What are my options if I can’t afford the premiums quoted for my company because I have one or more high-risk workers or dependents?
Every health insurance company conducting business in the Virginia small group market must offer both a standard plan and an essential plan. These plans were created for employers who may encounter high premiums due to the health status of their workers or dependents.
Important Facts to Know
Essential plans cover children under 18. Standard plans have no age restriction. Both plans offer a limited set of basic benefits. They include hospitalization; office visits; mental health, maternity, and emergency care; lab work and X-rays; adult physical exams; mammography screenings; well-child care; and access to generic prescription drugs. Standard plans also offer allergy treatment, audiology services, home health care, hospice care, skilled nursing facility care, and rehabilitative care.
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Unlike other types of health insurance sold to small businesses, standard and essential plans do not have to offer additional state-required benefits, which may help lower the cost of premiums. Both types of plans can deviate only 20 percent above or below the average premium for demographically similar groups for similar coverage.
Standard and Essential Plan Premiums
Virginia law requires health insurance companies that do business with small businesses in the Commonwealth to offer both standard and essential plans. Below are the quoted premiums for select standard and essential plans that would be available to three hypothetical companies. For businesses with one or more employees or dependends with a pre-existing ondition, these rates can increase no more than 20%.
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TOTAL PREMIUM FOR:
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PLAN |
2-person firm with 2 dependents |
8-person firm with 7 dependents |
15-person firm with 14 dependents |
CareFirst's Essential HMO |
$1,212 |
$4,428 |
$7,817 |
CareFirst's Standard HMO |
$1,306 |
$4,773 |
$8,425 |
Note: Whereas the premium quotes listed in the Regional Health Plan Comparisions chart on this site are base rates that almost always go up after medical underwriting, these standard and essential premium quotes could go up or down by 20% depending on the heath status of the firm.
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If I find group coverage unaffordable, are there any other options available to me, my employees, and our dependents?
 You and your employees could choose to purchase coverage separately in the individual health insurance market and be responsible for your own premiums. In the individual health insurance market, which operates differently from the small group market, healthy people generally can get affordable health insurance. People with pre-existing conditions may be denied coverage or subjected to a waiting period for coverage of their pre-existing conditions.
Some states operate high-risk pools for individuals who are denied insurance on the basis of poor health status. Virginia does not currently have a high-risk pool, although the state Bureau of Insurance reports considerable interest in creating one. Virginia does offer guaranteed issue on an open (year-round) enrollment basis through Anthem and CareFirst, the state’s two Blue Cross insurers. Although no one can be turned down for this coverage, the premiums are relatively high and there is a one-year waiting period for coverage of pre-existing conditions.
Insurance for Working Families
All states offer low-cost or free health insurance to eligible children of working parents and, in some cases, extend coverage to parents. Depending on their wages and other family income, your employees and/or their children may qualify. Coverage options may include Medicaid and the State Children’s Health Insurance Program (SCHIP), known as FAMIS (Family Access to Medical Insurance Security). To learn more, call 1-866-87-FAMIS or visit http://www.FAMIS.org.
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Here are some options for individuals, though availability may be limited:
Basic (Hospital/Surgical) Policies: These plans cover short-term hospitalization and routine surgery, but not lengthy hospitalization or costly medical care. Hospital Confinement Indemnity Insurance: This plan pays for each day, week, or month an insured person is hospitalized, up to a designated number of days. Some polices limit coverage of pre-existing conditions; some may not pay for hospitalization until the enrollee has been hospitalized for a certain number of days. Specified Disease Insurance Policies: These plans cover specific diseases, such as cancer, and are usually limited in the total amount they will pay out and may be restricted to the first occurrence of the disease. Limited Benefit Health Polices: These plans provide benefits that do not meet the minimum standards required by the state. Insurance companies may market such plans as long as they disclose and describe the limitations in detail. Health Savings Accounts (HSAs): These pre-tax income funding plans are not limited to the group market and can be purchased by individuals in combination with a high-deductible plan.
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Part 1: Insurance Basics