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Frequently Asked Questions

What is the difference between ‘group’ and ‘individual’?
At the most basic level, ‘individual’ plans are underwritten, meaning that someone from the carrier will review your medical history and either accept your application or decline it. ‘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. The carrier doesn’t ask any medical questions on a ‘group’ enrollment form, and can’t decline coverage for your employees.

How many employees do I need for a ‘group’ plan?
In the State of Oregon, you’ll need 2 enrolling employees in order to start a ‘group’ plan. This can be a husband and wife, provided that they both work for the business. 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?
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’?
In the State of Oregon, there is a 6-month pre-existing condition period on every new policy. This means that the new carrier will not cover any condition for which there was a consultation, diagnosis, or treatment until the new policy has been in place for 6 months. But not to worry, if you’ve had coverage for 6 months prior to the start date of the new policy, that coverage will credit against the pre-existing condition period. And you can have a gap in coverage for up to 63 days and still use the credit from your previous carrier. Also, if you begin coverage and on day 1, twist your ankle, that will be covered. A pre-existing conditon, only refers to something that happened prior to the effective date.

What is ‘participation’ and how many of my employees have to be enrolled in the plan?
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 wifes plan, then only 6 of the remaining 8 employees need to enroll in order to have 75% eligibility. Two of your employees can waive without affecting your ability to have a group plan.

Can I exclude part-time employees?
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.