What is Difference Between California Small Group and Large Group Health Insurance

“Group coverage” is used loosely to describe health insurance plans that are employer sponsored but there is a distinction between “Small Group” and “Large Group” health benefits which is important. Your company’s options can be quite different under these two umbrellas so let’s take a look at the how they differ both in terms of qualification and treatment under the law.

What is “Small Group” in terms of employer-sponsored health insurance In the State of California, Small Group health insurance is essentially employer-sponsored health insurance for companies with 2-50 employees. Eligibility requirements and protection is handled under AB1672.

First, “Guaranteed issue” is a very big advantage to establishing a Group health insurance plan in California versus other States. Regardless of the health of employees enrolling, the carrier must offer coverage to an eligible company. There are requirements that must be met by the company but the big three are 1) 2-50 employees/owners; 2) 75% of the eligible employees must go with the plan; and 3) the employer must pay at least 50% of the employee’s premium (does not mandate dependents). For more information on qualifying for Small Group coverage, please check our page of Small Group enrollment.

The ability of the company to change rates is also very important, especially for companies that have employees with health issues. In California, the carriers can up or down from the standard rate by 10%. This is called the RAF (Risk Adjustment Factor). The size of the group can affect this rate factor since the larger the group are more likely to get a lower RAF. The theory is that health issues are spread among a larger pool of people. It’s not atypical for carriers to offer RAF guarantees based on the size of the enrolling group.

Finally, the health carriers in California designate and file their Small Group plans with State agency responsible. Any eligible group can then apply for the same plan regardless of health. This is important to keep carriers from “cherry picking” healthy groups on to certain plan types and excluding less healthy groups.

How does Large Group health insurance differ?

Officially, large group health insurance is for groups with more than 50 employees/owners. Some carriers may allow groups that were originally designated as Small Group to remain on the Small Group suite of plans if they grow beyond 50 employees but they are not required to. There are some very big differences when comparing Large Group with Small Group described above.

Large group plans are not protected by AB 1672 and are not “guaranteed issue”. The carrier can decline coverage to groups based on claims experience and/or health history. Rates are built for that specific group’s claims experience and risk so total amounts can vary significantly from group to group. The plan options are different from those offered to Small Group and then to offer many more options. Some carriers even offer more of a cafeteria option where employer’s pick specific benefits to offer (i.e. choice of office copay, etc). Some Large group have tailor-made benefits to meet their needs and budget. Large group is quite different from Small Group and contacting an experienced agent is more important than ever when navigating this side of the business.