Frequently Asked Questions
Find quick answers about membership, benefits, eligibility, and how our collective buying power works.
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The nonprofit offers its eligible members access to a large-group health insurance program
designed to provide competitive pricing, broad network access, and enhanced benefits through the
collective purchasing strength of the membership.
The purpose is to use the nonprofit’s membership base to create greater purchasing leverage with health insurance carriers and provide members with access to benefits that may be difficult or more expensive to obtain individually.
No. The nonprofit is providing access to a group health insurance program. The actual insurance coverage is provided by the selected insurance carrier, subject to the carrier’s policy and contractual terms.
The nonprofit would select or contract with an insurance carrier capable of providing the desired network, benefits, service capabilities, and pricing.
The program can be designed around a broad PPO network, giving employees greater flexibility in choosing doctors and hospitals. This will allow coverage across not only the state of Texas but the entire United States.
Not necessarily. Provider participation should be reviewed before enrollment so members can determine whether their employees’ preferred physicians and hospitals participate in the proposed network.
Yes. One of the primary purposes of the program is to give nonprofit members access to the purchasing advantages of a larger group.
Premiums may be based on factors such as the overall group demographics, plan design, geographic area, carrier underwriting requirements, and applicable large-group rating rules.
That depends on the final underwriting and funding arrangement. The program should clearly explain how individual member claims experience affects that member’s premiums and how the overall group’s experience affects future rates.
Because the program is fully insured, participating organizations pay a fixed premium to the insurance carrier for the coverage selected. The insurance carrier assumes the financial risk for covered medical claims and is responsible for paying eligible claims according to the terms of the insurance policy
No. The program can provide access to competitive pricing, but health insurance premiums are affected by claims, healthcare costs, demographics, provider contracts, and market conditions.
Depending on the carrier and program design, members may be able to choose from multiple plan options with different deductibles, copays, coinsurance, and employee contribution levels.
Yes. Each participating organization can establish its employee contribution strategy, subject to applicable plan and regulatory requirements.
The nonprofit will be offering dental, vision, life, disability, and other ancillary benefits as part of the overall member benefits program.
Depending on the selected program, benefits could include:
The insurance carrier and its designated administrators would handle claims and plan administration. The nonprofit and its benefits consultant can provide member support, education, and program oversight.
Members will have a dedicated benefits representative and account management team to assist with enrollment, claims issues, provider questions, and benefit education.
Yes. A successful large-group program should include an implementation and employee education process, including benefit meetings, enrollment assistance, plan comparisons, and communication materials.
Your organization remains responsible for determining its employee contribution strategy and selecting from the available plan options. The nonprofit establishes the overall program structure and negotiates the group arrangement.
No. Membership in the nonprofit does not necessarily require an organization to purchase its health insurance through the nonprofit’s large-group health insurance program.
Yes. To maintain the stability and purchasing strength of the large-group program, participating organizations are expected to make a full 12-month commitment to the health insurance program.
The annual commitment allows the nonprofit and insurance carrier to establish the program based on a stable membership population rather than having organizations enter and exit throughout the year. This consistency can be important when negotiating rates, establishing plan options, and managing the overall program.
Employees can still gain or lose coverage in accordance with the eligibility provisions of the health plan. For example, an employee who terminates employment may lose active employee coverage, while applicable continuation coverage or special enrollment rights may apply depending on the circumstances. The Department of Labor recognizes termination of employment and certain reductions in hours as events that can trigger COBRA continuation rights for covered individuals when COBRA applies.
No. Individual employee health information should remain confidential and be handled in accordance with applicable privacy requirements. Members should not have access to another organization’s employee medical information.
The key difference is purchasing leverage.
Yes. Subject to the terms of the health plan, carrier approval, and applicable federal and state requirements, the program is designed to provide an eligibility pathway for qualified 1099 independent contractors to participate directly through the nonprofit’s member health insurance program.
Yes, when COBRA or another applicable continuation requirement applies, an eligible individual may have the right to continue group health coverage after certain qualifying events, such as termination of employment or a reduction in hours.
Potentially, yes. The program can be designed to accommodate retiree health coverage, subject to the insurance carrier’s approval, the plan’s eligibility provisions, and applicable federal and state requirements.
Retiree coverage can provide an organization with an additional option for maintaining health benefits for eligible retirees after they leave active employment.
Yes. Subject to the nonprofit’s membership requirements, the insurance carrier’s approval, and applicable federal and state requirements, a qualified sole proprietor may be eligible to participate directly in the nonprofit’s member health insurance program.
Participating organizations should not cancel their existing health insurance coverage until the new coverage has been formally approved, the effective date has been confirmed, and enrollment has been completed.
The member should coordinate with its current carrier and benefits advisor regarding its renewal and termination provisions. The nonprofit program can then coordinate the proposed effective date to minimize disruption and avoid an unintended lapse in coverage.