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Q&As: Mom and Pop Medical Insurance, In Network ER, and Bonus’s for Salaried Employees

2 Person Group Insurance

Question: Is a small owner-only business eligible for group medical insurance? At this time, our company is comprised of the owner and his wife. There are no other employees yet, but we plan to hire employees in the future. Can we buy a group policy now or do we have to wait until we have other employees?

Answer: The question of whether a “mom and pop” business can purchase medical coverage as a group often comes up. Each state’s insurance laws control the type of policies that can be sold in that state and also defines who is a “group.” Insurance laws vary from state to state, but generally a husband/wife business does not qualify as a group if there are no other employees. There must be at least one W-2 employee who is not an owner or business partner (or spouse of an owner or partner). In the meantime, the owner may apply for an individual policy to cover himself and spouse (and eligible children, if any).

Lastly, there is a small handful of states that continue to allow mom and pop businesses meeting certain criteria to qualify as a group. Carriers and brokers licensed in the state can provide specific information about the respective state’s rules.

Health Care Benefits and “Emergency Services”

 


Question: The Affordable Care Act (ACA) requires our medical plan to cover out-of-network emergency services at the in-network benefit level. Does that apply just to the emergency room charges, or also to follow-up care?

Answer: According to the ACA regulations, the definition of emergency services includes:

  • The initial evaluation or treatment in the emergency room or similar setting;
  • Related ancillary services; and
  • Further treatment if needed to stabilize the condition.

The plan cannot impose a time limit during which the emergency services are provided.

For instance, if the patient was treated in the emergency room and from there admitted to the hospital for surgery, it appears the emergency room services, hospitalization, and surgery are all within the ACA’s definition of emergency services.

Extra Comp for FLSA Exempt Employees

Question: May I provide an exempt employee with additional compensation for working longer hours on a time-sensitive project without losing the exemption?

Answer: Yes. If you have a position that is classified as exempt—meaning the position is exempt from minimum wage requirements and overtime pay as determined by the Fair Labor Standards Act (FLSA)—that does not prevent you from providing that employee with additional compensation to express appreciation when the employee works more hours than expected.

About the author, Rhamy

Rhamy grew up watching and working with his mother and grandmother in the seniors insurance market. This familiarity with the struggles faced by people trying to navigate the incredibly complicated and heavily regulated healthcare market led him to start Poplar Financial while working on his degree at the University of Memphis. After completing his MBA and Bachelors in Finance and Economics, Rhamy guided Poplar Financial through the disruptive opportunity that is the Affordable Care Act. Since then Poplar Financial has received numerous awards from major insurance carriers, and has completed its fourth year in a row of doubling in size. Now his team focuses on the processes around human resources, and specializes in providing companies with between 20 and 1000 employees with the payroll, benefits, and HR needs.

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