What You Need to Know About Health Insurance

Fall will be here soon and with it comes open enrollment for many health plans. Today I’ll cover issues for employers, employees who get insurance at work, individuals who aren’t covered at work and Medicare participants. Before I start, here are some general points to consider:

  • Politicians may or may not modify the Affordable Care Act (ACA) but until they do, it remains the law of the land.
    Health insurance has different rules by state. Any rules mentioned in this newsletter refer to California…if you have questions about other states, call us.
  • In some cases small businesses and individuals can buy health insurance online. It’s the same price if you use Desert Insurance Solutions or another broker. So use a good broker and get the help for free.
  • The good broker in our office is Colleen Flores. Health insurance is complicated so use our dedicated expert. Colleen has been studying this for years. Her contact information is on the right.


Group health plans help attract and retain employees, improve productivity and can help save money through tax benefits. According to the Kaiser Foundation, 53% small firms have plans, 89% medium firms have plans and 96% large firms have plans. So, if your firm doesn’t have a plan, you are at a competitive disadvantage regardless of size.

Here are some considerations and developments in group health:

  • Businesses with over 50 employees must offer health insurance or face penalties.
  • Previously businesses with 50-100 employees could offer “large group” plans, but that has changed so that only businesses with 100+ employees can offer those plans.
  • As a result, businesses with 50-100 employees with large group plans can expect changes in rates, premiums and plan availability.
  • As before, health plans are guaranteed to be issued regardless of the size or health of the group, and carriers cannot increase premium based on the size or health of the group either.

Any business with a plan must:

  • Have at least one full-time non-owner W-2 employee (averages at least 30 hours of work per week). You have a choice to offer to your part-time employees but if you do you must offer to all of them.
  • Cover at least 50 percent of the cost of health care premium for full-time employees based on the single rate. Some carriers offer a fixed dollar amount.
  • Have at least 70 percent of the eligible employees enrolled. Some carriers have a special offer for participation requirements.

Bottom line, this gets complicated, so if you have questions call Colleen. Many of these rules have little “footnotes” that can be used to your advantage.

Here’s something else for employers to consider. If you make a mistake you can be sued. You can get protection in the form of Employee Benefits Liability Insurance, which is an endorsement to your GL policy. You need to coordinate your health insurance and your property and casualty insurance. If both forms of insurance are with Desert Insurance Solutions, we do that for you.


Employees who get their insurance through work…you actually have it relatively good. Premiums and deductibles have been increasing but your employer is absorbing part of the pain. If you like your plan, do nothing. If you want to change, you need to wait until your open enrollment period, which is based on your employer’s renewal date. You can change earlier if there is a qualifying event such as:

  • Loss of coverage due to change in employment status
  • Medicare eligibility
  • Change in family status
  • Legal separation, divorce or dissolution of domestic partnership through whom you were covered as a dependent
  • Birth of a child
  • Loss of HMO coverage benefits because you no longer reside, live or work in the HMO service area


This is the Wild West of the ACA. Premiums and deductibles are going up and coverage is going down. If the ACA implodes it will be felt here first.

If you like your plan and renewal rate, do nothing. If you want to shop and/or your plan is being discontinued and you do not have a qualifying event (see above), the next open enrollment for on-exchange (Covered California) and off-exchange (enroll with a direct carrier) is November 1, 2017 – December 15, 2017. Here are the coverage issues we see for San Bernardino and Riverside Counties as of this time:

  • Anthem will be withdrawing from its HMO and their EPO product
  • Health Net is now offering a new PPO product

If you have either of these Anthem or Health Net individual health products, you will be given an opportunity to switch out.  Questions? Call our expert Colleen!


Medicare’s Annual Election Period, also known as open enrollment, happens every year from October 15th – December 7th. Medicare Annual Election Period allows you to switch Medicare Advantage and Part D Drug plans without going through any medical underwriting. This means if you don’t like your current plan you can use this time to switch to another plan and they must accept you. It might be a good time to compare your cost and coverage.

Final Thought

Health insurance remains a political football but meanwhile life goes on. Make sure you are comfortable with your plans and if you have issues call Colleen. The best advice I have for you about health insurance…stay healthy!

This site is informational and not a substitute for professional advice. Insurance coverage is subject to the language of the policies as issued.