Team Management

QSEHRA or Small Group Health Insurance? What’s the Difference?

Aartika Maniktala Compliance legal intern, Gusto 
QSEHRA or Small Group Health Insurance What's the Difference

Of all job perks, studies show that employees value medical, vision, and dental benefits the most. Not only does providing health benefits make for happier employees, more than 60 percent of employers say offering health insurance can help increase team productivity.

Gusto makes payroll, benefits, and HR actually easy.

So let’s say you’re sold on offering health benefits to your team. What comes next?

As a small business owner, you have two major options. You can offer health benefits through:

  • Small group health insurance (SGHI), or
  • QSEHRA, aka a Qualified Small Employer Health Reimbursement Arrangement

Small group health insurance

Small group health insurance is the most common way for small employers to provide benefits for their employees. How it generally works is you (the employer) sign a contract with insurance carriers, and your employees can then obtain coverage from your chosen carriers.

Small group plans are available to employers with two to 50 full-time employees, while in some states like California and New York these plans are available to employers with up to 100 employees.

Carriers set rates for their plans based on a few factors like:

  • Employee age
  • Location of your business

Unlike large group insurance, there is no room to negotiate rates in the small group insurance market. However, group rates are often cheaper than individual rates if your employees were to go out and get a plan on their own. Additionally, if plans are set up through a ”cafeteria” or pre-tax plan, then all premiums are tax-free.

QSEHRA

Another option gaining momentum amongst small employers is the QSEHRA, a type of health reimbursement arrangement (HRA) that was previously not allowed under the Affordable Care Act.

The QSEHRA allows employers to reimburse the health expenses of their employees without offering their own health insurance. As long as employees maintain an individual health plan that provides “minimum essential coverage,” and employers follow the setup requirements, the reimbursements under a QSEHRA are tax-free to both employers and employees.

Employers set their annual contribution amount for each employee, and then simply reimburse eligible expenses as they are incurred up to that amount.

A little bit on HRAs

HRAs are tax-advantaged, employer-funded accounts that employers use to reimburse employees for eligible medical expenses. Employers can use HRAs integrated with group policies to reimburse employees for medical expenses not covered by the group plan (e.g., deductibles, co-pays, etc.).

The ACA originally did not allow for “standalone HRAs,” or HRAs that would reimburse for medical expenses or premiums that were not coupled with group insurance. However, recent legislation authorized standalone HRAs for small employers—so long as they follow certain rules. This is the QSEHRA, which allows reimbursement of medical expenses or premiums when the small employer does not provide any group coverage.

Small group health insurance versus QSEHRA

So how do you know which of the two options is a better fit for your company? It depends on how much you want to contribute, how big your company is, and how involved you want to be in the health benefits of your employees.

Let’s break down the key features of small group insurance offered through a cafeteria plan and a QSEHRA.

Small group insuranceQSEHRA
Eligibility Businesses must have 2–50 full-time employees (some states allow small group up to 100 employees)Businesses must have 1–49 full-time employees
CostVariable—requires minimum employer contribution, in most cases at least 50% of premiumsLow—employer can choose how much to contribute, up to the maximum amount set by the IRS
Scope of coverageMedical, vision, and dental coverage. Both employees and their dependents can enroll, but enrollment may not be requiredCannot be offered in conjunction with any group health plan, including vision and dental plans. QSEHRA must be available to all eligible employees, but employees may choose not to seek reimbursements. Employers can choose to reimburse all eligible health expenses, or premiums only.
Who pays and how muchThe employer generally pays 50% or more of the employee premium; the employee covers the rest pre-taxOnly the employer can make QSEHRA contributions. The employer decides how much money to set aside for each employee, not exceeding the annual maximum set by the IRS ($4,950 for individual employees in 2019).
Tax benefitsEmployer and employee contributions are free of payroll taxes. Employee contributions are free of income tax. Employer contributions are deductible as a business expense.Employer contributions are free of payroll tax, and employees don’t pay income tax on contributions as long as employees are enrolled in minimum essential coverage. Employer contributions are deductible as well.

However, if employees purchase individual coverage, premiums are paid with after-tax dollars (unlike SGHI where premiums are paid pre-tax).
Time cost to employersHigh—Plan selection and plan renewal requires significant employer oversight. Employers must also provide an open enrollment period each year so employees can make changes to their benefits.Low—Employees find their own coverage either through the individual marketplace or their spouse’s group coverage. Employers need only select contribution amounts, and a third-party administrator can handle the rest.
Spending accountsOK:
– FSAs
– HSAs
– Integrated HRAs
NOT OK:
– Health FSAs

OK:
– HSAs, but only if coupled with a premium-only QSEHRA (a QSEHRA that reimburses only premiums, not other healthcare expenses)
Participation requirements Generally at least 60% of your team must enroll, but this varies by state and carrier0% (but all eligible employees must be offered a QSEHRA)

Even with all this info, deciding which option is better for your particular business isn’t cut and dry. To figure out the right option for you, ask your broker the following questions:

  • Which option will be most cost effective for my company?
  • Which option will provide the most value for my employees?
  • The average age of my employees is X, what will be most helpful to them?
  • My employees are/are not benefits-savvy, what will be easiest for them to understand?

The bottom line

In general, if you have the budget and time to invest in your team’s health benefits, small group may be a good option. Eligible employees can sign up for plans you’ve selected and access care when they need it.

But if saving money is currently essential for your business, the QSEHRA might be the right first step toward offering a health benefits package. There are no participation and employer contribution requirements, so you decide what and how much to reimburse. Your employees will have to find the right plan for them that meets minimum essential coverage requirements.

The best first step is to talk to a health insurance broker. We can help with that.

Updated: July 16, 2019

Aartika Maniktala
Aartika Maniktala Aartika Maniktala is on the Compliance team at Gusto. She utilizes her healthcare and startup background to ensure Gusto's employee benefits products comply with various laws and regulations. She is currently pursuing her J.D. at the UC Berkeley School of Law.

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