Small Group Fully Insured Health Plans: A Complete Guide for Employers & Advisors

Understand the structure, regulation, and mechanics of fully insured small group health plans — who the players are, how premiums are set, and what employers actually buy.

• The Small Group Market: Definition, Scope, and Players8 min
• ACA Requirements That Govern Small Group Plans10 min
• Premium Components: What You Are Actually Paying For9 min

Navigate the plan design decisions that define what employees pay and what the plan covers — metal tiers, deductibles, copays, coinsurance, out-of-pocket maximums, and network types.

• Metal Tiers: Bronze, Silver, Gold, and Platinum8 min
• Cost-Sharing Mechanics: Deductibles, Copays, Coinsurance, and OOP Max9 min
• Network Types: HMO, PPO, EPO, and POS Plans8 min

Understand how carriers calculate small group premiums — the rating factors they use, how renewals are priced, and what employers can do to influence their rates.

• Community Rating: How Small Group Premiums Are Set9 min
• Renewal Pricing: Why Rates Increase and What You Can Do10 min

Navigate the federal and state compliance obligations that apply to small group fully insured plans — from ACA reporting to ERISA, COBRA, HIPAA, and state mandates.

• ACA Compliance for Small Employers10 min
• ERISA, COBRA, and HIPAA for Small Group Plans10 min
• State Mandates and Mental Health Parity8 min

Master the operational mechanics of small group plan administration — eligibility rules, enrollment periods, qualifying life events, contribution strategies, and carrier administration.

• Eligibility Rules and Waiting Periods8 min
• Employer Contribution Strategies9 min

Understand how prescription drug benefits work in fully insured small group plans — formularies, tiers, prior authorization, specialty drugs, and cost-containment strategies.

• Formularies and Drug Tiers8 min
• Pharmacy Cost-Containment Strategies for Small Groups9 min

Design and implement wellness programs that reduce costs, improve employee health, and comply with HIPAA and ACA wellness program rules.

• ACA Preventive Care Requirements8 min
• Designing a Compliant Wellness Program10 min

Understand the role of supplemental and voluntary benefits — dental, vision, life, disability, FSAs, HSAs, and HRAs — in a comprehensive small group benefits package.

• Dental and Vision Benefits8 min
• Life, Disability, and Ancillary Benefits8 min

Develop a systematic framework for evaluating carrier proposals, comparing networks, and selecting the right carrier for your small group — beyond just the premium.

• Building a Carrier Evaluation Framework9 min
• Reading and Comparing Carrier Proposals9 min

Implement practical cost-containment strategies that reduce premium growth without reducing the quality of coverage — from plan design levers to value-based care and direct contracting.

• Plan Design as a Cost-Containment Tool9 min
• Value-Based Care and Alternative Payment Models8 min

Design a benefits communication strategy that drives enrollment, improves utilization, and increases employee satisfaction with the benefits package.

• Open Enrollment Communication Strategy9 min
• Year-Round Benefits Communication8 min

Navigate the claims and appeals process — how claims are processed, what to do when claims are denied, and how to advocate for employees in disputes with carriers.

• How Claims Are Processed8 min
• Appeals and External Review9 min

Navigate the growing importance of mental health and behavioral health benefits — parity requirements, EAP programs, telehealth, and building a culture of mental health support.

• Mental Health Parity: Requirements and Compliance9 min
• Employee Assistance Programs and Mental Health Resources8 min

Evaluate when and whether to move beyond fully insured coverage — level funding, self-funding, association health plans, and other alternatives — with a structured decision framework.

• Signs Your Group Has Outgrown Fully Insured Coverage9 min
• Association Health Plans and Other Alternatives8 min

Apply the concepts from this course to real-world scenarios — a 25-employee manufacturer evaluating plan options, a 45-employee professional services firm managing a renewal, and a 15-employee retailer exploring alternatives to fully insured coverage.

• Case Study: The 25-Employee Manufacturer10 min
• Case Study: The 45-Employee Professional Services Firm10 min