ONE Healthcare System: Decision Making Tool

Do you need a policy that will cover Full-time equivalent employees (FTEq) or will this plan just be for you and your family?

How many FTEq do you have in total?

A business with 50 eligible employees is subject to healthcare reform with standards in affordability and minimum value benefit coverage. This is defined as an Applicable Large Employer (ALE).

Affordability is defined each year. In 2025 premium for an individual for the lowest cost plan is less than 8.39% of income.

A health plan meets the minimum value standard for an employer if it is designed to pay at least 60% of the total cost of medical services.

Failure to offer coverage considered affordable or providing minimum value can create an excise tax of $3,000 per individual, or $2,000 for each eligible employee in the absence of any coverage.

There are two types of policies you can offer your employees, a minimum essential coverage (MEC) plan, and/or a minimum value plan (MVP). As an ALE, a minimum value plan that is considered affordable is required to comply with healthcare reform.

Are you ready to move forward?

There are two types of policies you can offer your employees, a minimum essential coverage (MEC) plan, and/or a minimum value plan (MVP). You do not have requirements as an employer under healthcare reform.

Are you ready to move forward?

Is anyone currently undergoing any treatment plans?

Are there anticipated changes in the treatment plan?

Do you see a physician more than four times per year?

Are you or a spouse pregnant or planning to start a family?

Unplanned facility expenses can be covered from a third party policy, as an example from an auto accident, or where there is another party liable.

Are you comfortable having limited to no facility coverage in the absence of a third party being liable for your expenses?

Plans are now available for individuals with an effective date of January 1, 2025. Continue?

Healthcare Reform offers subsidies to reduce premiums based on an income test.

Do you know if you qualify for a subsidy?

Please go to this Online Health Insurance Marketplace Calculator to estimate if you qualify for a premium subsidy.

Did the calculator say that you were eligible for a subsidy?

Are you more comfortable being able to search for a hospital/facility in a PPO network, or is it OK to call the Care Coordination Team and have them tell you what hospital/facility would be best for your procedure?

For prescriptions, are you more comfortable having full coverage for any any generic, brand, or specialty medication (with a copay), or is it OK to have limited coverage that won't cover most brand and specialty medications?

For prescriptions, are you more comfortable having full coverage for any any generic, brand, or specialty medication (with a copay), or is it OK to have limited coverage that won't cover most brand and specialty medications?

Are you younger than 55?

Are you a business owner, including a sole proprietor with an employer ID number (EIN), or are you a 1099 independent contractor?

The STANDARD Medical Plan is appropriate for Network Members who are older than 55, see the doctor frequently, are expecting facility charges, need coverage for specialty medications, or like protection for unforseen expenses during the plan year.

You have completed the decision matrix.

You have completed the decision matrix.

If you are currently pregnant, the ADVANCED Major Medical plan is available to you. The STANDARD Major Medical and ClearShare will not cover a pre-existing maternity. As there is not a hospital network in the ADVANCED plan, we will need contact the care co-ordination team to ensure continuity of care.

You have completed the decision matrix.

We have two options which might be appropriate for you, the ADVANCED Major Medical or the HEALTHSHARE (not insurance) by CLEARSHARE product.

Congratulations. You have completed the decision matrix, so we are ready to make a recommendation.

A Minimum Essential Coverage plan (MEC) might be appropriate for you or your employees. Consider adding a separate hospital indemnity plan to increase facility protection in the event of an unforseen event.

Thank you for trying the decision matrix. Come back when the new plans are announced.

Congratulations. You have completed the decision matrix, so we are ready to make our recommendations.

Since you qualify for a premium subsidy, we recommend researching policies available to you on Healthcare.gov that take advantage of those subsidies.

After you have researched Healthcare.gov, come back here and check out the individual and family policies available through this tool. These plans do not qualify for the subsidies that you see on Healthcare.gov, but even without the subsidies these policies can have competitve (or even have better) rates.

You have completed the decision matrix.