Understanding employer coverage
Employer, group or commercial plans is health insurance coverage offered by an employer to its employee.
The plan’s monthly premiums are covered by both the employer and the employee, and coverage can extend to the employee’s spouse and dependents up to age 26.
Large group vs. small group coverage
Large group refers to employers that have 51 or more employees. Small group refers to employers that have between 2 and 50 employees.
What’s the difference between networks?
We have several plan options for large and small employers. Plan differ by coverage area, copay savings and provider access. The networks include:
- Copay elite (small group only): this plan provides excellent health care coverage from local, trusted providers at a lower cost to you. In addition, employees who choose Tier 1 providers have office visit copays lower than traditional ones. View all the copay elite plan features.
- Focus: this plan features providers in Dane, Green, Rock and Sauk counties. It also contains unique specialists, such as chiropractors and pediatric vision hardware providers.
- Smart plan (large group only): when employees stay in-network, preventive care is covered at 100%, and an out-of-pocket maximum limits copays. Even e-Visits are covered 100%. When they reach their out-of-pocket maximum, they don’t pay anything else for in-network services for the rest of that plan year. View all the smart plan features.
- Value choice plan (large group only): this plan provides access to the care options employees want — with added savings on SSM Health provider office visit copays. Take advantage of lower copays for Tier 1 copay benefit plan provider office visits, or access Tier 2 copay benefit plan provider office visits with copays similar to traditional HMO plans. View all the value choice plan features.
- Point of service (POS): our POS plan offers the benefits of the HMO plan, like lower costs at network providers, with options for your employees to see out-of-network providers if necessary.
- Preferred provider organization (PPO): the PPO plan gives employees living outside the Dean service area access to a more significant footprint of providers in their communities.
- HMO plans: Dean Health Plan’s HMO plan is for employers who want the most comprehensive network. Employees have access to primary and specialty network providers across the entire 20 county service area.
What is a PPO Provider?
A PPO Provider is a provider that is part of the Preferred Provider Organization network. That means choosing a PPO provider gives you the ability to get care from a provider outside of SSM Health and the HMO network, but copays and other costs may be higher. View this guide for instructions on how to find a PPO provider.
Out-of-Area Dependent Care*
If you have a dependent on your employer health coverage who does not live in the area, such as a college student, learn more about their out-of-area dependent coverage.
*Out-of-area dependent care is a benefit for large groups only.
What is an ASO plan?
ASO or Administrative Services Only is a self-funded insurance product in which the employer acts as the insurer and Dean Health Plan acts as the administrator. It differs from fully-insured group plans in the following ways:
Payments
- Fully-funded: Employer pays monthly premiums to insurance company.
- Self-Funded: Employer doesn’t pay premiums; pays directly for medical costs.
Risk
- Fully- funded Insurance company assumes risk of medical claims.
- Self-Funded: Employer assumes risk of medical claims.
Plan Design
- Fully-Funded: Health plan design is limited by state mandates.
- Self-Funded: Employer has more control and freedom in plan design.
What is level-funded health insurance?
A level-funded health plan is a self-insured plan with a fully insured feel. Unlike traditional self-insured plans, the employer pays the same amount each month. Then, if your claims experiences is better than expected, you will have the opportunity to receive a refund of 50% of the expected claims funding surplus.