Insurance 101
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FOR GROUP ADMINISTRATORS
The Group Plan Management Guide
You keep your company's benefits running. This guide gives you the rules that come up most: who is eligible, when employees can enroll or make changes, what happens when someone leaves, and which deadlines matter.
ELIGIBILITY
Who can be on the plan
Employees. Employees must meet the eligibility requirements in your group's contract. Most contracts set a minimum number of hours per week and a waiting period for new hires.
Dependents. Eligible employees can also enroll their dependents if the dependents meet the criteria in your group's contract. In general, a dependent is one of the following:
Dependents. Eligible employees can also enroll their dependents if the dependents meet the criteria in your group's contract. In general, a dependent is one of the following:
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The lawful spouse of an employee
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A domestic partner, if your plan allows it. Domestic partner coverage is optional and set by the employer.
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A child of the employee, younger than 26. This includes natural and adopted children.
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A child for whom the employee or the employee's legal spouse has been appointed legal guardian by court order, if permitted by the employer
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A disabled child past age 26 who meets the requirements in your group contract
This section is a general overview based on federal guidelines. Your group's exact rules can vary by state, group size, funding type, and the choices your company made at setup. When in doubt, check your contract in the Documents section of EMI Central or ask your EMI Health Account Manager. The contract always controls.
ENROLLMENT AND CHANGES
When employees can enroll or make changes
Pick the situation you are dealing with. Each one has its own window and its own effective date.
Adding a new employee
Any timeCoverage starts: the first day of the calendar month after the employee completes your company's new-hire waiting period.
New employees can be added any time. Federal rules cap new-hire waiting periods at 90 days.
Submit new hires promptly. Late enrollment can keep an employee off the plan.
Your company's exact waiting period is in your group contract, in the Documents section of EMI Central.
Your once-a-year window
Once a yearCoverage starts: your renewal date.
Open enrollment happens once a year, one to two months before your renewal date. Scheduling it early gives us time to issue ID cards and get your billing right before coverage changes take effect.
During open enrollment you can:
- Add or remove employees and dependents
- Move current employees between plans
- Change which plans your company offers
Plan changes have their own deadline. See the renewal timeline for the dates to work backward from.
Enrolling outside open enrollment
30 or 31 daysCoverage starts: depends on the event. Each one is listed below.
Loss of other coverage. An employee who skipped enrollment because they had other coverage can enroll within 31 days of losing it. Proof of the loss is required before the application can be approved. This does not apply when coverage was lost for nonpayment of premium. Coverage is effective the date the other coverage ended.
Loss of Medicaid or CHIP. The employee or dependent can enroll within 30 days of losing coverage, with proof of the loss.
A new dependent. Marriage, birth, adoption, placement for adoption, or legal guardianship opens a 30-day window to enroll the new dependent, and the employee too if needed. Coverage is effective on the date of the marriage or birth. For adoptions and guardianship, the effective date follows the placement or court order.
Outside open enrollment, employees can enroll or make changes only after a qualifying life event.
Reporting a termination or eligibility change
Tell us within 31 daysCoverage starts: coverage ends on the last day of the month eligibility is lost. For divorce, coverage ends on the date the divorce is finalized.
Tell us within 31 days of any eligibility change. That includes terminations, divorce, retirement, death, reduced hours, and the end of COBRA coverage.
When coverage ends, continuation may be available. See COBRA and continuation of coverage.
How to submit
If your group uses EMI Central:
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The updated EMI Enrollment Form is in the portal under your group's documents
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Once completed upload and submit enrollments, changes, and terminations there within the portal
See click-by-click portal steps in EMI Central Help for Groups
If your group runs on an Employee Navigator or 834 file feed: Submit all changes through that file. Send files securely to enrollment@emihealth.com.
COBRA AND CONTINUATION
When coverage ends, continuation may be available
If your company has 20 or more employees, federal COBRA requires you to offer continuation coverage when someone loses coverage because of a qualifying event. COBRA can run 18 to 36 months depending on the event, as long as premiums are paid on time.
Offer continuation when coverage ends because of:
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Termination of employment, voluntary or involuntary, except gross misconduct
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A reduction in hours
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Divorce or legal separation (for the spouse)
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The employee's death (for dependents)
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A dependent child aging out of eligibility
COBRA compliance is the employer's responsibility unless EMI Health has been contracted as your COBRA administrator. Otherwise, our role is to verify eligibility, benefits, and claims.
State continuation for smaller groups
If your company has fewer than 20 employees, your state may have its own continuation rules, sometimes called mini-COBRA. Rules vary widely, and two of our states have no continuation law at all. Find your state below. Note that employees who live outside your group's state may not be eligible for that state's continuation coverage.
Arizona
Up to 18 months- Applies to
- Employers averaging 1 to 19 employees in the prior calendar year, with fully insured plans. Self-insured plans are exempt.
- How long
- Up to 18 months, with an 11-month extension in cases of disability.
- Key rules
The enrollee must have been on the plan for 90 days before the qualifying event. The employer must give written notice within 30 days of the event. The enrollee elects in writing within 60 days of the notice and pays the full premium plus up to a 5% administrative fee.
Statute: A.R.S. § 20-2330.
- Official source
- Arizona Department of Insurance and Financial Institutions
Georgia
Termination month plus 3 months- Applies to
- Employers with fewer than 20 employees.
- How long
- The rest of the termination month plus 3 additional months, with premiums paid in advance. If the employee or spouse was 60 or older when continuation began, coverage can continue until they join a new group plan or become Medicare-eligible.
- Key rules
The individual must have been continuously covered for at least six months. Georgia law prohibits the 2% administrative fee federal COBRA allows.
Statute: O.C.G.A. § 33-24-21.1.
- Official source
- Georgia Office of Insurance and Safety Fire Commissioner
Idaho
No state continuation law- Applies to
- No one. Idaho has no mini-COBRA. Federal COBRA still applies to employers with 20 or more employees.
- How long
- Not applicable.
- Key rules
Employees of smaller Idaho groups who lose coverage can enroll in an individual plan through a marketplace special enrollment period, or ask the carrier about converting to an individual policy.
- Official source
- Idaho Department of Insurance
Michigan
No state continuation law- Applies to
- No one. Michigan has no mini-COBRA. Federal COBRA still applies to employers with 20 or more employees.
- How long
- Not applicable.
- Key rules
Employees of smaller Michigan groups who lose coverage can enroll in an individual plan through a marketplace special enrollment period at HealthCare.gov, or ask the carrier about converting to an individual policy.
- Official source
- Michigan Department of Insurance and Financial Services
Ohio
Up to 12 months- Applies to
- Any employer offering group coverage, which fills the gap for groups under 20.
- How long
- Up to 12 months.
- Key rules
The employee must have been continuously covered for the three months before employment ended, must not have quit voluntarily or been terminated for gross misconduct, and must not be eligible for Medicare or other group coverage. The election window is short, as little as 10 days after the employer's notice, so employees should act immediately.
Statutes: Ohio Rev. Code §§ 3923.38 and 1751.53.
- Official source
- Ohio Department of Insurance
Pennsylvania
Up to 9 months- Applies to
- Employers with 2 to 19 employees, with fully insured hospital, surgical, or major medical plans. Self-funded plans are exempt.
- How long
- Up to 9 months, with no extensions.
- Key rules
The individual must have been continuously covered for the three months before the qualifying event. The employer must give notice within 30 days of the event, and the individual elects within 30 days of that notice. Premium can run up to 105% of the group rate. When mini-COBRA ends, the employee can enroll through Pennie, the state marketplace, using a special enrollment period.
Statute: Act 2 of 2009.
- Official source
- Pennsylvania Insurance Department
Texas
Up to 9 months, plus a COBRA extension- Applies to
- Two layers. State continuation covers employers with fewer than 20 employees. The COBRA extension covers employers with 20 or more.
- How long
- State continuation runs up to 9 months after a qualifying event. Employees who exhaust 18 months of federal COBRA can extend another 6 months, to 24 total, with premiums paid within the required window.
- Key rules
Premiums must be paid on time to keep either layer active.
- Official source
- Texas Department of Insurance
Utah
Up to 12 months- Applies to
- Utah companies under the 20-employee federal COBRA threshold.
- How long
- Up to 12 months.
- Key rules
Employees who live outside Utah are not eligible for Utah state continuation.
Statute: Utah Code § 31A-22-722.
- Official source
- Utah Insurance Department
For federal COBRA details, visit dol.gov or talk with your agent.
FREQUENTLY REQUESTED
Files and forms groups ask for most
For new coverage or adding a line of coverage. Your Account Manager or broker submits these with your enrollment materials.
Looking for something less common?
Appeal forms, disabled dependent coverage applications, telemedicine group applications, and every other employer form live in one place on emihealth.com.
BILLING
Billing, in plain terms
You can view invoices and pay your premium in EMI Central. Three payment options: pay the total due, pay your standard monthly amount, or pay a custom amount. ACH autopay can draft your premium from your account between the 1st and 10th each month.
If a payment is missed, you will hear from us three times before anything changes.
1
Past due notice
A banner on your EMI Central dashboard, plus an email to every listed group contact.
2
Pending termination notice
A second email warning that termination is pending.
3
Final termination notice
Emailed and mailed to the group, the broker, and all enrolled members.
See payment steps in EMI Central
Coming soon
Returned payments. A returned payment carries a $25 fee, due with your next invoice. Termination timing varies by state, funding type, and how long the balance has been open. Prompt payment and a quick monthly look at your dashboard prevent all of this. Questions: emiabilling@emihealth.com.
COMPLIANCE
What we file, and what stays with you
The IRS requires electronic filing for nearly all employers. Uploading a PDF does not count. Who files what depends on your size.
1095 reporting
Your group size
Fewer than 50 full-time equivalent employees
EMI Health handles
- Files your 1094 and 1095-B forms with the IRS by the annual deadline.
- Sends you eligibility reports by mid-January.
You handle
- Making 1095-B forms available to employees. You can mail them by early March, or post a notice that employees can request a copy.
Current Form 1095-B deadlines and instructions: irs.gov.
50 or more full-time equivalent employees, an Applicable Large Employer
EMI Health handles
Not your 1094 and 1095-C filing. We do not hold the employer-level data those forms require.
You handle
- Filing your 1094-C and 1095-C forms accurately and on time, through your payroll provider or broker.
- If you need an ACA reporting vendor, your Account Manager can point you to options.
Current deadlines, forms, and instructions for Applicable Large Employers: irs.gov.
EMI Health does not certify that Applicable Large Employers meet the ACA's affordability provisions.
Whatever your size
What EMI Health files for you
We submit annual RxDC prescription-cost reporting to the federal government, and you may be asked to confirm your contribution data. We file the annual Gag Clause attestation and complete CMS creditable coverage notifications for all groups.
We also maintain the public transparency disclosures the law requires: machine-readable files, pharmacy cost reporting, and price transparency tools.
PCORI fees
Fully insured group: EMI Health pays PCORI fees directly. You do nothing.
Self-funded group, including Pool and Private Exchange plans: you submit the fee to the IRS by July 31 each year. Every June we send a customized report with your amount due and step-by-step payment instructions.
Mental health parity
EMI Health's standard plans comply with the Mental Health Parity and Addiction Equity Act, including non-quantitative treatment limitations. A general compliance report is available on request.
Group-specific NQTL reports can be prepared for an official government request. A preparation fee may apply.
PARTICIPATION AND CONTRIBUTION
Keeping your plan in good standing
| Requirement | Medical | Dental & Vision |
|---|---|---|
| Employer contribution | At least 50% of the single rate. Some quotes require at least 90% of the single rate or 50% of all tiers. | Contributory plans: 50% of the single rate. If your company pays 100% of the employee rate, 100% of eligible employees must enroll. |
| Participation | At least 70% of eligible employees enrolled or covered elsewhere, and at least 50% enrolled on the EMI Health plan. Groups of 10 or fewer eligible employees: 75% enrolled. | Contributory plans: at least 75% of eligible employees enrolled. |
| Minimum enrollment | Self-funded, including Pools and Private Exchanges: 10 employees enrolled. Outside Utah, groups of 5 to 10 can be approved case by case; Utah law requires 10. Fully insured, where applicable: 51 employees. | A minimum of 2 employees on each plan. Offering two dental or vision options requires at least 10 total enrolled, with at least 2 on each plan. |
| Waivers that do not count against you | Employees who waive because they have other comprehensive coverage, through Medicare, another government program, a spouse, or a parent. |
EMI Health may audit payroll or quarterly tax statements to verify participation and eligibility. EMI Health does not certify that Applicable Large Employers meet the ACA's affordability provisions. Every plan has exclusions and limitations; the complete list is in your contract, in the Documents section of EMI Central.
WORK BACKWARD FROM THESE DATES
Renewal is the one window each year for plan changes
75–90
DAYS BEFORE RENEWAL
Renewal packet arrives
Your EMI Health representative delivers current plan details, rate changes, and new options.
30
DAYS BEFORE RENEWAL
Changes submitted in writing
All plan change requests must be in writing and submitted. Final selections confirmed with your EMI Health team.
Renewal Date
WHY THE DEADLINE MATTERS
Meeting the 30-day window gives us time to print and mail ID cards so employees have them the day coverage starts.
Renewal dates vary by group. Your EMI Health representative will confirm your specific windows. Reach out early; comparing options takes longer than confirming them.
Included with full medical plans
Your employees already have BeWell
Full medical plans include coaching, chronic condition support, mental health resources, screenings, and challenges, at no extra cost. The BeWell page has program details, printable flyers, and a form to request an onsite event, so you can promote it to your team without building anything yourself.
TOOLS FOR EMPLOYEES
Point employees to their own tools first
Most member questions answer themselves with these. Sharing them cuts the questions that land on your desk.
Visit Insurance 101
Member Materials Library
Printable flyers, booklets, and how-to videos for employees. Use it to answer a benefits question with a link instead of an explanation.
COMMON QUESTIONS
What group administrators ask most
When can an employee enroll outside open enrollment?
Only after a qualifying life event. Loss of other coverage opens a 31-day window and requires proof of the loss. Loss of Medicaid or CHIP opens a 30-day window, also with proof. Marriage, birth, adoption, placement for adoption, or legal guardianship opens a 30-day window to add the new dependent, and the employee too if needed.Only after a qualifying life event. Loss of other coverage opens a 31-day window and requires proof of the loss. Loss of Medicaid or CHIP opens a 30-day window, also with proof. Marriage, birth, adoption, placement for adoption, or legal guardianship opens a 30-day window to add the new dependent, and the employee too if needed.
When does coverage start for a new hire?
On the first day of the calendar month after the employee completes your company's new-hire waiting period. Your waiting period is set in your group contract, and federal rules cap waiting periods at 90 days. Submit new hires promptly, because late enrollment can keep an employee off the plan.On the first day of the calendar month after the employee completes your company's new-hire waiting period. Your waiting period is set in your group contract, and federal rules cap waiting periods at 90 days. Submit new hires promptly, because late enrollment can keep an employee off the plan.
How long do I have to report a termination or other eligibility change?
Tell us within 31 days. That includes terminations, divorce, retirement, death, reduced hours, and the end of COBRA coverage. In most cases coverage ends on the last day of the month eligibility is lost. For divorce, coverage ends on the date the divorce is finalized.
See all questions Show fewer questions
Does my company have to offer COBRA?
If your company has 20 or more employees, federal COBRA requires you to offer continuation coverage after a qualifying event, running 18 to 36 months depending on the event. If you have fewer than 20 employees, your state may have its own continuation rules, and those vary widely. COBRA compliance is the employer's responsibility unless EMI Health has been contracted as your COBRA administrator.
Who files 1095 forms, EMI Health or my company?
If you have fewer than 50 full-time equivalent employees, EMI Health files the 1094 and 1095-B forms with the IRS and sends you eligibility reports by mid-January so you can distribute 1095-B forms to employees. If you have 50 or more full-time equivalents, you are an Applicable Large Employer and file your own 1094-C and 1095-C forms through your payroll provider or broker. EMI Health cannot file those, because we do not hold the employer-level data they require.If you have fewer than 50 full-time equivalent employees, EMI Health files the 1094 and 1095-B forms with the IRS and sends you eligibility reports by mid-January so you can distribute 1095-B forms to employees. If you have 50 or more full-time equivalents, you are an Applicable Large Employer and file your own 1094-C and 1095-C forms through your payroll provider or broker. EMI Health cannot file those, because we do not hold the employer-level data they require.
Does my company owe PCORI fees?
If your group is fully insured, no. EMI Health pays PCORI fees directly and you do nothing. If your group is self-funded, including Pool and Private Exchange plans, you submit the fee to the IRS by July 31 each year. Every June we send a customized report with your amount due and step-by-step payment instructions.If your group is fully insured, no. EMI Health pays PCORI fees directly and you do nothing. If your group is self-funded, including Pool and Private Exchange plans, you submit the fee to the IRS by July 31 each year. Every June we send a customized report with your amount due and step-by-step payment instructions.
What happens if we miss a premium payment?
You will hear from us three times before anything changes: a past due notice as a banner on your EMI Central dashboard plus an email to every listed group contact, then a pending termination email, then a final termination notice emailed and mailed to the group, the broker, and all enrolled members. A returned payment carries a $25 fee, due with your next invoice. Termination timing varies by state, funding type, and how long the balance has been open.
When can we change which plans we offer?
At renewal. Your renewal packet arrives 75 to 90 days before your renewal date, and all plan change requests must be in writing 30 days before renewal. Meeting that 30-day window gives us time to print and mail ID cards so employees have them the day coverage starts.
WHO TO CONTACT
One table, every question
Need help with…
Who to contact
Billing, invoices, or payments
Enrollment processing or status
Renewals, contracts, escalations, or benefit clarification
Your EMI Health account manager
General benefit questions
To avoid missing important updates, keep your email address current with us and add emiabilling@emihealth.com to your contact list so our messages aren't filtered to spam.
Thank you for entrusting EMI Health with the care of your employees.
It's our privilege to serve your group, and we're committed to dependable service, clear support, and benefits that make a difference.
Questions about your plan?
This guide is a general resource for group plan administrators and appointed agents. It is not a legal contract, a guarantee of benefits, or a complete summary of coverage. Coverage terms, benefit details, and member rights are governed by your group insurance contract; if this guide and the contract differ, the contract controls. Eligibility is determined by your contract, state and federal law (including ERISA, the ACA, COBRA, and HIPAA), and EMI Health's underwriting requirements. Employers are responsible for timely notification of enrollment changes. EMI Health may update this guide at any time. Use of EMI Health systems, including EMI Central, is subject to applicable privacy and data security laws, including HIPAA.