Introducing the Best Resource on Association Health Plans

Get all the information you need: savings, benefits rules, regulations, plan types, & association requirements

Recent regulatory changes have made the savings and benefits flexibility of large group health plans accessible to smaller businesses as well as freelancers, sole proprietors, and the self-employed. Our website will help you understand:

  • Association health coverage basics
  • Why these health plans save money on insurance costs
  • Who can join an association plan
  • Benefit flexibility for “large group” association plans
  • How to get help if you want to launch your own association health plan

Understanding the Basics of Association Health Insurance

Simply stated, association health insurance is just a group health plan where multiple employers (including the self-employed) join together to offer health benefits. By joining together and increasing the number of participants to the point where the association qualifies as a “large group” health plan, the association can:

  • Design health plan benefits around employee needs & employer budgets
  • Negotiate better rates from healthcare providers and insurers
  • Consider self-insuring to lower plan administration costs further and avoid health insurance tax

For a more detailed overview of association health insurance, read our article “What Is an Association Health Plan?” or you can explore our book-length treatment Association Health Plans & the Future of American Health Insurance.

Why Association Health Plans Save Money

Much of the interest in association health plans (AHP) concerns its potential to lower health insurance costs for smaller employers as well as the self-employed, freelancers, and workers belonging to the “gig economy.” A survey by the National Federation of Independent Business (NFIB) found that the “cost of health insurance” was ranked as a critical problem by 52% of small business owners.

In a recent report, healthcare research firm Avalere has projected that association health plan premiums will have significant savings advantages over alternative insurance options. They predicted that association plan premiums will be “between $1,900 to $4,100 lower than the yearly premiums in the small group market and $8,700 to $10,800 lower than the yearly premiums in the individual market by 2022.”

There are multiple reasons why association health plans can reduce the cost of health insurance coverage. First, by allowing smaller employers as well as individuals to band together, association health plans can avoid the very expensive insurance options within the Affordable Care Act market. Second, in most states as few as 51 total employees in an association will qualify it for “large group health plan” status. Large groups are not constrained by all the benefit mandates of government exchange insurance and can design benefits around their employee needs rather than the one-size-fits-all approach of the Affordable Care Act market. Third, by banding together workers from many employers (as well as the self-employed) into a large group, associations increase the leverage these workers collectively have with respect to negotiations on insurance costs and healthcare provider reimbursement. Smaller businesses and isolated individuals have very little leverage in the traditional insurance context. Finally, the aggregation of many employees and self-employed in large groups enables the association to consider “self-insuring,” where the association manages the health benefits rather than paying a third-party insurance company to perform that function. By self-insuring, the association has the potential to lower administration costs as well as eliminate the profit paid to an insurance company.

Who Can Join an Association Health Plan?

At the heart of association health plan eligibility is the nature of the association sponsoring the health insurance. Associations can be founded on a membership requirement related to profession or related to geographic region. Membership in a professional association can be based on any of the following shared characteristics:

  • Industry
  • Line of business
  • Trade
  • Profession

Membership in a geographically-based association can be established on any of the following regional characteristics shared among the association members’ principal place of business:

  • State
  • County
  • City
  • Multi-state metro region

Both professional and regional associations can also use narrower membership definitions if they so choose. For example, a professional association could restrict its membership to cloud-based data storage vendors and a geographically-based association could be restricted to part of a county.

The Health Insurance Portability and Accountability Act prohibits group health plans from discriminating in eligibility, benefits, or premiums against an individual within a group of similarly situated individuals based on a health factor. Health factors, in this context, include diseases, illnesses and other medical conditions, claims experience, medical history, genetic characteristics, or disability. Since association health plans are a form of group health insurance, this prohibition applies to them as well.

While associations are composed of employers, employers can include freelancers, sole-proprietors, and also the self-employed. This opens up associations to the millions in the “gig economy,” where supplemental work done part-time can still qualify for association membership so long as the person meets the other criteria of membership and the association accepts “working owners.” Working owners are individuals who do work on their own, with or without incorporation. Within an association, a working owner is treated simultaneously as an employer who has a say in the control of the association and as an employee who can participate in the association’s health plan. For more information on how freelancers, sole-proprietors, and the self-employed can participate in association health plans, read “What is a “working owner?

Benefit Flexibility of Large Group Health Plans

Unlike traditional small group health plans, large group association plans are not required to provide all 10 Essential Health Benefits (EHB) mandated by the Affordable Care Act. Instead, these plans may tailor their health benefits around the needs of their employees.

While association large group health plans have more flexibility with respect to benefit design than Affordable Care Act health plans, they still have various requirements regarding benefits and the conditions under which they are offered. These benefit requirements include:

  • Coverage of pre-existing conditions within any coverage corresponding to an Essential Health Benefit category (see below)
  • Coverage of maternity and newborn care
  • Coverage of preventive care
  • Prohibition on annual and lifetime caps for medical costs within any covered Essential Health Benefit category
  • Limits on annual out-of-pocket costs for any covered Essential Health Benefit category
  • Coverage of dependent children up to age 26 if dependent coverage is part of the health plan
  • Prohibition on benefit “waiting periods” (e.g. a delay of insurance activation for new hires) that exceed 90 days

Even with the above requirements, large group association plans still have much more benefit latitude than insurance plans that must comply with the Affordable Care Act. As mentioned earlier, Affordable Care Act health plans must offer all Essential Health Benefits. Essential Health Benefit categories are groupings of medical benefits. The 10 standard categories mandated by the Affordable Care Act are listed below. An association health plan may design its benefits from within this framework, but they are not required to include all of these benefits (e.g. pediatric dental and vision benefits). Association health plans can also choose to add additional benefits outside of these categories (such as hearing or disability benefits). Within association health plans, some benefits (such as mental health care) have requirements dictating that out-of-pocket costs must be at the same level as other medical benefits within the plan.

  • Preventive Care – Preventive care encompasses various screenings, immunizations, and medical issue counseling. Under the Public Health Service (PHS) Act, group health plans (which includes association health plans) are required to provide a variety of these services specified by the government without cost sharing on the part of the enrollee
  • Ambulatory Services – Ambulatory services refer to patient care that can be done as an “outpatient” (i.e. someone who is visiting the healthcare provider and not being admitted to a care facility such as a hospital). Examples of ambulatory care are doctor visits and specialist visits. Ambulatory care is contrasted to inpatient care such as a multi-day hospital stay.
  • Hospital Services – Hospital services involve medical care (e.g. surgery) delivered within a hospital or similar facility. Hospital services is sometimes referred to as inpatient care.
  • Laboratory Services – Laboratory services pertain to diagnostic tests such as blood analysis performed by a medical laboratory.
  • Emergency Services – Emergency services consist of emergency room care and other critical services related to a medical emergency such as paramedic treatment and ambulance transport.
  • Drug Coverage – Drug coverage addresses the insurance coverage of prescription medications. Specifically, drug coverage pertains to what medications in each therapeutic class are covered, what the cost of those medications are to participants, and any restrictions placed on those medications.
  • Maternity & Newborn Care – Maternity and newborn care concerns medical services related to a mother’s pregnancy and birth as well as services addressing a newborn infant. Association health plans are required to provide maternity and newborn care. Associations as small as 15 employees are required to cover pregnancy, childbirth, and related medical conditions in a manner similar to other medical conditions covered under the association health plan.
  • Mental Health Care & Substance Use Disorder Care – Mental health care includes psychotherapy, counseling, and behavioral/mental inpatient treatment. Substance use disorder care involves treatment such as rehab services.
  • Rehabilitative & Habilitative Services – Rehabilitative services pertain to the restoration of a function impaired by injury or illness. Habilitative services pertain to therapy to acquire a function that was previously absent due to disability or other cause. Rehabilitative and habilitative services include medical devices.
  • Pediatric Care – Care for children under age 19 including dental and vision care. Dental and vision care is not required for adults under the Essential Health Benefits. Pediatric dental care does not have to include orthodontia care except in medically necessary cases like treatment for a cleft palate.

For additional information on federal and state benefit obligations for association health plans, see “Association Health Plan Benefit Requirements.”

Plan Types

Association health plans can be traditional “fully-insured” or “self-insured.” “Fully-insured” refers to a third party insurance company assuming all the risk associated with the payment of medical claims for health plan participants. “Self-insured” refers to the health plan retaining that risk and operating the health plan on its own (or through the use of various service vendors).

In the fully-insured model, the operations of the association health plan are largely handled by the third-party insurance company providing the medical coverage. The insurance company would not only handle activities such as claims management, record keeping, and compliance, but it would also produce the documents required for plan participants.

In the self-insured model, the association health plan is managed by the association itself, not by an insurance company. However, the association would still use third-party vendors for those activities where it lacked skills and experience.

For more information on the difference between the two plan types, see “Self-Insured Health Plans vs. Fully-Insured Health Plans.”

Whether fully-insured or self-insured, an association health plan can choose to deliver insurance benefits through a health maintenance organization (HMO), a preferred provider organization (PPO), an exclusive provider organization (EPO), or other common means of healthcare delivery.

Regulations

Association health plans are primarily regulated by the Employee Retirement Income Security Act of 1974 (ERISA). However, various other federal and state regulations apply to these plans. For example, association health plans have obligations under regulations such as:

  • The Health Insurance Portability and Accountability Act of 1996 (HIPAA)
  • The Civil Rights Act
  • The Public Health Service (PHS) Act
  • Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA)
  • Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA)
  • State-specific health insurance regulation

How to Launch Your Own Association

The government’s new regulations make it much easier to launch an association for the purposes of offering health insurance. AssociationHealthPlans.com is designed to help you start a new association health plan or improve an existing one. We have numerous resources to help you learn about the ins-and-outs of association health plans. We will continue to revise and expand these resources as time goes by.

To understand the basics of the association creation process, see our article “How to start an association health plan.”

Who Can Use Association Health Plans?

Employer Groups and Associations

Groups and associations can more easily form and sponsor an association health plan to expand access to affordable health care.

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Self-Employed Individuals

“Working owners” such as sole proprietors and other self-employed individuals are now able to participate in association health plans.

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Employees

Association health plan members must be in the same line of business, trade, industry or profession.

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