What is the difference between ‘group’ and ‘individual’?

At the most basic level, ‘individual’ plans are plans you choose which are enrolled directly with the carrier. You can enroll during Open Enrollment (November 1-December 15 every year) or within 60 days of a Qualifying Event. ‘Group’ plans are guarantee-issued, meaning that if an employee meets the criteria set by the employer, and they turn in an enrollment form, they’ll be on the plan, and enrolled as of the first of the month after they meet that criteria.

How many employees do I need for a ‘group’ plan? (Oregon)

In the State of Oregon, you’ll need a ‘non-spouse’ employee to enroll on the plan. Some carriers will require ownership documentation, and some will require an Oregon Form 132, which is a quarterly form filed with the State and lists the hours each employee worked in the last quarter.

What do I have to pay for my employee’s health insurance? (Oregon)

The State of Oregon requires you to pay at least 50% of the employee-only rate. This means that you don’t have to pay any of the rates for their dependents, but you do have to pay at least half of the employee rate.

What are ‘pre-existing conditions’?

Since the Affordable Care Act passed, pre-existing conditions are not part of the health insurance industry. Anyone with any medical issue can enroll on either an individual or group plan without concern about coverage for a pre-existing condition.

What is ‘participation’ and how many of my employees have to be enrolled in the plan? (Oregon)

Participation refers to the percentage of eligible employees enrolling in the plan. Typically, most carriers will require 75% participation. But employees who don’t meet your hourly requirement don’t count against your participation. As well, employees waiving to other group plans don’t count against your participation. If you have 10 employees, 1 who works less than the required hours, and 1 who is on his wife’s plan, then only 6 of the remaining 8 employees need to enroll in order to have 75% participation. Two of your employees can waive without affecting your ability to have a group plan.

Can I exclude part-time employees? (Oregon)

In the State of Oregon, you can set the hourly requirement anywhere between 17.5 and 40 hours a week in order for employees to be eligible for your group plan.

How many employees do I need for a group plan? (Washington)

Washington defines a small group as 1 to 50 employees. In practice, carriers want to see at least one eligible employee who is not an owner or the owner’s spouse, and they may ask for ownership documents or a quarterly wage report to confirm who works for the business.

What participation rules apply to group plans? (Washington)

Most carriers require roughly 75% of eligible employees to enroll. Employees who waive because they have other coverage usually do not count against your participation. That includes coverage through another employer’s plan (such as a spouse’s or parent’s plan), Medicare, Medicaid (called Apple Health in Washington), and TRICARE or other military and veterans coverage.

How does Washington Healthplanfinder work for individual coverage? (Washington)

Washington Healthplanfinder is the state’s marketplace for individual and family plans, and it is the only place to get premium tax credits and Cascade Care Savings if you qualify. Open enrollment runs November 1 through December 31, with coverage starting January 1. Outside that window, a qualifying life event such as losing other coverage, moving, or adding a family member opens a 60-day special enrollment period. We can quote plans, explain the trade-offs, and complete the enrollment with you at no extra cost.