given area by examining cash prices.

Why use fair-priced healthcare?

Typically, prices can vary dramatically depending on the provider or facility—even in the same area. Your health plan uses a fair-priced healthcare approach to ensure your plan pays a reasonable rate rather than accepting unnecessarily inflated costs.

This healthcare pricing strategy improves transparency for both plan sponsors and members alike, allowing both groups to benefit from fair prices for healthcare services.

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2025 HSA Contribution Limit Increase

Thu, 16 Jan 2025 01:14:11 GMT

Offering a High-Deductible Health Plan (HDHP) with a Health Savings Account (HSA) is a powerful way to support your employees’ financial and health goals. With the 2025 updates to HSA contribution limits, there are new opportunities to enhance these benefits while maximizing tax advantages.

What’s new for 2025

Under a qualifying high-deductible health plan, employees may contribute a certain amount each year to an HSA. This year that amount is higher, and so is the minimum deductible for a plan to qualify as “high deductible.”

Individual Coverage

Contribute up to $4,300 – up $150 from 2024

Minimum deductible of $1,650 – up $50 from 2024

Family Coverage

Contribute up to $8,550 – up $250 from 2024

Minimum deductible of $3,300 – up $100 from 2024

What these changes mean for your business

Higher contribution limits enable employees to save more tax-free dollars for healthcare and retirement. As an employer, you are not required to up your contributions this year, but you may want to adjust them to align with the new limits. Doing so may be good for morale and demonstrate an overall commitment to employee well-being.

Additionally, your business may benefit from upping your contributions to employee HSAs. Your contributions are fully tax-deductible as a business expense, reducing your taxable income and lowering your overall tax liability.

As for the deductible requirement adjustment for high-deductible health plans, it’s crucial to verify that your plan complies with the updated minimum deductibles for 2025. Keep in mind, these numbers will continue to evolve annually.

Most importantly, if your business offers a HDHP, it’s essential to communicate these updates to employees. You will want to make sure your employees understand their contribution options so they can make the most of their HSA benefits.

Communicate with your employees

When updating your team about the new contribution limits for 2025, you may also want to note a few important points.

Staying Within the Limit

While the new limits allow for more savings, exceeding them can trigger IRS penalties. If an employee inadvertently contributes too much, direct them to their HSA provider to request an Excess Contribution and Deposit Correction to avoid penalties.

Maximizing the Benefits

Encourage employees to fully fund their HSAs. For one, fully funding means maximum tax savings as contributions reduce their taxable income. On top of that, funds grow tax-free and roll over year to year, creating a financial safety net for healthcare and retirement.

How to Contribute

Remind employees of how they can contribute to their HSA:

Payroll Deductions: The easiest and most tax-efficient method.
Online Contributions: Direct transfers from other accounts, though less streamlined for tax purposes.

2024 Contribution Deadline Reminder

There’s still time for employees to maximize their 2024 contribution limit ($4,150 for individuals, $8,300 for families). Employees have until the April 2025 tax deadline to make contributions for the 2024 tax year.

By staying proactive and informed about these changes, your business can continue to foster a healthier, more financially secure workforce while capitalizing on valuable tax benefits. Make the most of the 2025 HSA contribution updates and reinforce your role as an employer of choice.

By exploring these insurance alternatives and communicating their advantages and limitations with clarity, you can help employees understand their options and feel more comfortable choosing the best fit. The more you educate and support your team through this process, the more likely they are to feel confident and satisfied with the benefits you offer.

Have questions?

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Questions to Kick-Start Your Benefits Strategy Planning in 2025

Mon, 30 Dec 2024 22:02:02 GMT

Is your benefits strategy contributing to your growth or quietly draining your resources? Being more strategic with your benefits program can seem overwhelming at first, but if you know the right questions to ask and do an honest assessment of your current benefits package, you can start to develop a benefits strategy that strengthens your business.

Despite the important role employee benefits play in driving retention and engagement, too often companies see benefits as a checkbox expense rather than an instrument for profitability. If you’re not sure whether your benefits strategy is pulling its weight, the new year is the perfect time to take a closer look and start thinking about how to make your employee benefits program work for you.

Crafting a benefits strategy that truly aligns with employee needs and business goals starts with asking yourself the right questions. By taking a curious, proactive approach, you can uncover gaps in your offering, highlight opportunities to boost the value of your benefits, and lay a strong foundation for a performance-driven benefits plan.

Once you begin, you’ll find that one question usually leads to another. And, that’s a good thing. As you dive deep into benefits planning, let the questions (and answers) shape a stronger, smarter strategy that grows with your company.

1. Are our benefits aligned with what our employees actually want?

Offering benefits that miss the mark or go unused is, simply, a waste of your time and money. To drive satisfaction and engagement, your benefits need to reflect what employees actually want and need. So, do you know what your employees actually want? When was the last time you asked them?

Regularly surveying employees about their benefits preferences can reveal what’s working and what should be retired. It’s also worth digging into the data that you likely have access to—are certain benefits consistently underused? Are there any patterns that point to generational differences in what employees value? Taking the time to ask, analyze, and make adjustments will help you make sure that your benefits aren’t just there; rather, you can make sure that what you do offer actively contributes to making your employees happier and more productive.

2. Are we striking the right balance between essential and value-added benefits?

Getting just the right blend of benefits can make all the difference in how effective your benefits strategy is. Core benefits like healthcare , retirement plans, and paid leave may form the foundation, but it’s the extras, or nice-to-haves, like a wellness program, flexible work options, and mental health support that can really set you apart and foster team loyalty.

The catch is: the definition of “essential” really can vary across different demographics, roles, and life stages. For some, flexible work options or mental health support are just as vital as medical insurance. Others may prioritize parental leave, elder care assistance, or access to digital health tools. When thinking in terms of government requirements, “essential” may not be enough to provide well-rounded support for your team.

A highly affordable, value-added benefit that you can easily add in to your offering is a direct primary care (DPC) membership. This benefit can enhance employee well-being and reduce long-term healthcare costs. Employees benefit from direct access to their primary care provider, quicker appointments, and more personalized care, while employers see savings through reduced emergency visits and improved overall health.

What is "Essential?"

Something necessary or indispensable

When we talk about essential vs. value-add benefits, that doesn't automatically mean the 10 essential health benefits mandated by the ACA . What we mean is what your team might consider essential. What are the benefits your team can't live without? What is most important to them?

3. How flexible and personalized are our benefits offerings?

A one-size-fits-all approach to benefits rarely—if ever— meets the diverse needs of your team . Sure, personalization and flexibility sound nice to have, but they also serve your employees by giving them more power to choose what matters most to them. As a result, they will be more likely to use their benefits, and your team as a whole will be more satisfied with what you offer.

Can your team customize their benefits, like opting into a wellness or professional development program? And beyond that, are flexible work arrangements, such as remote options or adjustable hours, part of the package? Also, think about the range of life stages your workforce represents—are there benefits that speak to early career growth, mid-career stability, and pre-retirement planning?

Getting a big-picture view of your offerings from the perspective of your employees will help you build a benefits program that can positively impact every employee, no matter where they are in their career.

4. Are we effectively communicating our benefits package?

At this point, you’ve figured out what your employees want, you’ve struck a good balance between essentials and perks, and you’ve built in some flexibility to your benefits program. Great! Now, you need to make sure that work doesn’t go to waste. You must help your employees understand what you’ve made available to them. Clear, consistent communication is what turns good benefits into truly valuable tools that drive engagement.

So, do your employees really know the full scope of their options? Are you only communicating about benefits once a year during open enrollment, or are you keeping the conversation going year-round? Using multiple channels, from email updates and in-person meetings to handouts and posters, helps ensure that the message will stick. When you clearly explain your benefits and make sure they are easy to access, your employees are more likely to take advantage of them, and your benefits program will actually pay off.

5. How can we maximize affordability without reducing value?

Cost concerns can make expanding—or even offering—benefits feel next to impossible. However, a thoughtful strategy and some expert guidance can make it entirely possible to enhance your benefit package without going over budget. The benefits that employees perceive to be the most valuable may not even be the most expensive. Options like mental health days, flexible work arrangements, or wellness initiatives can seriously boost morale and well-being, without adding significant costs.

Teaming up with an expert can help you better identify these high-impact, low-cost solutions while also reviewing your current benefits to find more affordable alternatives. Beyond immediate savings, a benefits administrator can bring more options and insights into how certain benefits can help your business reduce long-term healthcare expenses. But more than just cutting costs, a benefits administrator’s guidance will help you ensure that every dollar you spend on benefits works harder for your company.

6. What are our competitors offering, and how do we compare?

When creating a benefits strategy, you need to check out the competition, and make sure your benefits aren’t working against you. When what you offer falls behind industry standards, it can silently drive turnover and make recruitment much more difficult. For example, are you offering the kinds of perks common in your field (such as wellness stipends in tech or tuition reimbursement in healthcare)?

Understanding what other companies provide can help you keep up with the competition and even help you do more to set your business apart. And beyond the numbers, your employee benefits play a big role in shaping how your company is perceived as an employer. The choices you make can either reinforce your reputation as a place where people want to work—and stay, or not.

How to find the answers

The best place to start is with an audit of your current benefits. Your employees’ usage data can reveal a lot. Take a look at enrollment data and usage patterns to find out what is being used—and what isn’t.

From there, go straight to the source—your employees. Surveys and focus groups can uncover what they really value and where they see room for improvement. A quick, anonymous survey can also tell you how well they understand their options, helping you know where your communication may need improvement. Competitor analysis can add another layer, showing how your benefits package compares to what’s common or standard for your industry.

Finding the right answers to shape your benefits strategy doesn’t have to be overwhelming. And help is readily accessible. Collaborate with a benefits expert who can help you pull all these insights together, show options that match your team and budget, and make developing a benefits strategy a seamless process.

Review your current benefits portfolio.
Conduct a competitor analysis.
Consult with a benefits administrator.
Conduct employee surveys or focus groups to gather insights.
Develop a year-round benefits communication strategy.

Your benefits strategy is a business strategy

The benefits you offer say more about your company than you might think—they reflect your values, shape employee experiences, and directly impact retention and productivity. Taking the time to ask the right questions now can transform your benefits program from a necessary expense into a powerful tool for growth.

The good news? You don’t have to do it alone if you don’t want to. A benefits administrator can help you navigate the entire process and design a benefits strategy that keeps your team engaged and your business competitive. Start today. The right questions can lead to transformative results.

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How Employee Benefits Influence Company Morale and Productivity

Wed, 18 Dec 2024 22:33:48 GMT

Are you struggling to find ways to improve your team’s productivity? Or does your team’s morale need a boost? You might be surprised to know that implementing an employee benefits program could be one of the most effective ways to achieve those goals.

Providing the right benefits does more than just support employees’ well-being—it actively drives morale and improves productivity. In fact, Gallup’s State of the Global Workplace: 2024 Report found that highly engaged teams experience a 23% increase in organizational profitability, showing how critical employee satisfaction is to a company’s success.

Traditional raises simply aren’t enough to keep employees satisfied, in fact 88% of employees say that they would give a lower paying job with better health, dental, and vision insurance “some consideration” or “heavy consideration” over a higher paying job with fewer benefits. This highlights that investing in employee benefits isn’t just a nice-to-have; it’s a non-negotiable when it comes to building employee loyalty and attracting top talent.

Morale, productivity, and your business

Employee morale refers to the general mood, outlook, and satisfaction that employees feel within their workplace. It reflects how connected they feel to their roles, coworkers, and the organization as a whole. It’s no secret that happier employees perform better at work— research shows that happy workers are 13% more productive.

Productivity measures how efficiently resources are used to produce results. It’s essentially the ratio of what you put in compared to what you get out, with higher productivity meaning more is achieved with fewer resources.

When employees feel valued and have a strong sense of well-being, their focus improves, and their output increases. Research shows that a meaningful increase in employee well-being boosts productivity by approximately 10%. Providing benefits, fostering a sense of belonging, and ensuring employees feel heard are not just acts of goodwill—they’re strategic investments. Employees who feel cared for bring more energy and engagement to their roles, driving measurable improvements in company performance.

On the other hand, disengaged employees are more likely to "quiet quit," or simply go through the motions without contributing fully.

In 2023, Gallup’s report found that workers simply going through the motions contributed to losses of $8.8 trillion in the global economy with 60% of employees fitting into this category.

Many businesses can’t afford these kinds of losses, while others simply don’t want to deal with the time and headaches they bring. Either way, morale is not something a company can dictate—it is shaped by the personal experiences of employees. That doesn’t mean there is nothing employers can do to impact morale; employers can provide support through thoughtful interactions and benefits, which can in turn improve morale and drive company performance.

How benefits influence morale and productivity

Employee benefits are more than perks, they're a cornerstone of job satisfaction. In fact, 60% of employees rate benefits as a very important contributor of job satisfaction. On the other hand, if employees are dissatisfied with their benefits, studies show that dissatisfaction with benefits can have serious consequences like turning over half of your staff within the next year.

Benefits play a critical role in improving morale and productivity by providing employees with a sense of security, motivation, and value.

Security

Health insurance, retirement plans, and similar benefits reduce stress by addressing basic needs, allowing employees to focus on their work.

Motivation

Incentives like professional development opportunities encourage employees to stay engaged and strive for excellence.

Value

Employees who believe their employer genuinely cares about their well-being are more committed and productive.

When employees’ basic needs are met, they can thrive—resulting in higher morale, increased productivity, and overall business success.

Key benefits that directly impact morale and productivity

Healthcare: Access to care, including preventive care, reduces stress and absenteeism.

Mental Health Support: Shows a commitment to overall well-being, creating a supportive environment and reducing burn-out.

Wellness Programs: Gym memberships, fitness classes, and nutrition counseling promote healthier lifestyles, resulting in higher morale and overall health.

Remote Work : Opens your talent pool, reduces commute time, and allows for better work-life balance, resulting in lower absenteeism and increased morale.

Flexible Schedules: Helps employees manage personal and family responsibilities while staying productive.

Paid Time Off: Encourages employees to take a break and recharge, resulting in improved focus when they return.

Retirement Plans: Provides employees with a sense of security in their financial future.

Financial Wellness Programs: Offer education and tools to decrease financial stress and increase an employee’s financial confidence.

Long-term benefits of investing in employee morale and productivity

While providing benefits to employees can be challenging for some businesses, investing in employee morale and productivity has long-term benefits for both employees and employers.

Retention and Reduced Turnover

Approximately one in six U.S. employees leave their company for better pay or benefits. Providing fair pay and comprehensive benefits can reduce turnover, leading to increased loyalty, reduced hiring and training costs, and less time with positions unfilled.

Improved Team Dynamics and Collaboration

The vast majority of executives link poor communication with business failure.

High morale encourages teamwork and strengthens relationships within the organization, therefore strengthening the company and increasing productivity.

Attracting Top Talent

Close to one-third of senior talent leaders cite finding talent as their most significant managerial challenge. Competitive benefits packages make the company more appealing to skilled professionals, thus allowing the company to hire high morale and productive people.

Enhanced Organizational Performance

Most employees say that the workplace culture impacts their productivity. Higher morale and productivity translates into increased profitability and long-term success.

Benefits Tip

Nontraditional, budget-friendly options for the win

For businesses seeking budget-friendly options, nontraditional benefits like HealthShares and direct primary care memberships can provide affordable alternatives, ensuring employees still have access to essential healthcare without straining company resources.

Supporting your team for long-term success

Investing in employee benefits is one of the most effective ways to boost morale and productivity within your team. Carefully designed benefits not only support your employees’ well-being but also create an environment where they feel valued, motivated, and engaged.

By focusing on offering benefits that align with your team’s needs—like healthcare, mental health support, or flexible schedules—you can build a workplace culture that promotes high morale, productivity, and loyalty.

As you evaluate your company’s performance, consider how your benefits package supports your team. A well-crafted benefits strategy is an investment in your employees—and in your company’s future success. By making meaningful adjustments, you can set the foundation for long-term success for both your employees and your business.

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How to Talk to Your Employees About Nontraditional Benefits

Wed, 27 Nov 2024 21:40:17 GMT

For many business owners, the rising costs of traditional health insurance have created a challenging dilemma: how to provide valuable benefits without straining company finances. However, the recent rise of nontraditional healthcare options has made it easier for employers to provide fair benefits to their employees, without breaking the bank. What might not be as easy is introducing them to your team.

Nontraditional healthcare solutions are gaining popularity because they offer a refreshing change: flexible, affordable options that benefit both employers and employees. If you are considering nontraditional benefits, it’s important to think about how these options will impact your team and to communicate those benefits effectively.

Educating employees on how these insurance alternatives work and what they offer can help them make the best decisions for their health and well-being.

What are health insurance alternatives?

Health insurance alternatives are options that offer medical care outside the traditional insurance model. While they may not cover every possible medical need, they can be a great fit for people who are looking for a cost-effective way to manage their healthcare.

There are several types of health insurance alternatives including direct primary care (DPC), health savings accounts (HSAs), short-term insurance, association health plans, health discount cards, medical cost sharing programs, and virtual care. In this guide, we’ll take a closer look at three increasingly popular options—direct primary care memberships, HealthShare programs, and virtual care—and explore how you can introduce and begin to explain these choices to your employees.

Direct primary care (DPC)

In a world where subscription services make everything from entertainment to meal planning easier, it's no surprise that DPCs are becoming a popular choice for healthcare. In fact, direct primary care clinics have seen a 241% increase in membership across the U.S from 2017 to 2021.

Direct primary care clinics operate on a straightforward subscription model: patients pay a monthly membership fee for direct access to their medical provider and the services included in their membership. Because DPCs don’t accept insurance, they’re often referred to as “cash-only” practices. By removing the insurance middleman, DPCs can keep costs low while focusing on quality and personalized care.

Each DPC clinic can vary in focus. Some specialize in areas like sports medicine or wellness, while others provide family medicine and general preventive care. A typical family medicine DPC covers services like annual exams, routine screenings, and lab work within the monthly membership. Additionally, DPC memberships generally provide unlimited access—and often times remote access—to their care provider. However, it’s important to communicate that specialist visits, urgent care, hospital stays, and prescriptions are typically not included in a DPC membership.

What it Does

Preventive and routine care: Convenient access to general healthcare needs and routine checkups.
Affordable pricing: Low monthly fees and no deductible makes virtual care accessible to more people.
Direct access to care: Connect with providers easily, without navigating insurance requirements.
Transparent costs: Clear pricing with no hidden fees or surprise out-of-pocket expenses.

What it Doesn’t Do

Emergency care: Not intended for urgent or emergency medical situations.
Specialty care: Limited in scope for specialized treatments or in-depth medical procedures.

Why Should Employers Consider Offering a DPC?

Employers are increasingly drawn to direct primary care for its potential to improve employee well-being and satisfaction. According to Hint Health’s 2022 DPC Consumer Insights Survey, 84% of employers who offer a DPC renew it within the first year. In fact, a 2019 study on large group cases found that employees’ opinions of their employers improved by 80% after experiencing the benefits of their DPC.

One of the greatest advantages of DPCs is their focus on building a personal connection between patients and their primary care provider. Having a doctor who is readily available and familiar with an individual’s health history can lead to better health outcomes and a stronger sense of care. For both employers and employees, DPC membership often means lower costs and more accessible, stress-free healthcare—a win-win that promotes satisfaction and health across the board.

3 Key Points to Communicate to Employees

When introducing DPCs to your team, avoid making recommendations for specific employees; rather, provide clear and concise general information. Here’s what to you may want to emphasize:

Subscription model: Explain that DPCs operate on a simple monthly subscription.
Focus on preventive care: DPCs generally cover routine and preventive care but do not handle emergencies or specialized care.
Complementary pairing: DPCs can be paired with other benefits, like a HealthShare.

HealthShare

HealthShares might be a new concept for you and your employees. However, they are quickly growing in popularity, as more than 1.7 million Americans rely on medical cost sharing plans .

Health sharing is a health insurance alternative that provides a safeguard against large medical bills through a community-driven approach. Rather than being insured through a company, members contribute to a community fund that is used to help share eligible medical bills. Here’s how it works: members pay a monthly membership fee, and when a medical need arises, they visit a provider as a self-pay patient, covering an initial portion of the costs themselves (similar to a deductible). After that, the HealthShare steps in to help share qualifying expenses from the community funds.

Monthly membership fees are flexible and can often be tailored to fit individual needs. Typically, a higher monthly fee means a lower initial amount toward medical expenses, while a lower monthly fee means a higher initial out-of-pocket amount. This flexibility can make HealthShares especially attractive for individuals or families seeking an affordable safeguard against costly emergencies.

HealthShares are designed to be a financial protection for unexpected events, like ER visits, and other big medical bills, such as those for surgery or maternity. Each HealthShare has specific guidelines for what is and isn’t shareable, with a primary focus on significant medical expenses rather than routine care.

What it Does

Affordability: HealthShares operate on a cost-sharing basis, often providing more budget-friendly options than traditional insurance.
Flexibility: Members aren’t tied to specific networks, allowing them to choose their providers freely.
Transparency: Membership fees are generally clear-cut and list the medical events that are and are not shareable in the member guidelines.

Anytime enrollment: Members are not under any kind of contract, meaning employees can sign up whenever it’s convenient for them.

What it Doesn't Do

Not insurance: HealthShares aren’t insurance and operate differently.
Not MEC: Since they don’t need to follow ACA regulations, they do not qualify as Minimum Essential Coverage (MEC), and members should not expect a HealthShare to “cover” everything a typical health plan might.
Selective sharing: HealthShares only share expenses for qualifying events that align with their guidelines, which means not all types of medical events are included. Additionally, certain needs may only be shareable after a waiting period.
Risk of out-of-pocket costs: Because sharing is limited to eligible events, members will pay for unshareable expenses.

Why Should Employers Consider Offering HealthShares?

Employers are exploring HealthShares as a cost-effective alternative to traditional health insurance. HealthShares give employees the peace of mind that they’re protected in case of emergencies. The option to choose different membership tiers allows employees to find a plan that fits their unique needs. HealthShares also lighten the administrative load with less paperwork and fewer complexities, making things easier for HR teams. And with year-round enrollment, new employees can be onboarded quickly—keeping healthcare accessible from day one. This flexibility empowers employees and employers to prioritize their financial and healthcare needs in a way that works best for them.

3 Key Points to Communicate to Employees

Since HealthShares might be unfamiliar to some employees, it’s essential to introduce the concept with patience and clarity. If you are working with a broker or benefits administrator, it may be best to have them educate your employees about the finer details. When introducing this as an option, you might highlight these points:

Not insurance: HealthShares are cost-sharing memberships rather than traditional insurance.
Coverage limits: While HealthShares can be affordable and supportive during emergencies, they don’t share in all medical expenses. Make sure your employees have access to the member guidelines.
Pairing with other options: HealthShares can be paired with alternatives like MEC plans or DPC memberships to fill gaps, especially for routine care needs.

Virtual care

According to Wheel's (who surveyed more than 2,000 consumers) 2023 Consumerization of Care Survey , the demand for virtual healthcare options is rising quickly. Their report showed that around “64% of consumers would prefer to see their primary care provider virtually” if given the choice.

Virtual care makes healthcare more accessible by using technology to provide a range of digital health services beyond traditional, in-person visits. It encompasses everything from telemedicine (remote clinical appointments) to wellness coaching, mental health support, general medicine, and even patient advocacy. Some virtual care clinics offer broad services, while others specialize in areas like primary care or mental health support. Many direct primary care (DPC) clinics also incorporate virtual care, allowing patients to connect with their doctor remotely as needed.

Payment models for virtual care vary based on the provider and your specific needs. Some services operate on a pay-per-visit basis, while others offer subscription plans. Whether through video chats, texts, or phone calls, virtual care uses flexible technology to work with you on your schedule. While some appointments may require scheduling, virtual care often provides 24/7 access, offering quick and convenient support when you need it most.

What it Does

Convenient access: Ideal for those in rural areas, busy professionals, or individuals who may have difficulty visiting a doctor in person, like elderly patients.
Time-saving: Patients can access care without taking time off work or traveling to a clinic, reducing the impact on their day.
Cost-effective: Virtual care often comes with a low monthly fee and no deductible, making it an affordable option.
24/7 support: Provides round-the-clock access to healthcare professionals, so help is always available, whether it’s a common illness or general health question.
Quick diagnoses for minor issues : Simple ailments, like a sore throat or cold, can be diagnosed remotely, helping prevent the spread of infectious diseases by avoiding waiting rooms.
Guidance for non-emergent concerns: Patients can receive advice for non-urgent issues before resorting to costly ER visits, ensuring they get the right care when needed.

What it Doesn’t Do

Emergency care: Virtual care is best suited for non-emergency issues and is not a substitute for urgent medical care.
Continuity of care: For patients seeing different providers virtually, it can be challenging to build a rapport with their provider.
Technology requirements: Patients need reliable internet access and a smartphone or computer to use virtual care services.
In-person care for certain appointments: Some healthcare needs, like specific exams or procedures, still require an in-person visit.

Why Should Employers Consider Offering Virtual Care?

Virtual care is a convenient, cost-effective healthcare option that meets the needs of today’s busy workforce. By offering virtual care, employers can help employees access healthcare easily, saving them time and reducing the need to take paid time off for appointments. Virtual care also removes the logistical challenges of visiting a doctor in person, which is especially valuable for employees in remote areas, those with mobility limitations, or anyone balancing a demanding schedule.

For employers, virtual care simplifies benefits management with fewer administrative tasks and often lower costs. Plus, with 24/7 access to healthcare professionals, employees are more likely to seek care when they need it, promoting overall well-being and helping prevent minor issues from becoming major ones. Offering virtual care supports a healthier, more engaged workforce and demonstrates a commitment to flexible, accessible healthcare that benefits everyone involved.

3 Key Points to Communicate to Employees

When explaining virtual care to employees, remember to cover these key points:

Explain access: Provide clear instructions on how to access virtual care services.
Outline what’s included: Share a summary of the specific services that your virtual care provider does and does not offer.
Pairing with other benefits: Help employees see how virtual care can work alongside other healthcare options, like DPCs, to offer a comprehensive care plan.

Best practices for communicating nontraditional healthcare options to employees

Nontraditional healthcare options may be new to many. So, clear, open communication is essential to help your employees make the best choice for their needs. Here are some ways to approach the conversation and create a positive experience for everyone involved:

Be Transparent

Each option has its own pros and cons that vary depending on individual needs. Simply present the facts and let employees decide what works best for them.

Clarify the Differences

Explain that healthcare alternatives aren’t insurance. Discuss what these options cover and what they don’t, referring back to the “what it does” and "what it doesn’t do” sections in this article as needed.

Be Prepared for Questions

Anticipate common questions and have straightforward answers ready to go. This builds trust and helps employees feel supported.

Use Simple Language

Avoid industry jargon or technical terms. Instead, opt for clear, everyday language that everyone can understand.

Provide Multiple Ways to Reach Out

Schedule an informational meeting, send follow-up emails, and make it easy for employees to get answers to their questions.

Lean on Your Administrator for Guidance

Your benefits administrator is a key resource in understanding your healthcare options. Reach out to them for support in making these options clear and accessible for your team.

Exploring nontraditional healthcare options

There are times when traditional insurance is the best choice, especially for employees with chronic medical needs. However, many covered services in traditional insurance plans go unused, leaving both employers and employees paying for benefits they may not use to the full extent. Nontraditional healthcare options offer a flexible, cost-effective way to support your employees' health, often at a fraction of the cost.

While nontraditional benefits might be a new concept for some, they don’t have to be intimidating.

Want to explore insurance alternatives for your business? Chat with one of our Benefit Guides about how insurance alternatives can add value to your benefits offering.

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Why Are Businesses Looking for Alternatives to Insurance?

Thu, 07 Nov 2024 18:53:23 GMT

Businesses are being let down by the insurance industry—and their employees are already paying the price. With healthcare premiums likely to increase by 9% in 2025, many employers are being backed into a corner. Forced to decide between their budget and their people, businesses are looking for a Hail Mary.

While employees are certainly not immune from healthcare’s economic pressure —family premiums have skyrocketed over the past five years, and annual pay increases can’t keep up—employers are feeling the financial squeeze exponentially more acutely.

Employers typically cover 81% of health plan costs. And when premiums increase, as they inevitably do, employers absorb the majority of the blow.

To highlight the impact of this on employers, in the past 5 years family premiums have risen by 24%, or just under $5,000; employees are paying less than $300 of that.

In fact, on average, employers are paying a whopping 94.38% of that family premium increase (employees paying for 5.62% of the overall increase).

Cost challenges for large employers

In particular, the costs are piling up for larger employers offering traditional coverage. The ACA employer mandate requires employers to keep healthcare costs within certain affordability parameters, which generally means keeping the employee’s portion to around 9% of their annual household income.*

Premium increases have averaged about 4.4% since 2019, and every year employers have to contend with higher and higher costs at renewal. Unfortunately, 2025, is looking to exceed this average with the highest annual increase in years. Depending on who you ask, forecasters are predicting increases between 6%, and 9% **, but some of our new clients who have found us while shopping for other options have cited numbers closer to 15%.

Why are costs rising so dramatically? Employers surveyed by the International Foundation on Employee Benefit Plans cite specialty drugs, catastrophic claims, and provider costs as the top three reasons. These responses demonstrate the unpredictable nature of medical claims and the difficulty that presents for employers looking to manage costs.

Administrative difficulties for small and mid-size businesses

For small and mid-size businesses, the situation is not much better. Although they are not held to the same federal standards as larger companies, small businesses have their own gauntlet to contend with. For starters, the administrative challenges of offering benefits—coordinating enrollments, dealing with claims, managing regulatory concerns—can overwhelm even dedicated HR teams, much less a one-person department or business owner trying to do it all.

On top of the administrative burden, competing for employees against larger, more competitive companies can be daunting. Looking at what large companies are able to offer can be discouraging for small and mid-size businesses who feel like they simply can’t compete. For these businesses, adding on the pressure of relentless high-ticket premium increases presents such a financial strain that they either are in desperate search for other options, or wonder “what’s the point?” and discontinue their benefits program altogether.

Limited opportunity for employees

The more perplexing the situation becomes for employers, the more employees feel the impact either in lower quality benefits, fewer options, more restrictions, or losing benefits altogether.

This is a critical situation since more than half of the US population gets their healthcare coverage from their employer (that’s about 153 million people).

Though this is the primary way that American’s access healthcare, only 53% of all companies in the US offer health benefits ; and just half of small businesses offer health benefits. What this means is that many workers who might want health benefits through their employer, do not have the opportunity to do so. Furthermore, the more difficult it gets for all businesses, especially small and mid-size businesses to offer benefits, the less likely American workers are to have the option of employer-sponsored coverage. Many of these individuals are already looking for alternative options, while some are simply uninsured.

The more difficult it gets for businesses to offer benefits, the less likely American workers are to have the option of employer-sponsored coverage.

What can businesses do to face healthcare cost challenges?

With looming premium price increases, 53% of companies are planning to make cost-cutting changes to their plans this coming year. What are your options if you are also trying to make sure your healthcare benefits are sustainable? Here’s what companies are trying, or are planning to try, in 2025.

Raise deductibles and adjusting cost sharing: This strategy keeps the healthcare coverage the same but reduces monthly premium expenses by having employees be responsible for more of their healthcare costs when they actually need to use it. By having employees share more of the cost when they have claims, you can reduce the overall plan costs.

Switch to cost-saving plan types like HMOs : With emphasis on care led by a primary care doctor, these plans save costs by having a medical professional guide care decisions, reducing specialist care, and working within a cost-saving network. Oftentimes, this helps you better predict and manage healthcare expenses for your team. On the other hand, the need for referrals on these plans can make them cumbersome for employees who have to use them.

Pick plans with very narrow networks: By partnering with very specific facilities or providers, plans may be able to negotiate even better prices while keeping their team with a familiar group of care providers. A plan like this will allow you to dramatically reduce the risk of overspending; however, employees may not care for the increased plan restrictions.

Find plans that use reference-based pricing: This strategy can really help manage healthcare costs because your plan will have fixed rates for paying claims. The plan will encourage employees to find providers who will work with plan rates to avoid paying the difference. While this type of approach can be effective, it may be too much of a burden on your team doing the homework to find appropriate providers.

Ditch the benefits program: As a last resort, you might consider dropping your benefits program—something companies have opted to do, allowing their employees to shop in the Marketplace for health coverage. Though this is a dramatic attempt at managing healthcare costs, your employees will see it as a pay cut, and you may need to compensate with some other health-oriented program, workplace perks, and higher wages (so they can afford those Marketplace plans).

Note: If you are a large employer and you are considering this route, you will want to carefully weigh the cost of the tax penalties you would be liable for. Some companies may find that paying the penalty, rather than “playing” by offering benefits may save them money, while others would end up paying more.

Shop for insurance alternatives: As a compromise, you might start thinking about offering insurance alternatives for your employee benefits package. These can replace your traditional benefits package, or they can be mixed in with traditional options as a way for you to provide more options for your employees and still save money on healthcare costs.

What are some insurance alternatives for businesses?

Insurance alternatives may be new to you, and many of them are newer approaches to healthcare, though some have been around for a while. Generally, an insurance alternative is a solution that aims to help employees access healthcare outside of the traditional insurance model. Insurance alternatives provide valuable benefits while helping both employers and employees better manage healthcare expenses.

HDHP with HSA

A classic alternative that is closest to a traditional option is a high deductible health plan (HDHP) paired with a health savings account HSA . In this scenario, an employee can make tax-free contributions to their HSA and use those funds to pay for the healthcare they need until they meet their deductible. Since the health plan has a higher deductible, the monthly costs are lower. As a bonus, any unused funds roll over each year and can continue to grow tax-free.

There are various options for what kind of HDHP employers can choose to sponsor. A comprehensive health plan will provide more traditional coverage, while a preventive MEC plan will provided more limited benefits at a lower cost, allowing employers to contribute more to an employee’s HSA and still save money overall. Additionally, employers can decide to match HSA contributions up to a certain amount, or simply contribute a flat amount when employees choose this option.

DPC Membership

A direct primary care (DPC) membership focuses on access to routine care with a primary care provider that employees can build a quality relationship with. This is subscription-based healthcare where patients get unlimited access to their doctor for a flat monthly fee. The DPC doesn’t ever deal with insurance, allowing the provider to set the tone for their clinic, spend more time with patients, and focus on improved health outcomes rather than navigating insurance paperwork.

Employers can easily sponsor DPC memberships for their employees for predictable monthly fees. This option focuses on employees’ overall wellness, ensuring they have access to a doctor without any additional hurdles.

Medical Cost Sharing

Medical cost sharing has been around since the 1980s but is only recently becoming a viable insurance alternative for workplaces. Companies like Sedera Health and Zion HealthShare are making it possible for employers to offer medical cost sharing memberships as a benefit option for their employees. This option focuses on catastrophic care, the big scary medical bills that no one wants to ever deal with.

If you go down this route, you’ll pay a set monthly fee to sponsor the membership, you can split the cost with employees, or have them pay for it entirely. This kind of option can be paired with another alternative that focuses on everyday care for a more well-rounded healthcare solution. For example, pairing a HealthShare membership with a DPC membership has the potential to meet the needs of many employees while saving on overall costs.

Virtual Care

Virtual care goes by many names, telemedicine, telehealth, concierge medicine, and more. There are programs that focus on general medicine and provide a way for employees to call, text, or video chat with healthcare providers. More Americans than ever are using some form of telemedicine due to its convenience and cost effectiveness.

Employers can easily sponsor DPC memberships for their employees for predictable monthly fees....

...pairing a HealthShare membership with a DPC membership has the potential to meet the needs of many employees while saving on overall costs.

You can provide a general telemedicine program, or a more robust program like virtual primary care that will encompass concerns like mental health, weight counselling, and general patient advocacy.

Not every insurance alternative will be the right fit for every business’ employee population, but some alternatives, or a combination of insurance alternatives may give employers and employees the financial breathing room they need and more flexibility to decide how they want to spend their healthcare dollars.

What's next?

For the time being, healthcare costs continue to be a huge thorn in the side of businesses of all sizes. To escape the crushing weight of inflated costs and administrative tasks, employers are looking for insurance alternatives that will allow them to provide their employees with access to healthcare while protecting their bottom line. This ongoing challenge is spurring innovative approaches to healthcare cost management and promising efforts in healthcare technology.

In an upcoming article we will discuss in detail some of the insurance alternatives that are becoming more popular with employers, and how to talk to your employees about them.

End Notes:

*This is one way for large employers to calculate affordability (the rate is 8.39% for 2024 and 9.02% for 2025). Other methods are available such as the federal poverty line safe harbor . However, while other methods may be more straightforward, they may end up putting more financial responsibility on the employers.

** The IFEBP is predicting an average 8% increase, while Mercer is predicting between 5.8% and 7%.

Want to explore insurance alternatives for your business? Chat with one of our Benefit Guides about how insurance alternatives can add value to your benefits offering.

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Open Enrollment: Your Roadmap for Success

Tue, 22 Oct 2024 20:13:50 GMT

The end of the year is commonly when businesses review and renew their benefits offering. Open enrollment season is the perfect time for employers to look at their current benefits package, assess employee needs, and explore new options.

As the year winds down, open enrollment season is just around the corner, and if you are a business owner you may be dreading it. This annual period is a little different for businesses than for individuals looking to purchase health coverage from the Marketplace between November 1 ^st and December 15 ^th (for coverage starting in January). While people across the country are making decisions about their health coverage for the upcoming year, many business owners are preparing for their own specific open enrollment window—evaluating their current benefits and trying to ensure their employees are ready to select or update their benefits for the new year.

In this guide, we’ll talk through the steps your business should take to prepare for open enrollment, from reviewing health plan options to engaging with employees, ensuring a smooth and successful process for everyone involved.

Open enrollment basics

Open enrollment is the annual window when employees can sign up for or make changes to their health benefits. This window usually lasts 2-3 weeks, depending on the policies of the employer sponsoring the benefits. Most companies schedule this toward the end of the calendar year, as many plan years begin on January 1 ^st . Because enrollment forms must be submitted and processed several weeks in advance, many companies choose to have open enrollment in November.

It’s an important time because, outside of a qualifying life event—such as, getting married, divorced, or having a baby—this is the only opportunity for employees to adjust their coverage for the upcoming year.

Open enrollment is not only about compliance and deadlines, but also an opportunity to ensure your benefits package is valuable and competitive. During this time employees can

enroll in a health plan,
add dependents,
make changes to an existing plan or switch plans, or
sign up for additional coverage (dental, vision, life, etc.).

Before open enrollment

Preparation is key for a successful, not stressful, open enrollment. Here’s the steps we recommend you take to get ahead of the game:

Review your current health plan offering
Consult with a broker or benefits administrator
Stay informed about regulatory requirements

Review Your Current Health Plan Offering

The first step toward a successful open enrollment is taking a good look at what you currently offer. When reviewing what you’ve had for the past year and deciding whether to make changes or stick with the same options you’ll need to do some homework.

Ask yourself some questions about employee satisfaction and plan costs

Are my employees satisfied? Did they enroll last year? Did they actually use their benefits? Were there any complaints about the options? Are the costs of my benefits offering manageable?

Unfortunately, health insurance costs tend to rise every year, so assess whether the current options fit your budget while still providing value to your team.

Explore your options

Consider offering multiple plan tiers to accommodate different employee needs. For example, adding a high-deductible health plan paired with a health savings account (HSA) could be a solution some employees are looking for.

You can also get creative by looking outside the box of conventional health insurance options and adding a health insurance alternative like a HealthShare membership. Benefits administrators like Planstin who specialize in insurance alternatives can easily help you with this. Adding unique solutions like HealthShare memberships can offer flexibility and affordability that traditional options just can’t.

Consult with a Broker or Benefits Administrator

You don’t have to navigate the maze of healthcare options alone. A broker or benefits administrator can help you assess your options and determine which plans are the best fit for your company and your employees. Brokers can help you compare rates and coverage from different providers, and a benefits administrator can provide solutions like self-funded plans that can help you save on premiums while giving you more control over your benefits offering.

Getting a professional on your side can help you stay on top of the paperwork, deadlines, and changing healthcare regulations. They will help you keep your business compliant with federal and state requirements, especially if your company is subject to the Affordable Care Act’s employer mandate. ( find out if you are here. )

Stay Informed About Regulatory Requirements

For businesses subject to the ACA, offering health coverage that meets minimum essential coverage standards is a legal requirement. Even if you have a small business that isn’t bound by these regulations, it’s important to keep up with any changes to ensure you’re offering competitive and compliant plans. Keeping up with these standards helps you avoid penalties and ensure your employees are receiving the coverage the need.

Communicate with employees

Once you’ve reviewed and selected the plans that you’ll offer, the next step is to communicate clearly and effectively with your employees. Open enrollment can be overwhelming, especially with so many details to consider. Here’s what you can do to help your employees through the process:

Start early
Simplify the information
Highlight key details

Start Early

Communication is key, and it’s best to start at least 30 days before the open enrollment period begins. Early notice gives employees time to think through their options and ask questions. Besides giving early notice, you will want to use multiple communication channels to make sure you get your team’s attention.

Email announcements: Send a straightforward email outlining the dates for open enrollment, any new plans or changes, and instructions on how to enroll.

One-on-one meetings: Offer the option to meet with employees individually to go over their specific needs and options to help them make informed decisions

Educational materials: Whether printed or digital, a simple benefits guide or summary sheet can be very helpful for employees. Keep it simple, jargon-free, and easy to understand.

If you plan a team meeting to review the options for the coming year, be sure to include the details of that event in your email announcement and your educational materials.

Open Enrollment Tip

Communication is a key part of a successful open enrollment.

Most employees only deal with their benefits once per year, so they may have questions or need guidance. Communicate early in the process, make sure to clearly communicate deadlines, and don’t shy away from frequent communications in more public forums like company-wide Teams or Slack channels.

Simplify the Information

Insurance is riddled with jargon, and many employees likely find the options at least somewhat confusing. So, make sure you explain key terms like deductibles and out-of-pocket maximums in clear language that helps your employees understand how the options impact their day-to-day lives.

Examples:

Deductible: what you pay before your plan starts covering costs

Premium: The amount you will pay monthly for your health plan

By breaking down the details, employees are more likely to engage with the process, ask questions, and make decisions that best align with their needs.

Highlight Key Details

If you have made any changes to your plans or if there are differences in cost, be sure to highlight them. Employees need to know if their premiums, deductibles, or networks are changing. Make sure to clearly communicate any deadlines for submitting their choices—including a warning that missing the deadline could leave them locked into their current plan, or a new plan that is the closest match (and that they are unfamiliar with) for a full year.

Encourage employee engagement

Employees may not always prioritize health insurance decisions, especially if they’ve been on the same plan for years. Encouraging engagement during open enrollment can help ensure they’re making the best choices for their situation. Here are some things you can do to get employees involved in the process:

Host an open enrollment meeting
Use technology to simplify enrollment
Follow up often

Host an Open Enrollment Meeting

An open enrollment meeting—whether in person or virtually—can help guide employees through the process. Invite a benefits expert or your broker if you can, so you can provide a thorough overview of the benefits options and directly address any questions or concerns your employees may have. The better your team understands their options the more likely they are to make a choice that works well for them—ultimately leading to higher employee satisfaction.

Open enrollment meetings offer a valuable opportunity for you to not only highlight the unique aspects of your benefits program, but also emphasize your commitment to your employees’ well-being. This open interaction with your team can build trust and boost morale.

Use Technology to Simplify Enrollment

If you work with the right broker or benefits administrator, they should have tools that help make your life easier. For example, some companies offer online portals that allow employees to compare plan options and enroll digitally. If possible, make this option available to your team. Doing so will allow employees to log in at their convenience, explore details, and make their selections without the pressure of filling out paperwork.

Open Enrollment Tip

Follow Up!

Most enrollment tools will provide some type of report that will help track which employees have not completed their benefits. It’s important to follow up with them and make sure they complete the process before the deadline.

Follow Up and Send Reminders Often

Open enrollment is a short window and it will slip through your employees’ fingers before they know it. As the enrollment deadline nears, send reminders. Communicate everywhere you can: emails, office posters, teams or slack messages, or even text messages. This seeming barrage of communication will help keep the enrollment deadline in mind for employees who might otherwise forget to submit their selections on time.

After open enrollment

After the open enrollment period closes, your work is not quite done. There are a few final steps to ensure everything is set for the upcoming year.

Verify employee selections
Coordinate with your benefits administrator
Distribute plan materials

Verify Employee Selections

Double-check that all employee enrollments have been submitted correctly and completely. Look for any errors or omissions that need to be addressed, such as employees accidentally choosing the wrong plan or missing dependent coverage.

Coordinate with Your Insurance Provider or Benefits Administrator

Work with your broker or administrator to make sure all necessary paperwork has been submitted. Your administrator should help you make sure everything is processed on time, so your employees are covered starting on the effective date of your new plan year.

Distribute Plan Materials

Once open enrollment is over and everything is finalized, you’ll need to distribute plan documents, ID cards, and welcome letters or packets to your employees. You may want to provide ongoing education so your employees feel confident with their benefits and know who to contact if they have any questions.

Stress-free open enrollment

Open enrollment is more than just a formality—or a headache. It’s an opportunity to ensure that your employees have the coverage they need while making sure your business is staying on top of costs and compliance. With careful planning, clear communication, and a little (or a lot of) help from a benefits professional, you can make the process smooth and stress-free for both you and your employees.

Need help getting started? Planstin can help you with everything on the open enrollment checklist: from prepping your options and educating your employees to managing costs and compliance concerns. Let us help you make this year your easiest open enrollment yet.

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I Am an ALE. What Does That Mean for My Business?

Wed, 02 Oct 2024 18:13:23 GMT

When your business meets the criteria for applicable large employers, you’ll find yourself in a whole new world of compliance considerations. From reporting requirements to potential tax penalties, ALE status can have a big impact on the day-to-day operations of your company.

Has your business recently crossed the ALE threshold? Have you just discovered that your business is considered an applicable large employer? If so, you are likely trying to figure out what the implications of being an ALE are. By now you likely understand that being an ALE comes with specific responsibilities and strict consequences for avoiding or neglecting those responsibilities. So, you’ll want to be sure you know what your primary ALE responsibilities are and how you can effectively manage them.

Article Summary

As an applicable large employer (ALE), you are obligated to offer affordable health coverage to your full-time employees. To ensure compliance, accurately count your full-time employees, provide suitable coverage, and file the necessary IRS forms. This proactive approach will help you avoid tax penalties, maintain a positive reputation, and attract top talent.

Jump to ALE Responsibilities Jump to Tax Penalty Info

What is an ALE?

To recap our previous blog on this topic in simple terms, your ALE status is based on your workforce size. If you employ 50 or more full-time employees and equivalents, your business is an ALE.

For some, workforce size is easy to determine, but for many, finding out what their workforce size is in the eyes of the Affordable Care Act (ACA) is a bit more complex.

Fortunately, if you are unsure, help is available. Follow this link to find a simple ALE status calculator that can help you determine your workforce size. Additionally, if your situation is more complex, you can refer to our previous blog on this topic that includes helpful worksheets and more information about special employee types.

For now, let’s focus on what it means if you are an ALE.

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Why does ALE status matter?

Being an ALE has significant implications for your business. For example, ALEs are subject to the ACA’s employer mandate which requires large employers to offer affordable healthcare coverage to their full-time employees or face a penalty. This penalty is referred to as the Employer Shared Responsibility Payment, and it is enforced by the IRS (IRC 4980H).

In short, if you are an ALE and you do nothing, you are putting your business at risk financially—not to mention risking your company’s reputation. Following through on your responsibilities as an ALE can save you money, keep you on the IRS’ good side, and even give you a competitive hiring edge. Not only do most employees prefer to get benefits through their employer, but also, most candidates won’t take a job with a company that doesn’t offer them.

Your responsibilities as an ALE

So, what do you need to do? First, if you are unsure of your ALE status, take a moment to verify that before you move forward. If you are sure, then prepare to give careful consideration to these three primary ALE obligations:

Accurately count your full-time employee population.
Offer healthcare coverage to your full-time employees.
Report to the IRS.

Accurately count your full-time employee population

When you determined your ALE status, you calculated your workforce size using a combination of your full-time employees and the collective hours of your part-time workers. If you estimated, or for any other reason have any doubts about who your full-time employees are in the eyes of the ACA, you’ll want to spend some time ensuring you have accurate information.

Miscounting full-time employees or failing to identify employees who qualify as full-time could result in unintentional non-compliance. And whether non-compliance is intentional or not, you will still be liable for those hefty penalties. So, let’s look at some key information to keep in mind when assessing your full-time employee population.

Key points

Full-time employees average 130 hours per month (ACA standards may differ from your company’s definition of “full time.”
Count both hourly and salaried employees who work full-time hours
Your full-time employee count matters for determining who you must make offers of coverage to and what your potential ESRP liability is.
Part-time employee hours only matter when calculating full-time equivalents for determining your ALE status (they play no role in calculating your penalty liability)

How to Count Your Full-Time Employees

There are two primary ways to go about counting your full-time employees: the monthly measurement method and the lookback measurement method.

Monthly measurement method

The most straightforward method has you count employee hours each calendar month to determine who qualifies as full-time. Those working 130 hours or more per month on average (or 30+ hours per week on average) are your full-time employees.

Lookback measurement method

The lookback method is useful when you have variable-hour employees or seasonal employees who don’t follow a standard schedule. With this method you’ll average an employee’s hours over a set time period to determine their full-time status. Hint: seasonal workers relate to calculating workforce size while seasonal employees relate to counting full-time employees.

How To:

Average an employee’s hours over the measurement period (3-12 months)
Use a short administrative period (30-90 days) to finalize the employee’s full-time status and complete any work needed to make an offer of coverage.
Consider the employee full-time for a stability period (3 months) after you make the coverage offer.

Getting an accurate full-time employee count is not only important to determine your ALE status, but also it’s key for fulfilling your next ALE responsibility, offering healthcare coverage to your full-time employees.

Offer healthcare coverage to full-time employees

Your core ALE responsibility is to offer health coverage to 95% of your full-time employees and their dependents.

The ACA’s employer mandate requires that large employers must “offer minimum essential coverage that is affordable and that provides minimum value to their full-time employees (and their dependents).” The first part of this requirement focuses on simply offering something. You must offer what the ACA considers minimum essential coverage (MEC). The second part of the mandate focuses on the quality of that coverage when it is both “affordable” and meets “minimum value” standards.

Enforcement of the employer mandate is similarly broken down into two parts. The ESRP is enforced by internal revenue code (IRC) section 4980H , which has an A and a B part. If you offer minimum essential coverage to your employees, you can avoid the first and weightier part of the penalty. By offering coverage that also meets value and affordability standards, you can avoid both parts of the penalty.

Key points

The ACA requires large employers to offer healthcare coverage
The IRS enforces this requirement with the 4980H Part A & B penalties
Offering minimum essential coverage avoids Part A
Offering a minimum value plan avoids Part A & B
Minimum value means the health plan covers at least 60% of the total allowed medical expenses
Affordable means the covered employee’s cost doesn’t exceed 9.96% of their income (2026)

Play or Pay

Obviously, many companies will want to avoid the risk of being penalized, but all employers must decide if offering ACA-compliant coverage is right for their situation. The idea behind employer shared responsibility is that employers contribute in some way to employee healthcare costs. So, whether employers chose to “play” by offering healthcare benefits, or just “pay” the tax penalty, they are sharing responsibility for employee healthcare.

However, your decision to play or pay should also consider factors like employee loyalty and the impact of employee turnover. Oftentimes offering benefits is the more affordable option between paying for healthcare benefits and paying to constantly recruit and hire new people.

Bottom line: as an ALE you can avoid being penalized by the IRS by offering your employees healthcare coverage. The better the coverage you offer, the lower your penalty liability will be and the higher your team’s morale will be. Whether or not you make offers of coverage, you have one more crucial ALE responsibility: telling the IRS if you offered coverage, and who you offered it to.

MEC vs. MVP: What's the Difference?

The primary differences between a minimum essential coverage (MEC) plan and a minimum value plan (MVP) are the extent of the coverage and the penalty for not offering one or the other.

Report to the IRS

Since ALE status and regulations are enforced by the IRS, you’ll need to report information to the IRS about how your business has or hasn’t complied with ACA guidelines. Like other things on this list of responsibilities, not doing it, or doing it wrong can result in penalties. For 2024, the penalties can range from $60 to $310 per return ( IRC Sections 6721 and 6722 ).

So, what do you need to do? There are two main forms related to your ALE obligations that you’ll file together: Forms 1094-C and 1095-C.

File Forms 1095-C by March 31

You’ll file a 1095-C form for each full-time employee. This form details what health coverage, if any, you offered to the employee and if it met ACA standards. Basically, this form allows the IRS to verify that you have complied with the ACA’s employer shared responsibility provision—or if you owe a penalty.

You’ll also provide a copy of this form to each employee by January 31 ^st . Your employees use it to verify coverage, complete their tax returns, or possibly see if they qualify for a premium tax credit.

File Form 1094-C by March 31

You’ll file one 1094-C form as a cover sheet summarizing the 1095-C forms. This form provides an overview of your full-time employees and how many of them received offers of coverage. This form is meant to give the IRS a clear picture of whether or not you’ve complied with ACA requirements.

Reporting Tips

You can make the time-consuming process of reporting to the IRS much easier on yourself with a couple strategies. For example, you can integrate your reporting obligations with your payroll system. This way, you will get the most accurate data possible to inform your offers of coverage as well as reporting duties. Not only that, you’ll reduce the likelihood of errors in tracking hours worked and employee status—thus reducing your potential penalty risk.

Additionally, you can work with a benefits administrator who offers compliance support and will almost totally shoulder the burden of managing your reporting obligations. With an expert by your side, preparing and submitting your 1094-C and 1095-C forms will be nearly effortless.

Key points

Form 1095-C is filed for each full-time employee

Form 1094-C is an overview form filed with all the 1095-C forms

Provide employees with 1095-C forms by January 31

File 1095-C forms and 1094-C form by March 31 (electronic; February 28 paper).

Integrate reporting with your payroll system

Get expert compliance assistance from a benefits administrator

Adapting to your ALE status

Being an ALE might seem like a lot to handle, especially if this status is new to you. But with the right resources and a little professional help you can successfully navigate your ALE responsibilities with ease.

Remember, staying ACA-compliant isn’t just about meeting legal obligations and avoiding penalties; it’s also about demonstrating your commitment to your employees' well-being and creating a healthier workplace. So, take a proactive approach, seek expert advice if you need to, and enjoy the benefits of being a responsible ALE.

ALE Resources

Tools

Determine your ALE status with Planstin’s simplified ALE calculator .

Determine your ALE status and penalty liability with the robust IRS ESRP estimator .

Schedule a free meeting with a Benefit Guide.

How to know if you are an ALE

What is MEC?

What is Minimum Value?

Need help? Our Benefit Guides are standing by.

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The Future of Telehealth and the Impact on Healthcare

Thu, 12 Sep 2024 22:35:56 GMT

Telehealth is changing healthcare. What was once more of a niche service is now becoming a normal part of healthcare—and, for many, the preferred channel for personalized care.

Also called telemedicine or virtual care, this type of service really boomed during the COVID-19 pandemic, when more people had exposure to it and discovered how convenient and cost effective this growing form of healthcare can be. To understand how the future of virtual healthcare might shape up, it’s important to understand its appeal, its challenges, and the potential it holds to really change the way we receive care.

The current state of telehealth

The last several years have seen healthcare finding new forms in the development and adoption of telehealth services, certainly accelerated by the COVID-19 pandemic. Telehealth has shifted from being a new and niche service to what now looks to be a core component of healthcare in the United States. Prior to the pandemic, only 11% of US consumers had used telehealth services, but by mid-2020, this number had jumped to 46%. The constraints of in-person visits at the time introduced many people to this emerging form of healthcare.

During the peak of the pandemic, more than 97% of healthcare professionals were performing telehealth services, with 43% conducting at least half of their appointments virtually. This has continued, with 44% of US physicians performing telehealth services at least weekly, and 40% of them daily as of 2023, according to a survey by Statista .

Patient adoption has also been considerable, with approximately 74% of the US population having used telehealth services. This form of healthcare hasn’t just been gaining traction—it’s gained a foothold and become an essential part of healthcare.

The secret of telehealth’s success

While pandemic-era restrictions may have been the primary driver for the growth of telehealth, there are other explanations for its continued success. One major factor is affordability. On average, a virtual telehealth appointment costs about $79 , compared to $146 for an in-person office visit. This cost reduction is even larger when you consider more recent virtual care subscriptions that allow for unlimited visits for a low flat monthly fee. This cost difference makes telehealth an attractive healthcare option for patients and healthcare providers, reducing overall expenses by minimizing the need for physical facilities and allowing for more appointments with more patients.

Another important factor is convenience, largely facilitated by more recent developments in technology. With the widespread presence of smartphones, tablets, and reliable internet connections, patients can now consult with healthcare professionals from their homes, eliminating the need for travel and reducing wait times.

Apps are now available specifically to accommodate telehealth services, allowing it to be more directly integrated into regular healthcare practices.

Impact on patients

Telehealth has positive effects on patients, particularly in rural areas, by bridging a gap in practical healthcare access. In regions where healthcare providers are few and far between, telehealth services allow patients to consult with specialists and receive timely care without the need for extensive travel.

A 2022 study found that while 20% of the population lives in rural areas, only 9% of physicians serve these same areas. This means that many rural patients simply do not have access to a healthcare provider in their area, or they must be burdened by substantial travel costs in order to see one. This is a where telehealth services are starting to stand out, eliminating the need for travel, while still allowing patients to receive care.

Barriers and drawbacks of telehealth

While telehealth evidently offers numerous benefits, it is not without its challenges, many of which can impact both patients and providers. For virtual care services to be integrated and become a core component of standard healthcare, the issues below will need to be addressed.

Technology and Accessibility

Approximately 21 million Americans lack high-speed internet access, particularly in rural areas. While audio-only consultations are a workaround, they are often insufficient for proper medical attention. Additionally, around 20% of older adults struggle with digital tools, making it difficult for them to use virtual care platforms effectively.

Security and Privacy

Because these services are built on digital systems, security remains a considerable issue, with the healthcare industry seeing a 25% increase in successful cybersecurity attacks during the pandemic. The frequency of these attacks is sure to increase as additional smaller services launch their own platforms, leaving patient information potentially exposed.

Reimbursement Issues

How insurance treats telehealth services is inconsistent, and reimbursement rates often lag behind those for in-person services. This could create financial challenges for providers fully embracing telehealth.

Quality of Care

Some healthcare professionals worry that virtual care may not allow for thorough examinations, potentially leading to more frequent misdiagnoses. Much of the time, attempting to treat illnesses or conditions of a certain nature are harder to address virtually and can, according to Health Affairs, lead to increased spending (though it should be noted that this is telehealth data collected pre-pandemic).

What comes next for telehealth?

Despite the challenges, telemedicine and virtual care are showing no signs of slowing. We should expect this form of healthcare to continue to grow and develop as new technologies emerge and policies enacted.

Healthcare-Centered Software & Business

The development of new software and virtual care platforms is streamlining patient-to-provider communication, improving scheduling, reminders, and overall management of personal healthcare. Practitioners are launching their own independent programs and channels to act as virtual direct primary care providers, building up more close relationships with their patients and fulfilling the needs they perceive in their markets—and typically at a cost savings for the patient.

Integration with Traditional Care

Providers understand that virtual care can serve to complement their in-person visits, creating a flexible model that combines remote and face-to-face interactions. This allows initial consultations and follow-ups to be conducted online, while reserving in-person visit times for more complex cases. For example, patients can manage chronic conditions through regular virtual check-ins and only visit their provider in person for necessary tests or physical examinations.

Policy and Regulation

The rise of telemedicine and virtual care has happened fast, and policymakers are still trying to catch up. Efforts are underway, led by the American Medical Association , to reach price parity so that insurance companies will cover telehealth services as they would traditional in-person visits. During the COVID-19 pandemic, temporary regulatory changes expanded telehealth coverage and access. Now that the benefits of telehealth are more widely understood, policymakers areconsidering making some of these changes permanent. Policy support like this will only help the continued growth of telemedicine and its integration into the wider healthcare system. Expanded coverage and increased reimbursement rates for telehealth services will be important for sustaining its growth.

Telehealth is modern healthcare

Healthcare has changed substantially from what it looked like just a few years ago, and telehealth and virtual care are a large part of that change. While there are certainly challenges to overcome, its affordability, convenience, and its ability to broaden healthcare access are hard to overlook.

With ongoing technological improvements and supportive policy changes, telehealth is positioned to become a core part of our healthcare system.

Offering telehealth benefits is within reach. Book a free meeting with one of our Benefit Guides to learn how you can make virtual care available to your team.

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Open Enrollment 2025

Tue, 10 Sep 2024 18:48:16 GMT

What is Open Enrollment? When does it take place? Most importantly, how does it apply to you and your business?

Open Enrollment is the time period each year when individuals and families can enroll in health coverage or make changes to their existing coverage. If an individual is enrolling in an ACA-compliant Marketplace plan, this period is from November 1 through January 31 ( with some exceptions ). If an individual is enrolling in employer-sponsored benefits, the timeline may vary, but the period typically occurs in the fall for coverage the following year.

If you want coverage by January 1, 2025, you’ll want to enroll by December 15, 2024. There may be some wiggle room on this depending on the state you live in, but not if you can enroll through Healthcare.gov .

What if I miss open enrollment?

If you miss open enrollment, there are limited options for when you can enroll in a marketplace plan. You may be eligible for a Special Enrollment Period (SEP) if you have experienced one of these qualifying events

· Marriage

· Divorce

· Citizenship status

· Adoption

· Loss of coverage

In order to qualify for a SEP, you must have had MEC coverage before the qualifying life event.

Can I just get health coverage now?

If want to find healthcare coverage right now, or sign up on your own schedule, you can shop directly for an individual plan—by contacting the company yourself. If you run your own business or are self-employed, a third-party administrator may be able to help you find or build a plan that meets your specific needs. Third-party administrators have a lot of flexibility and can help you sign up anytime.

Penalties

There is no longer a federally imposed individual penalty for not enrolling in a health plan . However, there are some states that will still penalize residents without minimum essential healthcare coverage. These states include California, Massachusetts, New Jersey, Rhode Island, Vermont, and District of Columbia. Each state has its own criteria, so if you live in one of these states, make sure you research how penalties are assessed.

There is a federally imposed penalty for businesses that fail to offer minimum essential coverage to their employees. For businesses that offer nothing, the annual penalty will be $2,900 (2025) per employee (minus the first 30). This penalty can really add up for small to mid-size businesses (those with 50 or more employees). And it can be avoided by offering a benefits package that includes an MEC plan .

Enrolling in group benefits

Though the open enrollment period for individuals is in the fall, a business may enroll in group benefits at any time. If your business does not currently offer health benefits to your employees, now is an excellent time to consider enrolling your business so you can offer a health plan in time for Open Enrollment.

Why enroll in group benefits

There are many reasons to consider enrolling in group benefits. Besides saving money by avoiding penalties, offering a benefits package can help you keep your employees happy and even attract top talent. This is why Planstin has focused on solutions for businesses of all sizes.

Qualifying for a group health plan

If you are looking for affordable employee benefits to meet the federal requirements and avoid penalties, your best bet is to find a qualifying minimum essential coverage plan , or MEC plan. This kind of health plan will allow you to offer health coverage to your employees for things like preventive care and pre-existing conditions.

Qualifying for a group health plan should be relatively easy. Planstin Benefit Guides are happy to help you discuss your options and find a plan that will fit your budget. Let us help you pick a plan, avoid penalties, and keep your employees happy.

This is not legal advice. For questions regarding your specific situation, please consult an attorney.

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Are You an Applicable Large Employer (ALE)?

Tue, 03 Sep 2024 23:03:51 GMT

A critical factor that determines your obligations under the ACA is your status as an Applicable Large Employer (ALE). If you are unsure if your business qualifies as an ALE, you’re not alone.

The line between a small business and a large one can be blurry since business sizes are often loosely defined. What one source might classify as small business another might label mid-sized. However, as far as the IRS is concerned, as you get closer to having 50 full-time employees on staff, you get closer to—and may already have reached —an important employee population threshold.

If you have anywhere from 25-45 full-time employees, you’re likely in a growth phase where understanding your ALE status is critical. Not sure where your company stands? You’re in the right place. This article will break down the ALE criteria, guide you through calculating your workforce size, and provide insight on your role as an ALE.

Key Takeaways

You are an ALE if you had 50 or more full-time employees, including full-time equivalents, in the previous year.

The ACA defines full-time as 30+ hours per week.

Full-time equivalents (or FTEs) are determined by totaling part time hours and dividing by 120.

To determine ALE status, combine your full-time employees and full-time equivalents.

Certain employees may not count toward your workforce size, such as seasonal employees working less than 120 days a year.

Businesses in controlled employer groups (parent-subsidiary, brother-sister) must combine workforces to determine ALE status.

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What is an ALE?

The term ALE is a designation defined by the Affordable Care Act (ACA) and regulated by the IRS. The ACA defines an ALE as an employer that had 50 or more full-time employees, including full-time equivalents, during the preceding calendar year . Businesses who qualify as ALEs are subject to specific provisions of the ACA including the employer mandate, which requires large employers to provide healthcare coverage to full-time employees and their dependents.

What is an aggregate ALE?

Determining your ALE status can be complex if your business is connected to other businesses. If your company is part of an Aggregate ALE, your workforce is combined with those of related businesses to determine if the group meets the ALE threshold. If the total workforce across the group exceeds 50 full-time employees, your business must comply with ACA guidelines, even if you individually employ fewer than 50.

In some cases, not all businesses in a group may be part of the Aggregate ALE. For example, if one entity in a group of five businesses is owned more than 20% by a different entity, it might not be included under the Aggregate ALE rules. However, this does not exempt the entire group from ALE status.

Examples of Aggregate ALEs

The ACA includes safeguards like the Common Control Rule to prevent businesses from splitting into smaller entities to avoid ALE status. The Common Control Rule governs when businesses are treated as a single employer under three main types of groups:

Parent-Subsidiary Group – A parent company directly or indirectly owns 80% or more of the related subsidiaries.

Brother-Sister Group – Five or fewer individuals, estates, or trusts collectively own at least 80% of the related companies, and have more than 50% control over them.

Combined Group – Related businesses are connected through both parent-subsidiary and brother-sister relationships.

If you think you might be part of an employer group, click here to learn more about Aggregate ALEs .

Am I an ALE?

So, are you an ALE? There is really only one way to be sure: doing the math. To arrive at the correct answer, you’ll need to follow these 4 steps.

1. Count Full-Time Employees

First you will count up your employees who work an average of at least 30 hours per week or 130 hours per month. Count them for each month of last year.

2. Calculate Full-Time Equivalents

Next, you will combine all hours worked by part-time employees for each month (basically anyone not counted in the first step—with some exceptions considered later). Divide that total by 120. Repeat that for every month of last year. This will determine the number of full-time equivalents you have for each month.

3. Total Monthly Workforce Size

Now, you’ll use the totals from step one and two to find your total workforce for each month. Add the number of full-time employees and equivalents for each month to arrive at your monthly totals.

4. Average Annual Workforce Size

Finally, add up the monthly workforce totals for the year, and divide by 12 to find your annual average workforce size.

Though some exceptions or special cases may apply for your business, this is the basic equation to determine your ALE status.

If you are having difficulty with step one, counting your full-time employees, there are two methods to determine how many full-time employees you have: the monthly measurement method and the lookback method. For more information about these methods and how to properly calculate hours of service visit irs.gov .

Employee types and the role they play in your ALE status

As you can see, your different types of employees will play different roles in calculating your workforce size. The ACA may define these types of employees differently than you’d expect, so understanding the distinctions between them can help you make sure you get an accurate workforce count.

Full-Time Employees

The ACA’s definition of a full-time employee may be quite different from what you are used to, or what your business considers to be a full-time employee. It is common for businesses to consider full-time a 40-hour work week, but the ACA dictates that a full-time employee averages 30 hours or more per week, or 130 hours per month . By that definition you may have more “full-time” employees than you assumed.

Part-Time Employes

Once you understand how the ACA defines full-time employees, it’s easier to understand who your part-time employees are. The ACA considers anyone who averages fewer than 30 hours per week a part-time employee. Though you won’t count this group in your full-time workforce, they play a crucial role in calculating your full-time equivalents.

Full-Time Equivalents

Understanding what full-time equivalents are is one of the trickier parts of determining your ALE status. Though we’ve listed equivalents under employee types, a full-time equivalent is not really an employee, it is a unit of measurement used to quantify the workload of your employee population. The basic FTE calculation is total monthly part time hours worked / 120hours = FTE total .

It is unlikely that the number of part-time employees you have will divide evenly into FTEs. For example, if you have nine employees who work a collective 520 hours per month, that breaks down to 4.33 FTEs (520hours /120hours). As long as your annual average workforce total is under 50, you are not an ALE. That means, even if your total comes out to 49.95, you are still not considered an ALE.

Seasonal Workers

There is an exception for seasonal workers that is crucial for businesses with fluctuating employee numbers due to seasonal demands, such as those in the retail, agriculture, and tourism industries.

If you have more than 50 full-time employees for only a short period of time in any given year (120 days or less) because of seasonal hiring , you will not be considered an ALE.

Leased Employees (Staffing Agencies)

Another possible exception to your workforce count could be any employees you’ve hired through staffing agencies. If your business uses a staffing agency, those workers are likely considered employees of that agency rather than your business. If that’s the case, you would not count them when calculating your workforce size. Of course, this depends on the contractual arrangement between your business and the agency, so if you are unsure, check your contract or contact the agency directly.

Variable-Hour Employees

Any employees whose hours vary or who do not have a predictable schedule may require the most careful tracking. To determine whether or not your variable-hour employees should be counted among your full-time employees, you may need to use the lookback measurement method. When you use this method, you will be tracking the hours worked during a specific period that can be anywhere from 3-12 months.

To learn more about the look-back measurement method, click here .

Employees With Military-Sponsored Healthcare

Lastly, if you have any employees who receive medical care or healthcare coverage through the military, they do not count toward your employee population for the purposes of determining your ALE status.

For more details see this page .

Additional Exceptions

Your situation may have layers of complexity beyond “full-time” and “part-time.” You may have a number of special employee types on your payroll, for example if you run a winter resort, you may have mostly seasonal employees.

Other employees that are excepted or given special consideration by ACA and IRS guidelines are:

Volunteers
Interns
Student employees participating in a work study
Independent contractors
Sole proprietors
Partners
2% shareholders in an S corp
Employees of a religious order
Hours for work not taxed as US income

If you have a number of different types of employees, you may want to consult with a professional for assistance properly calculating your workforce size.

*Note: More exceptions or special cases may apply. For assistance with your particular situation, reach out to a Benefit Guide at 888-920-7526 or schedule a meeting .

Example workforce calculation s

Free Workforce Calculation Worksheets

Are you ready to find out your ALE status? Use one of our free ALE worksheets to get started. If you feel like you have a good handle on your employee types and how many full-time employees you have, we recommend starting with the simplified worksheet. If you want to have a list of excepted types handy, we recommend starting with the detailed worksheet.

Understanding your ALE status

By accurately calculating your full-time employees and full-time equivalents, you can determine your ALE status and prepare for the responsibilities that come with it. Knowing your status can help you plan strategically for your company’s future. It puts you in a better position to comply with ACA requirements—and avoid hefty tax penalties.

In a later article we will explore what those ACA requirements are, how being an ALE will impact your business operations, and the steps you need to take to remain ACA compliant.

Need help? Our Benefit Guides are standing by.

Glossary

ACA: The Patient Protection and Affordable Care Act, commonly known as the ACA, is a healthcare reform law enacted in 2010 designed to expand health insurance coverage and reduce healthcare costs in the US.

Aggregate ALE: A group of related employers that are considered a single entity for the purpose of determining Affordable Care Act (ACA) compliance.

ALE: A business that employs 50 or more full-time employees, including full-time equivalents (FTEs), on average per month during the previous calendar year.

Employer Mandate: An ACA requirement that applicable large employers (ALEs) offer 95% of their full-time workforce affordable MEC health plans that meet ACA minimum value standards.

FT Employee: An individual who averages 130 work hours, or more, per month (or 30+ hours per week)

FT Equivalent: A unit resulting from combining all part-time employee work hours for a month and dividing by 120.

PT Employee: An individual who averages fewer than 30 work hours per week.

Seasonal Worker: An employee hired into a position for which the customary annual employment is six months or less. These positions typically occur at the same time each year, such as agricultural and or holiday jobs.

Variable-Hour Employee : those whose weekly work hours are not predictable at the start of employment. Do not consistently meet the full-time threshold of 30 hours per week or 130 hours per month.

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The Essential Role of Virtual Care in Your Benefits Offering

Mon, 26 Aug 2024 19:47:58 GMT

Employees in the US are using telehealth more than ever—mostly because people need flexible healthcare options that fit into their lives. Even doctors see the benefits of virtual healthcare, with more than 70% of physicians reporting using telehealth in 2023—nearly 3 times higher than 2018.

The rise of digital health solutions is transforming the way employees access medical care, offering convenience, efficiency, and improved health outcomes. This blog will explore the importance of incorporating virtual care into your employee benefits offering and how it can enhance the overall well-being of your workforce.

What is virtual care?

Virtual care, also known as telehealth or telemedicine, enables employees to consult with healthcare providers remotely via phone, video calls, or online messaging. This mode of healthcare delivery offers a range of services, including routine check-ups, mental health support, specialist consultations, and chronic disease management, all from the comfort of an employee's home or office. Virtual care has fundamentally transformed how Americans access medical services.

According to a survey , 76% of patients report satisfaction with telehealth services, citing convenience and accessibility as major benefits. In fact, 61% of Americans have used telehealth services in 2023, up from just 9% in 2019.

This rapid adoption highlights a significant shift towards more flexible and responsive healthcare options, allowing employees to receive timely care without the need for time-consuming office visits.

Benefits of virtual care for employers and employees

By integrating virtual care into your benefits packages, you offer a modern and efficient healthcare option that brings numerous advantages to both your business and your employees. Here’s a closer look at the benefits of virtual care for both employers and employees.

For Employers

Cost Savings: Implementing virtual care can significantly reduce healthcare costs for employers. Telehealth visits are generally less expensive than in-person visits, which can lead to lower overall healthcare expenses.

Increased Productivity: Virtual care allows employees to access medical consultations without needing to take extended time off work. This convenience helps maintain productivity levels and reduces absenteeism.

Enhanced Employee Retention: Offering virtual care as part of a comprehensive benefits package can boost employee satisfaction and retention. Employees value the flexibility and accessibility of telehealth services, which can make them more likely to stay with their current employer.

Attractive Benefit for Recruitment : In a competitive job market, offering virtual care can be a differentiator in someone wanting to work for you. It can attract top talent by providing a modern, flexible healthcare solution that aligns with the needs of today’s workforce.

For Employees

Convenience and Accessibility: Virtual care enables employees to consult with healthcare providers from the comfort of their home or office, reducing the need for travel and wait times. This convenience is particularly beneficial for those with busy schedules or limited access to healthcare facilities.

Improved Health Outcomes: Employees have quicker and more frequent access to healthcare providers, which can lead to early detection and management of health issues. This proactive approach can improve overall health outcomes and reduce the severity of illnesses.

Mental Health Support: Virtual care often includes mental health services, providing employees with easy access to counseling and support. This is crucial as mental health awareness grows and employees seek more comprehensive support for their well-being.

Cost Efficiency: For employees, virtual care can lower out-of-pocket costs by reducing the need for expensive emergency room visits and enabling cost-effective management of chronic conditions.

Introducing Primestin Care: A new virtual care solution

As the demand for flexible and accessible healthcare continues to rise, Primestin Care was recently created to meet these needs. With a Primestin Care membership, individuals would have access to quality virtual primary care services.

Primestin Care’s Virtual Care membership* includes a variety of benefits that make healthcare more accessible and efficient for employees. Members can easily connect with healthcare providers through video calls, phone consultations, or online messaging. This allows for routine check-ups, mental health support, specialist consultations, and chronic disease management without the need for in-person visits.

*Primestin Care has additional membership options for in-person care.

Virtual care shouldn’t be a luxury

Incorporating virtual healthcare into your employee benefits package is no longer a luxury but a necessity in today’s dynamic work environment.

By offering virtual care, employers can achieve significant cost savings, increase productivity, and enhance employee satisfaction and retention. Employees, in turn, gain convenient access to essential healthcare services, improving their overall health and well-being.

Virtual care shouldn’t be a luxury

Incorporating virtual healthcare into your employee benefits package is no longer a luxury but a necessity in today’s dynamic work environment.

To learn how Planstin Administration can assist you in incorporating virtual care into your benefits offering, you can book a free meeting with one of our Benefit Guides below.

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Planstin Recognized at the Utah Business Innovation Awards

Thu, 08 Aug 2024 21:44:07 GMT

Planstin Administration was a finalist at the 2024 Innovation Awards for their efforts in making healthcare benefits accessible and more affordable to more businesses.

ST. GEORGE — Local company Planstin Administration was recognized as a finalist at the 2024 Innovation Awards for their efforts in making healthcare benefits accessible and more affordable to more businesses.

Planstin — an administrator for employee benefits located in St. George — received honorable mention in the Professional Services and Community category during the event on August 8, in Salt Lake City. The Utah Business Innovation Awards, presented by Foley & Lardner LLC , recognize companies throughout Utah that are working to solve complex problems with innovative solutions.

“Planstin Administration has developed an innovative approach to benefits that prioritizes the employers’ and employees’ specific needs — offering flexible, affordable and time-saving solutions to enable more businesses to provide healthcare benefits and support their employees’ well-being,” the article on the awards states.

President and Founder Nathan Udy said it’s an honor to be recognized as a company looking to innovate in the health benefits industry and improve our community.

“We are grateful to be able to help people have broader access to health care at lower costs with better outcomes,” he said.

Planstin’s innovative approach focuses on creating benefits solutions that are cost-effective, flexible, and easy-to-implement. With expertise in customizable benefits plan design and efficient administrative support, Planstin can help businesses overcome the challenges of offering benefits to their employees.

“We empower small to mid-size companies to retain and attract top performers in their industries,” Udy said.

To learn more about Planstin, you can visit planstin.com. To read Utah Business’s full article on the awards, click here .

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Is maternity covered?

Thu, 01 Aug 2024 23:08:43 GMT

Maybe.

Preventive Basic, Preventive HSA, and Preventive Copay plans do not cover maternity. However, all Care+ health plans do include coverage for maternity care.

Additionally, many members with a preventive health plan also become Zion HealthShare members. A Zion HealthShare membership is designed for larger, medical needs like maternity.

Learn More

To learn more about Zion HealthShare click here .

Read the Zion HealthShare Member Guidelines here .

Click here to learn more about Care+.

Contact Member Services if you have further questions about your coverage: 888-920-7526 .

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3 Benefits Strategies for Small Businesses

Wed, 31 Jul 2024 23:48:01 GMT

Many small business owners assume they cannot afford to offer benefits to their employees, often due to how expensive traditional health insurance is. With the right strategy, any business can offer benefits.

Many small business owners assume they cannot afford to offer benefits to their employees, often due to how expensive traditional health insurance is, especially for smaller groups that cannot benefit from the same economies of scale that larger companies can. But there are ways to offer benefits that will keep your employees happy and not be a financial burden on your business.

Benefits strategy #1: Start small

If you’re running a small business, you shouldn’t expect to jump into a benefits program that doesn’t fit you. While big moves like matching 401k and health savings account contributions might not be a reality now, you can still offer your employees valuable benefits that will keep them happy and help them stick around longer.

Here are some ways you can start small with benefits for your employees:

Wellness Programs

According to the Chapman Institute , workplace wellness programs can reduce sick leave by 25%. Even simple initiatives can make a big difference in productivity and produce a return on investment.

Partner with a local gym to provide membership discounts for your employees.
Organize monthly or quarterly wellness challenges with small incentives or rewards.

Flexible Work Arrangements

Now more than ever, workers are placing high value on flexibility in their work schedules and commuting expectations. A Stanford study shows companies that accommodate remote work see 50% less turnover and a 17% increase in productivity—nearly a full day per week.

If possible, offer flexible working hours to accommodate personal schedules.
Allow employees to work from home on certain days.

Work-Life Balance

When employees can find a balance between life and work that feels enjoyable and sustainable according to this breakdown of work-life statistics, they are 21% more productive and 33% more likely to stay with the company.

These types of initiatives can offer hard-to-trace savings in the form of retaining your best employees and not having to retrain new employees.

Offer a few extra paid days off per year for vacation or personal time.
Offer the option to work longer hours on fewer days, allowing employees to enjoy an extra day off each week.

Benefits strategy #2: Take advantage of nontraditional benefits

There is no shortage of lesser known but high-quality health benefits and programs out there, and many are turning to these nontraditional options as an affordable alternative to health insurance. With these services, your employees still have access to the quality of healthcare they would expect, while not becoming a financial burden of traditional benefits.

HealthShare Membership

A HealthShare is a community of individuals that all contribute to one another’s medical expenses.

Membership in a HealthShare will offer your employees a safeguard against large medical expenses at a much lower monthly cost to them.
You can learn more about HealthShares here.

Direct Primary Care

Direct Primary Care (DPC) memberships provide unlimited access to primary care services for a flat monthly fee. DPC’s can reduce overall healthcare costs by up to 20%.

Offer your employees a direct primary care membership at a local clinic to provide access to routine and preventive services like checkups, screenings, and vaccinations.
Partner with a local clinic or healthcare provider to offer preventive services at discounted rates.

Virtual Care

Virtual care can provide cost-effective and convenient access to healthcare professionals. Many data points, compiled by the Olson Group , suggest that employees with access to virtual care enjoy more timely access to professionals and thus see lower hospital admissions, lower depression, anxiety, and stress.

Provide virtual care memberships to your employees, allowing them to connect with healthcare providers virtually at a lower cost.
You might consider including mental health support through a virtual care program for online counseling or therapy sessions.

Benefits strategy #3: Use a third-party administrator

While the benefits above can add a lot of value for your employees at a lower cost than a traditional benefits package, the process of researching options and making necessary arrangements and enrollments can be time consuming for small business owners that need to focus on their operation. To alleviate this burden, consider using a third-party administrator (TPA) as part of your benefits strategy.

Administration & Support

TPA’s handle the complexity and burden of benefits administration, from enrollment to claims to support.

Expert Guidance

TPA’s are experts in the field of employee benefits. They stay up to date on trends, regulations, and best practices, so they are able to provide informed guidance.

Better Rates

TPA’s have the leverage to negotiate better rates with benefit providers due to their large client base, leading to increased savings for your business.

Compliance

TPA’s are equipped to handle compliance issues and reduce the risk of government penalties.

How Planstin can help with your benefits strategy

At Planstin, we blend the strategies above into unique benefits solutions tailored for businesses of all sizes. We ease the administrative burden of an employee benefits program while designing packages that use nontraditional benefit options to provide access to quality healthcare at more affordable rates. We also show businesses how to use level funding and stop-loss protection as another layer of savings.

Consider a New Benefits Strategy with Planstin:

We’ll design benefits packages to fit the unique shape of your business and employees, using nontraditional options to provide quality healthcare at lower costs.
We’ll handle the management of your benefits program, from enrollment to claims, while making sure you stay compliant with government regulations.
We’ll show you how to use a level-funding strategy combined with stop-loss protection so you and your employees will save 40-60% over packages based in traditional health insurance.

No matter the size of your company, some level of employee benefits is achievable and can be perceived as a value to your employees. So, start small with manageable options like a wellness program and flexible work arrangements, or look into more robust nontraditional benefits like HealthShares or direct primary care. Each approach offers advantages that will feel like a real value to your best employees, keeping them happy and retaining them for longer.

Start Small

Employee benefits can be as simple as discounted gym membership and extra days off work.

Nontraditional Benefits

Provide your employees with health benefits that are not insurance but feel like it for a fraction of the cost.

Third-Party Administration

If you prefer a more well-rounded solution, Planstin can help design a benefits package that blends the lower-cost alternatives to insurance to provide your employees with access to healthcare for 40-60% less than traditional insurance.

Even the smallest step along any of these paths will be felt by your employees, and you’ll be on your way to a more productive and satisfied team. Consider your options, your business’s needs, and take the route that aligns best with your goals.

If you’re ready to take the next step or would like some guidance on where to start, Planstin is here to help. Contact us to learn more about how you can make benefits a reality for your business.

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The Role of Comprehensive Benefits in Employee Retention Strategies

Thu, 18 Jul 2024 15:15:00 GMT

The cost of employee turnover can be staggering, with companies spending thousands on hiring and training new employees, not to mention the hidden costs of lost productivity and decreased morale.

Did you know that 73% of workers are more likely to stay with their current employer if they were offered more workplace benefits? Employee retention is not just a buzzword; it's a crucial issue for all businesses.

One of the most effective strategies for retaining employees is offering comprehensive benefits. In this blog, we will explore what comprehensive benefits are and the advantage they give you in retaining employees. We will also provide useful insights for business owners who want to stand out with an unbeatable benefits package.

What are comprehensive benefits?

Employees today expect competitive compensation and comprehensive benefits packages. Large and mid-size companies often face stiff competition from other employers who may offer more attractive benefits, higher salaries, or more appealing work environments.

Comprehensive benefits go beyond basic salary compensation to include a wide range of perks and programs designed to support employees' overall well-being.

These benefits typically include:

Health Plans: Coverage for medical , dental , and vision care.

Retirement Plans: 401(k) plans with company matches or pensions.

Paid Time Off: Vacation days, sick leave, and holidays.

Life and Disability Insurance: Financial protection in the event of an employee's death or disability.

Wellness Programs: Initiatives that promote physical and mental health.

Flexible Work Arrangements: Options such as remote work, flexible hours, and compressed workweeks.

Professional Development: Training programs, tuition reimbursement, and career development opportunities.

The value of comprehensive benefits for large companies

For Applicable Large Employers (employers with 50 or more full-time employees, also known as ALEs) and companies nearing 50 full-time employees, offering comprehensive benefits is crucial in attracting and retaining top talent.

The modern workforce places significant value on not just their paychecks, but also on the quality and breadth of the benefits package offered.

Here are some key reasons why comprehensive benefits are valuable to medium-sized businesses and ALEs:

Attracting and Retaining Talent

A competitive benefits package is often a decisive factor for candidates when choosing between job offers.

Pay and benefits were the top reasons employees left their jobs in 2023. According to a 2023 study by Gallup , 58% of employees consider accepting a new job opportunity for increases in income and improvements in their benefits packages.

By offering comprehensive benefits, businesses can differentiate themselves in a crowded job market and reduce turnover rates.

Enhancing Employee Well-being

Comprehensive benefits support the physical, mental, and financial well-being of employees. Health insurance, retirement plans, paid time off, and wellness programs contribute to a holistic approach to employee health.

Employees who feel their employer cares about their well-being are more engaged and productive—leading to lower absenteeism and higher morale.

Fostering Loyalty and Reducing Turnover

A comprehensive benefits package can foster a sense of loyalty among employees. When employees feel valued and supported, they are more likely to stay with the company long-term.

Improving Financial Security

Offering benefits such as retirement plans, life insurance, and disability insurance provides employees with financial security. This security reduces financial stress and allows employees to focus on their work, knowing they and their families are protected against unexpected financial hardships.

Compliance with Regulatory Requirements

For ALEs, providing health coverage is not just beneficial but also a regulatory requirement under the Affordable Care Act (ACA). Failure to comply with ACA mandates can result in significant penalties.

By offering comprehensive benefits that adhere to ACA minimum value and affordability guidelines, businesses ensure compliance with federal regulations and avoid potential fines. Maintaining compliance also enhances your company’s reputation as a responsible and employee-centric organization.

Customization is key in implementing comprehensive benefits

One-size-fits-all benefits packages are becoming less effective as employees increasingly seek benefits tailored to their individual needs. Customization allows employees to choose the benefits that matter most to them, enhancing their satisfaction and loyalty to the company.

For example, younger employees might prioritize student loan repayment assistance, while older employees might value enhanced retirement contributions.

Companies can offer customization through flexible benefits plans, allowing employees to allocate a set amount of benefits dollars to the options that best meet their needs.

Planstin Administration and comprehensive benefits

Understanding and managing employee benefits can be challenging, especially for larger businesses with diverse workforce needs. Planstin is here to simplify this process and help you create a well-rounded benefits package that truly supports your employees.

Personalized Consultation

Our team of experts collaborates closely with you to understand your specific business needs and employee preferences.

For larger companies, this tailored approach ensures that the benefits package we design aligns perfectly with your organization's values and goals.

Streamlined Administration

Managing benefits for a large organization can be complex. Planstin simplifies this process with our user-friendly platform and white-glove service, making it easy to administer your benefits package.

This allows you to focus on running your business while we handle the administrative tasks, ensuring everything runs smoothly and efficiently.

Continuous Support and Education

Beyond the initial setup, Planstin offers ongoing support and education for both you and your employees. We ensure your team fully understands their benefits and how to use them. This continuous engagement helps maintain employee satisfaction and retention.

Partnering with Planstin provides the tools and support necessary for large businesses to offer comprehensive benefits, comply with regulatory requirements, and maintain a competitive edge in employee retention.

Learn more about how we can assist your business by clicking below.

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Small Business Health Plans: 3 Alternatives to Traditional Insurance

Thu, 27 Jun 2024 19:19:52 GMT

We consistently hear from many small business owners about the challenges they face in trying to offer benefits. Fortunately, there are alternatives to traditional insurance that are creating more positive outcomes for small businesses.

As a small business owner, you have a lot on your plate—tracking cash flow, purchasing supplies, taking care of customers, and much more. And most importantly, you’re trying to take care of the people who help make your business come alive, your employees.

If you’ve thought about offering your employees health benefits but decided not to because of costs associated with small business health plans, the amount of time it takes to manage benefits, and the complex regulations you must follow, you’re not alone. Nearly 50% of businesses in the U.S. still don’t offer benefits.

Why small businesses should consider alternatives to traditional insurance

It’s essential to understand why exploring different healthcare options, like the ones mentioned later in this article, can be beneficial for your business.

Cost Savings

Traditional health insurance premiums are continuing to rise each year, making it difficult for small businesses to afford the coverage they need for their employees.

Average annual premiums increased 7% in 2023, with $8,435 for single coverage and $23,938 for family coverage. In the same 2023 report from KFF , the growth in the average premium for family coverage (47%) has far outpaced the rate of inflation (30%) in the last 10 years.

Simplicity and Flexibility

The time you spend managing benefits varies with the number of employees. Typical tasks for managing employee benefits include coordinating open enrollment and new hire enrollments, handling payments to insurance carriers, helping employees with claims issues, and filing reports with government agencies.

Many alternative options come with less administrative complexity and more flexible plans, allowing you to tailor healthcare solutions to your employees' needs.

Employee Satisfaction

Employees’ satisfaction with their benefits fell to 61% in 2023, according to MetLife’s 2023 Employee Satisfaction Survey . The well-being and care of employees is one of the top reasons employers are starting to invest more in employee benefits. By offering more than traditional health plan options , you’re showing your employees that you care about their mental and physical well-being.

Three alternatives for small business health plans

Now, let’s explore three innovative alternatives to traditional health insurance that can provide quality care and cost-effective solutions for your small business.

1. HealthShare Membership

HealthShare memberships are programs where members contribute monthly to share medical expenses. These programs, often run by nonprofit organizations, pool contributions to share members' healthcare costs.

Benefits

Lower costs: Generally, HealthShare memberships have lower monthly contributions compared to traditional insurance premiums.

Community support: These programs often foster a sense of community among members, who support each other’s medical needs.

Flexibility: HealthShare memberships can share in a wide range of medical expenses, including alternative and holistic treatments.

Considerations

Though HealthShare memberships can assist with many medical costs, they are not insurance and may not share in all medical expenses.

Though many HealthShares will assist with expenses related to pre-existing conditions, there may be limitations.

2. Direct Primary Care

Direct Primary Care (DPC) is a healthcare model where patients pay a flat monthly fee directly to their primary care provider for a range of services. This fee typically covers all primary care services, including routine checkups, chronic disease management, and preventive care.

Benefits

Personalized care : DPC allows for longer, more personalized visits with your primary care provider.

Cost transparency : The flat monthly fee ensures no surprise billing, and additional costs are communicated upfront.

Accessibility: DPC often includes easier access to your doctor, including same-day or next-day appointments.

Considerations

DPC typically does not cover specialist care or hospitalizations, so it may need to be paired with a health plan or another form of catastrophic coverage.

What about alternative health plans for large businesses?

If you are a business owner with a larger group of employees, alternatives to traditional health plans may also benefit your business.

Adding non-traditional benefits to your benefits lineup can enhance your offerings without entirely replacing traditional plans. This approach is particularly beneficial for Applicable Large Employers (ALEs) who need to maintain compliance and may not want to move solely to these alternatives.

3. Virtual Care

Virtual care (also known as telehealth or telemedicine) provides medical consultations and healthcare services through digital communication tools like video calls, phone calls, or messaging apps. This model has grown significantly in popularity due to its convenience and effectiveness.

Benefits

Convenience : Employees can access healthcare from the comfort of their home or workplace, reducing time off work for medical appointments.

Lower costs : Virtual care often comes at a lower cost than in-person visits and can reduce overall healthcare expenses.

Wide range of services : Telehealth can cover various services, including primary care, mental health, and specialist consultations.

Considerations

Not all medical conditions can be addressed remotely, so it might need to be part of a broader healthcare strategy.

Embracing innovative solutions

As a small business owner, balancing all your responsibilities while ensuring your employees are well taken care of can be challenging. Traditional health insurance might seem like the only option for your small business health plan, but it often comes with high costs, time-consuming management, and complex regulations. Thankfully, alternatives like HealthShare memberships, Direct Primary Care, and virtual care offer innovative and practical solutions.

Exploring these alternatives can lead to cost savings, simplified administration, and higher employee satisfaction. By offering flexible and modern healthcare options, you not only support your employees' well-being but also show them that you value their contributions to your business.

Take the time to consider these alternatives for your small business health plan and see how they can benefit your business and your team. Your employees deserve the best care, and with these alternatives, you can provide it without the traditional hassles.

Don't let traditional insurance options keep you from offering a small business health plan. Explore alternative benefits options that can unlock your business' potential.

For a closer look at how we can help your business create a benefits package that works for your team and your budget, click below.

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Understanding PCORI Fees: A Guide for Employers

Tue, 25 Jun 2024 00:12:57 GMT

Although the Affordable Care Act mandates PCORI fees, they may not be widely recognized, in fact, this may be the first you are hearing of them. However, all self-funded plan sponsors need to be aware of PCORI fees and their obligation to pay them.

The Patient-Centered Outcomes Research Institute is working to raise the bar for healthcare experiences across the industry, work directly funded by mandatory PCORI fees. In this article, we will explore what PCORI fees are, who must pay them, how they are calculated, and their impact on the healthcare industry.

Key Takeaways

PCORI fees must be paid by any employer who wishes to offer a self-funded health plan.

PCORI fees are based on the average number of lives covered under the plan.

Current fee is $3.00 per covered life, it is set to increase to $3.22 for plans years ending after September 30, 2023, and before October 1, 2024.

The fees must be reported using Form 720 (Quarterly Federal Excise Tax Return)

The fees must be paid by July 31 ^st of the applicable year

Fees fund the Patient-Centered Outcomes Research Institute, which exists to help improve healthcare decision making.

What are PCORI fees, and who pays them?

In 2019, the Patient-Centered Outcomes Research Trust Fund fee was extended for 10 years. This fee, also known as the Patient-Centered Outcomes Research Institute or PCORI fee, is imposed on health insurance policy issuers and self-funded health plan sponsors every year. The fees support the Patient-Centered Outcomes Research Institute (PCORI), and they are crucial in funding research that helps patients, clinicians, purchasers, and policymakers make better-informed healthcare decisions.

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Health Insurance Issuers

Insurers offering specified health insurance policies.

Plan Sponsors

Employers (or other entities) that sponsor self-insured health plans. Health reimbursement arrangements (HRAs) and certain flexible spending arrangements (FSAs) may also be subject to the fee.

How expensive are PCORI Fees?

The individual PCORI fee is fairly reasonable, but depending on the average number of lives your health plan covers, the amount can add up. Currently, the fee is $3.00 or $3.22 per covered life (depending on your plan year end dates). However, since the fee is paid annually, it is not likely to be a tremendous financial burden.

For example, a business whose self-funded health plan ended before October, 1 2023 and covers 100 lives will pay just $300 for the year.

How to calculate your PCORI Fees

The most important part of calculating your fees is determining how many lives your plan covers on average throughout the plan year. Keep in mind, this is total covered lives, and not just the number of covered employees. Once you have that total, you simply multiply the fee amount by the number of covered lives.

When to pay and report PCORI fees

Your PCORI fees must be reported annually. You have until July 31 ^st of the year following the last day of the plan year to pay your fees. For example, if your plan year ended in January 2023 , you have all the way until July of 2024 to pay your fees. Unfortunately, if you have a TPA, they cannot report or pay the fees for you. You must report directly to the IRS using Form 720.

For plan years ending in 2024, you will have until July 31, 2025 to report and pay your fees.

Planstin Administration & PCORI Fees

Setting up and managing a robust employee benefits package can be a complex but rewarding endeavor for small business owners. As you go through this journey, it's crucial to keep several key factors in mind to ensure that your benefits strategy aligns with both your business objectives and the needs of your employees.

From selecting the right mix of benefits to understanding the legal and financial implications, each decision plays a vital role in the success of your benefits program.

Additionally, the administrative aspect of efficiently managing these benefits introduces complexities that may initially seem challenging to navigate for many small businesses.

This is where the advantages of partnering with a third-party administrator (TPA) like Planstin comes into play. We can offer valuable assistance in not only simplifying the complexity associated with benefits administration but also in optimizing your benefits package to ensure it's both competitive and compliant.

What do PCORI fees go toward?

Patients and caregivers are at the forefront of the Patient-Centered Outcomes Research Institute’s work. So, the fees paid by insurers directly fund research that improves healthcare delivery and patient outcomes.

The PCORI is committed to feeding “ high-integrity, evidence-based ” information to the healthcare industry about the effectiveness (or ineffectiveness) of various medical treatments and services. These insights help the greater healthcare community make better decisions and lead to better overall healthcare quality and value.

PCORI: More effective healthcare for all

Annual PCORI fees are an essential part of funding research that enhances healthcare outcomes and decision-making. Understanding who needs to pay these fees, how they are calculated, and their impact on the healthcare system is crucial for insurers and plan sponsors.

By supporting PCORI, these fees advance patient-centered research, and help elevate healthcare for everyone.

Resources:

For more detailed information, please refer to the IRS guidelines here.

More Information about calculating the fee can be found here .

Not sure you’re subject to the fee? View this chart on IRS.gov

If you’re a business owner looking for benefits designed to fit your needs, there are solutions for you.

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What is Reference-Based Pricing, or RBP?

Thu, 06 Jun 2024 21:49:55 GMT

In a conventional health plan, providers set their rates and then negotiate discounts with insurance companies. This often creates uncertainty for employees regarding their healthcare costs, as prices can vary greatly between different providers.

Reference-based pricing is an answer to the increasing cost of healthcare and unpredictable nature of provider pricing. In any given area, three providers offering the same service may charge three vastly different prices, leaving consumers and health plan sponsors at the mercy of over-inflated prices. In an attempt to contain these costs, reference-based pricing attempts to set a standard price for medical services, avoiding the uncertainty that often comes with medical billing, and encouraging providers to offer their services at a price closer to the reference point.

Key Insights

RBP uses predefined reference rates rather than contracted provider networks.

Employers can save on healthcare costs and reinvest in competitive salaries and a variety of benefits.

Using predefined reference rates allows for price transparency and allows employees to make informed decisions.

Employees may be balance billed if they see a provider who does not accept RBP rates.

Employers who use a TPA to manage their self-funded plan benefit from the advocacy and negotiation services the TPA will provide for employees.

The more plans that use RBP rates, the more providers are encouraged to offer care in line with the reference price.

What is RBP?

Reference-based pricing is first and foremost a cost-containment strategy. This strategy is a key component in many employer-sponsored self-funded health plans. Why? Because RBP allows the employer to dictate how much they are willing to spend on a healthcare service.

Typically, healthcare costs are first determined by looking at the provider’s rate for a given service. Unfortunately, provider rates can vary greatly, making it difficult to assess the true cost of a service. By designing a plan that uses an RBP strategy, an employer can better predict and contain healthcare costs.

Why is RBP used?

Cost Savings

For employers, cost savings is built-in with an RBP methodology, and may be what enables a business to offer benefits for the first time. For those employers who have been offering benefits and paying inflated costs, using an RBP strategy provides savings that can turn into an opportunity to re-invest in their business.

Accessibility

When a health plan uses a network, not every employee will have ready access to an in-network provider. And out-of-network claims can come with high price tags for the employer and employee. Health plans with reference-based pricing eliminate the need for contracted networks, and make sure members have access to preventive services and other care near them.

Flexibility

Unlike the contracted provider networks that traditional health plans typically use, reference-based pricing eliminates in– and out-of-network distinctions and allows employees to choose any provider.

Who uses RBP?

Health plans that use a RBP strategy are often self-funded plans offered by employers working with third-party administrators. Employers chose to self-fund plans as opposed to purchasing insurance from a carrier often do so in an effort to better control healthcare costs and provide more flexibility. To contain costs even further, employers offering self-funded plans will design health plans with their TPA that use reference-based pricing. With their TPA managing the plan and providing negotiation and advocacy services, the employer can offer an effective health plan that respects their budget.

How does RBP work?

A health plan that uses a reference-based pricing methodology usually covers costs based on the Medicare rate plus a percentage for provider fees or a reasonable margin. To benefit from the reference-based price, employees must visit providers who accept the reference-based price as full payment.

If employees select a provider whose price matches or is below the reference price, they will only pay that amount. If they choose a provider with higher charges, they may have to pay the difference between the reference price and the provider's charge.

How Does RBP Benefit Employers?

By implementing RBP, employers can protect their health plan from excessive and unpredictable costs—an especially important consideration for self-funded health plans.

When an employer-sponsored health plan sets a maximum allowable amount based on a fair reference point, the employer avoids paying inflated charges from healthcare providers. The comparison shown here between billed charges and re-priced amounts demonstrates just how substantial the savings may be for the health plan.

By saving on healthcare expenses, employers can put more money into their business, including building a more robust workplace culture. Better benefits with the flexibility of RBP can lead to better retention rates and the ability to attract top talent.

How Does RBP Impact Employees?

From the start, employees will benefit from the lower monthly costs typically associated with RBP-driven health plans. While employees may benefit from the cost-savings of choosing a provider who accepts RBP rates, they still have the freedom to select any provider they choose. However, using any provider, regardless of whether they accept RBP rates, may result in balance billing. For instance, in the earlier RBP billing example, if the employee did not use a provider who accepted the plan’s allowed RBP amounts, they could see a significant balance bill.

Employees can get the most benefit from RBP if they are able to disconnect from the traditional, network-based approach of finding providers. This may mean a fundamental shift in how the employees shop for healthcare.

Ultimately, the more active role the employee takes in their healthcare decisions, the better RBP can work for them. Knowing this, employers who chose to use a health plan with RBP should prioritize employee education and make sure the TPA they work with to administer their plan offers advocacy services and negotiation support.

Dealing with balance billing

If employees are consistently seeing providers who do not accept RBP rates, they may consistently receive balance bills, which could lead to negative view of the employer-sponsored plan. How can employers overcome this, or avoid this altogether? The most important thing an employer can do is educate their employees about the plan and how RBP works. A capable TPA will support you in this effort, making sure you have the information you need to speak to your employees. The more the employees know, the better equipped they will be to get the most out of their benefits. When balance bills happen, your TPA may be able to negotiate on your employees’ behalf.

How does Planstin integrate RBP into plan designs?

Third-party administrators like Planstin negotiate rates and pre-determine allowed amounts using reference points. Many RBP health plans use Medicare rates as a reference point because of their wide acceptance and standardized pricing. Planstin’s health plan designs also use Medicare rates as their primary pricing reference point.

As stated earlier, a RBP plan will take a reference point, add a reasonable margin (and possibly an additional percentage for facility or provider fees), and calculate the amount the plan will pay for a given service. With Planstin’s plan designs, the reference rate is 100% of the Medicare* rate, and the reasonable margin is 50% of the Medicare rate. In total, the allowed amount for any given service is 150% of the Medicare rate.

Occasionally, a Medicare rate may not be available for a service. If this happens, plans will pay a usual, customary, and reasonable (UCR) rate (generally a rate equal to the 75th percentile of charges billed by providers in your geographical area).

*Medicare pricing comes directly from the Centers for Medicare and Medicaid Services (CMS), using the current physician fee schedule, the clinical laboratory fee schedules, and other fee schedules offered directly from CMS.

RBP: Standardizing healthcare pricing

The traditional health plan pricing model based on contracted network rates can work well when employees are able to use in-network providers. However, out-of-network services often result in higher out of pocket expenses—or are completely excluded. Reference-based pricing (RBP) takes an alternative approach, generally stabilizing or reducing claim costs and potentially transforming the healthcare industry by setting standard prices for medical services.

Terms to Know

Balance bill – a bill sent from a provider to a patient for any extra cost owed when the provider’s rate is higher than the plan’s RBP rate.

Medicare Rate – the amount that Medicare will reimburse for a medical service.

Reference-based pricing (RBP) – an alternative healthcare pricing system that sets a standard price, or reference point, for medical services.

Self-funded plan – a type of health plan sponsored by an employer who pays employee healthcare claims directly (as opposed to purchasing insurance from a traditional carrier).

Usual, Customary, Reasonable (UCR) – A standard used to determine the fair price for a medical service in a specific geographic area.

Don't let traditional insurance options keep you from offering a small business health plan. Explore alternative benefits options that can unlock your business' potential.

For a closer look at how we can help your business create a benefits package that works for your team and your budget, click below.

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Do I have to enroll in a health plan to enroll in Zion HealthShare?

Tue, 04 Jun 2024 23:25:54 GMT

No.

You are not required to enroll in a health plan. You can enroll in Zion HealthShare only if you prefer.

However, we do recommend pairing a preventive health plan with a Zion HealthShare Membership if possible for a more well-rounded solution.

Learn More

Visit zionhealthshare.org/member-guidelines to learn more about eligible medical costs.

To learn more about the sharing request process click here .

To learn more about how to use a HealthShare to complement a health plan click here .

Are you a HealthShare member? Contact Member Services to verify your benefits: 888-920-7526 .

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How do I use my HealthShare membership with my health plan?

Mon, 03 Jun 2024 01:03:51 GMT

Using a HealthShare membership and a preventive health plan together is an alternative to traditional insurance that can effectively meet many, if not most of your healthcare needs.

The key to using these two pieces together is to understand what each one is for and when to use it.

Your Preventive Health Plan

The main part of your healthcare solution focuses on your routine needs like an annual checkup, medications, immunizations, and preventive screenings.

Your HealthShare Membership

The other part of your healthcare solution works best for bigger medical concerns, such as emergency care, maternity, and hospitalization for planned or unplanned surgery.

Knowing When & How to Use Your HealthShare

If this healthcare pairing is new to you, you will likely have questions about when to use which piece.

The chart below can help you decide which service to use, and what steps to take to use it effectively.

Of course, if you have any questions, we are here to help. Contact Member Services at 888-920-7526 with any questions.

While your situation may involve details that are best discussed with Member Services or Zion HealthShare member care specialist, here is some general guidance to help get you started.

Getting routine care?

Show your health plan ID card to your provider

They will bill your health plan, and you will pay $0 for all preventive visits.

Getting a preventive screening?

Show your health plan ID card to your provider. They will bill your health plan, and you’ll pay $0.

Filling a prescription?

Use your included prescription service to order your medications and have them delivered.

Getting lab work done?

Before getting your tests, ask your provider to contact Planstin and verify if the labs are covered by your plan.

In need of a flu shot?

Your health plan covers it if you receive it at a doctor’s office. The same applies to COVID vaccines and other standard immunizations.

Newly pregnant?

Congratulations! Submit a sharing request as soon as you know you are expecting.

Having surgery?

Inform the provider you are a self-pay patient. If

possible, submit a sharing request prior to surgery.

Getting emergency care?

nform the provider you are a self-pay patient.

Submit a sharing request immediately. You’ll pay for care up to your IUA amount, and share the rest

Recently injured or suddenly ill?

Submit a sharing request as soon as possible. Call your HealthShare for further guidance.

Do Your Homework

Whether or not you’re new to a HealthShare and health plan combo, it's important to get a full picture of what these services can do for you. The most important steps you should take include reading your plan documents, which will explain what your health plan covers, and reading the Zion HealthShare member guidelines, which will detail which medical costs are eligible for sharing.

Learn More

Download a PDF version of this article here .

Learn more about the sharing process here .

Visit zionhealthshare.org/member-guidelines to learn more about eligible medical costs.

Are you a HealthShare member? Contact Member Services to verify your benefits: 888-920-7526

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How do I find my plan documents?

Wed, 22 May 2024 17:03:51 GMT

Login to your portal here .

If you have trouble finding your plan documents, or if you have questions, please reach out to Member Services at 888-920-7526.

Learn More

Contact Member Services for help understanding your plan details at 888-920-7526 .

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Employee Benefits 101 for Small Business Owners

Tue, 21 May 2024 16:26:20 GMT

While the employee benefits industry can seem overwhelming and complicated, it doesn’t have to be. This guide explores the different types of employee benefits, what’s required of you as an employer, why benefits are financially possible, and how to get started.

At the core of every small business lies a drive for success—a goal that transcends the quality of products or services and deeply involves the team that powers its operations.

The strength of a business's workforce is fundamental, underscoring the importance of not just assembling a skilled team but also understanding and addressing their diverse needs. As a business owner, you have the power to address your team’s needs by offering employee benefits.

The bedrock of benefits: More than just perks

An employee benefits package extends beyond mere perks to reflect your business's values and commitment to its team. These benefits—encompassing health plans , retirement plans, wellness programs, and more—are not just tools for enhancing employee satisfaction; they are vital components in fostering a supportive and engaged workplace culture.

Healthcare for Employee Well-being

By offering healthcare benefits, perhaps the most common employee benefit, you can significantly impact your employees' lives, ensuring access to necessary medical care without the looming fear of financial ruin.

Futureproofing through Retirement Planning

Retirement benefits, often perceived as the domain of larger corporations, are equally within reach for small businesses like yours. Options like SIMPLE IRAs and 401(k) plans not only empower employees to secure their future but also offer tax advantages that can bolster your business's bottom line.

Cultivating a Culture of Wellness

Wellness programs, from in-office fitness initiatives to mental health support, underscore a holistic approach to employee benefits. These programs echo a growing recognition of the interplay between physical well-being and workplace productivity, presenting an opportunity for your business to invest in their employees' health in broad and impactful ways.

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Different types of benefits

For small business owners, crafting an employee benefits package requires careful consideration and strategic planning. The size of your business, what industry you belong to, and your employees’ preferences can determine what benefits you decide to offer to your employees.

Health and Wellness Benefits

Health and wellness benefits are foundational to any comprehensive employee benefits package, aiming to support the physical and mental health of employees. These benefits range from medical, dental , and vision insurance, which cover essential health care needs, to wellness programs designed to promote healthy lifestyles and prevent disease.

As a business owner, you have the power to address your team’s needs by offering employee benefits.

Health

Coverage for medical expenses, often including prescription drugs, emergency care, and preventive services.

Dental

Coverage for dental care services such as cleanings, x-rays, fillings, and sometimes orthodontics.

Vision

Coverage for eye exams, prescription eyewear, and sometimes eye surgery.

Health savings accounts (HSAs) and flexible spending accounts (FSAs)

Accounts where employees can save pre-tax dollars for eligible healthcare expenses.

Wellness programs

Initiatives aimed at promoting healthy lifestyles, such as gym membership discounts, smoking cessation programs, and stress management workshops.

Employee assistance programs (EAPs)

Confidential counseling and support services for personal and work-related issues.

Financial and Retirement Benefits

Financial security is a major concern for employees, and benefits in this category are designed to address those needs, both in the present and the future.

Retirement plans, such as 401(k)s and pensions, help employees save for their post-work years, often with the added boost of employer contributions. Life and disability insurance offer protection against unforeseen circumstances, ensuring financial stability. Additionally, tuition reimbursement programs support ongoing education and career development, further securing an employee's financial future.

Retirement plans : 401(k) plans, pension plans, Savings Incentive Match Plan for Employees (SIMPLE) IRAs, and Simple Employee Pension (SEP) IRAs offer employees a way to save for retirement, often with employer contributions.
Life insurance: Provides a monetary benefit to a designated beneficiary upon the employee's death, often at no cost to the employee for a basic policy.
Disability insurance: Offers income protection to employees unable to work due to a disability. This includes both short-term and long-term disability insurance.
Tuition reimbursement: Financial assistance for further education relevant to the employee's job or career path.

Leave and Time-Off Benefits

Time away from work is crucial for employee satisfaction and mental health. Leave and time-off benefits, including paid time off (PTO), family and medical leave, and parental leave, provide employees with the time needed to rest, recover, and attend to personal matters.

Paid time off (PTO): Can include vacation days, sick leave, and personal days. PTO policies vary widely among employers.
Family and medical leave: Unpaid, job-protected leave for specified family and medical reasons, with continuation of group health insurance coverage, as mandated by the Family and Medical Leave Act (FMLA) in the U.S.
Parental leave: Paid or unpaid time off for the birth or adoption of a child. This is beyond what's required by FMLA in some states.
Sabbaticals: Extended leave that may be offered after a certain period of service, often unpaid but with the guarantee of a job upon return.

Work-life balance and flexibility

In addition to leave and time-off, benefits that encourage work-life balance, such as flexible working hours and remote work opportunities, empower employees to design a work schedule that fits their lifestyle. Childcare assistance, whether through on-site facilities or financial support, helps employees manage their family responsibilities alongside their career.

Flexible Working Hours: Options such as flextime, compressed workweeks, or shift work to accommodate personal needs and preferences.
Remote Work Opportunities: The ability to work from home or other locations outside the traditional office setting, either full -time or part- time.
Childcare Assistance: Benefits that help employees with their childcare needs, such as on-site childcare facilities, childcare subsidies, or access to a dependent care flexible spending account.

Professional development

Investing in employees' growth and development is beneficial both for the individuals and the business. Professional development benefits, including training programs and career advancement opportunities, enable employees to acquire new skills, improve their job performance, and advance their careers. This not only contributes to personal fulfillment but also ensures the company has a skilled and motivated workforce ready to meet future challenges.

Training and development programs: Opportunities for employees to acquire new skills or enhance existing ones, including workshops, courses, and seminars.
Career advancement opportunities: Pathways for promotion and internal mobility that are communicated and accessible to employees.

Additional Perks and Miscellaneous Benefits

Beyond the core categories, a variety of additional perks and miscellaneous benefits can make a workplace more attractive. Employee discounts, transportation benefits, and relocation assistance are examples of perks that add extra value to the employment package.

Employee discounts: Reduced prices on the company's products or services, or discounts arranged with other companies.
Transportation benefits: Subsidies or reimbursement for commuting costs, such as public transit passes, parking fees, or bike-to-work programs.
Relocation assistance: Support for employees who are moving for work, covering expenses like moving costs and temporary housing.

Understanding mandatory vs. optional benefits

Understanding which benefits are required by law versus those that are discretionary can help you make informed decisions that align with both your business objectives and your team’s needs.

Mandatory Benefits

Below is a list of benefits you are legally required to provide to your employees. It’s important to note that these requirements can vary depending on what state your business is located in.

Social security and medicare contributions: Employers are required to pay Social Security and Medicare taxes for their employees, matching the amounts withheld from employees' paychecks.
Worker’s compensation insurance: This insurance provides benefits to employees who suffer job-related injuries or illnesses. While requirements can vary, having some form of workers' compensation coverage is generally mandatory across the United States.
Unemployment insurance: Employers must pay into the state unemployment insurance program. This program provides temporary financial assistance to workers who have lost their jobs through no fault of their own.
Family and medical leave (FMLA): In the United States, the federal Family and Medical Leave Act (FMLA) requires covered employers to provide employees with unpaid, job-protected leave for specified family and medical reasons. However, FMLA applies to employers with 50 or more employees, so it may not affect the smallest businesses unless they are in states with more stringent requirements.
Disability insurance: Some states require employers to provide short-term disability benefits. This is not a federal requirement, but states like California, New York, New Jersey, Rhode Island, and Hawaii have their own mandates.

Optional benefits

While understanding mandatory benefits is crucial for compliance, exploring optional benefits opens a realm of opportunity for small business owners to truly differentiate themselves as employers of choice. Optional benefits—ranging from health insurance for smaller entities, retirement savings plans, to wellness programs and more—offer a powerful tool to attract, retain, and motivate a talented workforce.

Compliance considerations

The employee benefits industry is fraught with legal intricacies, from mandatory offerings like social security contributions to the nuanced requirements of the Affordable Care Act (ACA). For small business owners, understanding these obligations is paramount if you choose to offer benefits, not just to ensure compliance but to build a foundation of trust and transparency within your team.

Understanding ERISA

The Employee Retirement Income Security Act (ERISA) is a federal law that sets standards for most voluntarily established retirement and health plans in private industry to provide protection for individuals in these plans. If you offer retirement benefits or healthcare coverage regulated by ERISA, here are some things you need to know:

Compliance: Ensure that your retirement plans, such as 401(k)s, and health plans comply with ERISA's requirements. This includes providing plan information to employees and establishing a claims and appeals process.
Reporting and disclosure : ERISA requires plan administrators to report and disclose plan information to the federal government and participants. This includes the Summary Plan Description (SPD), which must be provided to participants and beneficiaries.
Fiduciary responsibilities : If you're making decisions about how your employee benefits plan is run or how its funds are handled, you're seen as a fiduciary. Being a fiduciary means you have a critical duty to always act in the best interest of your employees and their families who are covered by the plan. You're expected to meet a high standard of care and honesty, ensuring the plan's assets are managed properly for the benefit of those participating in the plan.

If you're making decisions about how your employee benefits plan is run or how its funds are handled, you're seen as a fiduciary. Being a fiduciary means you have a critical duty to always act in the best interest of your employees and their families who are covered by the plan.

Implementing Section 125 Plans

If you decide to offer benefits to your employees, you will want to consider setting up a Section 125 plan. Section 125 will allow you to offer pre-tax benefit deductions to your employees—saving them and your business on taxes.

Any business, regardless of size, can offer a Section 125 plan. Here are important considerations:

Types of cafeteria plans: The most common types include Premium Only Plans (POPs), which allow for pre-tax benefit deductions, and Flexible Spending Accounts (FSAs), which let employees set aside pre-tax dollars for medical and dependent care expenses.
Non-discrimination testing: To ensure that benefits are offered equitably and not just to highly compensated employees or key employees, Section 125 plans must pass non-discrimination tests. Failure to pass these tests can result in penalties.
Plan documents and employee communication: It's essential to have a written plan document outlining the benefits and operations of your Section 125 plan. You also need to effectively communicate plan options and rules to your employees.

Benefits of Offering a MEC plan

The Affordable Care Act (ACA) includes provisions that affect businesses with 50 or more full-time equivalent employees, such as the requirement to offer health coverage. If your business has 50 or more full-time employees or equivalents, there is a mandate under the ACA that requires you to offer healthcare coverage that meets Minimum Essential Coverage (MEC) requirements. Failure to do so may result in tax penalties.

As a small business owner, you aren’t subject to the Employer Shared Responsibility Payment if you have less than 50 full-time employees. However, you may still want to offer health coverage that meets MEC requirements because it ensures that your team has access to preventive services, treatments, and procedures that are essential for maintaining their health.

Budget and financial considerations

While the prospect of offering benefits may seem financially daunting, the reality is more encouraging. Strategic planning and leveraging tax advantages can make offering benefits more attainable than many small business owners realize. Moreover, the investment in a robust benefits package can pay dividends in attracting talent and reducing turnover, ultimately contributing to your business's success and sustainability.

Funding Options: Self-Funding vs. Fully-Insured

Understanding the various fund options for employee benefits can be a deciding factor on whether you choose to offer benefits. Selecting the right funding strategy is critical for balancing financial health with a competitive edge in employee benefits.

Self-funding, or self-insuring, is an option where businesses assume direct financial responsibility for the healthcare costs of their employees.

This approach offers more control over the benefits plan, and can potentially lead to cost savings by eliminating insurer profit margins and overhead costs.

Self-funding

Self-funding , or self-insuring, is an option where businesses assume direct financial responsibility for the healthcare costs of their employees. This approach offers greater control over the benefits plan, potentially leading to cost savings by eliminating insurer profit margins and overhead costs.

Self-funded plans require careful financial management and risk assessment, as you would be responsible for covering claims.

Level-funding

Level-funding is a type of self-funding with stop loss coverage attached. Like a self-funded plan, the employer assumes direct financial responsibility for the healthcare costs for their employees. However, part of the cost is paid towards having stop loss coverage.

Stop-loss coverage is added protection for business owners who choose the self-funding route. It means that if health claims exceed the employer's claims fund, this coverage helps to cover the excess, ensuring that one large claim doesn't drain the employer's finances.

Fully-insured

In contrast, fully insured plans involve purchasing health insurance from an insurance provider, who assumes the risk. This approach does offer a certain level of cost predictability, with premiums set for the year, and it's generally simpler to handle than managing a self-funded plan. However, for small businesses, the higher costs associated with these plans—often due to the insurance provider's markups—can make them a less feasible option.

While the stability and straightforward nature of fully insured plans are appealing, small business owners are increasingly considering the potential benefits of self-funding or level-funding to better control expenses.

Harnessing Tax Credits to Ease Financial Burdens

Tax credits and tax-advantaged accounts are additional tools available to small business owners that reduce the overall cost burden of health benefits but also add substantial value to your benefits package.

Tax-Advantaged Accounts: HSAs and FSAs

Health Savings Accounts (HSAs) and Flexible Spending Accounts (FSAs) offer tax advantages for both employers and employees. Contributions made by the business to these accounts are tax-deductible, and employees benefit from tax-free contributions and withdrawals for qualified medical expenses. These accounts not only provide financial benefits but also enhance the overall value of your health benefits package.

Managing Costs with Voluntary Benefits

Offering voluntary benefits—additional benefits that employees can choose to purchase at group rates—can enrich your benefits package without significantly impacting your budget. These benefits, which are explained in an earlier section of this guide, are typically paid for by the employee through payroll deductions.

For small businesses, voluntary benefits offer a cost-effective way to provide a more comprehensive benefits package and meet diverse employee needs.

Implementing and managing employee benefits

From selecting the right mix of benefits to understanding the legal and financial implications, each decision plays a vital role in the success of your benefits program.

Additionally, the administrative aspect of efficiently managing these benefits introduces complexities that may initially seem challenging to navigate for many small businesses.

The Advantages of Partnering with Planstin

Partnering with a third-party administrator such as Planstin brings a multitude of advantages to the table:

Expertise and compliance: Our professionals ensure that your benefits program not only meets regulations but also is finely tuned to align with your business' specific needs. We can help you craft and administer benefits that are valuable for you and your team.
Administrative efficiency: We can help lighten the load of benefits administration through our comprehensive support— encompassing enrollment, management, and adherence to compliance requirements. Our services allow you to dedicate more time and resources to your primary business operations.
Tailored solutions: We collaborate with you to craft a benefits package that perfectly caters to the distinctive needs of your employees, thereby boosting satisfaction and loyalty among your team.
Cost-effective benefits: With our unique solutions, like pairing a preventive health plan that meets MEC requirements with a HealthShare membership, we can save you more money compared to traditional health plans. This allows you to focus on growing your business.

Your partner in overcoming obstacles in benefits administration

Learning about employee benefits and implementing them can be a daunting task for small business owners. Yet, the importance of constructing a comprehensive and compliant benefits package cannot be overstated. It's a crucial factor in attracting and retaining the talent that will drive your business forward.

If you feel overwhelmed at the thought of offering benefits and don’t know where to start, you’re not alone. Partnering with us allows you to leverage our expertise and resources, ensuring that you don’t have to go through this process alone. Our goal is to guide you to better benefits through crafting and administering benefits that are flexible, budget-friendly, and simple to understand.

If you’re interested in learning more about how we can help your small business, visit planstin.com to book a free call with our team.

If you’re a small business owner looking for benefits designed to fit your needs, there are solutions for you.

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SUGGESTED FOR YOU

How do I know what plan I have?

Fri, 17 May 2024 17:06:12 GMT

Follow the instructions below.

1. Find your member ID card

2. Locate the plan information on the front, in the top right corner

This plan description code under “plan information” can be used to find your health plan documents, which will provide more details about your plan.

If you have trouble finding your plan documents, or if you have questions, please reach out to Member Services at 888-920-7526.

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Learn how to find your plan documents here .

Contact Member Services for help understanding your plan details at 888-920-7526 .

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How do I find a provider?

Thu, 02 May 2024 22:08:43 GMT

The best way to find a provider and make best use of your benefits is to contact our Care Coordination team.

Learn more about care coordination here .

Does your plan use a network?

Most Planstin-managed health plans do not use a provider network. Those that do, use PHCS to keep rates low while directing members to high-quality care.

If your health plan does use the PHCS network, you will not use the Care Coordination team . Rather, you can find a provider following the instructions below.

1.) Visit planstin.com/phcs

2.) Search for a provider

You can search by name, specialty, facility type, National Provider Identifier Number (NPI#), or license number.

Note: When selecting a provider, contact the provider’s office to verify that they are still in-network.

Learn More

Looking for a dental provider? Start here .

Do you have a Planstin-managed health plan? Does it require you to see in-network providers? If you are unsure, contact Member Services for help understanding your benefits details at 888-920-7526 .

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Do I pay out of pocket and get reimbursed?

Wed, 01 May 2024 23:25:54 GMT

No.

Instead, if you have a health plan, you will be issued an ID card for medical services, and separate ones for dental and vision. Both digital and physical copies of these cards will be sent to you—the digital copies via email and the physical ones via mail. When you visit a doctor's or dentist's office, you should present the appropriate ID card. The healthcare provider will then bill us directly.

There is an exception for vision care.

In most cases, vision service providers may ask you to pay up front. If you do pay out-of-pocket for vision services, your plan can reimburse you upon submission of an itemized receipt. This receipt needs to include the patient's name, member number, group number, the date of service and/or purchase, and the billing codes.

Learn More

Question about appeals? Click here .

Contact Member Services for help understanding your plan details at 888-720-7526 .

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As a new hire, when can I enroll?

Wed, 01 May 2024 23:25:54 GMT

You can enroll as soon as you hit your company’s eligibility date.

Your benefits will be effective on the first day of the month following your eligibility date.

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Contact Member Services for help understanding your benefits details at 888-720-7526 .

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If I choose not to enroll now, can I enroll later?

Wed, 01 May 2024 23:25:54 GMT

Maybe.

Employees need to enroll during open enrollment, usually a 2-week period. If you choose not to enroll now (before the enrollment deadline), you will need to wait until next year to add benefits.

The only time you can enroll mid-year is if you have had a Qualifying Life Event (QLE) within the past 60 days (such as a marriage, divorce, or birth).

Learn More

See a full list of QLEs here .

Contact Member Services for help at 888-720-7526 .

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How do I fund my Health Savings Account (HSA)?

Wed, 01 May 2024 23:25:54 GMT

For new groups, this happens during the enrollment process.

For others, simply inform the owner or HR department about the amount you wish to contribute each month, and they will relay the information to us. Typically, it takes between 2 to 4 weeks after invoice processing for the funds to be credited to your account.

Optum Bank will dispatch a debit card via mail. You have the option to register through the online portal to monitor your account balance.

*Please note, an initial deposit of at least $10 is necessary to activate your HSA.

Learn More

Use this checklist to get started with your HSA contributions.

Click here to download the Optum app.

Call Planstin’s Member Services team at 888-920-7526 for more information about how to make contributions or changes to reoccurring contributions.

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Why haven't I received my HSA debit card?

Wed, 01 May 2024 23:25:54 GMT

If you are unsure about the status of your account or need further assistance, you can contact Optum directly at 866-234-8913 .

Should you need additional support, the Member Services team is also available to assist you at 888-920-7526 or member@planstin.com .

Learn More

Use this checklist to get started with your HSA contributions.

Click here to download the Optum app.

Call Planstin’s Member Services team at 888-920-7526 for further assistance.

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Is there an HSA app that I can use?

Wed, 01 May 2024 23:25:54 GMT

Yes!

Learn More

Use this checklist to get started with your HSA contributions.

Click here to download the Optum app.

Call Planstin’s Member Services team at 888-920-7526 for more information about how to make contributions or changes to reoccurring contributions.

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Do I have to use Optum Bank for my HSA?

Wed, 01 May 2024 23:25:54 GMT

No. An employer can set up deposits into an HSA at whatever bank an employee desires.

Learn More

Use this checklist to get started with your HSA contributions.

Click here to download the Optum app.

Call Planstin’s Member Services team at 888-920-7526 for further assistance.

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How do I submit a sharing request?

Wed, 01 May 2024 23:25:54 GMT

Follow the steps below.

1. Go to zionhealthshare.org/members

2. Click on “Member Portal Login” and sign in

3. Click on "Begin New Sharing Request" and follow the instructions

Learn More

Learn more about the sharing process here .

Visit zionhealthshare.org/member-guidelines to learn more about eligible medical costs.

Are you a HealthShare member? If you are unsure, contact Member Services to verify your benefits: 888-920-7526 .

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If I have a medical need what do I do?

Wed, 01 May 2024 23:25:54 GMT

If you are a Zion HealthShare member, for major medical events like hospitalizations, surgeries, or maternity you should identify yourself as a self-pay patient at the provider's office and request an itemized statement that includes a self-pay discount.

To manage these expenses, you will need to coordinate directly with Zion HealthShare. This involves using your Zion HealthShare Member Portal to upload statements, facilitate bill payments, or process reimbursements if you have already paid these costs out-of-pocket.

Learn More

Learn more about the sharing process here .

Visit zionhealthshare.org/member-guidelines to learn more about eligible medical costs.

Are you a HealthShare member? Contact Member Services to verify your benefits: 888-920-7526 .

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Does Zion HealthShare share pre-existing conditions?

Wed, 01 May 2024 23:25:54 GMT

Zion HealthShare defines a pre-existing condition, or what they call a “pre-membership medical condition,” as any medical issue for which a member has received treatment, taken medication, or experienced symptoms in the 24 months leading up to their enrollment.

There is a one-year waiting period before such conditions become eligible for sharing within the community. However, there are exceptions for certain conditions like diabetes, high cholesterol, and high blood pressure. If an employee has not been hospitalized for these conditions in the past 12 months and can manage them through medication or diet, they will not be classified as pre-membership medical conditions.

Learn More

Visit zionhealthshare.org to learn more.

Visit zionhealthshare.org/member-guidelines to learn more about eligible medical costs.

To learn more about the sharing request process click here .

Are you a HealthShare member? Contact Member Services to verify your benefits: 888-920-7526 .

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Why was my preventive visit or lab not covered?

Wed, 01 May 2024 23:25:54 GMT

If you have a health plan that covers preventive care, it may depend on how the doctor bills for your visit. For example, if you discuss specific health issues during an annual preventive visit, your doctor might bill an additional appointment for an office visit or sick visit, leading to a copay or full payment required for the additional visit.

Also, it is important to note that n ot all procedures or tests recommended by your doctor will qualify as preventive care under the Affordable Care Act (ACA).

Learn More

Read the full list of ACA preventive services for adults and children here .

For more information on preventive vs. diagnostic care click here .

Do you have a health plan? If you are unsure, contact Member Services at 888-920-7526 for more help understanding your benefits details.

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How do I use Teladoc Health?

Wed, 01 May 2024 23:25:54 GMT

Attention: Do your benefits include a Teladoc Health membership? If you are unsure, call Planstin’s Member Services team at 888-920-7526 for more help understanding your plan details.

You can register on Teladoc.com or using the Teladoc Health app on your phone (see the steps below).

You must register with the information that you provided to us upon enrollment (i.e. name, zip code, DOB, and email address). Once registered, you will enter medical information and then you can request a visit with a provider.

Please note: A spouse cannot register for the primary employee. You will need to add your spouse and children to the account after you have already registered.

Register for Teladoc Health

Step 1

Click HERE and complete the online form

Select your health plan—confirm the Planstin option

Create username, password, and security questions

Click “Complete Registration”

Helpful Tips

Wait 24 hours after receiving your Planstin welcome email to register for Teladoc Health.
If you have difficulty registering online, try registering with the mobile App.

Step 2

Complete your registration using the same information you used to enroll in your health plan. Make sure you use the primary subscriber information—not a dependent’s information.

Step 3

You will be automatically matched with a benefits provider, simply confirm the selection and click “continue.” If you experience issues, please contact a Benefit Advocate at 888-920-7526 .

There’s an App for that!

You can enroll through the Teladoc Health mobile app. Simply download the Teladoc Health app through the Google Play Store or App Store. The registration process is the same as the online Teledoc Health registration.

Learn More

Get help directly from Teladoc Health Support staff here .

Download the Teladoc Health App for Android here .

Download the Teladoc Health App for Apple here .

Do your benefits include a Teladoc membership? If you are unsure, call Planstin’s Member Services team at 888-920-7526 for more help understanding your benefits details.

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Can I enroll in Amaze Health if I am on a different insurance plan through my spouse?

Wed, 01 May 2024 23:25:54 GMT

Yes.

You can enroll in Amaze by itself, and they can work with any insurance plan you have.

Need help setting up the App or getting started?

Visit: amazehealth.com/support/

Call: 720-577-5251

Learn More

Watch this video on how to set up the Amaze App.

Learn more about how you can use Amaze Health here.

Download the Amaze Health App for Android here .

Download the Amaze Health App for Apple here .

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What is a HealthShare?

Wed, 01 May 2024 22:09:07 GMT

A HealthShare is a cooperative arrangement where individuals with similar beliefs pool funds to help pay each other's medical expenses.

The HealthShare company facilitates this sharing according to guidelines that each member agrees to when they join. Members contribute monthly toward community expenses, and may have their needs shared as outlined by the member guidelines. HealthShares are not insurance.

Learn More

Visit zionhealthshare.org to learn more about the HealthShare Planstin partners with.

Are you a HealthShare member? Contact Member Services to verify your benefits: 888-920-7526 .

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Are preventive services covered?

Wed, 01 May 2024 22:08:50 GMT

Most likely.

If you have Preventive series or Care+ series health plan it covers preventive services as outlined by the Affordable Care Act.

If you do not have a Planstin-managed health plan and you have questions about your benefits, contact Member Services at 888-920-7526 .

Learn More

Read the full list of ACA preventive services for adults and children here .

Contact Member Services if you have questions about your coverage: 888-920-7526 .

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How is preventive care different from diagnostic care?

Wed, 01 May 2024 22:08:43 GMT

Preventive care is what you receive when you are symptom free and have no reason to believe you might be unhealthy. Preventive care is often part of a routine physical or checkup.

Diagnostic care is what you receive when you have symptoms or risk factors, and your doctor wants to diagnose them.

Learn More

For more information on preventive vs. diagnostic care click here .

Contact Member Services for help understanding your plan details at 888-720-7526 .

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What is PHCS?

Wed, 01 May 2024 22:08:43 GMT

The abbreviation PHCS stands for Private Healthcare Systems. This large, nationwide healthcare provider network is affiliated with MultiPlan. Planstin works with the PHCS MultiPlan network to negotiate rates on behalf of our members.

If you have a health plan that uses this network it will be indicated on your ID card.

Unsure if your health plan uses PHCS?

Click on " Plan Documents " and search for the plan name listed on your member ID card. Your search results should include both your plan SBC and outline.

Learn More

Still not sure? Call Planstin’s Member Services team at 888-920-7526 for more help.

Find an in-network provider at planstin.com/phcs .

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What is Planstin?

Wed, 01 May 2024 20:25:18 GMT

Planstin is a third-party administrator for self-funded healthcare benefits. We help employers customize workplace benefit plans tailored to fit business and employee needs.

Learn More

Explore the Planstin Help Center here .

Explore the Planstin Blog here .

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Is Planstin insurance?

Wed, 01 May 2024 19:33:17 GMT

No.

Planstin is a third-party administrator for company benefits. We help employers design and manage benefit plans that fit their budget and employee needs.

Learn More

Explore the Planstin Help Center here .

Explore the Planstin Blog here .

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What do I need to know about Preventive HSA?

Wed, 01 May 2024 00:16:47 GMT

Preventive HSA is an HSA-qualified health plan that focuses on preventive care. This health plan meets ACA requirements for minimum essential coverage (otherwise known as MEC).

Fair-priced healthcare

This health plan uses an innovative healthcare pricing strategy called fair-priced healthcare. To learn more about fair-priced healthcare, click here .

Care coordination

Preventive HSA health plans have no network restrictions and include care coordination services to help you make appointments and locate providers that work well with your benefits. To learn more about care coordination click here .

To view information about your Preventive HSA health plan, click here and select your specific plan name.

Learn More

Use this checklist to get started with HSA contributions.

Click here to download the Optum app.

Call Planstin’s Member Services team at 888-920-7526 for further assistance.

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What do I need to know about Preventive Copay?

Wed, 01 May 2024 00:16:47 GMT

Preventive Copay is a health plan that focuses on preventive care. The plan provides limited access to select healthcare services through copays. These services may include lab work, imaging, and office visits.

This health plan meets ACA requirements for minimum essential coverage (otherwise known as MEC).

Fair-priced healthcare

This health plan uses an innovative healthcare pricing strategy called fair-priced healthcare. To learn more about fair-priced healthcare, click here .

Care coordination

Preventive Core health plans have no network restrictions and include care coordination services to help you make appointments and locate providers that work well with your benefits. To learn more about care coordination click here .

To view information about your Preventive Copay health plan, including what services are available with a copay, click here and select your specific plan name.

Learn More

Call Planstin’s Member Services team at 888-920-7526 for further assistance.

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What do I need to know about Preventive Basic?

Wed, 01 May 2024 00:16:47 GMT

Preventive Basic health plans are now known as Preventive Core health plans.

Click here to visit the Preventive Core article.

Learn More

Call Planstin’s Member Services team at 888-920-7526 for further assistance.

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What do I need to know about Care+ HSA?

Wed, 01 May 2024 00:16:47 GMT

Care+ HSA is a comprehensive coverage, anywhere plan that covers essential medical needs and does not restrict you to a provider network.

This health plan uses an innovative healthcare pricing strategy called fair-priced healthcare. To learn more about fair-priced healthcare, click here .

To view information about your Care+ HSA health plan, click here and select your specific plan name.

Learn More

Use this checklist to get started with HSA contributions.

Click here to download the Optum app.

Call Planstin’s Member Services team at 888-920-7526 for further assistance.

Explore

What do I need to know about Care+ Copay?

Wed, 01 May 2024 00:16:47 GMT

Care+ Copay is a comprehensive coverage, anywhere plan that covers essential medical needs and does not restrict you to a provider network.

Fair-priced healthcare

This health plan uses an innovative healthcare pricing strategy called fair-priced healthcare. To learn more about fair-priced healthcare, click here .

Copays

Care+ Copay provides access to some healthcare services with copays. For these services the deductible is waived.

To view information about your Care+ Copay health plan, click here and select your specific plan name.

Learn More

Call Planstin’s Member Services team at 888-920-7526 for further assistance.

Explore

What do I need to know about Care+ Core?

Wed, 01 May 2024 00:16:47 GMT

Care+ Core is a comprehensive coverage, anywhere plan that covers essential medical needs and does not restrict you to a provider network.

This health plan uses an innovative healthcare pricing strategy called fair-priced healthcare. To learn more about fair-priced healthcare, click here .

For more information about your Care+ Core health plan, click here and then select your specific plan name.

Learn More

Call Planstin’s Member Services team at 888-920-7526 for further assistance.

Learn more about care coordination services here .

Explore

Do I get telemedicine with Care+?

Wed, 01 May 2024 00:16:47 GMT

Maybe.

Some Care+ plans come with Amaze Health telemedicine and concierge services. However, most Care+ plans do not automatically include telemedicine services. Rather, virtual care services may be available to you through a different, add-on benefit.

If you are unsure whether or not you have access to telemedicine or virtual care, contact Member Services at 888-920-7526 . You can also check your plan details by clicking on "Plan Documents" and searching for your plan name (as found on your member ID card).

Learn More

Unsure if you have Amaze Health? Contact Member Services at 888-720-9526 .

Watch this video on how to set up your Amaze App.

Learn more about how you can use Amaze Health here .

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Is blood work covered with my annual physical?

Tue, 30 Apr 2024 21:26:40 GMT

It depends.

Your health plan covers preventive services, including some routine, preventive blood work, as outlined by the Affordable Care Act (ACA).

To be certain of whether or not your lab work will be covered, your provider can contact the Member Services team to verify that the labs they want to order for you will be covered by your health plan.

Learn More

Do your benefits include a health plan? Call Planstin’s Member Services team at 888-920-7526 for more help understanding your benefit details.

To view a list of all ACA preventive services, click here .

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What is reference-based pricing?

Tue, 30 Apr 2024 02:10:19 GMT

Reference-based pricing uses reference points to determine the most reasonable or fair rate for a service. If your Planstin-managed health plan uses this pricing method, the primary reference point will be the Medicare reimbursement rate.

With fair-priced healthcare that uses RBP, you may choose your provider, and you do not need to worry about penalties for going out of network.

How to talk to your provider about RBP

Though your provider may not be familiar with third-party administrators, like Planstin, they are likely familiar with reference-based pricing.

Once you have located a provider, be sure to discuss your service in advance. Inform your provider that your health plan uses reference-based pricing before making an appointment. Doing so will ensure that you and your provider are on the same page before you receive care.

Learn More

Download this helpful flyer about how RBP works.

Read about your right to pick your provider here .

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Why is there a copay, deductible, and out-of-pocket max listed on my member ID card?

Tue, 30 Apr 2024 00:16:47 GMT

To make contributions to a Health Savings Account (HSA), enrollment in a High Deductible Health Plan (HDHP) is required.

Thus, the Preventive HSA plan is designed accordingly. Under this plan, the deductible applies only to specific services such as sick or primary care office visits, specialist office visits, and lab tests. If a member meets the deductible through these services, they will then be subject to a copay for sick office visits and labs. This copay is only applicable after meeting the deductible.

Note: For employees who are also members of Zion HealthShare, they will work with their IUA when using their HealthShare membership for medical expenses not covered by their health plan.

Learn More

Be sure to register online or through the Optum App to track payments and reimbursements and monitor your account balance.

Call Planstin’s Member Services team at 888-920-7526 for more help understanding your benefits details.

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Why isn't "Planstin" listed when I try registering for Teladoc?

Mon, 29 Apr 2024 23:25:54 GMT

Attention: Do your benefits include a Teladoc Health membership? If you are unsure, contact Member Services at 888-920-7526 for assistance.

When initially registering for Teladoc Health, only the primary member, using their original enrollment information, can activate the account. If a dependent tries to register with their information first, the Planstin option will not appear.

After the primary member's enrollment, the primary member will be able to add dependents to the Teladoc Health account. Once the dependents are added, any over 18 will be prompted by Teladoc Health via email to create their own accounts under the primary member’s account.

You may also want to verify that your benefits include a Teladoc membership. If you are not sure, you can contact Member Services for assistance at 888-920-7526.

Learn More

Get help directly from Teladoc Health Support staff here .

Download the Teladoc Health App for Android here .

Download the Teladoc Health App for Apple here .

Call Planstin’s Member Services team at 888-920-7526 for more help understanding your plan details.

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How do I access the member portal?

Mon, 29 Apr 2024 20:25:18 GMT

Click be low to login.

Learn More

Contact Member Services for help understanding your benefit details at 888-720-7526 .

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Your right to understand what you're reading.

Mon, 29 Apr 2024 20:25:18 GMT

Planstin provides free

Aid to those with disabilities to help them communicate with us, such as sign language interpreters and written information in other formats (large print, audio, electronic formats, other).

Language help for those whose first language is not English, such as Interpreters and member materials written in other languages. The plan must provide, upon request, a notice in any non-English language.

Assistance with filing claims and appeals in any non-English language.

Language Access Services

For help, please call Benefit Advocacy at 888-920-7526 (TTY users: 711).

Spanish (Español) : Para obtener asistencia en Español, llame al 888-920-7526.

Traditional Chinese (中文) : 如果需要中文的幫助, 請撥打這個號碼 888-920-7526.

Navajo (Dine) : Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 888-920-7526.

Pennsylvania Dutch (Deitsch) : Fer Hilf griege in Deitsch, ruf 888-920-7526 uff.

Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 888- 920-7526.

Samoan (Gagana Samoa) : Mo se fesoasoani i le Gagana Samoa, vala’au mai i le numera telefoni 888-920-7526.

Carolinian (Kapasal Falawasch ) : ngere aukke ghut alillis reel kapasal Falawasch au fafaingi tilifon ye 888-920-7526.

Chamorro (Chamoru) : Para un ma ayuda gi finu Chamoru, å’gang 888-920-7526.

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Your right to choose a provider

Mon, 29 Apr 2024 20:25:18 GMT

If your employer is sponsoring a health plan with Planstin’s help, the health plan likely uses reference-based pricing (RBP) to help prevent inflated healthcare costs.

What is RBP?

Reference based pricing, or RBP, is a healthcare pricing system that uses reference points to determine the value of a service. The reference point Planstin-managed health plans primarily use is the Medicare reimbursement rate.

This reference-based pricing strategy can result in savings for both you and your plan sponsor.

How to talk to your provider about RBP

Though your provider may not be familiar with third-party administrators, like Planstin, they are likely familiar with reference-based pricing.

Once you have located a provider, be sure to discuss your service in advance. Inform your provider that your health plan uses reference-based pricing before making an appointment. Doing so will ensure that you and your provider are on the same page before you receive care.

Do you have a plan that uses RBP?

Your employer may have designed a plan with us that requires the use of the PHCS Network. In this case, you are free to choose a provider within that network using the search tool located here . If you are unsure if your plan uses this network, you can call 888-920-7526 .

Learn More

To learn more about RBP and your health plan click here .

To find out if your health plan uses RBP, search for your plan documents here .

To learn more about your rights under the No Surprises Act (NSA) click here .

Questions about your coverage? Contact Member Services at 888-920-7526 .

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Do I have to enroll in a medical plan to enroll in dental?

Sun, 28 Apr 2024 23:25:54 GMT

Maybe.

Unless your group has more than five participating employees, you will need to enroll in a health plan to enroll in a dental or vision plan.

Learn More

Learn more about your dental plan here .

Contact Member Services for help understanding your plan details at 888-920-7526 .

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Do I have to enroll in a medical plan to enroll in vision?

Sun, 28 Apr 2024 23:25:54 GMT

Maybe.

Unless your group has more than five participating employees, you will need to enroll in a health plan to enroll in a dental or vision plan.

Learn More

Learn more about your vision plan here.

Contact Member Services for help understanding your plan details at 888-920-7526 .

Explore

Will my dental plan cover out-of-network services?

Sun, 28 Apr 2024 23:25:54 GMT

Yes.

Please refer to the plan outlines linked below to see the out-of-network coverages.

Standard Dental: click here

Enhanced Dental: click here

Why Stay In-Network?

Using in-network providers allows your plan to keep rates low and directs members to high-quality dental care.

Learn More

Learn more about your dental plan here .

Visit the Connection Dental Network homepage .

Contact Member Services for help understanding your benefits details at 888-920-7526 .

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How do I find in-network vision providers?

Sun, 28 Apr 2024 23:25:54 GMT

Any licensed provider is acceptable. There is no network.

To avoid paying copays, you can go to Costco, Sams Club, or Walmart.

Learn More

Learn more about your vision plan here.

Are you enrolled in a Vision plan? Contact Member Services for help understanding your benefits details at 888-920-7526 .

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Where do I submit for vision expense reimbursement?

Sun, 28 Apr 2024 23:25:54 GMT

Click below.

Learn More

Learn more about your vision plan here.

Are you enrolled in a Vision plan? Contact Member Services for help understanding your benefits details at 888-920-7526 .

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Do I pay for vision services and equipment and then get reimbursed?

Sun, 28 Apr 2024 23:25:54 GMT

Yes.

If you have a Planstin-managed vision plan, in most cases, vision service providers may ask you to pay up front. If you do pay out-of-pocket for vision services, you can get reimbursed upon submission of an itemized receipt.

This receipt needs to include the Patient's Name, Member Number, Group Number, and the Date of Services and/or Purchase. To claim reimbursement, attach a detailed invoice to an email and send it to claims@planstin.com .

Learn More

Learn more about your vision plan here .

Contact Member Services for help understanding your plan details at 888-920-7526 .

Explore

Are Your Small Business Benefits Risking Your Employees' Marketplace Subsidies?

Thu, 25 Apr 2024 23:00:49 GMT

If you are a small business owner thinking about offering benefits or expanding your current benefits package, you may worry about preventing employees from being eligible for subsidies if they decide to purchase Marketplace coverage.

In our work designing benefits packages for small businesses, one common topic we often find ourselves clarifying for clients is the impact of the Affordable Care Act (ACA) on health insurance accessibility and affordability, especially when it comes to employer-sponsored benefits. At Planstin, our goal is to make benefits accessible to more people. As part of this, we want to address and resolve confusion and help employers offer benefits with confidence.

The ACA, the Marketplace, and subsidies

One of the ways the ACA expands access to health insurance for more Americans is through the Health Insurance Marketplace, a platform where users can compare and purchase health insurance coverage. While the health insurance available on the Marketplace does have standard market premium costs, the ACA allows for subsidies for those in lower income brackets. These subsidies, essentially financial assistance from the government, make coverage purchased through the Marketplace more affordable.

Another mechanism through which the ACA expands access to health insurance is by imposing requirements and considerations on businesses based on their size.

Businesses with More Than 50 Full-Time Employees

These businesses are considered large employers under the ACA and are required to provide health insurance that meets the ACA’s standards of Minimum Essential Coverage (MEC) , Minimum Value , and affordability . If a business of this size fails to comply, either by offering no health coverage or insufficient health coverage, this results in financial penalties. These penalties help incentivize large businesses to offer these types of benefits.

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The ACA allows subsidies for those in lower income brackets. These subsidies, essentially financial assistance from the government, make coverage purchased through the Marketplace more affordable.

Minimum Essential Coverage: This is the type of coverage an individual needs to have to meet the ACA’s individual responsibility requirement (often termed the individual mandate). Most employer-sponsored health benefits meet this standard.

Minimum Value: The ACA considers a plan as meeting Minimum Value standards if it covers at least 60% of the total cost of medical services for a standard population, as well as substantially covers inpatient hospitalization services and physician services.

Affordability: For 2024, the affordability threshold is set at 8.39% of an employee’s household income. If an employer only offers insurance that costs an employee more than this, it is considered unaffordable under the ACA.

Businesses with Fewer than 50 Full-Time Employees

Small businesses fall outside the mandate that requires providing health insurance, and thus the requirements listed above do not apply to them. However, many small businesses still choose to offer health benefits to attract and retain talent on their teams. The ACA provides options and incentives for small businesses in these scenarios, including the Small Business Health Options Program (SHOP) Marketplace , to help make purchasing health insurance more manageable for small employers.

As mentioned earlier, subsidies play an important role in expanding health insurance access, but these subsidies aren’t available to everyone. Only those with low-to-mid-level incomes that do not have ACA-compliant employer-sponsored benefits options available to them can qualify for these subsidies.

What ends up confusing some employers is whether offering any health benefits will make it so their employees can’t access these subsidies. To clarify: you can offer your employees health benefits without jeopardizing their eligibility for marketplace subsidies. Let’s see how.

MEC + HealthShare: An affordable alternative

Preventive MEC plan designs focus on preventive care services. They are specifically designed to cover basic health services, including preventive care like routine checkups, immunizations, and screenings that can be important for maintaining health and preventing illness. As MEC-compliant plans, they allow employees to meet the individual mandate, but they do not include the more comprehensive benefits of a Minimum Value-compliant health plan.

To complement the preventive care provided by a MEC plan and fill the gaps for larger unexpected medical needs, Planstin partners with Zion HealthShare to provide clients access to HealthShare membership options. HealthShares are not insurance, but instead are a cooperative medical cost sharing program through which funds are pooled by members and distributed to those with eligible medical costs.

MEC vs MV: What’s the Difference?

Because the ACA imposes a mandate for individuals to have insurance, the MEC standard must be met to satisfy this individual mandate. Simply put, the distinction between the two is that MEC is about coverage requirement, and MV is about coverage quality.

It should also be noted that while previously individuals might face penalties for not meeting the individual mandate, these penalties are not currently in effect.

This model supports members in managing larger and unexpected medical expenses, particularly for events or treatments not covered under a preventive MEC plan. You can learn more about Zion HealthShare membership here .

For small businesses seeking to offer more well-rounded health benefits while managing costs, combining MEC with HealthShare membership offers a balanced and affordable solution. This combination provides employees with access to essential preventive services while also providing a safety net for more significant medical expenses through a supportive community-based approach.

What MEC + HealthShare won’t do, however, is disqualify your employees from Marketplace subsidies.

As a small business owner, you may want to offer affordable benefits like MEC + ZHS but are concerned that having this option available might make your employees lose out on subsidies they could use to buy coverage through the Marketplace. In reality, this should not be a concern, and you can rest assured that Planstin will help you design a plan to support your employees’ health without affecting their eligibility for subsidies.

Offering MEC + HealthShare does not impact subsidy eligibility

The simple answer here is that MEC plans do not meet the ACA’s Minimum Value standards for comprehensive health coverage. And because HealthShare membership is not a form of insurance, it also does not meet the Minimum Value criteria. With this being the case, your employees can still qualify for subsidies if they choose to purchase insurance through the marketplace.

You can offer your employees health benefits without jeopardizing their eligibility for marketplace subsidies.

When subsidy eligibility may be affected

Typically, employees’ eligibility for Marketplace subsidies are affected at larger companies where the ACA’s requirements apply. If a company opts to provide plans that meet these standards, such as a Care+ plan , employees’ subsidy eligibility could be affected, even if they choose not to enroll.

But when businesses with fewer than 50 employees, who are not subject to the employer mandate, choose to offer a MEC + Zion HealthShare combination, the scenario is different. Their employees are not disqualified from Marketplace subsidies if they offer MEC + HealthShare.

Tailor your benefits

At Planstin, we help you design a benefits package to do the most good for your company and employees. Our approach is tailored, recognizing that while we do work with plan designs that meet the ACA’s Minimum Value requirements, these plans are not necessarily the answer for small businesses that are not required to offer them. This understanding shapes our ability to help clients with MEC + HealthShare combinations— packages designed to offer a well-rounded healthcare solution without risking your employees’ eligibility for Marketplace subsidies.

If you’re a small business owner looking for benefits designed to fit your needs, there are solutions for you.

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SUGGESTED FOR YOU

Is telemedicine covered?

Wed, 10 Apr 2024 22:09:07 GMT

Maybe.

Some Planstin-managed health plans include remote or virtual care services. Telemedicine may be made available to members through Teladoc Health, Amaze Health, or Primestin Care depending on their specific health plan and other benefits.

To verify if your health plan includes telemedicine or virtual care services you can:

1) Ask your employer.

2) Contact Member Services at 888-920-7526 .

3) Click on " Plan Documents " and search for the plan name listed on your member ID card. Your search results will include a plan outline and SBC with your plan details.

Note: Your employer may have offered you telemedicine services separate from a health plan.

Learn More

For more details about the coverage of your specific plan, click here and search for your plan ID.

To learn more about Primestin Care, click here .

To learn more about Teladoc Health, click here .

To learn more about Amaze Health, click here .

Contact Member Services if you have questions about your benefits: 888-920-7526 .

Explore

Is lab work covered?

Wed, 10 Apr 2024 22:09:07 GMT

Maybe.

All Planstin-managed health plans cover preventive labs as outlined by the ACA. Beyond that, certain labs may be covered depending on your health plan.

For example, if you have the Preventive Copay health plan, or the Care+ Copay plan, you have coverage for a limited number of labs—up to $100 per lab test*.

*Please note: this is per test not per blood draw.

To learn more about your specific plan coverage, please click on " Plan Documents " and search for the plan name listed on your member ID card. As you type in your plan name your search results will include a plan outline and SBC.

Learn More

For more details about the coverage of your specific health plan, click here and search for your plan ID.

Contact Member Services if you have further questions about your coverage: 888-920-7526 .

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Is surgery covered?

Wed, 10 Apr 2024 22:09:07 GMT

Maybe.

Preventive Basic, Preventive HSA, and Preventive Copay plans do not cover surgery. However, all Care+ health plans do include coverage for in-patient and out-patient medical concerns.

Additionally, many members with a preventive health plan also become Zion HealthShare members. A Zion HealthShare membership is designed for larger, unexpected medical needs like surgery.

Learn More

To learn more about Zion HealthShare click here .

Read the Zion HealthShare Member Guidelines here .

Click here to learn more about Care+.

For more details about the coverage of your specific plan, click here and search for your plan ID.

Contact Member Services if you have further questions about your coverage: 888-920-7526 .

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Are emergency room (ER) visits covered?

Wed, 10 Apr 2024 22:09:07 GMT

Maybe.

Preventive Basic, Preventive HSA and Preventive Copay plans do not cover ER visits. However, all Care+ health plans do include coverage for ER visits.

Additionally, many members with a Preventive health plan also become Zion HealthShare members. A Zion HealthShare membership is designed for larger, unexpected medical needs like trips to the emergency room.

Learn More

To learn more about Zion HealthShare click here .

Read the Zion HealthShare Member Guidelines here .

Click here to learn more about Care+.

For more details about the coverage of your specific health plan, click here and search for your plan ID.

Contact Member Services if you have further questions about your coverage: 888-920-7526

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What is Zion HealthShare?

Wed, 10 Apr 2024 22:08:50 GMT

Zion HealthShare is a nonprofit medical cost sharing organization that provides an organized structure for members to contribute toward each other’s medical costs.

This alternative solution is well suited to complement a preventive (MEC) health plan.

Learn More

Visit zionhealthshare.org to learn more.

Visit zionhealthshare.org/member-guidelines to learn more about eligible medical costs.

View one HealthShare member's story by clicking here .

Are you a HealthShare member? Contact Member Services to verify your benefits: 888-920-7526

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What is an IUA?

Wed, 10 Apr 2024 22:08:50 GMT

An initial unshareable amount, or IUA, is the amount a HealthShare member must commit to paying for a medical need before the medical cost sharing community will begin to share expenses related to that need.

Learn More

Click here to learn more about IUAs.

Visit zionhealthshare.org/member-guidelines to learn more about eligible medical costs.

View one HealthShare member's story by clicking here .

Are you a HealthShare member? Contact Member Services to verify your benefits: 888-920-7526 .

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Can my deductible go toward my IUA?

Wed, 10 Apr 2024 22:08:50 GMT

No.

Deductibles and IUA’s are not related. Your deductible applies to your health plan as the amount you pay for covered health care services before your health plan starts to pay.

Your initial unshareable amount, or IUA, is the amount you must pay before expenses related to a medical need become shareable with the Zion HealthShare community.

Learn More

Click here to learn more about the IUA.

Visit zionhealthshare.org/member-guidelines to learn more about eligible medical costs.

Are you a HealthShare member? Do you have a health plan with a deductible? If you are unsure, contact Member Services to verify your benefits: 888-920-7526

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Do you cover pre-existing conditions?

Wed, 10 Apr 2024 22:08:50 GMT

Yes.

If you have a Preventive series or Care+ series health plan, there are no limitations on pre-existing conditions for plan covered services .

*Please note: if you have a Zion HealthShare membership, there are some pre-membership medical conditions that cannot be shared with the community.

Learn More

For more details about the coverage of your specific health plan, click here and search for your plan ID.

Contact Member Services if you have questions about your coverage: 888-920-7526 .

To learn more about Zion HealthShare please read their member guidelines .

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Do you cover COVID vaccines?

Wed, 10 Apr 2024 22:08:43 GMT

Yes.

If you have a Preventive series or Care+ series health plan, COVID-19 vaccines are covered when administered in a doctor's office*.

*Note: The vaccine will not be covered if received at a pharmacy.

What options do I have to get the vaccine?

Option 1: Use a federal or state program to obtain the vaccine: https://www.vaccines.gov/ .

Option 2: Go to a provider to obtain the vaccine. Your plan will pay the Medicare or UCR rate, and there should be $0 patient responsibility.

If you receive a bill for a preventive service, such as a flu or COVID vaccine, contact Member Services immediately.

Learn More

For more details about the coverage of your specific health plan, click here and search for your plan ID.

Contact Member Services if you have further questions about your coverage: 888-920-7526 .

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How do I find a dental provider?

Wed, 10 Apr 2024 22:08:43 GMT

1.) Visit the Connection Dental Network homepage

2.) Enter your zip code

3.) Search for a provider*

You can search by group name, facility name, dentist name, or specialty. You can also create a general, printable directory of in-network providers near you by clicking on the “Create Directory” button.

*Please Note: When selecting a provider, contact the provider’s office to verify that they are still in-network with Connection Dental.

Why In-Network?

Using in-network providers allows your plan to keep rates low and directs members to high-quality dental care.

Learn More

Do you have a Planstin-managed dental plan? If you are unsure, contact Member Services at 888-920-7526 for assistance.

Learn more about your dental plan here .

Need help understanding your plan details? Call us at 888-920-7526 .

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Can I make changes to my plan?

Wed, 10 Apr 2024 22:08:43 GMT

To make changes to your health plan outside of your annual renewal period, you must have had a qualifying life event (QLE), and informed us, within 60 days of the event.

Examples of qualifying life events (QLEs) include:

Marriage
Divorce
Birth

Learn More

For more information on qualifying life events click here .

Contact Member Services for help understanding your plan details at 888-720-7526 .

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What are HSA contributions?

Wed, 10 Apr 2024 22:08:43 GMT

Your HSA contribution is the money you deposit into your health savings account. This contribution amount is separate from what you pay for your health plan.

If you are enrolled in an HSA-qualified health plan, there should be two line items on your paystub, one for your health plan and one for the amount you contribute to your health savings account.

If you have an HSA-qualified health plan, and you do not see a line item for an HSA contribution on your invoice or paystub, that means you have not set up contributions yet.

Learn More

To learn how to get started contributing to your HSA click here .

Optum Bank’s website has a search tool to show what is eligible to be purchased with your HSA. Click here to use the tool .

Call Planstin’s Member Services team at 888-920-7526 for more help understanding your plan details.

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What is TELUS Health (LifeWorks)?

Wed, 10 Apr 2024 22:08:43 GMT

LifeWorks, now known as TELUS Health, offers members mental health resources, such as virtual consultations with mental health professionals. These services are available 24/7 via phone, web, or mobile app.

Learn More

Learn more about TELUS Health here .

Download the TELUS Health App for Android here .

Download the TELUS Health App for Apple here .

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What is Amaze Health?

Wed, 10 Apr 2024 22:08:43 GMT

Amaze provides a complete virtual care solution that is completely hassle free. Amaze Health members have access to virtual urgent care, virtual primary care, health education, and much more!

Need help getting started with Amaze Health?

Visit: amazehealth.com/support/

Call: 720-577-5251

Learn More

Not sure you have an Amaze Health membership? Contact Member Services 888-920-7526 .

Watch this video on how to set up your Amaze App.

Learn more about how you can use Amaze Health here .

Download the Amaze Health App for Android here .

Download the Amaze Health App for Apple here .

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What is Rx Valet?

Wed, 10 Apr 2024 22:08:23 GMT

Rx Valet is a robust, discount prescription program that provides its members more ways to save and convenient support for all their prescription needs.

Members with access to Rx Valet simply register at rxvalet.com using their Member ID and Group ID.

Unsure if you have access to Rx Valet?

Check your Member ID card; Your prescription benefit information should be listed there.

Alternatively, you can click on " Plan Documents " and search for your health plan documents using the plan name on your Member ID card. Your plan outline and SBC will contain information about your prescription benefits.

Rx Valet & Advanced Pharmacy

Rx Valet partners with Advanced Pharmacy for mail order delivery. Members may be contacted by Advanced Pharmacy with updates about their prescription order delivery.

Advanced Pharmacy Information

350 Feaster Road, Ste. D

Greenville, SC 29615

Phone: 855-240-9368

Fax: 888-240-3823

Learn More

Learn more about how you can use Rx Valet here .

Download the quick start guide here .

Contact Member Services for help understanding your benefits details at 888-720-7526 .

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Your rights as a patient

Wed, 10 Apr 2024 22:08:23 GMT

The Affordable Care Act’s Patient’s Bill of Rights outlines rights that include access to coverage for pre-existing conditions, limits on when an insurance company may rescind or cancel coverage, and coverage without lifetime or annual limits.

Your patient rights include

Right to coverage for pre-existing conditions
Right to coverage without lifetime limits
Right to continuing coverage
Right to choose a provider
Right to information
Right to complain or appeal
Right to dependent coverage (up to 26)

Learn More

Read more about the original Patient’s Bill of Rights here .

Red more about the ACA's expansion of the Pat ient's Bill of Rights here .

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Your right to understand your coverage.

Wed, 10 Apr 2024 22:08:23 GMT

It’s important to understand how the Affordable Care Act (ACA) impacts your employer-sponsored health benefits.

ACA's individual mandate

Under the ACA, individuals must have qualifying health coverage, or minimum essential coverage (MEC). You can obtain this coverage through an employer-sponsored plan, an individually purchased plan, or a government-sponsored plan.

California, New Jersey, Rhode Island, Vermont, Massachusetts, and the District of Columbia, impose fines if individuals don’t have qualifying coverage.

ACA’s employer mandate

The ACA also includes an employer mandate for employers who have 50 or more full-time employees. If your employer has 50 or more full-time employees, they are legally required to offer you a health plan option that meets minimum essential coverage and minimum value standards. Failure to do so results in penalties and fines.

What is minimum essential coverage (MEC)?

For your health plan to qualify as MEC, it needs to cover preventive care as outlined by the ACA and adhere to the Patient’s Bill of Rights.

What is minimum value?

For your health plan to qualify as meeting minimum value standards, it needs to cover a minimum of 60% of the overall costs for plan covered services and include a broad range of medical services, including inpatient and outpatient surgery, maternity care, and emergency and urgent care.

Learn More

To learn more about the individual mandate, visit healthinsurance.org .

To learn more about the employer mandate, visit irs.gov .

For a detailed list of what qualifies as MEC, visit healthcare.gov .

Read more about the original Patient’s Bill of Rights here .

Red more about the ACA's expansion of the Patient's Bill of Rights here .

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Your right to obtain preventive care.

Wed, 10 Apr 2024 22:08:23 GMT

If you have an employer-sponsored, Planstin-managed health plan, it includes preventive care as outlined by the Affordable Care Act. All of these preventive services are 100% covered by your plan.

Your 100% covered preventive services include:

Annual Wellness Visit
Health Screenings
Immunizations
Cancer Screenings
Child's Vision Acuity Screening

You can access the full list of preventive services here .

If you receive preventive care covered by your health plan, your plan will take care of the bill. If, for any reason, you receive a bill for preventive care from your provider, contact Member Services at 888-920-7526 .

Learn More

View all ACA outlined preventive services here .

Red more about the ACA's expansion of the Patient's Bill of Rights here .

Questions about your coverage? Contact Member Services at 888-920-7526 .

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Your right to appeal.

Wed, 10 Apr 2024 22:08:23 GMT

After getting a denial or refusal from your health plan, you or an authorized person have 180 days to appeal it. This appeal process is for situations like denied benefits, unpaid services, or canceled coverage —otherwise known as an Adverse Benefit Determination.

How to appeal

You may request an appeal by sending a written request to the following address:

Planstin Administration

ATTN: Claims/Appeals

1506 S. Silicon Way, Suite 2B

St. George, UT 84770

Please include the following information in your written request:

Member Name & Date of Birth
Member ID & Group Number
Claim Number
Date of Service
Name of Provider
Reason for Appeal

During the appeal process, all comments, documents, and information related to your claim will be reconsidered, regardless of whether they were looked at before. The review will be handled by a new decision-maker from the plan, who wasn't involved in the original denial. This ensures an unbiased, fresh review of your appeal.

Learn More

Read more about your appeal rights here .

To learn more about the appeal process, visit planstin.com/for-providers .

Questions about your coverage? Contact Member Services at 888-920-7526 .

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Your right to understand the difference between preventive and diagnostic care.

Wed, 10 Apr 2024 22:08:23 GMT

Group health plans managed by Planstin offer preventive care coverage as outlined by the ACA. Some plans may require that these preventive services be performed in-network for coverage. Not all plans cover diagnostic exams.

Note: Please see your plan’s Statement of Benefits and Coverage (SBC) or call us a t 888-920-7526 for specific details about your plan.

What is a preventive health screening?

A preventive health screening, such as a colonoscopy or mammogram, is performed as a part of your routine health care. Your doctor may order one once you reach a certain age to ensure there are no unseen health changes.

What is a diagnostic health exam?

A diagnostic health exam, such as a diagnostic colonoscopy or mammogram, is performed when you or your doctor are concerned about changes in your health. Your doctor will order a diagnostic exam to try and find the cause of your symptoms and to make a medical diagnosis.

Learn More

To learn more about preventive and diagnostic care, click here .

View all ACA outlined preventive services here .

Red more about the ACA's expansion of the Patient's Bill of Rights here .

Questions about your coverage? Contact Member Services at 888-920-7526 .

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Your right to transparent coverage.

Wed, 10 Apr 2024 22:08:23 GMT

Machine-Readable Files (MRFs)

In compliance with The Transparency in Coverage Rule (TiC), health plans and health insurance issuers must publish two Machine-Readable Files (MRFs) containing in-network and out-of-network details.

About Transparency in Coverage (TiC)

The Transparency in Coverage Rule requires most health insurance issuers and group health plans to disclose pricing and cost-sharing information to participants, enrollees, and beneficiaries. Pricing information includes billed charges, negotiated rates, and allowed amounts paid for out-of-network providers using two Machine-Readable Files (MRFs).

Learn More

To access the In-Network and Out-of-Network MFRs, visit planstin.com/transparency-in-coverage .

Questions about your benefits? Contact Member Services at 888-920-7526 .

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Your right to avoid a surprise bill.

Wed, 10 Apr 2024 22:07:52 GMT

If you are over a certain age, or have specific risk factors, your doctor may recommend that you get a preventive health screening, like a colonoscopy or a mammogram.

Before you schedule the appointment, it’s important to know who will be reviewing your results, and what will happen if the preventive screening discovers something.

Situations where you might receive a surprise bill

Your preventive screening revealed something that needs to be examined more closely (diagnostic).
Your screening was reviewed by an out-of-network doctor.

No Surprises Act

Under the No Surprises Act, you cannot be charged for more than the in-network rate if you are receiving services covered by your plan at an in-network facility.

Learn More

To learn more about preventive and diagnostic care, click here .

To learn more about your rights under the No Surprises Act (NSA) click here .

Questions about your benefits? Contact Member Services at 888-920-7526 .

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Why did my claim come back as out of network?

Tue, 09 Apr 2024 23:58:22 GMT

If your health plan uses a network, using the PHCS “find a provider” tool does not necessarily guarantee that the provider is still in-network with PHCS.

We recommend that you call your provider to verify that they are still participating in the network before receiving care.

Learn More

To search for an in-network provider, visit planstin.com/PHCS

Does your health plan require you to use a provider network? Find your plan documents here . Or call Member Services for help understanding your plan details 888-920-7526 .

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How do I contribute to my HSA?

Tue, 09 Apr 2024 23:58:18 GMT

You will elect how much to regularly contribute to your HSA when you enroll in your health plan.

Optum Bank will send you an HSA debit card via mail. You'll have the option to register online or through their App to monitor your account balance.

If you wish to change your regular contribution about, you can inform your boss, or HR department about the amount you want to contribute each month, and they will relay the information to us. Typically, it takes between 2 to 4 weeks for the change to take effect.

*Please note, an initial deposit of at least $10 is necessary to activate your HSA.

Learn More

Use this checklist to get started with your HSA contributions.

Call Planstin’s Member Services team at 888-920-7526 for more information about how to make contributions or changes to reoccurring contributions.

Does your health plan include an HSA? Verify your benefits by clicking on "Benefit Documents" under "Explore." Then search for the plan name listed on your Member ID card. Click here to for more help finding out what plan you have.

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How do I submit a claim?

Tue, 09 Apr 2024 23:58:13 GMT

Through your provider.

Claims should be sent to us through electronic data interchange (EDI) by your provider. If your provider cannot, or will not, submit a claim to Planstin, then you can call the Member Services team for assistance with a reimbursement.

Claims Contact Information

EDI Payer ID: 65241

Address: P.O. Box 21747, Eagan, MN 55121

Learn More

Question about appeals? Click here .

Contact Member Services for help understanding your plan details at 888-720-7526 .

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How do I get started with Rx Valet?

Tue, 09 Apr 2024 21:27:56 GMT

Follow the steps below.

1.) Visit rxvalet.com

2.) Click “login with member/group ID”

3.) Enter your credentials: Member Number and RxGrp code from your ID card

4.) Click “Log In” to update your profile and create a new password

5.) Start saving on your prescription needs

Need help getting started?

Call: 855-798-2538

Email: info@rxvalet.com

Live Chat: rxvalet.com

Learn More

Learn more about how you can use Rx Valet here .

Download the quick start guide here .

Not sure if your benefits include Rx Valet? Contact Member Services for help understanding your plan details at 888-720-7526 .

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How do I start using Amaze Health?

Tue, 09 Apr 2024 21:27:43 GMT

Attention: Do your benefits include an Amaze Health membership? If you are unsure, contact Member Services at 888-920-7526 for assistance.

Follow the steps below.

1. Register. Complete the online registration form on AmazeHealth.com or the Amaze Health app.

*Note: Use the same name and email that is associated with the primary member on your Planstin membership.

2. Select your health plan. You should be automatically matched with your health plan. If you experience issues, contact Member Services at 888-920-7526 .

3. Create your account. Create a username and password, and fill out your medical history.

Need help setting up the App or getting started?

Visit: amazehealth.com/support/

Call: 720-577-5251

Learn More

Watch this video on how to set up your Amaze App.

Learn more about how you can use Amaze Health here .

Download the Amaze Health App for Android here .

Download the Amaze Health App for Apple here .

Do you have benefits that include an Amaze Health membership? If you are unsure, contact Member Services at 888-920-7526 to verify.

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How do I register for TELUS Health (LifeWorks)?

Tue, 09 Apr 2024 21:27:25 GMT

Attention: Do your benefits include an TELUS Health (LifeWorks) membership? If you are unsure, contact Member Services at 888-920-7526 for assistance.

Follow the steps below.

1. Visit the LifeWorks website tor download the app from the Google Play Store or App Store.

2. Login.

a. Username: Planstin

b. Password: Lifeworks

3. Create your account. Once you’ve logged in with the above credentials, you can create a personal account with your own email and password.

Learn More

Download the TELUS Health App for Android here .

Download the TELUS Health App for Apple here .

Do your benefits include a TELUS Health (LifeWorks) membership? If you are unsure, call Planstin’s Member Services team at 888-920-7526 for more help understanding your plan details.

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How do I register for Teladoc Health?

Tue, 09 Apr 2024 21:27:10 GMT

Attention: Do your benefits include a Teladoc Health membership? If you are unsure, contact Member Services at 888-920-7526 for assistance.

Follow the steps below.

Step 1

Click HERE and complete the online form

Select your health plan—confirm the Planstin option

Create username, password, and security questions

Click “Complete Registration”

Helpful Tips

Wait 24 hours after receiving your Planstin welcome email to register for Teladoc Health.
If you have difficulty registering online, try registering with the mobile App.

Step 2

Complete your registration using the same information you used to enroll in your health plan. Make sure you use the primary subscriber information—not a dependent’s information.

Step 3

You will be automatically matched with a benefits provider, simply confirm the selection and click “continue.” If you experience issues, please contact a Member Services at 888-920-7526 .

There’s an App for that!

You can enroll through the Teladoc Health mobile app. Simply download the Teladoc Health app through the Google Play Store or App Store. The registration process is the same as the online Teledoc Health registration.

Learn More

Get help directly from Teladoc Health support staff here .

Download the Teladoc Health App for Android here .

Download the Teladoc Health App for Apple here .

Do your benefits include a Teladoc Health membership? If you are unsure, contact Member Services 888-920-7526 for assistance.

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How do I find out what my prescription benefits are?

Tue, 09 Apr 2024 21:26:22 GMT

Your prescription benefits are listed on your ID card.

You may use the plan code listed on your ID card to pull up your plan outline and SBC here . The benefit information specific to your plan, including your prescription benefits, will be detailed in those documents.

Learn More

Call Planstin’s Member Services team at 888-920-7526 for more help understanding your plan details.

Learn more about how Rx Valet works here .

Explore OptumRx prescription services at rx.planstin.com .

Don't see any prescription benefits listed on your ID card? Contact Member Services for help.

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What can I use my HSA to pay for?

Tue, 09 Apr 2024 21:25:57 GMT

You can use HSA funds to pay for deductibles, copayments, coinsurance, and other qualified medical expenses. To find out if an expense is HSA-qualified visit planstin.com/hsa .

Optum Bank will send you an HSA debit card via mail that you may use for qualified expenses. You may also submit expenses for reimbursement. All withdrawals to pay eligible medical expenses (whether by debit or reimbursement) are tax-free.

Unspent HSA funds roll over from year to year, allowing you to build tax-free savings to pay for medical care later.

Learn More

Optum Bank’s website has a search tool to show what is eligible to be purchased with your HSA. Click here to use the tool .

Call Planstin’s Member Services team at 888-920-7526 for more help understanding your plan details.

Does your health plan include an HSA? Verify your benefits by clicking on "Plan Documents" under "Explore." Then search for the plan name listed on your Member ID card. Click here to for more help finding out what plan you have.

Explore

Rx Valet: What Is It and How Does It Work?

Thu, 04 Apr 2024 22:49:16 GMT

With Rx Valet, members can get affordable access to the medications they need—even specialty meds that may typically be cost prohibitive. Not only does the program make prescriptions more affordable, it makes getting them more convenient.

In the past decade the net cost of prescription drugs rose more than three times faster than the rate of inflation, and roughly 20% of an employers’ staff has at least one chronic medical condition and takes four or more meds. These numbers emphasize the serious need for employers to offer a more affordable solution for their team. Planstin Administration has found a way to help employers do just that: Rx Valet. In this article we will cover what Rx Valet is, how it works, and how to get started.

Rx Valet Highlights

Works with over 70,000 pharmacies in all 50 states
Live chat with Rx Service Specialists
Rx ID card ready to use wherever you go
Membership provides access to pet medication discounts
Search for medications and receive instant prices
Set reminders to take your medications
International sourcing for specialty and high-price drugs for significant savings

What is Rx Valet?

Rx Valet is a robust prescription discount program. A high-performing complement to your standard health plan coverage. When we say high performing, we mean it. Through the Rx Valet program, members may pay as little as $0 for routine prescriptions, and no more than $15 for other common medications.

Explore

In addition, members have access to 90-day mail order refills without any extra legwork. Our dedicated Rx Valet support team will help you get started with mail order and notify you when you have an upcoming refill. If you don’t have any refills left, they will reach out to your provider and handle it, ensuring that you never miss a dose.

If you don’t have time to wait for mail order, you can opt to pick up your first fill prescription from your local pharmacy or from a pharmacy selected by Rx Valet. You can pay ahead, or pay at the pharmacy, depending on the available options.

Rx Valet is a robust prescription discount program.

A high-performing complement to your standard health plan coverage.

Mail order

The primary way you will receive your prescriptions with this program is through mail order. In fact, after the initial script is filled at your local pharmacy, you will need to log in to your Rx Valet portal and set up mail delivery for any future refills. After that, Rx Valet will take care of the rest. This way, you get maximum cost savings, and benefit from the convenience of medications delivered to your doorstep.

Sometimes, you will need a medication immediately, and you can certainly pick those up at your pharmacy right away. But, generally, Rx Valet, works through mail-order as that is the primary way that we are able to save members so much money. It’s also extremely convenient and easy to manage through your member portal.

What If You Forget to Set Up Mail-Order Refills?

Rx Valet will reach out to you after your first fill to help you get your mail order set up. If for some reason you are not contacted and you return to the pharmacy for your refill, the pharmacist will inform you that you must obtain a refill through mail order to properly use your benefits. And then the pharmacist will likely inform you of the cash

Mail-order is the primary way that Rx Valet is able to save members so much money.

price. If this happens, contact us right away. We will do our best to help you get what you need as soon as possible. If that means filling an in-person pick up for a few pills while waiting for mail order, we will make it happen.

Package Tracking

If you have sensitive medications, Rx Valet knows how to handle them. Not only are all medication shipments tracked, but certain specialty medications are also packaged with equipment that allows Rx Valet to monitor their temperature.

If your medications are ever compromised during shipping, Rx Valet is notified immediately so that they can begin to locate a replacement. We will contact you with an update about your order and how you will receive your replacement (even if that need be through a local retail pharmacy).

Purchasing options: First fill

Pre-Pay Select; Guaranteed Price – Rx Valet will direct you to a specific pharmacy, and you must pay online before you go to pick it up.

Pre-Pay Choice; Guaranteed Price – You select your favorite pharmacy, and Rx Valet finds you the lowest price available at that location. You will pay in advance through your Rx Valet portal and be sent a Rx Valet Drug Card with processing information. Then all you need to do is present the card at the pharmacy for pick up.

Pre-Pay Home Delivery; Guaranteed Price – Place your order online through your member portal. Make sure you can wait up to 10 business days if necessary for your order to arrive. You can get up to a 90-day supply and set up auto-shipped refills for maintenance medications.

Rx Discount Card (retail); No Guaranteed Price – Search for your medication using the Rx Valet search tool and locate the nearest pharmacy with the lowest listed price. Select the pharmacy you want to pick up from, and your Rx Valet portal will populate an Rx Card with the price listed. Take the card and present it at the pharmacy. You will pay for the medication at the location.

Copay Cards – If you have been prescribed a brand-name medication, reach out to Rx Valet immediately. While there is no guarantee, the Rx Valet team will do what they can to find a copay card if one is available to help you save as much as possible on your first fill.

Purchasing options: Refill

Home Delivery – All refills for maintenance medications must be filled through mail order. You can get up to a 90-day supply and set up auto-shipped refills so you never miss a dose.

Pickup – Refills for controlled substances may be processed for in-person pick up. You will place the order through your member portal and pickup at and the selected location. Additionally, for medications that must be received immediately (no time to wait for delivery), exceptions to the home delivery requirement can be made. For questions or assistance, reach out to the Rx Valet team by phone or chat.

Prescription assistance program (PAP)

For members who need financial assistance, Rx Valet has a prescription assistance program with over 1,200 covered medications. You may qualify based on income requirements and can complete an eligibility form through your member portal. If you are eligible for the program, your PAP benefits will be built into the prices displayed when you are logged in.

If you are not eligible to participate in the PAP, you can still contact the PlanstinRx team for assistance in finding your medication at the most affordable price possible.

Rx Valet partner pharmacies

We work with all major pharmacies, many smaller chains, and independent locations. If your local pharmacy is not contracted with us, reach out to our dedicated service team, and we will do what we can to add them to our nationwide pharmacy network.

International pharmacy

One of the ways Rx Valet is able to save members so much money, is through international pharmacy sourcing. Rx Valet works with pharmacies in Canada, Australia, New Zealand, and England to source affordable prices for specialty and brand-name prescriptions. Through international mail order, Rx Valet can save members significant amounts over domestic pricing.

For example, take a look at the graphic below for an example of the savings possible using international sourcing.

Your actual savings will depend on the health plan you are enrolled in and the medications that you order. To see how your health plan works with Rx Valet, view the details listed under your health plan below.

How your health benefits work with Rx Valet

How to use it: Getting started with Rx Valet

Setting Up Your Account

As soon as you receive your Planstin Member ID card, you should visit rxvalet.com and sign up.

It will take you less than five minutes to login and update your profile. You can add your local pharmacy information, your doctor’s information, and start looking for medications right away.

Searching for Medications

When you search for medications you will see prices instantly, and you will be presented with options for how to receive your meds.

Orders & Refills

Your first order can always be placed for local pickup; however, all subsequent refills (with few exceptions for controlled substances and urgent refills) must be set up for mail-order delivery.

Once you have a prescription's information loaded in your profile, Rx Valet will manage your recurring deliveries, making sure you never miss a refill.

How to use it: Placing an order with Rx Valet

1.) Search alphabetically, or use the search bar to look up your medication name.

2.) Select the proper dosage and quantity, then choose your delivery or pick up method, and add to cart.

3.) After you add to cart, you will confirm your purchase and complete some order details that will help Rx Valet fill your prescription and get it to the right address (such as physician information and your delivery address).

1.) Search

2.) Select

3.) Save

4.) Wait 7-10 days for your first delivery.

5.) For your refills, Rx Valet will reach out to you well in advance to remind you of the upcoming order.

Note: Rx Valet partners with a mail order pharmacy by the name of “Advanced Pharmacy.” You may receive direct contact from Advanced Pharmacy with any questions about your order. Otherwise, you will be contacted by the Rx Valet Services team.

Need Help?

Live Chat www.rxvalet.com

Email info@rxvalet.com

Call 855-798-2538 or 855-240-9368

Hours: M-Th 8-8 ET; Fri 8-7 ET

Weekends and holidays are monitored for urgent/emergency situations.

Advanced Pharmacy

350 Feaster Road, Ste. D

Greenville, SC 29615

Fax: 888-870-3823

Phone: 855-240-9368

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The Essential Role of Employee Benefits in Small Business Retention

Wed, 28 Feb 2024 17:22:03 GMT

High turnover can significantly harm a business, impacting everything from operational efficiency to company culture. As a business owner, building and retaining a loyal, productive team is more important than ever as competition for talent intensifies.

“Are my employees satisfied?”

We would say that’s the million-dollar question, but your employees are worth much more than that. Some say that employees are the most valuable asset for a company.

We know that high turnover can significantly harm a business, impacting everything from operational efficiency to company culture. As a business owner, building and retaining a loyal, productive team is more important than ever as competition for talent intensifies.

Impact of Employee Turnover

Let’s get straight to the point. Employee turnover is expensive, especially for small businesses.

According to the Work Institute , the cost of employee turnover is estimated to be approximately 33% of employees’ base pay. In simpler terms, losing an employee means losing money. Factors that go into calculating the cost of employee turnover include loss of productivity, recruiting and hiring costs, and onboarding expenses.

For small businesses with close-knit teams, other employees may start to ‘jump ship’ if a valued team member chooses to leave. If you lose an employee who handled critical tasks within your business, you also lose important knowledge and experience— which disrupts your day-to-day operations.

Losing an employee also puts extra strain on your remaining employees—leading to increased workloads, longer hours, and heightened stress. You might also find it difficult to recruit new employees if you have a high turnover rate damaging your business’s reputation. While there are countless ways employee turnover can impact your business, there are plenty of retention opportunities for you to capitalize on. Let’s look at some of the most effective employee retention strategies for your small business.

Invest in your employees

Employee retention has evolved far beyond the simple equation of salary = loyalty. Today’s workforce, especially the younger generation, values a holistic approach to employment, one that encompasses not only financial compensation but also personal well-being and work-life balance.

According to a 2023 Workforce Trends Report , retaining talent ranks as a number one priority for employers. While increased wages and bonus programs remain key tools for retaining employees, it’s not always possible for small businesses to offer above-market salaries. So, how do you stand out among the competition and keep your employees invested?

Answer: employee benefits. And not just ordinary benefits but benefits that are personalized, flexible, and meet the needs of your valued team.

Employee retention has evolved far beyond the simple equation of salary = loyalty.

The power of benefits

Benefits hold a crucial place in not just drawing talented individuals to your company, but also in nurturing their engagement and fostering a deep sense of commitment. We understand how vital it is to ensure your team feels valued and supported.

Here’s how your benefits offering can affect whether an employee stays with your company.

Your benefits package is a statement of your company’s values and commitment to your employees’ well-being. A thoughtful benefits offering can set your small business apart, make it a more attractive place to work, and give a compelling reason for employees to stay.

Benefits Enhance Employee Well-Being

Benefits that support physical, mental, and financial health demonstrate that you care about your employees as individuals. This can include healthcare, retirement plans, mental health support, and flexible working arrangements. Employees who feel valued and supported are more likely to report higher levels of engagement, satisfaction, and motivation.

Benefits Foster a Positive Company Culture

Benefits that encourage work-life balance, such as flexible working hours, remote work options, and generous leave policies, contribute to a positive company culture. This kind of culture not only attracts employees but also makes them want to stay.

With the year 2022 being deemed the "Great Resignation,” employers are continuing to see increased rates of employee turnover. This doesn’t have to be the case for your business. By fostering a strong, positive company culture—supported by benefits—you can reduce turnover rates and build a sense of belonging among your team.

Benefits Give You a Competitive Edge

In a tight labor market, your benefits package can give you the competitive edge needed to retain your best employees. Small businesses often have the advantage of offering more personalized and flexible benefits, which can be tailored to meet the unique needs of your workforce. This level of personalization can make a significant difference in an employee’s decision to stay with your company.

Your benefits strategy

Understanding the importance of benefits in employee retention is just the first step. The next is crafting a benefits strategy that aligns with both the needs of your business and employees. Get started with the tips below.

Conduct a Needs Assessment

Engage with your employees to understand their needs and preferences. Surveys, focus groups, and one-on-one conversations can provide valuable insights.

Benchmark Against Your Industry

Research what competitors and similar-sized businesses in your industry are offering in terms of benefits. This can help you identify gaps and opportunities in your own offerings.

Offer Flexibility

Consider offering a range of benefits that cater to the different needs and life stages of your employees.

Communicate Effectively

Ensure that your employees understand the value of the benefits you offer. Regular education and communication about their benefits can enhance their perceived value.

While increased wages and bonus programs remain key tools for fighting turnover, it’s not always possible for small businesses to offer above-market salaries.

So, how do you stand out among the competition and keep your employees invested?

Answer: employee benefits.

How can Planstin help?

Personalized consultation: Our team of experts works closely with you to understand your specific business needs and employee preferences. This collaborative approach ensures that the benefits package we design together is perfectly aligned with your company's values and goals.

Streamlined administration: We take the complexity out of benefits administration. Our user-friendly platform makes managing your benefits package easy, allowing you to focus on what you do best—running your business.

Continuous support and education: Beyond the initial setup, Planstin provides ongoing support and educ ation for both you and your employees. We ensure that your team fully understands and appreciates the value of their benefits, fostering a culture of gratitude and loyalty.

Don't let the challenge of employee retention be a stumbling block in your business's path to success. Embrace the opportunity to make a lasting impact on the lives of those who contribute to your business every day.

For a closer look at how we can help your small business create a benefits package that truly resonates with your team, click below.

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Understanding Section 125 Premium Only Plans (POP): A Guide for Business Owners

Fri, 23 Feb 2024 02:14:28 GMT

Understanding Section 125 Premium Only Plans (POP) is crucial for any business looking to maximize their tax savings and remain competitive in the hiring market. This helpful guide provides an overview of Section 125 POPs, why you should have one, how they work, how to avoid common errors, and how Planstin can help you navigate your plan.

Key Insights

A Section 125 Premium Only Plan legally allows employees to reduce taxable income by contributing to health premiums pre-tax.

Section 125 POPs allow employers to reduce payroll taxes.

Your POP must be formally drafted and adopted to comply with IRS regulations.

Section 125 POPs have strict rules on what is and isn’t eligible for deduction.

Almost any business can offer a Section 125 POP, but not all employees may be eligible to participate.

Due to complex regulations and compliance concerns, it’s best to seek help from a professional, like a CPA, to ensure your Section 125 POP is set up and maintained properly.

What is a Section 125 Plan?

A Section 125 Plan, often known as a Cafeteria Plan , is a written plan that allows employees to pay for certain out-of-pocket expenses, like health plan premiums and medical costs, with pre-tax dollars. These plans are named after the section of the IRS Code that governs them and nicknamed for the flexibility they can offer in how employees receive benefits and compensation.

Nearly any business, regardless of size, can set up a Section 125 Plan. To offer this benefit, you must have a Section 125 document, which serves as the backbone of the plan, outlining the specifics and ensuring compliance with tax regulations.

Why was Section 125 created?

Section 125 was added to the Internal Revenue Code (IRC) in 1978 (and has been amended many times since) with the aim of encouraging businesses to offer employee benefits. The addition was also meant to increase the affordability and accessibility of health benefits.

What is a Section 125 Premium Only Plan?

A Premium Only Plan (POP) is the most common Section 125 Plan. A POP allows employers to deduct health premium contributions from employee paychecks before taxes—something that many employees consider a given with workplace benefits. This type of plan may or may not also include a cash-in-lieu provision which allows employees to choose a taxable cash payment instead of opting-in for health benefits.

A Section 125 Plan, often known as a Cafeteria Plan , is a written plan that allows employees to pay for certain out-of-pocket expenses, like health insurance premiums and medical costs, with pre-tax dollars.

What can a Section 125 POP cover?

As its name suggests, a Premium Only Plan is designed to cover healthcare premiums. This means that coverage is limited to traditional health benefits items like health insurance, dental , vision , and other qualifying health plans . Nontraditional and supplemental options are typically not eligible* for the pre-tax treatment of a POP.

As an example, here is a list of benefits administered by Planstin separated by whether or not they are eligible for a Section 125 POP.

*Note: Consult one of our benefit administration professionals if you have questions about Section 125 POP compliance. Our team is available to assist at 888-920-7526.

Compliant (pre-tax) health benefits

Preventive Series
Care+ Series
Standard & Enhanced Dental
Standard Vision
HSA Contributions

Post-tax health benefits

Planstin Accident
Giving Accident Indemnity
Giving Hospital Indemnity
Giving Critical Illness
Standalone Amaze Health Membership
HealthShare Membership

Who can participate in a Section 125 Plan?

Most employees, whether full or part time, can benefit from a Section 125 POP—so long as they are not in one of the groups that t he IRC prohibits from participating. For example, in a sole proprietorship, the proprietor and their family members may not participate. Other nondiscrimination rules would prohibit high-earning employees, and employees that are more than 2% shareholders.

Other than the IRC participation regulations, businesses may choose to establish their own participation requirements, such as a certain length of service at the company.

How you benefit

The primary, and maybe most obvious benefit of a Section 125 Plan for employers is the tax savings. By reducing employees’ taxable income, employers may see significant payroll tax savings. However, there are related benefits to these savings.

Tax Savings

Contributions made by employees are deducted from their salaries, ultimately reducing the employer’s payroll taxes.

Attract and Retain Talent

Enhanced benefit packages make your company more attractive to current and potential employees. Offering a Section 125 Plan may end up being an effective pay raise for employees who opt to participate (a pay raise that may ultimately save your business money).

How your employees benefit

For your employees, enrolling in a Section 125 Premium Only Plan should be nearly effortless. You will present them with the choice to opt in or out of the program, and after they make their choice, your payroll process will do the rest. Once they opt in, the employee will enjoy the benefits of the pre-tax deductions of their health benefits.

Reduced Taxable Income

Employees’ premiums are now paid pre-tax, which reduces their taxable income.

Increased Take-Home Pay

With less money taken out for taxes, your employees will see more money in their pockets throughout the year.

Starting and managing your Section 125 Plan

Running a Section 125 Plan can be relatively painless, particularly if you are working with a Third-Party Administrator (TPA) like Planstin. Your TPA can help you through each stage of the process and ensure your plan remains compliant after it is established. Listed below are all steps Planstin can help you through.

1. Draft a Written Plan Document

We will help you outline your plan, the benefits offered, and the rules that will govern your plan.

2. Formally Adopt the Plan

You’ll make it official with a resolution, your signature, or similar formal action.

3. Communicate with Your Employees

We will help you inform your employees about your plan and how it works. Typically, this is done during the oboarding timeframe when you provide the Summary Plan Description (SPD) prepared by Planstin. Your employees will also be presented with the choice to opt out or choose a cash payout in lieu of benefits.

4. Comply with Nondiscrimination Rules

We will help ensure your plan is in line with Section 125 nondiscrimination guardrails, which are designed to prevent your plan from favoring some employees over others.

Section 125 Nondiscrimination Basics

Eligibility – employees other than highly compensated employees (HCEs) must be eligible for your plan.
Benefits and Contributions – all participants must be able to elect the same benefits and amounts.
Key Employee Concentration – benefits for key employees cannot exceed 25% of the total for all employees.
Utilization – HCEs should not be taking disproportionate advantage of the plan.

For detailed rules read more here .

5. Report to the IRS

Section 125 plans are subject to ERISA, and thus may require filing Form 5500, an annual report filed with the DOL and IRS that provides information about your benefit plan’s financial condition and operation.

Y ou may need to file Form 5500 for your Section 125 plan if

Your plan has more than 100 employees participating
Your plan offers a Flexible Spending Account
Your plan offers group-term life insurance

You do not need Form 5500 for your Section 125 plan if

Your plan has fewer than 100 employees participating
Your plan is a POP Section 125 plan

6. Review and Update as Needed

We will also make sure your plan stays up to date with both legal regulations and your employee population. Adjustments may need to be made as often as every year.

Common Section 125 mistakes to avoid

As common as Premium Only Plans are, mistakes are still possible, especially without expert help. Since even small oversights could lead to significant issues, you’ll want to be aware of some of the common pitfalls. Of course, Planstin is here to not only educate you about these pitfalls, but also to make sure you don’t get caught in any of them.

Not Having a Written, Compliant Section 125 Plan

This first one may seem obvious; however, many employers may not realize that pre-tax payroll deductions for health benefits need to be made official with a written Section 125 POP that adheres to the regulations laid out by the internal revenue code.

If you have a payroll service and trust that they have taken care of this for you, you may want to think again. A Section 125 plan is your responsibility to set up. And you will be the one on the hook for any penalty for noncompliance, not your payroll company. The plan must be in writing, and it must be formally adopted.

Failure to Update Plan Documents

Setting up your Premium Only Plan is not a one-and-done. Like many things regulated by complex policies, regular updates may be needed to reflect changes in legislation, company policy, and employee population.

Noncompliance with Non-Discrimination Rules

This is not a step to skip. Section 125 Plans must be equitable, and you must be able to prove that they are. Reports about your non-discrimination tests should be kept internally in case you need them.

Poor Communication with Employees

Part of the requirements for Section 125 plans is that you provide detailed information to your employees. Section 125 is built on the idea of giving employees an option. So, no matter which type of Section 125 plan you offer, your employees must be able to opt in or out with a full understanding of what is being offered to them. If your Section 125 document is set up to require a formal election, employees who wish to opt out should complete a waiver, which the employer should keep on file.

Operating Outside of the Plan

Even if you have a Section 125 POP document, that doesn't automatically ensure a plan's compliance. The employer must operate according to the policies outlined in the plan.

A POP allows employers to deduct health premium contributions from employee paychecks before taxes—something that many employees consider a given ... however, many employers may not realize that pre-tax payroll deductions for health benefits need to be made official with a written Section 125 plan.

Dangers of noncompliance

Have you been deducting employee benefit contributions pretax without a written Section 125 plan? Or do you have a written plan, but you’ve skipped one of the other important steps, like adequately informing your employees of their options? Now is the time to course correct. If your Premium Only Plan does not follow the Section 125 rules, you and your employees may be at risk.

Tax Penalties

Your business and your employees could face penalties for underpayment, back taxes, and interest. Correcting this issue retroactively can be complex and might not always be possible, which could lead to a loss of tax benefits for previous periods and plan disqualification.

Plan Disqualification

If your Section 125 plan isn’t set up correctly, you could lose the ability to offer one, resulting in loss of tax benefits for everyone involved.

Legal Challenges

Failure to comply with IRS rules could lead to audits, legal challenges, and refiling, further complicating your situation.

Planstin hassle-free, $0-fee Section 125 service

Implementing a Section 125 Premium Only Plan is a strategic move to elevate your benefits offering while balancing your budget. However, your plan’s success will depend on how well you understand the complexities and comply with detailed regulations.

Working with a Third-Party Administrator like Planstin Administration can help you navigate the intricacies of establishing and maintaining a Section 125 plan and effectively communicate with your employees for maximum participation (and thus, maximum savings).

We know how critical a Premium Only Plan can be to your business’s success, which is why we provide Section 125 documents, at no extra charge, for our clients (a service that can typically cost anywhere from $100-$600).

Our complimentary Section 125 service ensures compliance, accuracy, and timeliness, allowing you to focus on running your business.

Reach out to Planstin today and take the first step toward optimizing your budget, boosting your retention, and simplifying your benefits administration.

Legal disclaimer: This is not legal advice. For questions regarding your specific situation, please consult an attorney. For more information about non-discrimination testing, please consult your CPA.

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HealthShares: An Affordable Strategy for Small Business Benefits

Thu, 15 Feb 2024 18:53:10 GMT

Across the country, the challenge of affording quality health benefits is a common struggle for small business owners. For those with a limited number of employees, providing comprehensive health insurance can understandably feel financially daunting.

Facing this reality, some have turned to alternative options when traditional health insurance turns out not to be a viable option. One solution that is gaining traction among small businesses, and one that Planstin uniquely builds into its benefits, is HealthShare membership—a less-known but growing health insurance alternative.

This approach has been key for many small businesses, allowing them to offer benefits at a fraction of the cost of traditional insurance. In certain industries or business types where an employee would rarely expect to receive benefits, adopting this model has set some businesses apart from others, providing much-needed support for their employees at far lower costs than standard insurance premiums.

The cost of annual health insurance premiums have increased by 47% in the last decade, reaching $23,968 for a family in 2023.

Compared to the rising premiums of health insurance, medical cost sharing organizations like Zion HealthShare offer more affordable options, often resulting in savings of 40-60%. There are lots of entrepreneurs out there looking for the best small business health insurance, and this alternative should catch their eye.

Catastrophic healthcare and small business benefits

HealthShares are organizations which take a community-based approach to managing large healthcare expenses. Though many tend to think of them as similar to insurance, they differ fundamentally in their structure and practices.

Unlike conventional insurance, where a company collects premiums to cover the healthcare costs of its policyholders, HealthShares involve a group of individuals contributing to a pooled fund that is managed by the organization and distributed to community members’ eligible medical expenses.

Small businesses that offer benefits often cite improved employee morale and the ability to attract and retain quality workers as significant advantages.

Also, unlike insurance, the main focus of HealthShare membership lies in addressing more catastrophic medical events, offering a mode of relief for large, unexpected healthcare costs that can be burdensome for people to bear alone.

Understandably, this emphasis on catastrophic care can raise concerns about routine and preventive healthcare expenses, areas typically covered by traditional health insurance. Critics often point out that while HealthShares effectively support members during major health crises, regular medical services like preventive care, routine checkups, and prescriptions, are paid by members out of pocket.

Addressing these concerns, companies like Planstin have created unique solutions, combining HealthShare membership with additional benefits that feature preventive care. The unique combination of a preventive health plan with HealthShare membership is specifically designed to bridge this gap. This combination not only facilitates the sharing of funds for major medical events, but also provides affordable access to preventive care, prescriptions, and more modern services like telemedicine. It is this type of alternative solution that makes benefits viable for small businesses, combining the low-cost insurance alternative in HealthShares with affordable services to create a well-rounded healthcare experience.

Low costs and high retention rates with HealthShares

As pointed out already, integrating HealthShare membership into an employee benefits package is a much less expensive prospect for a small business than traditional health insurance. We at Planstin have taken this even further by building self-guided tools that business owners can use to manage their own benefit offerings. They can make changes, invite employees, and set contribution levels for employee plans. It is worth noting that even in scenarios where employers opt not to contribute, employees still find themselves facing much lower costs than with insurance options.

The positive impact of Planstin’s HealthShare-oriented benefits packages on employee retention cannot be overstated. A survey by WTW found that 60% of employees feel their healthcare plan is an important reason to stay with a current employer. Could your business use a low cost health insurance alternative that will keep your best employees happy?

A survey by WTW found that 60% of employees feel their healthcare plan is an important reason to stay with a current employer.

Small business benefits are within reach

Many small business owners do not think that benefits are a viable option for them, having unsuccessfully looked for affordable health insurance for small business and not realizing other options exist. Only 38% provide benefits, with this figure decreasing further among businesses with smaller revenues. For instance, a survey by Paychex found only 22% of businesses earning less than $500,000 report offering benefits. This small business reluctance to offer benefits most often stems from financial considerations and the lack of a legal mandate for businesses with less than 50 employees.

Despite this, the value of offering benefits, particularly healthcare, is widely recognized. Small businesses that do offer benefits often cite improved employee morale and the ability to attract and retain quality workers as significant advantages. While it is no surprise that small businesses with smaller budgets would be reluctant to offer expensive insurance, alternative solutions like preventive health plans that integrate HealthShare membership offer a viable, value-driven healthcare option for small businesses and their employees.

Why are businesses choosing to offer or not offer benefits?

For large businesses, offering benefits to employees is almost a given, mainly due to legal requirements that levy fines against those that don't. Small businesses, on the other hand, tend to see benefits as a luxury they can't afford yet, generally opting out due to perceived financial constraints. But with Planstin's solutions to small business benefits concerns, we can make benefits packages affordable and possible for your business.

What small businesses might want to know about HealthShares

For small business owners considering a HealthShare-anchored benefit solution, there are usually a couple common concerns we address:

Are HealthShares dependable in their paying medical bills?

When you are dealing with a reputable company with clear sharing guidelines, absolutely! In designing benefits, Planstin collaborates with Zion HealthShare, the most highly rated and fastest growing HealthShare organization available. Zion’s clear guidelines and strong track record offer reassurance about their resolve to support the needs of their members.

How does the IUA (initial unshareable amount) work?

Many members liken the IUA to a traditional insurance deductible: it’s what members are responsible for paying before the shared funding kicks in. For a simple illustration of how a HealthShare IUA works and saves you money, see the graphic below comparing two people’s costs related to a broken leg.

As illustrated above, Maya’s $1,000 IUA was her responsibility to pay toward medical costs for this injury. The rest of the funds necessary were shared by the HealthShare community, creating a savings scenario for Maya that is hard to ignore.

Are the options robust enough to meet people’s needs?

When big savings often mean a compromise of quality, access, or convenience, this concern is certainly understandable. With a HealthShare membership alone, specific benefits commonly provided by traditional insurance might be absent, like regular and routine care such as checkups, maintenance medications, and preventive care.

This is where Planstin comes in.

Our packages combine HealthShare membership (for larger catastrophic needs) with a collection of preventive-focused products to create well-rounded and unified health benefits that are equipped to meet the diverse needs of your workforce.

The preventive health plan component of this strategy is designed to cater to smaller medical needs like checkups, prescriptions, and other routine care. Members can enjoy these services while knowing that they have a HealthShare membership in their pocket for the larger, unforeseen medical expenses.

By combining these benefits you can offer your employees an affordable, well-rounded benefits package that gives them access to the care they need at a price point you can afford.

HealthShare Membership and a Preventive Health Plan pair up to make an effective benefits package for small businesses.

Are you a small business owner looking for a small business benefits package?

Discover how Planstin and Zion HealthShare are redefining benefits with HealthShare memberships for employees.

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What are the tiers for Rx Valet?

Fri, 02 Feb 2024 01:16:47 GMT

1. Generic

2. Preferred Brand

3. Non-Preferred Brand

4. Specialty

Unsure if you have access to Rx Valet?

Check your Member ID card, your prescription benefit information should be listed there.

Alternatively, you can review your plan outline and SBC, which will contain information about your prescription benefits.

Learn More

Learn more about how you can use Rx Valet here .

Download the quick start guide here .

Contact Member Services for help understanding your plan details at 888-920-7526 .

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Does Rx Valet use a step therapy program?

Fri, 02 Feb 2024 01:16:47 GMT

Yes.

Rx Valet uses a step therapy program. Step therapy is a program that requires patients to try a lower cost prescription drug that treats a given condition before “stepping up” to drugs that cost more.

Learn More

Learn more about how you can use Rx Valet here .

Download the quick start guide here .

Contact Member Services for help understanding your plan details at 888-920-7526 .

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Will all members with Rx Valet use the same formulary?

Fri, 02 Feb 2024 01:16:47 GMT

Yes.

However, prices will vary depending on which plan you are enrolled in.

Unsure if you have access to Rx Valet?

Check your Member ID card, your prescription benefit information should be listed there.

Learn More

Learn more about how you can use Rx Valet here .

Download the quick start guide here .

Contact Member Services for help understanding your plan details at 888-920-7526 .

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Does Rx Valet have a patient assistance program (PAP)?

Fri, 02 Feb 2024 01:16:47 GMT

Yes.

A patient assistance program (PAP) is a program that provides financial assistance to low-income individuals to augment their existing prescription drug coverage.

Rx Valet has a patient assistance program. The income-based assistance program is built into the Rx service available on the website. Members can complete a form to see if they qualify and if the medication(s) of interest will qualify for the PAP.

Unsure if you have access to Rx Valet?

Check your Member ID card, your prescription benefit information should be listed there.

Learn More

Learn more about how you can use Rx Valet here .

Download the quick start guide here .

Contact Member Services for help understanding your plan details at 888-920-7526 .

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How can Rx Valet members qualify for prescription assistance?

Fri, 02 Feb 2024 01:16:47 GMT

Members can complete a form on the Rx Valet website to see if they qualify for financial assistance through the PAP.

For medications to be funded through a PAP, they cannot be processed through an employer provided pharmacy plan. Members qualify as being underinsured when the plan does not cover their medication(s).

Unsure if you have access to Rx Valet?

Check your Member ID card, your prescription benefit information should be listed there.

Learn More

Learn more about how you can use Rx Valet here .

Download the quick start guide here .

Contact Member Services for help understanding your plan details at 888-920-7526 .

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How does Rx Valet handle prior authorizations?

Fri, 02 Feb 2024 01:16:47 GMT

Rx Valet manages prior authorizations through Rx Valet customer care. Member Services does not manage prior authorizations.

There is no action required by the member.

Unsure if you have access to Rx Valet?

Check your Member ID card, your prescription benefit information should be listed there.

Learn More

Learn more about how you can use Rx Valet here .

Download the quick start guide here .

Contact Member Services for help understanding your plan details at 888-920-7526 .

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When does Rx Valet require mail order/home delivery?

Fri, 02 Feb 2024 01:16:47 GMT

The first order for any prescription can be through retail. Members can call in to the pharmacy directly, or select a pharmacy based on the best available price through the Rx Valet portal. All subsequent refills may be required to be filled via Rx Valet’s mail order program.

Supplies of more than 30 days may be required to be filled through home delivery. Depending on your health plan, maintenance medications may need to be filled through home delivery. Controlled substances are an exception to these requirements.

Please contact Member Services to verify your prescription benefit details.

Learn More

Learn more about how you can use Rx Valet here .

Download the quick start guide here .

Contact Member Services for help understanding your plan details at 888-920-7526 .

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Does Rx Valet have significant shipping costs?

Fri, 02 Feb 2024 01:16:47 GMT

No .

Shipping costs are well managed as part of Rx Valet.

Free shipping is automatically provided for any order greater than $12.95. And any medication with a set price, for example a $5 or $10 copay, ships for free.

Learn More

Learn more about how you can use Rx Valet here .

Download the quick start guide here .

Contact Member Services for help understanding your plan details at 888-920-7526 .

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What are Rx Valet shipping timelines?

Fri, 02 Feb 2024 01:16:47 GMT

If a prescription is mailed from a US location, shipping takes 2-4 days.

If a prescription is mailed from an international location, such as Canada, then shipping can take up to 7 days. Members will usually be given options but can save more on many prescriptions when using the international pharmacy options.

Please note: Initial orders can take up to 11 business days to process and ship.

Learn More

Learn more about how you can use Rx Valet here .

Download the quick start guide here .

Contact Member Services for help understanding your plan details at 888-920-7526 .

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Do I Need Enrollment Support? - An Interview with a Planstin Benefit Guide

Wed, 31 Jan 2024 17:59:40 GMT

Learn how personalized support from a Planstin Benefit Guide simplifies the enrollment process, tailors benefits to your company's needs, and ensures your employees are well-informed and supported throughout their benefit journey.

Managing employee benefits can be a daunting task, but with the right support, successful navigation is within reach. From understanding health plans and educating employees to maintaining compliance, we’re here to help you through it all. We want you to make informed decisions about your employee benefits that will be valuable for your employees and business. We sat down with a Planstin Benefit Guide to discuss benefit enrollment and why some companies may need more support.

Q: What exactly is enrollment support, and why should my business consider it?

A: Think of enrollment support as having a personal GPS for the journey of employee benefits for each employee. Our enrollment support is designed to help assist each employee with selecting plans, understanding costs, and helping employees through enrollment without a hitch. You will have an actual person to assist you with any questions and to help each employee understand their benefits offering.

Q: My company is small. Can enrollment support still make a difference for us?

A: Absolutely. Whether you have five employees or fifty, enrollment support can be tailored to fit your company's size and needs.

All enrollments include one-on-one enrollment sessions for better employee education. Companies with more than 50 employees can arrange for onsite meetings as well. Enrollment support ensures that even the smallest team doesn't miss out on the benefits of a well-organized plan, and one-on-one guidance.

Q: Isn’t choosing health plans and additional benefits enough? Why do I need support?

A: Choosing your health benefits is a great start. Enrollment support helps with effectively communicating these benefits to your employees, ensuring they understand and utilize the benefits for the best return on your investment.

Q: Can I just use Planstin’s Enrollment Manager to simplify the enrollment process?

A: Planstin's Enrollment Manager turns a multi-step ordeal into a seamless three-step process. It’s designed to make enrollment as straightforward as registering an email, selecting tailored benefits, and inviting employees to enroll. It's about making sure you spend less time on paperwork and more time growing your business.

Our Enrollment Manager process is straightforward; however, our direct enrollment support can be more useful when you have unique needs or questions. Enrollment support gives the one-on-one attention that your employees need as they consider their benefit options.

Q: What if my employees have questions or issues with their benefits?

A: That's where a robust support system comes into play. We understand that benefits can be overwhelming for most employees. That’s why we offer each employee individualized education. By doing so, we hope to get ahead of any questions or issues that they might have.

If you choose to move forward with us, a calendar invitation will be sent to all your employees to schedule a one-on-one, virtual benefit education meeting. These meetings are designed to provide the personal benefits and enrollment education they will need to get started and address any concerns.

Q: How do I get started with enrollment support?

A: Getting started is as simple as scheduling a consultation with a Benefit Guide. From there, your Benefit Guide will learn more about your business’ unique needs and help design a customized plan that meets the needs of your business and employees.

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Maximize Your Benefits: Take Advantage of the HSA Contribution Limit Increase in 2024

Thu, 18 Jan 2024 23:24:42 GMT

In 2024, the IRS has upped the HSA contribution limits, offering an excellent opportunity to put more of your money to work for your physical and financial health. Let’s dive into what these changes mean for you and why maxing out your HSA is a wise choice for your budget and your peace of mind.

What’s new for 2024

Under a qualifying high-deductible health plan, you may contribute a certain amount each year to your HSA. This year that amount is higher, and so is the minimum deductible for your plan to qualify as “high deductible.”

Individual Coverage

Can contribute up to $4,150 – up $300 from 2023

minimum deductible of $1,600 – up $100 from 2023

Family Coverage

Can contribute up to $8,300 – up $550 from 2023

minimum deductible of $3,200 – up $200 from 2023

What the new HSA contribution guidelines mean for you

Simply put, the limit increase provides you the opportunity to save more. By adjusting your contributions for 2024 to meet the new limit, you’ll maximize your tax savings as well as give yourself a little extra toward your future medical needs. As you can see above, the contribution limits tend to increase year over year, so don’t miss your chance to take advantage of every tax-free penny.

You should also take note that the qualifications for what counts as a “high deductible health plan” tend to change each year. So, you will want to check your health plan details to ensure your deductible meets the updated minimum for 2024.

Stay within the limit

Though the limit is higher, you still need to keep in mind that exceeding the limit can result in IRS penalties. Keep tabs on your contributions, including any from your employer, to stay safe.

Mistakes happen, and if despite your best efforts you overshoot the limit, there is a way to fix it and avoid the IRS penalty. You can use an Excess Contribution and Deposit Correction Request Form from your HSA provider to set things straight.

Getting the most from 2023’s limit

Are you just now realizing that you could have contributed more in 2023? There is still time to hit the 2023 contribution limit of $3,850 (individuals) or $7,750 (families). In fact, HSA holders have until the April tax deadline to backfill their HSA. So, there’s still time to maximize last year’s savings.

Additionally, if you are 55 or older, you can contribute an additional “catch-up amount” of $1,000 each year. If you’re married, and your spouse is also over 55, they can open an HSA and add their own catch-up contributions.

Why maxing out matters

In a nutshell: the more you save, the more you save. Since your contributions are tax deductible, by maxing out your HSA you lower your taxable income. Additionally, the money in your account grows tax-free and any unused HSA funds roll over allowing you to build a nest egg for any future health needs or even retirement. Ultimately, a full HSA can mean a significant boost for your peace of mind; by maxing out your savings opportunity, you’ll know you’ve done your best to prepare for your future.

How to contribute

Contributing is easy, but we’ll review your options anyway. You can set up recurring contributions or send a lump sum a few times a year. However you choose to contribute, keep in mind that any money your employer may contribute also counts toward your contribution limit.

Payroll Deductions

Simply check with your employer about automatically deducting your contribution from your paycheck. This is typically the most convenient way to contribute since your employer can easily deduct the contribution before applying taxes.

Online Contributions

Contribute once or more regularly by setting up direct recurring contributions through your account. Contributing this way may lead to some extra work when you do your taxes.

Have questions? We are ready to help. Give us a call at 888-920-7526 .

Contributing to your HSA is more than just a smart health move, it’s a savvy financial strategy. By leveraging new contribution limits, and staying informed, you can make the most of your HSA in 2024 and secure a healthier financial future.

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Discover Your Perfect Health Plan

Tue, 16 Jan 2024 21:39:05 GMT

Navigating your health plan choices can be a bit like exploring a new city–exciting but a tad overwhelming. But don't worry, we're here to be your friendly guide, helping you find the perfect health plan that fits just like your favorite pair of jeans–comfortable, reliable, and just right for you.

Here is an overview to help you understand each option and make an informed decision that best suits your health needs.

Preventive health plans

These plans are all about keeping you healthy. Enjoy easy access to regular health check-ups and screenings that are kind to your wallet.

Preventive Basic

Think of this as your health plan starter pack. It’s easy on the wallet and gets you all the essential preventive services, plus some sweet deals on prescriptions and unlimited telemedicine. It’s perfect for those who love being in the driver’s seat of their health journey.

Preventive HSA

Here's a plan that loves your wallet as much as it loves your health. A Health Savings Account (HSA) is like a piggy bank for your health expenses–but with tax benefits. A smart pick for the savvy health planner in you.

Preventive Copay

Hate surprises, especially when it comes to healthcare costs? This plan's got your back with lower copays for everyday health services. It’s ideal if you’re the kind of person who's always on the move, needing quick access to specialists or urgent care.

Care+ health plans

These plans are like a health care treasure chest, packed with amazing extras at no additional cost, and the freedom of having no network restrictions. Imagine being able to access the healthcare providers of your choice, anytime, anywhere. Add to that 24/7 telemedicine, expert virtual care, and a dedicated team ready to manage everything from chronic diseases to billing queries and you have the flexibility and convenience you need. Plus, mental health support, weight management, and even smoking cessation education programs are all part of the deal.

Care+ Core

This plan is versatile and comprehensive. It's for those who want an ideal balance between cost-effectiveness and thorough health coverage.

Care+ HSA

This plan is a savvy financial move. With its HSA component, it's like getting a health coverage plan with a built-in tax break. A great choice for those who love a good deal.

Care+ Copay

This plan is like your health BFF–reliable and always there when you need it. It offers extensive coverage with predictable costs, making it a go-to for those who like to plan ahead.

HealthShare membership

Think of this as your health parachute. A HealthShare Membership from Zion HealthShare is there to catch you in case of serious, unexpected medical needs that your preventive health plan might not cover. Plus, there are perks like efficient sharing request processing, no deductibles, unlimited sharing, and affordable contribution amounts. What's more, Zion HealthShare does not use a provider network, so you're free to see whichever provider you choose.

Add-on benefits

Your benefits go beyond basic health plans with a range of add-on benefits, designed to cater to diverse needs and enhance your healthcare experience. These additional options include dental , vision , accident , and hospital coverage.

We’re here for you

Choosing a health plan shouldn’t be a chore–it should be as exciting as planning your next vacation. And we're here to make that journey as smooth and enjoyable as possible. So, dive in, explore, and find the plan that makes you say, "Yep, that's the one for me!"

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5 Essential Health Plan Features Every Employer Should Offer

Fri, 05 Jan 2024 18:29:46 GMT

In an era where employee health and well-being are more crucial than ever, employers play a pivotal role in offering effective health plans.

These plans are not just benefits but are foundational to ensuring a healthy, productive workforce. With the rising demand for flexible and quality healthcare, understanding and implementing key health plan features becomes imperative for businesses of all sizes.

This blog delves into the five essential health plan features that employers should offer.

Telemedicine services

Providing telemedicine as part of your health plan is vital. It offers employees 24/7 access to healthcare professionals, ensuring prompt medical advice and treatment, regardless of their location. This convenience leads to improved health outcomes and enhanced employee satisfaction.

Preventive care

Plans that prioritize preventive care are essential. Preventive health plans , which comply with ACA guidelines, focus on routine care, helping to detect and manage health issues early on. This proactive approach reduces long-term healthcare costs and improves the overall health of your workforce.

Prescription benefits

Prescription benefits play a significant role in managing and treating various health conditions, from chronic diseases to acute illnesses. By including this in your health plan, you not only help in alleviating the financial burden associated with purchasing medications but also promote adherence to essential drug therapies. This leads to better health outcomes and reduces the overall healthcare costs for both you and your employees.

Customization

The ability to customize health plans to align with the specific needs of your business and employees is crucial. Offering a variety of plans maximizes the effectiveness of your benefits package and ensures that every employee’s unique health needs are met.

Employee education

Engaging employees in the health plan selection process and providing them with educational resources ensures they understand and utilize their benefits effectively. This involvement increases satisfaction and encourages a proactive approach to health.

By offering these key features in your health plans , you not only protect your team’s well-being but also foster a positive and productive work environment. Remember, a healthy workforce is a happy and efficient one!

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Planstin Administration Wins Top Benefits Administrator Award

Wed, 06 Dec 2023 01:50:05 GMT

Planstin Administration wins spot as one of the top 10 benefits administrators of 2022 in Manage HR Magazine.

Read the article at https://www.managehrmagazine.com/planstin-administration

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Navigating Rising Healthcare Costs: Strategies for Employers

Tue, 05 Dec 2023 21:31:16 GMT

The rising cost of healthcare in the US is a pressing concern, with family insurance premiums approaching $24,000 this year, a 7% increase from the previous year according to a KFF survey . During open enrollment season, employers in a competitive job market face the challenge of offering appealing benefits while managing these escalating costs. This blog explores effective strategies to tackle these challenges.

Understanding the drivers of high healthcare costs and what you can do about them

While some factors driving healthcare costs are beyond employers’ control, there are areas where businesses can exert influence. We'll focus on three controllable factors: the health of employees, the lack of choice in healthcare plans, and inflated prices from healthcare providers.

Factor 1: Unhealthy Employees

Chronic illnesses and mental health conditions, often exacerbated by obesity and delayed medical care, contribute significantly to the $3.7 trillion annual healthcare expenditure in the US, according to the Centers for Disease Control and Prevention.

Strategies for improving employee health

By introducing wellness programs as part of your employee benefits package, your employees will be happier and healthier — leading to reduced medical expenses, and potentially lower future medical premiums.

Additionally, incorporating telehealth services into your benefits can help your employees seek care more often due to the conveniency and savings virtual appointments provide.

Factor 2: Limited Choice in Healthcare Plans

About 159 million American workers have employer-chosen health insurance, often selected based on factors like ACA compliance and budget constraints, leaving employees with little say in their healthcare options.

Strategy for providing more options

Providing employees with options , such as a traditional health plan paired with a non-traditional product like a Minimum Essential Coverage (MEC) plan and a HealthShare membership, can save companies about 30-40% while maintaining ACA compliance. Giving your employees choices will also enhance how they feel about you as an employer.

Factor 3: Pricing Power of Hospitals and Providers

The trend of mergers and partnerships in the healthcare sector often leads to near-monopolies, enabling providers to demand higher prices.

Strategies for lowering healthcare costs

Reference-based pricing (RBP) plans allow employers to negotiate directly with healthcare providers, potentially achieving significant discounts and reducing out-of-pocket costs for your employees.

Employers can also opt for level-funded plans , a type of self-funded plan with a fixed monthly contribution covering administration, claims payments, and stop-loss insurance. Understanding the thresholds for stop-loss coverage is crucial to avoid surprise charges.

Don’t let high costs stop you from offering benefits

Rising healthcare costs may seem daunting, but by adopting these strategies, you can offer employees meaningful choices and manage expenses effectively. At Planstin, the right benefit guide can assist in setting up these options, ensuring both employer satisfaction and employee welfare.

Let us help you figure out the right strategy for your business today!

Legal disclaimer: This is not legal advice. For questions regarding your specific situation, please consult an attorney.

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Set up Your Employee Benefits Program in 3 Steps with Planstin's Enrollment Manager

Wed, 22 Nov 2023 16:33:22 GMT

At Planstin, we’re not just administering benefits; we’re reimagining them from the ground up. We understand the complexities of healthcare benefits and are committed to solutions that make benefits more approachable.

We believe that simplicity is the key and that benefits should be easy to understand and manage. That’s why we developed Enrollment Manager, a new tool for self-guided benefits enrollment for business owners and decision makers. By streamlining the often-complex processes of employee benefits enrollment, we hope to open doors for businesses and their employees to have positive healthcare experiences.

Step 1: Account Setup

Starting with Planstin’s Enrollment Manager is straightforward and efficient. All it takes is a valid email address to register, followed by a few essential business details.

Step 2: Customize & Contribute

Empowerment is at the core of Planstin’s approach to benefits. With Enrollment Manager, you’ll have the flexibility to tailor a benefits package that aligns with the needs of your business and your employees. You’ll start here with the health plans to be offered to your employees, followed by add-on benefits options like dental coverage, vision coverage, or an accident plan. You’re not just selecting benefits; you’re creating a package that speaks directly to the needs of your employees.

Once you’ve selected your health plans and add-on benefits, you’ll then determine the level to which the business will contribute to your employees’ plans, allowing you to balance both employee wellness and business budgetary constraints. This level of customization not only caters to the diverse needs of your employee base, but also opens up opportunities to save money for your budget.

Step 3: Add & Invite Employees

Once your benefits package is set, adding your employees is simple! Enrollment Manager allows you to upload employee data effortlessly and distribute enrollment links with a single click. When your employees click that link, they’ll find it as easy to enroll in benefits as it was for you to build them.

At Planstin, we believe that if benefits are made to be simple and easy, then more people will get to enjoy them. So, we’ve made it our mission to create innovative tools and processes to assist employers in offering affordable and approachable benefits, while helping inform employees how they can best use the benefits available to them. Enrollment Manager is a huge step toward our goal, but it’s only the first step. We’re excited for what’s to come and can’t wait to help make benefits available to more people.

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Business Tax Incentives for Offering Employee Benefits

Thu, 16 Nov 2023 20:48:34 GMT

Employee benefits, a staple in modern business practices, are often perceived as a financial burden by small and medium-sized businesses. But here’s some good news: there are a lot of tax incentives out there to lighten the cost load of perks like health plans and retirement plans.

It’s a win-win: you as a business owner get to keep your team happy and motivated, and at the same time, the government gives you a financial pat on the back for doing so. Let’s take a look at some of these tax breaks and show how they can help your business do right by your team without breaking the bank.

Understanding employee benefits and tax deductions

Employee benefits include everything from health plans and retirement plans to paid sick leave and vacation time. For businesses, these benefits are not just tools for attracting talent but also opportunities for tax savings.

Here is a breakdown of key employee benefits that are tax deductible

Health Benefits

Health Plans: Premiums paid for employee health , dental , and vision insurance
Health Savings Account (HSA): Contributions made to an employee’s HSA
Long-Term Care: Premiums paid for employees’ long-term care insurance

Salary & Wages

Bonuses: Cash bonuses given to employees
Sick Pay: Wages paid to employees during sick leave
Disability Benefits: Cost of providing short-term or long-term disability benefits

Fringe Benefits

Life Insurance: Premiums for group term life insurance (see below for applicable limits)
Education Expenses: Costs for employee education and training that enhance job skills
Retirement Plan Contributions: Contributions to employee retirement plans, like 401(k)

Complexity of deductions for employee benefits

There’s a lot to know when it comes to tax deductions for employee benefits, and to maximize your tax advantages while remaining compliant with IRS regulations, you’ll probably want to consult a professional. Here’s a closer look at navigating these complexities:

Valuing employee benefits for deduction purposes

The value of employee benefits for tax deduction purposes often depends on the type of benefit. For example, the cost of health plan premiums paid by the employer is generally the amount deductible. But for benefits like life insurance or the use of a company car, the IRS provides specific guidelines to determine the deductible value. In the case of retirement plan contributions, the deduction value is usually the amount contributed to the plans within that tax year.

Understanding limits and qualifications for deductions

There are caps and qualifications on deductions for certain benefits. For example, the deduction for group-term life insurance premiums is only up to the cost of $50,000 of coverage per employee. Contributions to retirement plans also have annual limits, beyond which they are not deductible. For health benefits, particularly in small businesses and S Corps, the deductibility can vary based on business structure and number of employees.

The role of fair market value in determining deductible amounts

Fair Market Value (FMV) plays an important role in determining the deductible amount for certain benefits. This is is the price that the benefit would sell for on the open market. For benefits like personal use of a company vehicle or housing provided by an employer, the FMV of the benefit must be determined and reported as part of the employee’s income. The employer can then deduct the cost of providing these benefits. All FMV figures used must be realistic and justifiable.

These more technical and nuanced aspects of employee benefits deductions require a thorough understanding of tax laws and often the guidance of a tax professional or third-party administrator.

By accurately valuing benefits and understanding the limits and qualifications for deductions, businesses can manage their tax liabilities and benefit from offering comprehensive benefits packages. Embracing these opportunities will not only improve your team’s morale and loyalty, but also solidifies your status as an appealing potential employer.

Legal disclaimer: This is not legal advice. For questions regarding your specific situation, please consult an attorney.

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What is Minimum Value? Understanding Minimum Value Plans

Thu, 02 Nov 2023 19:00:50 GMT

Reduce turnover, build employee loyalty, and maintain compliance with MVP options.

Navigating the Affordable Care Act can be a daunting task for business owners; But it doesn’t have to be. Let's look at the ACA’s minimum value standards, potential penalties for non-compliance, and why businesses should consider offering minimum value plans (MVPs).

What is a minimum value plan (MVP)?

The Affordable Care Act (ACA) established baseline criteria for employer-backed health benefits. Among these criteria is the minimum value requirement. To qualify as providing “minimum value,” a health plan needs to cover a minimum of 60% of the overall plan costs and include a broad range of medical services, including inpatient and outpatient surgery, maternity care, and emergency and urgent care. Basically, the plan needs to foot the bill for the majority of the insured medical costs, and the employee pays the rest through deductibles, copays, and coinsurance.

How are MVP and MEC different?

In a previous post we covered MEC plans and why offering qualifying healthcare coverage is crucial for large employers. Minimum essential coverage plans are only required to cover preventive care and follow the requirements of the ACA’s extended patient bill of rights . MVP benefits are similarly important for large employers to consider; however, as stated above, they go beyond minimum essential coverage by including much more substantial coverage for comprehensive healthcare services.

The MEC and MVP thresholds are both important because meeting them helps employers avoid some serious tax penalties. While meeting MEC requirements will help an applicable large employer (ALE) avoid the Employer Shared Responsibility-Part A penalty, to avoid Part B of the penalty, employer-sponsored benefits must include an MVP option.

The Employer Shared Responsibility Penalty

If an ALE’s employer-sponsored health plan does not meet the minimum value requirements, employees may qualify for premium tax credits and be eligible to receive coverage in the Marketplace. If this happens, the employer may be penalized through the Employer Shared Responsibility – Part B . In 2025, the Employer Shared Responsibility-Part B fine is $4,350 per year, per employee.

The penalty is assessed on a case-by-case basis, meaning you may be penalized if just one employee declines your benefits and turns to the Marketplace for subsidized coverage. However, you are only penalized for each employee who receives subsidized coverage, not for your entire employee population.

While potential tax penalties serve as a strong incentive for offering an MVP option, sponsoring workplace benefits that meet ACA minimum value standards can help you in other important ways.

Are you an ALE?

All ALEs are subject to the Employer Shared Responsibility. But, how do you know if you are one?

An ALE has an average of at least 50 full-time employees. However, the way the government outlines full-time employees may differ from how your organization defines full-time status. Furthermore, calculating the exact number of full-time employees can get complex since part-time employee hours are factored in when assessing ALE status.

We recommend using the Taxpayer Advocate Service’s ESRP Estimator , reading the IRS page on the topic , or asking a professional for help when determining whether you are considered an ALE.

Why even small businesses should consider MVP options

Access to a minimum value plan means your employees, and their families, have more substantial coverage they can rely on. With better coverage they will be better able to tackle health challenges that come their way throughout the working year. Your employees will be healthier, and they will have you to thank for it.

Besides the fact that employees want access to better benefits, the MVP standard is designed to ensure that people have access to quality health coverage. The penalties for non-compliance are in place to incentivize businesses to offer adequate coverage to their employees. By understanding and meeting these requirements, large employers contribute to the health and wellbeing of their employees—something that businesses of all sizes can benefit from.

Employee retention is a serious issue in the current job market, and employees stay longer when they’re healthy and happy. Offering quality, comprehensive benefits helps attract top talent as well as retain and motivate your employees. It also ensures your employees, and their families, are covered in the event of illness or injury—and they will have you to thank for providing that coverage.

How Planstin works with MVP

Understanding and complying with the ACA’s requirements can be a burden for a growing business. It involves staying up to date with the latest changes, accurately calculating affordability based on safe harbors, and ensuring that your healthcare benefits meet necessary standards. While this may seem overwhelming, remember that you’re not alone. There are plenty of resources available to help you navigate these complexities. Professional advisors, industry peers, and companies like Planstin can provide valuable service and guidance.

Offering benefits doesn’t have to be a Herculean task reserved only for Fortune 500 companies—you can do it too. We are here to help you make it happen. Let us help you around whatever barriers stand between your business and offering benefits.

To learn more:

Read our blog on MEC plans

Review our MVP options

Legal disclaimer: This is not legal advice. For questions regarding your specific situation, please consult an attorney.

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Planstin Administration Featured in The Silicon Review

Mon, 16 Oct 2023 21:46:11 GMT

"We’re challenging the status quo and embracing innovation." Founder Nathan Udy, interviewed by The Silicon Review, discusses how Planstin Administration is creating better healthcare experiences and reducing costs.

Read the article at https://thesiliconreview.com/magazine/profile/planstin-administration-is-creating-better-healthcare-experiences

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Planstin & Tech4Wishes

Mon, 15 May 2023 23:32:36 GMT

Planstin Administration unites with fellow Tech Ridge companies to grant wishes for children with critical illnesses.

Original press release issued by Planstin Administration

ST. GEORGE — In an effort to make an impact in the Southern Utah community, Planstin Administration — a local third-party benefits administrator — participated in the third annual Tech 4 Wishes campaign.

The annual campaign aimed to raise enough funds to grant 10 wishes this year to Make-A-Wish children in Southern Utah. Overall, Planstin and seven other Tech Ridge companies were able to raise more than $72,000, which will grant 12 wishes.

Planstin employees used exercise as a unique way to raise funds in honor of the campaign’s inspiration this year, Ethan. Ethan has lymphoma and wishes to visit Space Camp at the George C. Marshall Space Flight Center in Alabama.

“Not only did we want to come together to grant Ethan’s wish to go to space camp, but we wanted to raise funds to support other local children as well,” said Tegan Wainwright, Planstin’s Human Resources Manager, at the campaign’s closing event on May 11.

In honor of Ethan and in keeping with the company's values, Planstin committed to donating $2 to the Make-A-Wish foundation in Utah for every 30 minutes of exercise an employee completed. Employees also had the opportunity to contribute individual donations.

Over the span of nine weeks, Planstin employees raised $10,150 for the campaign.

Both Wainwright and Senior Engineering Manager Layton Everson emphasized the importance of building up communities and stepping in to help in times of medical crisis.

“The love for our community is a value that is deeply ingrained in our culture,” Everson said, “especially in the products we provide.”

“We strive to offer affordable benefits to those who may not have access to them otherwise, or who might otherwise have to pay exorbitant insurance premiums for coverage they never use.”

Although the company was established in St. George in 2016, Planstin offers its products and services nationwide with the goal of combating the rising costs of health care benefits.

“The benefits we offer are revolutionary,” Wainwright said. “At the end of the day, we just want health benefits to be accessible to everyone and help provide better coverage and better service.”

Due to the growth the startup company is experiencing, Planstin plans to move its headquarters to the SkyView building on Tech Ridge, which is set to break ground sometime this year.

When Everson joined the company in 2019, he was the fifth employee. Planstin now has over 80 employees with several remote positions across the U.S.

Planstin has committed to a large enough share of the SkyView building that it will be renamed the “Planstin” building. Once construction starts, Wainwright said the company expects to move into its new headquarters within two years.

“The move to Tech Ridge is a commitment to building up the community around us,” Wainwright said. “We want to join the other companies in building up the local tech industry and providing more quality jobs to benefit the area.”

About Planstin Administration

Planstin Administration is a third-party administrator for health care benefits. Planstin is dedicated to revolutionizing benefits administration by making benefits simple and offering customizable self-funded benefits packages for companies of all sizes.

Read the published version from St. George News

https://www.cedarcityutah.com/news/archive/2023/05/26/prc-tech-ridge-companies-raise-72k-to-make-wishes-become-reality-for-12-southern-utah-children/

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Self-funded Benefits: What Are They?

Wed, 09 Nov 2022 00:34:50 GMT

When you think of benefits, you may think strictly about the health insurance options offered to you by your employer—or if you are the employer, you may think about the benefit options you make available for your employees.

Benefits like dental , vision , and health plans are common employer offerings especially when a company has over 50 employees. However, whether your company has 50 or 500 employees, another approach may work better for your employees and your bottom line: self-funded benefits.

What are self-funded benefits?

Self-funded benefits or self-insurance is an alternative to traditional fully-insured plans. Self-funded benefits are a type of plan where the employer “takes on the responsibility of paying employees’ and dependents’ medical claims.” As with a fully-insured plan, the funds for the plan may come from both the employer and the employees . However, the employer takes on the responsibility for their employees’ healthcare benefits instead of paying an insurance company to handle their employees’ healthcare benefits.

When a company decides to self-fund, they will generally set up a trust fund (specifically for employee healthcare) where funds will be collected and distributed from whenever claims are submitted. Since healthcare claims can be unpredictable, self-insured companies, particularly smaller ones, will obtain stop-loss insurance coverage to help absorb exorbitant claims. This way, a self-insured company can provide customized benefits for their employees at a more reasonable price, while still protecting themselves from catastrophic costs.

What are the regulations?

Self-funded benefits are not regulated the same as fully-insured benefits . When a company decides to self-fund, they are not required to comply with state insurance laws for medical benefit plan administrators. Rather, they are obligated to comply with certain federal regulations that include

the Employee Retirement Income Security Act ( ERISA ),
HIPAA,
COBRA, and
the Americans with Disabilities Act (ADA).

Self-insured companies are also obligated to generate a Summary Plan Description (SPD) for their employees.

Though self-funded plans are subject to select federal regulations, they do not need to comply with some parts of the ACA like the ten essential health benefits requirement and premium increase reviews. On the other hand, all self-funded plans are required to comply with other provisions of the ACA like adhering to the Patient’s Bill of Rights and providing things like preventive care and coverage for pre-existing conditions.

The regulations that govern self-insurance provide employees with confidence that they will receive important coverage while simultaneously providing employers with the flexibility to offer benefits that best suit their specific company needs.

Why choose self-funded benefits?

Employers traditionally offer benefits that are fully-insured —or that are purchased from and administrated through an insurance company like Aetna, Blue Shield, or UnitedHealthcare. In these scenarios, the employer pays the insurance company for healthcare coverage for their employees. Of course, the employer pays a set amount no matter how much the employees use their benefits. These premiums are not cheap, and employers can end up paying for a lot of services that their employees may or may not use.

In an attempt to pay for what they actually use, employers may opt to self-fund their benefits packages. In the past, this has been more common with large corporations , since larger companies are generally in a better position to handle the burden of costly claims. However, self-funded plans are becoming more and more popular for even small companies.

A small or mid-size company might prefer a self-funded plan for the following reasons:

Avoid pre-payment for coverage; only pay when claims are submitted
Not subject to state regulations; self-funded plans are federally regulated (by ERISA)
Fewer extra costs (e.g. no state premium taxes)
Don’t pay for insurance company profits
Contract with a provider network of your choice – reflecting your employee population.

Using a third-party administrator

When a company uses a traditional insurance plan, they benefit from the administrative capacity of the insurance company that they work with. Without that assistance, self-funding a plan can be a lot of extra work, and it can strain limited company resources. That is why many companies who want to self-insure may end up working with a third-party administrator (TPA). Though self-funded plans can be totally autonomous, where the company handles the administration of the plan in-house, those who choose to work with a TPA will get help with:

Reporting
Adjudicating claims
Lowering overhead costs
Consolidating billing for providers
Accessing a reputable provider network
Remaining compliant with federal regulations

Overall, a TPA helps by taking on the administrative burden of funding your own benefit plan. By using a TPA an employer can conserve the resources of their HR and finance departments, allowing the TPA to take responsibility for managing the benefit plan.

Summary

Self-funded benefits allow you the opportunity to create something truly customized for your workforce. Since you know your employee population, you can provide benefits that your employees need and use and not spend money on benefits that are rarely needed.

If your company decides to go the self-funded route you will have a bit more flexibility than with the traditional insurance route. Though self-funded plans are not as heavily regulated as fully insured ones, there is still a good deal of accountability. Choosing this strategy can give your company an opportunity to save money while still taking excellent care of your employees’ healthcare needs.

Legal disclaimer: This is not legal advice. For questions regarding your specific situation, please consult an attorney.

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What Is a MEC Plan?

Wed, 09 Nov 2022 00:30:37 GMT

Since the Affordable Care Act (ACA) went into effect, there has been a lot of talk about Minimum Essential Coverage (MEC). But, what really constitutes minimum essential coverage, and what does it mean when a plan is MEC-compliant or advertised as a MEC plan?

ACA mandates

Many people are familiar with the ACA’s individual mandate (individual shared responsibility requirement) that requires each individual to have qualifying health coverage, or minimum essential coverage. An individual may obtain this kind of coverage with an employer-sponsored plan, an individually-purchased plan, or a government-sponsored program . Up until 2019, an individual without qualifying coverage would be fined by means of a tax penalty. While that federal tax penalty has since been repealed, some states do still impose a fine.

The ACA also includes an employer mandate. This mandate is still in place for applicable large employers (ALEs) that have a workforce of 50 or more full-time employees, and it requires employers to offer affordable MEC plans that also meet minimum value standards as defined by the ACA. This mandate also requires that at least 95% of a company’s full-time employee population be enrolled in the employer-sponsored health benefits.

Defining MEC

Sorting out exactly what minimum essential coverage is can be tricky because many definitions are vague. For example, any employer-sponsored coverage qualifies as minimum essential coverage. A MEC plan should also adhere to the ACA’s Patient’s Bill of Rights. The Patient’s Bill of Rights outlines rights that include access to coverage for pre-existing conditions, limits on when an insurance company may rescind or cancel coverage, and coverage without lifetime or annual limits.

A more detailed list of plans that qualify as minimum essential coverage is available here .

ACA Penalties

If an ALE does not offer its full-time employees MEC health coverage, they will be penalized. For 2026, in the event that an ALE does not offer any health coverage, they will be assessed a penalty of $3,340 per full-time, or full-time equivalent, employee (minus the first 30). So, for example, if a company employs 200 people full-time and does not offer any health coverage, they will be penalized $567,800 over the course of the year (200-30 x $3,340), or $47,317 monthly ($493,000/12).

In the event that an ALE offers health benefits to its full-time (or full-time equivalent) employees that don’t quite measure up to ACA standards for minimum value (MV) or affordability, the employer is at risk for a different penalty. For any full-time employee who declines employer-sponsored MEC coverage, seeks insurance from one of the marketplaces, and obtains a premium tax credit, the employer will be assessed a $417.50 monthly ($5,010 annually) penalty. If even one employee receives a premium tax credit, the employer will be penalized.

It's worth noting that when an employer does offer benefits, it is far less likely that their employees will seek coverage in the marketplace. So, although an employer’s benefits package may not be affordable or measure up to the ACA’s minimum value standards, the penalty is only assessed if an employee declines employer-sponsored benefits, seeks coverage in the marketplace, and qualifies for a premium tax credit.

In the first scenario, the penalty is automatic, and very costly. In the second scenario, the penalty is assessed on a case-by-case basis. If the employer-sponsored plan is robust enough, employees may be satisfied with it, and a penalty might not be an issue.

How Planstin works with MEC

Planstin specializes in helping companies offer customizable, MEC plans that help businesses comply with ACA requirements. Additionally, these MEC plans are affordable and easy to use. With Planstin, you can offer an ACA-friendly, MEC-compliant plan for as low as $35 per employee. These MEC plans will help you save money by avoiding tax penalties, retain more employees, and attract top talent. If you are curious about how this can work for your company, you can set up a complimentary virtual meeting and get a free quote tailored to your business needs.

MEC and small business

What if a company has less than 50 full-time equivalent employees? In that case, they are not subject to the same ACA requirements, and “no small employer…is subject to the Employer Shared Responsibility Payment.” However, a small business may still wish to offer MEC-compliant plans since the concept behind minimum essential coverage is important. There are also potential benefits for any small business (under 50 full-time employees) that offers a MEC plan.

The ACA set up the Small Business Health Options Program (SHOP) which, when enrolled, may allow a small business to qualify for a tax credit.

This is not legal advice. For questions regarding your specific situation, please consult an attorney.

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planstin

What Your PPO Network Was Actually Designed to Do

Access and cost control are not the same thing

The access promise is shakier than it appears

The default became the strategy

What employers are beginning to ask

The bottom line

Ready to stop fighting a n outdated system and start building benefits that work? ﻿

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The Myth of PPO Savings

When discounts are calculated from inflated list prices, they can create the illusion of savings without addressing the underlying cost of care. Understanding how these pricing mechanics work is an important first step for employers trying to manage healthcare spending more effectively.

Why discounts aren’t always the same as savings

The discount percentage alone tells us very little about the price that ultimately matters: the actual price of the care.

The starting price was never real

Why discount percentages can be misleading

What independent research shows

A better question for employers

The bottom line

Ready to stop fighting a n outdated system and start building benefits that work? ﻿

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How Health Insurance Alternatives Can Save Your Small Business Money

Small businesses don’t have to accept rising premiums as the cost of offering benefits. Health insurance alternatives are giving employers a smarter, more sustainable way to support their teams.

Why traditional group insurance no longer fits

The issue isn’t that small businesses misunderstand how benefits should work, it’s that the traditional model was never built to serve them in the first place

A flexible model that reflects today’s workforce

HealthShares: A practical cost-sharing option

For small businesses that are priced out of traditional insurance—or that want to provide meaningful healthcare support without absorbing the full administrative and financial burden of a group plan—HealthShares offer an attractive option.

Rethinking the role of the employer

Choosing the right path

How Planstin helps

Ready to stop fighting a n outdated system and start building benefits that work? ﻿

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Why Telemedicine Is the Next Big Step for HSAs

Over 32 million people will benefit from HSA-compatible telemedicine under the new OBBBA law. Here’s why this change matters—and how it reshapes access to care.

Out with the old: How Telemedicine fit into HSA rules before the new law

In with the new: Telemedicine is now clearly HSA-Compatible

What this means for patients

What's next?

Interested in what adding virtual care can do for your benefits package? Let’s talk.

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Benefits Trends for 2026

Benefits are getting more expensive, and traditional models are cracking under the pressure. In 2026, businesses will need smarter, more flexible ways to care for their teams.

Trend #1: Health insurance premiums are increasing

Trend #2: Employers are shifting more costs to employees

Trend #3: A focus on access to primary care

Trend #4: A focus on mental wellness and voluntary benefits

Trend #5: More employers are using alternative plans and models

The future in alternatives and innovations

Are your benefits keeping up? Let’s talk.

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Strategies for Effective Health Plan Renewals

Renewal season rarely waits for a quiet calendar. As projects stack up, so do the questions. What do our people need most? Where are we paying too much? Mercer projects a 6.5 percent increase in employer health benefit costs in 2026 , which can make open enrollment feel daunting. ﻿

1. Start early and stay ahead

90-Day Blueprint:

2. Use data to drive smarter decisions

What to look for

How to act on what you see

Bring employees into the picture

3. Drive employee participation through communication

Key Drivers of Employee Participation

Make Education Your Anchor

4. Optimize costs without sacrificing value

Proven Strategies to Consider:

5. Ensure compliance and smooth operations

Compliance Must Haves

Operations that Keep Things Smooth

Turning renewal into opportunity

Need help with your benefits renewal? Have other benefits questions? Let’s talk.

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How to Communicate Your Benefits Package Effectively to Your Employees

When communication works well, trust grows, engagement rises, and people feel confident that the benefits you provide are truly for them. That sense of value makes all the difference. ﻿

Start with clarity

Meet employees where they are

Lead with what matters to them

Roll out changes with purpose

Make enrollment feel simple

Keep the conversation going

Invite dialogue and listen

Measure, learn, improve

Final thoughts

Ready to stop fighting a n outdated system and start building benefits that work?

Ready to stop fighting a n outdated system and start building benefits that work?

Ready to stop fighting a n outdated system and start building benefits that work?

Renewal season rarely waits for a quiet calendar. As projects stack up, so do the questions. What do our people need most? Where are we paying too much? Mercer projects a 6.5 percent increase in employer health benefit costs in 2026 , which can make open enrollment feel daunting.

When communication works well, trust grows, engagement rises, and people feel confident that the benefits you provide are truly for them. That sense of value makes all the difference.