Sample Health Insurance Plans Medical Dental Vision

Sample_Documents

DISCLAIMER: This is a sample template provided for informational purposes only. It does not constitute legal, tax, or financial advice. Organizations should consult their own legal and tax advisors and tailor this document to reflect their specific business needs, geographies, and applicable laws.

Document Header

Field	Value
Title	Health Insurance Plans (Medical, Dental, Vision) - <Company Name>
Document Type	Health Insurance Plans (Medical, Dental, Vision)
Category	Benefits & Wellness
Version	v<Version Number>
Effective Date	<Date>
Supersedes	<Date or N/A>
Document Owner	<Title/Department> (e.g., Total Rewards)
Primary Contact	<Name> (<Email>)
Approved By	<Name/Title> on <Date>
Next Review Date	<Date> (Review cycle: <Months> months)
Geographies Covered	<Country>, <Region>, <Entity/Legal Employer>
Audience	Total Rewards, HR Business Partners, Benefits Operations, Payroll, HRIS, Legal, Finance, People Managers
Confidentiality	Internal Use Only

Purpose and Objectives

• Provide a comprehensive, configurable framework for administering medical, dental, and vision benefits at <Company Name>.
• Define plan options, eligibility rules, employer/employee contributions, and administrative processes.
• Establish governance, compliance, and quality controls consistent with laws in <Country> and applicable jurisdictions.
• Enable predictable annual planning, budgeting, and vendor management.
• Facilitate clear and timely employee communications, focusing on equitable access and value.

Scope and Applicability

In Scope

• Employer-sponsored medical, dental, and vision benefit plans offered by <Company Name>.
• Plan designs, eligibility, enrollment, payroll deductions, and continuation coverage.
• Vendor management, data integrations, and service levels related to health insurance.
• Compliance with applicable regulations in <Country> and other relevant jurisdictions.
• Communication materials and timelines for Open Enrollment and Qualified Life Events.

Out of Scope

• Life insurance, disability, accident, critical illness, hospital indemnity, and other non-health benefits.
• Retirement plans, time off programs, and non-insurance wellbeing initiatives not embedded in health plans.
• Country-specific statutory health coverage administration outside of employer-sponsored voluntary plans, unless integrated.
• Individual international assignment policies and totalization agreements, except where explicitly referenced.

Applicability

• Applies to all eligible employees of <Company Name> and participating affiliates within the covered geographies.
• Certain provisions may vary by legal entity, bargaining unit, or local regulation; such variances must be documented in addenda.

Governance and Plan Documentation

• Plans may be insured, ASO/self-funded, or hybrid. Funding model at <Company Name>: <Insured/Self-Funded/Hybrid> with stop-loss at <Amount> specific deductible.
• Plan Year: <Start Month/Day> to <End Month/Day> each year.
• Official governing documents include the Plan Document, Summary Plan Description (SPD) or local equivalent, Summary of Benefits and Coverage (SBC) where applicable, and required notices.
• In case of conflict, the Plan Document or legally required notice governs. <Company Name> reserves the right to amend or terminate plans at any time, subject to applicable law.
• Plan Sponsor: <Company Name Legal Entity>; Plan Administrator: <Title/Committee>; Agent for Service of Process: <Name/Address>.
• Plan Numbers (if applicable, e.g., in <Country> under ERISA): Medical <Number>, Dental <Number>, Vision <Number>.

Plan Overview

Medical Plans

• Vendors: <Vendor Name> (Medical Network and Claims), <Vendor Name> (Pharmacy Benefit Manager), <Vendor Name> (Virtual Care).
• Standard options offered by <Company Name>:
  • PPO Plan with in-network and out-of-network coverage.
  • HDHP with HSA eligible plan to encourage consumer-directed healthcare.
  • HMO/EPO Plan (where available) with in-network-only coverage for lower premiums.

Feature	PPO Plan	HDHP with HSA	HMO/EPO
In-Network Deductible (Individual/Family)	<Amount>/<Amount>	<Amount>/<Amount>	<Amount>/<Amount>
Out-of-Pocket Max (Ind/Family)	<Amount>/<Amount>	<Amount>/<Amount>	<Amount>/<Amount>
Coinsurance (In-Network)	<Percentage>% after deductible	<Percentage>% after deductible	<Percentage>% after deductible
Primary Care Visit	<Amount> copay	Deductible then <Percentage>%	<Amount> copay
Specialist Visit	<Amount> copay	Deductible then <Percentage>%	<Amount> copay
Urgent Care	<Amount> copay	Deductible then <Percentage>%	<Amount> copay
ER Facility	<Amount> copay then <Percentage>%	Deductible then <Percentage>%	<Amount> copay then <Percentage>%
Rx Tier 1/2/3/Specialty	<Amount>/<Amount>/<Amount>/<Percentage>%	Deductible then <Amount>/<Amount>/<Amount>/<Percentage>%	<Amount>/<Amount>/<Amount>/<Percentage>%

• The HDHP meets HSA eligibility criteria; participants cannot be covered by disqualifying other coverage and cannot enroll in a general-purpose Health FSA simultaneously.

Dental Plans

• Vendors: <Vendor Name> (Dental Network and Claims).
• Typical designs:
  • PPO Dental with preventive at <Percentage>% covered, basic at <Percentage>%, major at <Percentage>% after deductible.
  • DHMO in limited markets with fixed copays and assigned providers.

Dental Feature	PPO Dental
Annual Deductible (Ind/Family)	<Amount>/<Amount>
Annual Maximum Benefit	<Amount>
Preventive/Diagnostic	<Percentage>% (no deductible)
Basic Services	<Percentage>% after deductible
Major Services	<Percentage>% after deductible
Orthodontia (Child/Adult)	<Percentage>% up to <Amount> lifetime max

Vision Plan

• Vendors: <Vendor Name> (Vision Network and Claims).
• Coverage includes exams, lenses, frames, and contacts with allowances and frequency limits.

Vision Feature	In-Network
Eye Exam	<Amount> copay, once every <Months> months
Lenses (single/bifocal/trifocal)	<Amount> copay
Frames	Allowance <Amount> every <Months> months
Contact Lenses (elective)	Allowance <Amount> in lieu of glasses
Contact Lens Fitting	<Amount> copay

Eligibility and Dependent Definitions

Employee Eligibility

• Regular employees scheduled to work at least <Hours> hours per week are eligible on the first of the month following <Days> days of employment, or as required by local law.
• Temporary, interns, contingent workers, and contractors are not eligible unless mandated by law or explicitly included by written addendum.
• Variable-hour measurement periods (if applicable under local law) will be managed per <Company Name> policy and legal requirements.

Dependent Eligibility

• Legal spouse or domestic partner (affidavit or proof per <Company Name> policy and local law).
• Children up to age <Age> or over-age dependents meeting student or disability criteria per plan rules.
• Proof of relationship is required within <Days> days of enrollment (e.g., marriage certificate, birth certificate, domestic partner documentation).
• Spousal surcharge may apply when spouse has access to employer-sponsored coverage elsewhere: <Amount> per pay period.

Waiting Periods and Effective Dates

• New hire coverage effective <Date Rule> (e.g., first of month after hire).
• Rehires within <Days> days may be reinstated per prior elections subject to legal requirements.
• Leaves of absence handled according to leave policy and local law.

Enrollment and Change Events

Enrollment Windows

• New Hire: <Days> days from date of hire to elect coverage.
• Open Enrollment: Annual window each <Month> for a <Days>-day period with elections effective <Date>.
• Qualified Life Events: Changes permitted within <Days> days of event (e.g., marriage, birth/adoption, loss of coverage, move impacting network).

Documentation Requirements

• Life event documentation must be submitted within the window; late submissions may be denied.
• Domestic partner enrollments require affidavit and proof of shared residency/financial interdependence per policy.

Section 125 and Mid-Year Changes (if applicable)

• Pre-tax elections are generally irrevocable during the plan year except for qualifying changes in status under applicable tax rules.
• Changes must be consistent with the event.

Enrollment Process Steps

1. Review plan options and costs in the benefits portal by <Date>.
2. Confirm eligibility for dependents and gather required documentation.
3. Make elections and submit in the HRIS/benefits system by <Deadline Time> on <Date>.
4. Provide supporting documents via secure upload within <Days> days.
5. Verify first payroll deduction on <Pay Date> and report discrepancies to <Contact>.

Contributions and Payroll Deductions

• Employer contribution targets: <Percentage>% of total premium for Employee Only tier for base plan; contribution differentials by tier for dependent coverage.
• Payroll deductions made on a <Frequency> basis (e.g., biweekly, semi-monthly).
• Pre-tax deductions applied where permitted; post-tax for domestic partner imputed income or where required by law.
• Tobacco Surcharge (if applicable): <Amount> per pay period unless enrolled in a cessation program.
• Wellness Incentive: Up to <Amount> annual premium credit for completion of <Activities> by <Date>.

Coverage Tier	PPO Employee Cost per Pay Period	HDHP Employee Cost per Pay Period	HMO/EPO Employee Cost per Pay Period
Employee Only	<Amount>	<Amount>	<Amount>
Employee + Spouse/Domestic Partner	<Amount>	<Amount>	<Amount>
Employee + Child(ren)	<Amount>	<Amount>	<Amount>
Family	<Amount>	<Amount>	<Amount>

• Employer HSA contribution (if HDHP): <Amount> for Employee Only, <Amount> for Family, funded <Lump Sum/Per Pay Period>.
• IRS or local limits may apply. Example annual HSA limits: <Amount> for individual, <Amount> for family, plus catch-up of <Amount> for age <Age>+.

Health Accounts and Spending Options

Health Savings Account (HSA) for HDHP Enrollees

• Eligibility required: enrollment in an HSA-qualified HDHP, no other disqualifying coverage, not claimed as a dependent, not enrolled in Medicare.
• Contributions are pre-tax up to legal limits. <Company Name> may seed contributions of <Amount>.
• Funds are portable and roll over year to year.

Health Reimbursement Arrangement (HRA)

• If offered, <Company Name> credits <Amount> annually to offset eligible medical expenses. Unused balances may rollover per plan rules: <Yes/No/Amount Limit>.
• Notional employer-funded account; no employee contributions.

Flexible Spending Accounts (FSA)

• Health Care FSA (general-purpose or limited-purpose if enrolled in HDHP) up to <Amount> annually; dependent care FSA up to <Amount> per household.
• Grace period or carryover: <Carryover Amount> or <Grace Period Months> months, per plan design.
• Elections are use-it-or-lose-it subject to carryover/grace provisions.

Provider Networks and Access

• In-network providers deliver discounted rates and lower out-of-pocket costs.
• Out-of-network coverage varies by plan; balance billing may apply where not prohibited by law.
• Prior authorization required for certain services (e.g., advanced imaging, inpatient admissions, specialty drugs). Non-compliance may reduce or deny coverage.
• Virtual care available via <Vendor Name> with <Amount> copay or coinsurance.
• Travel and access:
  • Coverage for urgent and emergency care while traveling is included; notify the plan within <Days> days after emergency admissions.
  • International care coverage varies; use assistance program <Vendor Name> for referrals and claims submission.

Dental Plan Details

• Preventive services (cleanings, exams, X-rays) typically covered at <Percentage>% in-network without deductible.
• Basic services (fillings, simple extractions) covered at <Percentage>% after deductible.
• Major services (crowns, bridges, implants if covered) at <Percentage>% after deductible; waiting periods may apply for late entrants: <Months> months.
• Orthodontia coverage may be limited to dependent children under age <Age> and subject to a lifetime maximum of <Amount>.

Vision Plan Details

• Frequency limits apply to exams, lenses, and frames as defined in the summary table.
• Out-of-network reimbursements paid up to scheduled amounts; higher value achieved in-network.
• Specialty lens options and coatings may incur additional copays.

Coordination of Benefits and Medicare

• When multiple plans cover an individual, the order of benefits is determined by standard rules (e.g., active employee plan pays primary before retiree plan; for dependent children, birthday rule applies unless court order dictates otherwise).
• If enrolled in Medicare:
  • For active employees in groups of <Number>+ employees, the employer plan generally pays primary; smaller groups may have Medicare as primary.
  • HSA eligibility ceases upon Medicare enrollment; contributions must stop the month Medicare begins.

Leaves, Termination, and Continuation Coverage

• During paid leaves, benefits generally continue with normal payroll deductions.
• During unpaid leaves, employees may remit premiums directly within <Days> days of invoice; failure to pay may result in coverage suspension subject to legal protections.
• Upon termination or reduction of hours, continuation coverage may be available under local law (e.g., COBRA in <Country>) for up to <Months> months; applicable administrative fees up to <Percentage>% may apply.
• Reinstatement of coverage on return from protected leave occurs per legal requirements and plan rules.

Compliance and Required Notices

• Compliance may include ACA employer mandate reporting, SBC distribution, HIPAA privacy/security (or local equivalents), nondiscrimination testing, and required notices (e.g., special enrollment rights, marketplace or equivalent notices).
• Privacy: Protected health information is handled in compliance with applicable privacy laws in <Country> and other jurisdictions. Access restricted to authorized personnel and vendors under data processing agreements.
• Records retention for benefits documentation is <Years> years or as required by law.

Special Programs and Care Management

• Condition and case management through <Vendor Name> for chronic conditions (e.g., diabetes, hypertension) with incentives of up to <Amount>.
• Maternity program offering prenatal support and <Amount> incentive upon program completion.
• Second opinion services through <Vendor Name> for complex diagnoses and procedures.
• Travel benefit for centers of excellence: coverage for travel/lodging up to <Amount> when using designated facilities for specific procedures.

Vendor Management and Service Levels

• Vendors: <Medical Vendor>, <Dental Vendor>, <Vision Vendor>, <PBM Vendor>.
• Service Level Agreements:
  • Claims accuracy: <Percentage>% within <Days> days.
  • Call center response: <Seconds> average speed of answer; abandonment rate <Percentage>%.
  • EDI processing: eligibility file posted by <Time> <Days of Week> with <Hours> turnaround to effect.
  • Implementation: zero critical defects at go-live; issue remediation within <Hours> hours.
• Performance guarantees with at-risk fees up to <Percentage>% of admin fees for missed SLAs.
• Escalation path: Tier 1 <Vendor Team> to Tier 3 <Executive Sponsor> within <Hours> hours for severity 1 issues.
• Business reviews: Quarterly Operating Reviews and annual strategic planning with scorecards and trend analytics.

Roles and Responsibilities

• Total Rewards/Benefits Strategy
  • Design plan portfolio, set employer contribution policy, steward annual renewal and governance.
  • Own vendor selection and performance management.
• Benefits Operations
  • Administer eligibility, enrollment, life events, and carrier file transmissions.
  • Manage case escalations and appeals routing per plan rules.
• Payroll
  • Set up and audit deductions, arrears processing, and imputed income for domestic partner benefits.
• HRIS
  • Maintain system configuration, EDI integrations, and data quality controls.
• Legal/Compliance
  • Review plan documents, notices, and regulatory requirements across jurisdictions.
• Finance
  • Budget, accruals (IBNR), forecasting, and plan financial reporting.
• Procurement
  • Contract negotiation, business associate/data processing agreements, and renewal terms.
• Communications
  • Develop employee-facing materials, campaigns, and templates aligned to brand guidelines.
• People Managers
  • Reinforce timelines and guide employees to official resources without advising on plan selection.
• Vendors
  • Deliver services per SLA, provide reporting, and support employee experience.

Key Processes and Controls

Annual Renewal and Open Enrollment

1. Conduct claims and utilization analysis with <Vendor Name/Broker> by <Date>.
2. Model plan design and contribution scenarios; select final designs by <Date>.
3. Update plan documents, SBCs, and system configuration by <Date>.
4. Perform end-to-end user acceptance testing including rates, eligibility, and payroll by <Date>.
5. Launch Open Enrollment communications, decision support tools, and office hours by <Date>.
6. Post-enrollment audit and carrier reconciliation completed by <Date>.

Eligibility and EDI Controls

1. Source of truth for eligibility: <HRIS Name>.
2. Daily or weekly 834 or equivalent EDI files to carriers with effective dating logic and retro thresholds of <Days> days.
3. Three-way reconciliation: HRIS, carrier, and payroll monthly; discrepancy threshold of <Amount> triggers root-cause analysis.
4. Benefit QA: sample-based audits of life events and documentation.

Billing and Financial Reconciliation

1. Carriers deliver invoices by <Day> each month.
2. Benefits Operations validates headcount and coverage tiers; Finance validates rates and prior adjustments.
3. Variance > <Percentage>% requires joint review and approval sign-off by <Title> before payment.

Appeals and Grievances Routing

1. First-level inquiries resolved by <Vendor Name> member services.
2. Formal appeals filed within <Days> days of adverse determination per plan documents.
3. External review process available where mandated by law.

Implementation Guidelines

• Project timeline: minimum <Weeks> weeks from contract signature to go-live, including requirements, configuration, testing, training, and stabilization.
• RACI defined for all tasks; change requests logged and approved by <Steering Committee Name>.
• Data migration checklist includes eligibility history, contributions, COBRA/continuation populations, and prior accumulators where feasible.
• Cutover strategy:
  • Freeze window from <Date> to <Date>.
  • Dual maintenance and parallel payroll validation for <Pay Cycles> cycles.
• Risk management:
  • Identify risks (e.g., file timing, rate tables, plan mappings) and mitigation owners.
  • Conduct go/no-go readiness review <Days> days prior to launch.

Data, Systems, and Integrations

• EDI Standards: 834 or local equivalent for eligibility; 820 for remittance where supported.
• Transport: SFTP with encryption; keys rotated every <Months> months.
• Data elements include SSN/Employee ID, coverage tier, plan code, effective dates, dependents with relationship and DOB.
• Privacy and security:
  • Minimum necessary access, role-based controls.
  • Incident response within <Hours> hours and notification per data protection law in <Country>.
• Retention: eligibility files and confirmations retained for <Years> years.

Cost Management and Analytics

• Funding strategy: <Self-funded with ASO/Insured>; trend assumption <Percentage>% medical, <Percentage>% Rx.
• Stop-loss: Specific at <Amount> with aggregate at <Percentage>% of expected claims.
• Pharmacy strategies: formulary management, specialty channel shift, prior authorization, step therapy, and biosimilar adoption with target savings of <Percentage>%.
• Network steerage: tiered networks, centers of excellence, and telehealth optimization.
• KPIs:
  • Medical loss ratio versus budget.
  • Net paid PMPM, trend versus prior year.
  • Avoidable ER utilization rate per 1,000.
  • Generic dispensing rate and specialty spend as % of total Rx.
  • Member engagement in care management and preventive compliance rates.

Review and Approval Process

• Drafting by Total Rewards, review by Legal and Finance, operational review by Benefits Operations and Payroll.
• Approvals required:

1. Total Rewards Leader approval on <Date>.
2. Legal approval on <Date>.
3. Finance approval on <Date>.
4. Executive sponsor approval on <Date>.

• Exceptions:
  • Benefit exceptions require approval by <Committee/Title> and documentation with expiration date.
• Version control:
  • All updates logged in change history with reason, approver, and effective date.
  • Prior versions archived for <Years> years.

Additional Legal Disclaimers

• This document is a summary and does not replace the official plan documents or legally required notices. If there is a discrepancy, the official plan document governs.
• <Company Name> reserves the right to modify, suspend, or terminate any plan at any time, with or without notice, subject to applicable law and collective bargaining obligations where applicable.
• Participation in wellness programs is voluntary; reasonable alternatives will be provided in accordance with law upon request.
• Tax treatment of benefits may vary by individual circumstances and jurisdiction.

Glossary

• ASO - Administrative Services Only arrangement where employer self-funds claims and pays a vendor to administer.
• COBRA/Continuation - Continuation coverage rights after certain qualifying events, terminology may differ by <Country>.
• Coinsurance - Percentage of costs you pay after meeting the deductible.
• Copay - Fixed dollar amount you pay for a service.
• Deductible - Amount you pay before the plan begins to pay for covered services.
• EPO - Exclusive Provider Organization with in-network services only.
• HDHP - High Deductible Health Plan that may allow HSA contributions.
• HMO - Health Maintenance Organization with primary care coordination and in-network requirements.
• HSA - Health Savings Account with tax-advantaged contributions and withdrawals for qualified expenses.
• HRA - Health Reimbursement Arrangement funded by the employer.
• IBNR - Incurred But Not Reported claims, used in financial accruals.
• In-Network - Providers who have agreed to discounted rates with the plan.
• Out-of-Network - Providers without negotiated discounts; higher cost sharing and possible balance billing.
• PBM - Pharmacy Benefit Manager administering prescription drug benefits.
• PPO - Preferred Provider Organization with in- and out-of-network coverage.
• SBC - Summary of Benefits and Coverage required in certain jurisdictions.
• SPD - Summary Plan Description required in certain jurisdictions for ERISA plans.
• Stop-Loss - Insurance that caps the employer’s liability in self-funded plans.

Communication Section: Employee and Manager Guide

Welcome to Your Health Benefits at <Company Name>

At <Company Name>, your health and wellbeing matter. This guide gives you a clear view of your medical, dental, and vision plans so you can choose the coverage that fits you and your family. We designed plans to balance quality care, choice, and affordability. Whether you prefer a plan with predictable copays or you want to pair a lower premium with an HSA, you have options.

Who Is Eligible and When Coverage Begins

If you are a regular employee scheduled to work at least <Hours> hours per week, you are eligible for benefits. Coverage typically starts on <Effective Rule> (for example, the first of the month after your hire date). You can enroll your eligible dependents, including your spouse or domestic partner and your children up to age <Age>. You will need to provide proof of relationship for dependents within <Days> days of enrolling.

Your Plan Options at a Glance

You can choose from up to three medical plan types:

• PPO Plan: In-network and out-of-network coverage with predictable copays for common services.
• HDHP with HSA: Lower paycheck costs and the ability to save pre-tax dollars in a Health Savings Account. You pay the plan deductible first, then coinsurance.
• HMO/EPO: Lower premiums with in-network-only coverage. You must use network providers for services to be covered.

Dental coverage helps pay for cleanings, fillings, and major services, plus orthodontia in some plans. Vision coverage helps with exams, glasses, and contacts with allowances for frames or lenses. Using in-network providers typically saves you money.

What You Pay and What <Company Name> Pays

We share the cost of coverage. <Company Name> pays a significant portion of the premium, and you pay the rest through pre-tax payroll deductions. What you pay depends on the plan you choose and who you cover. For example, Employee Only coverage costs less than Family coverage. If you enroll in the HDHP, <Company Name> may contribute <Amount> to your HSA to help with out-of-pocket costs.

If you use tobacco, a surcharge of <Amount> per pay period may apply unless you participate in a cessation program. If your spouse has access to another employer’s plan, a spousal surcharge of <Amount> per pay period may apply.

How to Enroll

You have <Days> days from your hire date to enroll. Each year, you can also make changes during Open Enrollment in <Month>. Outside of those times, you can change your elections only if you have a qualifying life event, such as getting married, having a baby, or losing other coverage. Life event changes must be made within <Days> days of the event, and you will need to upload documentation.

Enrolling is simple:

1. Review the plan summaries and costs in the benefits system.
2. Choose the plan and coverage level that meets your needs.
3. Add dependents and upload required documents.
4. Submit your elections by <Date> and look for a confirmation.
5. Check your first paycheck after enrollment to confirm your deductions.

Tips to Get the Most from Your Benefits

• Use in-network providers to pay less and avoid surprise bills.
• Take advantage of preventive care, which is covered at <Percentage>% in-network in most plans.
• Compare costs using the carrier’s cost estimator before a test or procedure.
• Consider the HDHP with HSA if you want lower paycheck costs and tax-advantaged savings for healthcare.
• Register for virtual care for convenient access to doctors for non-emergencies.
• If you take maintenance medications, ask about mail-order options that can save money.

Need Help or Have Questions?

We are here to help. Contact <Vendor Name> member services for questions about claims, networks, or ID cards. For help with enrollment or life events, contact <Company Name> Benefits at <Email> or <Phone>. If you have a medical emergency, call your local emergency number or go to the nearest emergency facility.

This section is a summary. For full details about coverage, costs, and limitations, refer to the official plan documents and required notices. If there is any difference between this summary and the plan documents, the plan documents will control.

---

Document Information:

• Document Type: Health Insurance Plans (Medical, Dental, Vision)
• Category: Benefits & Wellness
• Generated: August 24, 2025
• Status: Sample Template
• Next Review: <Insert Review Date>

Usage Instructions:

1. Replace all text in angle brackets < > with your company-specific information
2. Review all sections for applicability to your organization
3. Customize content to reflect your company's policies and local regulations
4. Have legal and HR leadership review before implementation
5. Update document header with your company's version control information
6. At bottom of the document you find a short example on how the content could be communicated to end-users, for instance employees.

This sample document is provided for reference only and should be customized to meet your organization's specific needs and local legal requirements.