Health Insurance

  1. FAQs
  2. INTRODUCTION
  3. HEALTH INSURANCE
    1. Fee-for-Service Plans
    2. Health Maintenance Organization (HMO)
    3. Point of Service Plan (POS)
    4. Preferred Provider Organization (PPO)
    5. Tax Consequences to the Employer
    6. Tax Consequences to the Employee
    7. Qualifying Medical Care
  4. HEALTHCARE UNDER THE PPACA (“Obamacare”)
  5. COBRA CONTINUATION OF COVERAGE
  6. HEALTH INSURANCE AT-A-GLANCE
  7. FORMS AND CHECKLISTS
  8. State Insurance Departments

Frequently Asked Health Benefits Questions

  1. What is a fee-for-service plan?
  2. What is the difference between an HMO and a PPO?
  3. Are there any legal requirements for setting up a health plan?
  4. What are the tax consequences to the employer of providing health insurance?
  5. Are health insurance benefits taxable to the employee?
  6. Which expenses qualify as “medical care”?
  7. What is COBRA?
  8. How does an employee become eligible for COBRA benefits?

Introduction

This section discusses employer-provided health insurance, including administration, funding, tax consequences and legal compliance. In addition, it outlines some of the popular policies and options. The U.S. Department of Labor has an extensive site devoted to Consumer Information on Health Plans & Benefits. For a discussion of life and disability insurance, see our Life Insurance section.

For most employees, health care is the most important employer-provided fringe benefit. It is for this reason that many employers offer medical insurance coverage, even though such coverage is generally not required by law. In fact, most companies with over 100 employees offer some type of health insurance.

Healthcare Reform – “Obamacare”

Affordable Care Act (ACA)

For tips, fact sheets, questions and answers, videos and more information on the Affordable Care Act (also referred to as Healthcare Reform or “Obamacare”), see the IRS ACA Tax information page. For the tax implications of the ACA, see the Affordable Care Act Tax Page.

Health Insurance Marketplace

Definitions

Although this section deals mainly with the “mechanics” of choosing, setting up and administering a health plan, as well as some of the tax and legal implications—we must first define several terms commonly used in relation to various types of plans. (For additional terminology, please refer to the Glossary.)… Premium Subscribers Only

Retiree Medical Benefits

Retiree medical benefits are a matter of great concern to both employers and employees. For the employer who is committed to providing such benefits, rising costs cause concern. Costs are rising as people are living longer.

The first action the employer will want to take is to review its commitment to the employee. One major concern is whether it is binding or not. For example, if the agreement is found in a union contract, and is clearly found to be in force, then an obligation exists—versus something that may be interpreted to be implied in a manual.

It has been held that the plan description (SPD) required by ERISA and distributed to employees controls. If the SPD reserves the right of the employer to alter, modify, or eliminate the plan—which many do—this may override any implied promise of lifetime or no-cost medical benefits contained in an employee manual or brochure.

Care should be taken to review terms used in manuals or brochures to make sure that the intention of the employer is being properly communicated. If promises are made, their binding nature could be costly.

Each employer should make a cost-benefit analysis in terms of its own workforce, age categories, turnover rate, health state, and all other factors bearing on the present and future costs. On the benefit side, the employer will want to consider what is being offered by competitors tapping the same labor pool and what effect this will have on recruitment and retention of talent.

Compliance with Federal Laws

If an employer does choose to offer health care coverage, it must comply with several federal laws. The most notable of these are: … Premium Subscribers Only

Tax Considerations

As long as the employer’s group health plan satisfies certain nondiscrimination and qualification requirements, the premium it pays for such coverage and the benefits received from it are generally excluded from the employee’s income. Moreover, an employer’s costs associated with its employee health plan generally will be deductible as an ordinary and necessary cost of business, regardless of the ultimate tax treatment of the benefits to the recipients.

Tax Consequences to the Employer

Insurance premiums and other costs associated with an employer’s health plan generally will be deductible for tax purposes, as an “ordinary and necessary” cost of doing business, regardless of the ultimate tax treatment of the benefits to the recipient.

NOTE: Group health plans must often comply with state law, as well. For example, in New York, an employer may not claim a deduction for any amounts paid or incurred in connection with a group health plan if the plan fails to reimburse hospitals for inpatient services provided in New York State at the same rate that commercial insurers licensed in New York are required to reimburse hospitals for inpatient services for individuals not covered by a group health plan. The same rule applies to plans that provide inpatient hospital services through a health maintenance organization (HMO) or through a Blue Cross and Blue Shield corporation.

Tax Consequences to the Employee

The value (premiums paid) of health insurance coverage is generally not considered income to the employee, and is therefore not included in income for tax purposes. Similarly, the reimbursements for actual medical expenses paid by the insurance carrier are generally not included in income.

Although, to be deductible by an individual, medical expenses generally must rise above a 7.5% (of Adjusted Gross Income) “floor,” employer-provided reimbursements do not have to exceed a certain floor.

However, amounts received by an employee as payment for personal injuries or sickness under an accident or health insurance plan, are included in gross income, to the extent they are attributable to employer-paid premiums that were not included in the employee’s taxable income (or were paid directly by the employer).

Qualifying Medical Care

Employees may be entitled to an itemized deduction for expenses paid for “medical care” if that care is not covered by the employer’s health plan (or if the employee is not covered by any health plan). Such expenses may be paid for the medical care of the employee, a spouse, or a dependent.

The term “medical care” is broadly defined in the tax law to include amounts that may not even be covered under a health insurance plan. Expenses that will be considered to be incurred for “medical care” include amounts paid for the following: … Premium Subscribers Only

Documentation and Employee Communication

It is essential for employers to continually refine their health management strategies. An increase in health options, new legislation, and a changing workforce are transforming the option of redefining employee health insurance into a necessity. As health care reform measures have worked their way through Congress, employers must address the current needs of their workforce rather than take a complacent stance regarding this extremely important employee benefit.… Premium Subscribers Only

Benefits for Domestic Partners

The traditional American concept of “family” has undergone dramatic change. Contemporary families now include not only the traditional married couple with children but also the unmarried opposite- or same-sex couple, adoptive families, step-families, and grandparents raising grandchildren. In recognition of the diversity in family representations, a small but growing number of employers offer health insurance benefits to their employees’ domestic partners/spousal equivalents.

Who to include as a domestic partner is a crucial decision for employers.

COBRA Continuation Of Coverage

Federal law requires most employers with group health plans to offer employees and their spouses and dependents a temporary period of continued health care coverage if their employer-provided coverage should cease. These continuation requirements are commonly referred to as COBRA (the Consolidated Omnibus Budget Reconciliation Act of 1985).

COBRA contains requirements for group health plans to provide continuation coverage to covered employees and their “qualified beneficiaries” upon the occurrence of a “qualified event.”

Generally, an employer with 20 or more employees must continue to offer coverage in their group health plan to certain former employees, retirees, spouses, and dependent children. The length of continuation coverage offered depends on the “qualifying event.”

COBRA Qualifying Events

Qualifying events are certain types of events that would otherwise cause an individual to lose health coverage—if not for the COBRA provisions. The type of qualifying event will determine who is entitled for continuation coverage and the required amount of time that the plan must offer the health coverage under COBRA.

Under COBRA, the affected employee or family member may qualify to keep their group health plan benefits for a set period of time, depending on the reason for losing the health coverage. The following represents a basic overview of some basic information on periods of continuation coverage:

Beneficiary Qualifying Event Period of Coverage
Employee, Spouse, Dependent child Termination or Reduced hours 18 months*
Spouse, Dependent child Employee entitled to Medicare Divorce or legal separation, Death of covered employee 36 months
Dependent child Loss of dependent status 36 months
*This 18-month period may be extended for all qualified beneficiaries if certain conditions are met in cases where a qualified beneficiary is determined to be disabled under COBRA.

In general, employers must offer coverage for a period of up to:

  • 18 months for covered employees, as well as their spouses and dependents, when health plan coverage is lost due to termination or a reduction of hours.
  • 36 months for spouses and dependents who lose coverage due to divorce or legal separation, the employee’s death, or another specified “qualifying event.”

However, COBRA also provides that your continuation coverage may be cut short in certain cases.

For Additional COBRA Information

For more on the COBRA requirements, see the section on Employee Termination.

The Health Insurance Portability and Accountability Act

The Health Insurance Portability and Accountability Act (HIPAA), signed into law by President Clinton on August 21, 1996, offers protections for millions of American workers that improves portability and continuity of health insurance coverage.

The Affordable Care Act (ACA) generally provides health protections beyond HIPAA. For more information on the ACA, visit the Affordable Care Act web page. Also, visit the Department of Health and Human Services (HHS) Website.

For a more complete discussion of the HIPAA requirements, click here.

For Additional Information

Health Insurance At-A-Glance

  1. For most employees, health care is the most important employer-provided fringe benefit.
  2. The premiums paid by the employer for health insurance coverage and the benefits received under the plans are generally excluded from the employee’s income.
  3. An employer’s costs associated with its employee health plan generally will be deductible as an ordinary cost of doing business.
  4. Unlike other employer-provided benefits, such as pensions, an employee is usually entitled to begin receiving health benefits shortly after commencing employment.
  5. Subject to certain limitations, expenses incurred for transportation and lodging away from home essential to medical care are treated as medical care expenses.

Forms and Checklists

HRgear.com – The Business Tools you need. Developed by leading HR experts.