Answering Michigan’s Top Employee Benefits Questions

You can make changes to your current benefit elections during your annual open enrollment period or when you experience a qualified life event.

For an employee to make changes to their elections outside of the open enrollment period, an employee must experience a qualified life event.

Qualified life events include:

If Austin Benefits Group is your benefits agency, you can contact your Austin Enrollment Specialist for help with a replacement card. If you are unsure who your Enrollment Specialist is, you can contact your dedicated Account Manager, or you can call our help desk at 248-594-5550. We will work directly with the carrier to make sure that you have everything that you need.

If you are not a client of Austin Benefits Group, you can contact your human resources department, or you can contact your insurance carrier directly.

Evidence of Insurability (EOI) is an application process to provide an insurance company with information on your health status in order to get certain types of insurance coverage. EOI is required when electing more life insurance than the guaranteed issue amount of coverage. If you elect coverage that requires an EOI, the coverage is not valid until the EOI process is completed and the carrier has approved it.

Step therapy is used by insurance carriers to help control the rising costs of prescription drugs. With step therapy, you will be required to try a medication or dosage before stepping up to a drug that costs more.

A generic drug is identically equivalent to the brand-name drug in form, safety, strength, quality and intended use. Although identical, generic drugs are substantially cheaper than their brand name counterparts.

A formulary drug is a drug that is listed on a preferred drug list from your insurance carrier. They are drugs that insurance carriers believe to be well-suited to treat specific conditions, while keeping costs more manageable for both the carrier and the insured individual.

A specialty drug is a high-cost medication used to treat a chronic or complex health condition. These drugs require special handling, administration, or monitoring, and generally need prior authorization to be ordered.

An in-network physician is part of your insurance company’s network and is contracted by your carrier to provide lower costs for services. If you have a PPO insurance plan, you are allowed to see providers that are out-of-network; however, you are subject to higher costs, and generally, you will pay a larger percentage of the total cost of care. If you have an HMO or EPO plan, you will generally pay all costs associated with providers that are outside of your network.

The best way to find an in-network physician is to go to your insurance carrier website. Each insurance carrier has a listing of physicians affiliated with their networks. You can find your insurance carrier on our Provider Directory. CLICK HERE to access our directory.

A Health Reimbursement Arrangement (HRA) is also referred to as a Health Reimbursement Account. With an HRA, your employer sets aside money for you to use on qualified medical expenses. Your employer will decide which qualified medical expenses are eligible for coverage, however, HRAs generally cover deductibles, coinsurance, and copays (PPO only). An HRA cannot be used to pay your monthly insurance premium.

A Flexible Spending Account (FSA) is an account that is set up for individuals to set aside pre-tax money to be used for eligible health care expenses. Many FSAs provide debit cards for you to use, rather than having to seek reimbursement after the fact. There are legal limits to contributions allowed in FSAs, which may change from year to year.

If you leave your company, the FSA account only remains available to you if you elect COBRA and the contributions are continued. If you do not elect COBRA, the FSA funds are not available after you leave the company, unlike an HSA.

Health Savings Accounts are savings accounts for individuals with High Deductible Health Plans (HDHP). These savings accounts allow you to pay for qualified out-of-pocket expenses with pre-tax dollars.

Unlike a Flexible Spending Account (FSA), the funds in an HSA belong to you, not to your employer, and remain with you even if you change jobs. Funds in an HSA can grow tax-deferred. After age 65, you can withdraw HSA funds, and they are only taxed as ordinary income.

At Austin, we understand that benefits terminology can be complicated and confusing. That’s why we created a benefit glossary that highlights some of the most common benefits terms and what they mean. CLICK HERE for our glossary of benefit terms. We take pride in creating communication materials that are easy-to-understand with real-world, relatable examples. If you still have questions, please reach out to your dedicated Account Manager for further guidance.

To log in to your SmartBenefits account, CLICK HERE. If you are logging into your account for the first time, your username will be your first initial + the first 6 letters of your last name + the last 4 digits of your Social Security number. Your password is your date of birth, formatted as follows: YYYYMMDD (Example: 19760325).

Note: SmartBenefits Online accounts are only available if your employer has elected this service from Austin Benefits Group.

Where you seek treatment can have a huge impact on the overall cost of your care. For non-emergent situations, most plans offer several options, including doctor’s offices, urgent care centers, and telemedicine.

Your Doctor’s Office: If you can wait to be seen during normal office hours, your doctor offers a trusted, ongoing relationship to manage your care. Many doctors now offer extended hours and can be reached by phone or email for after-hours questions.

Telemedicine: No appointments or waiting room, available when your doctor isn’t, care is delivered via smartphone, tablet, or computer. Great for sore throat, cough, low-grade fever, earache, cold and flu, mild allergies, skin rash, eye irritation, sprains and strains, and minor asthma.

Urgent Care Center: Evening and weekend walk-in hours with convenient locations. Urgent Care Centers generally have a higher co-pay but offer a convenient solution when your doctor’s office is not open. Great for sore throat, cough, low-grade fever, earache, cold and flu, mild allergies, skin rash, eye irritation, sprains and strains, and minor asthma.

Emergency Room: If you are experiencing a life-threatening situation, you should call 911 or go to the nearest emergency room. The emergency room is open 24/7 and is suitable for all emergency situations. Emergency room co-pays are higher than Urgent Care and Office Visit co-pays.

Make sure to check if your provider is in-network. Use our Provider Directory to search in-network providers for your insurance carrier.

A deductible is the amount of money that you pay before your insurance begins to pay. If your plan has a $1,000 deductible, you will pay 100 percent for most services until you have reached $1,000. After you have met your deductible, you will begin to pay coinsurance and co-pays as determined by your plan design.

A co-pay is a fixed amount that you pay for a healthcare service. The amount of the co-pay can vary by the type of service and for some services you may have both a co-pay and coinsurance. An example of a co-pay is a $30 office visit charge or $40 prescription co-pay.

Coinsurance is your share of the costs of a healthcare service. You begin to pay your coinsurance after you have met your plan’s deductible. It is generally a percentage of the allowed amount that your plan covers for a service.

If Austin Benefits Group is your benefits agency, you can contact your dedicated Account Manager to help resolve your claim. They will work with you to get the needed information to dispute the claim on your behalf.

If you do not have your account manager’s contact information, you can contact service@austinbenefits.com, or you can call our helpline at 248-594-5550 for additional help. Your account manager will work directly with the carrier to provide claim resolution.

If Austin is not your benefits agency, you will need to contact your carrier directly or work with your HR department for further assistance.

An HMO is a Health Maintenance Organization that covers services solely by providers within their specific network. A Primary Care Physician (PCP) is required; the PCP is responsible for coordinating all medical care and making referrals to in-network specialty providers.

A PPO is a Preferred Provider Organization that has a network of providers but also allows use of medical providers outside of the plan’s network, typically with greater employee cost sharing. A PPO is generally more flexible than an HMO, as a Primary Care Physician (PCP) and referrals for specialty providers are not generally required.

Selecting the benefits that are right for you and your dependents is a very personal process, as every individual has a unique set of needs. Your dedicated Austin Account Manager can help guide you in the decision-making process and answer any questions that you may have. If you are unsure of who your account manager is, you can contact our service desk at service@austinbenefits.com for additional help.

SmartBenefits Online is an easy-to-use online platform for you to review your benefit information and enroll conveniently online.

The Austin Advantage means doing employee benefits differently—with smarter strategies, simpler processes, and solutions that actually fit your business. More than a benefits provider, Austin Benefits Group becomes a hands-on partner, helping you build a program that mirrors your company culture and supports where you’re headed.

Clients get access to a full range of services—member support, COBRA administration, 1094/1095 and 5500 filings, and up-to-date compliance guidance for ACA, FMLA, COBRA, and HIPAA—without extra fees or fine print. The real difference? A people-first approach that’s intentional and personal. Programs are thoughtfully built, rolled out with care, and designed to truly connect with your team.

This is about more than benefits—it’s about creating a place where your people feel seen, supported, and equipped to grow.

Mental Health Connect is the Austin Benefits Group program that makes mental health support more accessible, less confusing, and genuinely helpful. This exclusive program connects individuals with care that fits their needs—and their insurance coverage—through confidential behavioral health navigation. No guesswork, no endless searching, just real help from real people who know the system.

For employers, it brings tools and guidance to support a healthier, more balanced workplace culture. It’s built to support individuals and teams in meaningful ways, and the impact speaks for itself—lives are changing, workplaces are growing stronger, and access to care is finally within reach.

An HMO is a Health Maintenance Organization that covers services solely by providers within their specific network. A Primary Care Physician (PCP) is required; the PCP is responsible for coordinating all medical care and making referrals to in-network specialty providers.

A PPO is a Preferred Provider Organization that has a network of providers but also allows use of medical providers outside of the plan’s network, typically with greater employee cost sharing. A PPO is generally more flexible than an HMO, as a Primary Care Physician (PCP) and referrals for specialty providers are not generally required.

The Affordable Care Act prohibits group health plans from including a benefit waiting period that exceeds 90 calendar days for full-time employees.

The Affordable Care Act Employer Mandate requires employers with 50 or more full-time equivalent (FTE) employees to provide group health coverage to full-time employees or pay a tax penalty. Health coverage must be offered to full-time employees and their dependents.

For an employee to make changes to their elections outside of the open enrollment period, an employee must experience a qualified life event.

Qualified life events include:

FMLA stands for the Family Medical Leave Act and applies to employers with 50 or more full-time employees or employee equivalents. It provides unpaid, job-protected leave for specified family and medical reasons with continuation of group health coverage under the same terms and conditions as if the employee had not taken leave. For an employee to be eligible for FMLA, they must be employed for at least 12 months and have worked at least 1,250 hours in the past 12 months.

Eligible employees are allowed 12 workweeks of leave in a 12-month period for the following reasons:

COBRA stands for Consolidated Omnibus Budget Reconciliation Act; it is a federal law that requires employers that offer group health plans to offer the benefit of continuing coverage at group rates to those individuals who are losing coverage due to termination or a reduction in the number of hours of employment. COBRA benefits must be offered when a company has 20 or more employees in the previous calendar year.

Employers with 50 or more full-time employees (including full-time equivalents) in the preceding calendar year are required to submit 1094-C and 1095-C forms to the IRS. The 1094-C form provides summary information for each employer and the form 1095-C provides report information on each employee.

These forms are used to determine if an employer is liable for payment under the employer shared responsibility provisions of the Affordable Care Act. Form 1095-C is also used by the IRS and the employee to determine the eligibility of the employee for premium tax credits.

CLICK HERE to find information about current tax deadlines.

Long-Term Disability Insurance will pay an employee a portion of their pay if they are unable to work due to an illness or injury for more than several weeks. Most Long-Term Disability plans are designed to go into effect after the Short-Term Disability policy ends and can extend up until age 65 or, in some cases, the employee’s lifetime. Keep in mind that both short and long-term disability policies generally have waiting periods from the time of the illness or accident before they begin paying out.

Short-Term Disability Insurance will pay an employee a portion of their pay if they are unable to work for several weeks due to a covered illness or injury. It is intended to cover employees who cannot work for brief periods of time. The employer determines the exact benefit period as well as the percentage that is paid to employees.

A Dependent Care FSA is an account that is set up for individuals to set aside pre-tax money to be used for dependent care expenses. It can pay for the care of dependent children under age 13 by a babysitter, day care center, or before and after school programs.

Care for a disabled spouse, parent, or child is also eligible if the individual lives with the employee and cannot care for himself or herself. Care must be given during normal working hours (for example, a babysitter who watches your children on the weekend for recreational time is not allowed).

The annual contribution limit for a dependent care FSA may vary from year to year. Dependent Care expenses cannot be reimbursed until they are incurred, and expenses must be substantiated by a third party to make sure that they are eligible expenses. Also, you can only use the funds that have been deposited into the account; you cannot use the funds in advance of the money being available in the account.

Preventive Advantage is offered by several dental carriers. If your employees seek care from an in-network dentist, they can access all preventative care without having the benefit deducted from their annual maximum. The annual maximum will be preserved for other, generally more expensive, dental services, including fillings, root canals, and crowns.

Changing your Benefit Advisor to Austin Benefits Group is easy! Once you have decided to make the change, we will walk you through the process. There are five steps that are required when changing your benefits advisor.

The best time to change your benefits advisor is at least six months before your next renewal date.

Six months is recommended to allow ample time for your new benefits advisor to build their files, learn about your needs, address urgent plan or provider issues, and lead you through an organized assessment of insurance, benefit, and communication options.

Although six months is optimal, we have worked with many new clients with condensed timelines. Please contact us at 248-594-5550 to discuss your specific needs.

Most group insurance contracts require employers to pay premiums on a monthly basis. The insurance company or service provider then pays the Broker of Record according to the terms of a commission agreement.

In most cases, the insurer will commence payment to a newly appointed broker beginning on the date of a change in the Broker of Record. In certain instances, commissions are vested with a broker who originally placed the insurance or investment contract.

This vesting period can be as short as the remainder of the policy period, to as long as the balance of the life of the insurance contract. If you are compensating a new broker via commissions, it is important to understand how the commissions are affected by a change in Broker of Record.

Yes, you may keep the same benefit plan provider if you change your consultant or broker. Your current insurance and service providers do not have to change just because you change your benefits advisor. If you are retaining a new broker, you should confirm they are, or will be, appointed with your existing insurers.