Fully-Insured

Fully-Insured

Traditionally-funded insurance arrangements typically works like this:

The consumer contracts with an insurance company as the consumer agrees to pay a specified premium for medical claims coverage and administrative expenses. Most self-insurance arrangements also work like this, except for 1 big difference. Unlike most self-insurance arrangements, fully-insured applicants are not medically underwritten. Rather, underwriting is estimated off 2 factors, your age and geographic location ONLY, otherwise known in the insurance industry as community-rating.

 

 

What You Need To Know

Payment Method-

  • Mailed check for 1st month premium OR
  • Set-up ACH with:

Account #

Routing #

  • Credit cards are not allowed

Eligibility-

  • Full-Time Employees ONLY but Employer group size does not apply- N/A.
  • At least 1 employee on payroll and enrolling into the plan is needed! Can't be spouse of controlling owner. 

Who is a full-time employee-

  • Works 25 hours per week, (30 hours for the purposes of the Full-Time Equivalent Calculation), for at least 120 days in the calendar year.

FTE Inclusion-

Include

  • All full-time employees of a group if the business is affiliated with another employer, under common ownership or part of a controlled group 
  • Part-time employees 

Don’t Include

  • Union employees partners
  • Shareholders or Owners without Common Law Employee Status
  • Family Members or Dependents
  • Seasonal Workers- Worked Full-time LESS than 120 days per year
  • Independent Contractors who are not common law employees- 1099 workers

FTE Calculation-

  • Use the following full-time equivalent calculation to determine appropriate group size:

a) Employees working 30 or more hours per week are full-time employees and each full-time employee counts as 1.

b) Employees working fewer than 30 hours per week are part-time and counted as the sum of the hours each part-time employee works per week multiplied by 4 and the product divided by 120 and rounded down to the nearest whole number.

c) Add a and b. This gives you the employer FTE.

Note: Only 1 person on payroll needs to be working 30+ hours per week. 25+ hours per week is used for insurance eligibility and participation requirements.

Example 1: 15 employees working 30 hours or more=15. 5 employees working 20 hours per week= 100 hours x multiplier of 4= 400/120= 3.33= 3... 15+3= 18 FTE's 

Average number of FTE Employer Contribution-

  • At least 10% of the total premium.

Participation-

  • 75% including valid waivers unless applying within the Open Enrollment Period

Non-Contributory Plans (self-funded employer pays all plan contributions)- 100% participation excluding valid waivers

Contributory Plans (plan contribution is paid by both the employer and enrolled employee)- 75% including valid waivers

Tax Documentation Needed, (Required for Groups under 5 full-time employees)-

  • Most recent Quarterly Wage and Tax Statement (QWTS), WR-30 or most recent payroll information if not available.
  • Documentation demonstrating employer business status:

Need 1 of the following-

IRS Form 1120

Form 1040

Schedule C

Form 1065

Schedule K-1