Healthcare in America 16-Apr-2019
Can “Limited Funding” reduce your health insurance costs? 3-Apr-2019
Federal Court Unravels Association Health Plans
While the specific details of what the replacement program for the ACA will look like, there are several ideas you will find very interesting. This is a detailed white paper from Milliman that looks at several important issues that will affect healthcare going forward. These include;
- continuous coverage provisions
- the role of high risk health pools
- open enrollment
- premium and cost sharing subsidies
- tax treatment of individual and group premiums, and
- coverage restrictions
We all know there is much room for improvement with the current ACA plans and regulations. The questions is, what's going to change and how will it effect each of our insurance options and the premiums charged for them. Time will tell but this report gives you a better understanding of what may be coming in the near future.
On November 18, 2016, the IRS released Notice 2016-70 to extend the due date for employers to furnish Form 1095-C or 1095-B under the Affordable Care Act's employer reporting requirement. Employers will have an extra 30 days to prepare and distribute the 2016 form to individuals. The due dates for filing forms with the IRS are not extended.
Applicable large employers (ALEs), who generally are entities that employed 50 or more full-time and full-time-equivalent employees in 2015, are required to report information about the health coverage they offered or did not offer to certain employees in 2016. To meet this reporting requirement, the ALE will furnish Form 1095-C to the employee or former employee and file copies, along with transmittal Form 1094-C, with the IRS.
Employers, regardless of size, that sponsored a self-funded (self-insured) health plan providing minimum essential coverage in 2016 are required to report coverage information about enrollees. To meet this reporting requirement, the employer will furnish Form 1095-B to the primary enrollee and file copies, along with transmittal Form 1094-B, with the IRS. Self-funded employers who also are ALEs may use Forms 1095-C and 1094-C in lieu of Forms 1095-B and 1094-B.
Extended Due Dates
Specifically, Notice 2016-70 extends the following due dates:
- The deadline for furnishing 2016 Form 1095-C, or Form 1095-B, if applicable, to employees and individuals is March 2, 2017 (extended from January 31, 2017).
- The deadline for filing copies of the 2016 Forms 1095-C, along with transmittal Form 1094-C (or copies of Forms 1095-B with transmittal Form 1094-B), if applicable, with the IRS is:
- If filing by paper, February 28, 2017.
- If filing electronically, March 31, 2017.
Prior to the IRS announcement, a process existed for employers to file Form 8809 to request a 30-day extension of the due date to furnish forms to individuals. Notice 2016-70 explains that the new extended due date applies automatically so individual requests are not needed. Employers that had already submitted extension requests will not receive a reply.
Notice 2016-70 also provides guidance to taxpayers who do not receive a Form 1095-B or 1095-C by the time they file their 2016 individual tax return.
Lastly, the IRS encourages employers, insurers, and other reporting entities to furnish forms to individuals and file reports with the IRS as soon as they are ready.
We have been getting a LOT of calls about help with individual policies. Unfortunately, the carriers no longer want brokers and consultants helping individuals find and manage their health insurance policies. Just for grins I decided to run a quote for my family with what I consider the best individual option available in Nashville, Farm Bureau.
My family had a TRH policy several years ago and while very basic coverage, it was affordable and would cover claims if something happened. I just ran quotes for the same policy I used to have and a similar ACA compliant policy. This is not stellar, Platinum coverage, it's a basic $3,000 deductible plan with a $6,000 out of pocket, not bells and whistles.
My family consists of me (age 55) my wife (age 54) and two sons age 19 and 22. All are healthy non smokers.
The cost for my old Non Compliant policy $447 per month. This policy requires underwriting and is subject to pre-existing conditions. The cost for a new ObamaCare ACA compliant plan, $2,276.62. Yes, that is not a typo and it's not quarterly that is a monthly number. You can run your own quotes at www.fbhealthplans.com
What do I get for the extra $22,000 per year? Guarantee issue with no pre-existing conditions. That is not important to me because we are all healthy. So what if I buy the non-compliant plan? I get to pay the penalty of 2.5% of our adjusted gross income with non deductible dollars. Fortunately we have a small group plan where I pay $1,317 per month for a similar policy.
Broken? You decide
Great news! After years of trying to find a compromise on out of network Emergency Room charges BlueCross and BlueShield of Tennessee and TriStar Health have come to terms. It's important to know that this is only for true emergency claims.
The agreement states "Any emergency services provided from January 1, 2015 until now (October 1, 2016) will be subject to the patient's normal in-network co-pay or co-insurance and deductible amounts". If your visit is deemed to be non-emergent visit your charged will be limited to $1,500 for any ER visit and $4,500 for an inpatient admission resulting from an emergency room visit.
This has been a big time challenge for many of our clients and the new agreement should eliminate many fears from our members.
See the Press Release here
Beginning on January 1, 2017 BlueCross BlueShield of TN will stop selling individual health insurance policies in the three major cities of Tennessee. Nearly 120,000 residents of the Memphis, Nashville and Tennessee regions will have to find other policies from the very few carriers left to sell them. Citing large and continuing losses BCBST is not willing to risk another bad year and will transfer that risk to their competitors.
The challenge for most will be finding coverage suitable for their needs and budget. For those who qualify for subsidies affordable coverage will be there but most may find the networks inadequate. For those who earn too much to qualify for ObamaCare assistance, not only will the networks be very limited the cost will be unbearable.
What are the options? If you need coverage without pre-existing conditions you will be limited to the exchange and ACA compliant plans. If you are relatively healthy there are some options to consider. Many religious organizations offer comprehensive plans that are NOT subject to the ACA penalties. These policies come with exclusions, limitations and pre-existing conditions but may be an affordable option. If your income is too high for a subsidy but you would not consider yourself "rich", a non compliant TRH policy can be a very affordable option. The thing to know is you will have to pay an ACA penalty of $695 per adult or 2.5% of your AGI whichever is greater.
My recommendation is to start looking as early as possible. January 1 rates should be available by mid October.
Tennessee's insurance regulator approved hefty rate increases for the three carriers on the Obamacare exchange in an attempt to stabilize the already-limited number of insurers in the state.
The rate approvals, while a tough decision, were necessary to ensure that consumers around the state had options when open enrollment begins in November, said Julie Mix McPeak, commissioner of the Tennessee Department of Commerce and Insurance. BlueCross BlueShield of Tennessee is the only insurer to sell statewide and there was the possibility that Cigna and Humana would reduce their footprints or leave the market altogether.
"I would characterize the exchange market in Tennessee as very near collapse ... and that all of our efforts are really focused on making sure we have as many writers in the areas as possible, knowing that might be one. I'm doing everything I can to prevent a situation where that turns to zero," McPeak said to The Tennessean.
BCBST, the only insurer that's sold statewide in first three years of the federal exchange, agrees with McPeak. The Chattanooga-based insurer is estimating that by the end of 2016 it will have lost close to $500 million on the exchange in three years, which is unsustainable, said Roy Vaughn, chief communications officer of BCBST.
The insurer, which has previously underscored its support for the individual market, is still weighing what its presence in 2017 will look like.
"We agree with the assessment of the ACA marketplace in Tennessee. We appreciate the support of our request to close the gap between our rates and medical expenses for ACA marketplace plans. Beyond rates as we've discussed with the (TDCI) we continue to have concerns about uncertainty with the ACA at the federal level," Vaughn said to The Tennessean. "Due to these concerns we are keeping all of our options open at this point about participating in the 2017 marketplace. We anticipate making a final decision in mid-September."
Cigna and Humana both refiled their requests earlier this month after telling the TDCI that the first requests were likely too low.
McPeak said insurers asked for the opportunity to refile rates last year but she said no. This year, however, was different because many of areas of the state will only have one or two choices. UnitedHealthcare, which sold statewide, dropped off the exchange earlier this year
"I felt like I didn't have any choice but to allow them to refile their rates," said McPeak, who is concerned about the limited number of insurers.
Cigna asked for and received an average 46.3 percent increase.
Humana asked for and received an average 44.3 percent increase.
BlueCross BlueShield of Tennessee, which did not refile its request, asked for and received a 62 percent increase.
United HealthCare is pulling out of Tennessee.
The insurers will now go to the U.S. Department of Health and Human Services for approval as federally qualified health plans, which is expected toward the end of September.
Doctors and patients say the Mylan pharmaceutical company has jacked up the prices for an EpiPen - the portable device that can stop a potentially life-threatening allergic reaction - from around $100 in 2008 to $500 and up today.
That's a hike of over 400 percent. When I look on www.goodrx.com for my local stores, I see the lowest cost at Kroger's for $614 with a coupon. I helped a client get one of these several years ago for $300. My advice to him, buy it in Canada.
Does that sound crazy to you? Listen to this, I just looked at www.pharmacyrxworld.com a Canadian pharmacy and guess how much it costs across the boarder? $79 American.
Do you think healthcare in America is broken? How can this be? I am not an expert but it could be that much those superpac election funds are coming from the drug companies that don't want America and Medicare to negotiate prescription prices. I suspect they have our elected officals ears.
Health insurance rates going up again? Do you watch the nightly news and see all those drug commercials telling you to ask your doctor about this new, awesome drug. Check out the cost on www.goodrx.com and you will quickly understand why they are spending all this money on advertising. Now check the cost in Canada, Europe, Australia or any other country and be prepared to get upset.
No, I don't know the answer but we have a serious problem.
Thanks for reading.
Soon the U.S. Department of Health and Human Services (HHS) will begin notifying employers about employees receiving advance premium tax credits (APTC) or subsidies for 2016 on the ACA federally facilitated exchange. For an idea of what the notice will look like, see the sample employer notice recently posted by HHS. If you receive a notice despite providing ACA-compliant health coverage, you may take the following two actions: 1) Appeal to HHS and 2) Notify employee.
Steps for Reviewing and Responding to an Exchange Notice
First, confirm who is sending the request. Some of the steps outlined below, such as use of the model appeal form, apply only to notices from the Federal exchange or a state-based exchange operating in California, Maryland, Colorado, Massachusetts, the District of Columbia, New York, Kentucky, or Vermont. If employer receives a notice from another state-based exchange, it would be necessary to review the contents of the notice regarding required appeal steps and documentation to be provided (although many state exchanges are likely to apply a similar process to the one used by the HHS).
Then check your records to confirm whether the person listed is an employee of the employer, or a dependent of the employee. If the notice does not provide enough detail for employer to confirm this point, such as a name that is similar to the name of an employee, but slightly different from the information in employer's records, it may be necessary to call the phone number provided in the notice in an attempt to confirm whether the notice identifies an employee or dependent.
Assuming that the notice does identify an employer's employee (or dependent of an employee), it will then be necessary to confirm:
- Whether an offer of coverage was made for the applicable time period described in the exchange notice, and
- If not, was there a reason that no offer of coverage was made, such as the person being classified as a part-time employee.
Appealing an Exchange Notice
Although employers are not technically required to appeal an exchange notice, employers may want to consider doing so in the following situations:
Where the information reflected on the notice appears to be incorrect (for example, the identified individual is not an employee); where the notice identifies a full-time employee who was offered affordable, minimum value coverage; or where coverage was not offered because it would not be required in order to avoid penalties (for example, because the employee was correctly classified as part-time or had previously terminated employment).
Appealing the notice in these situations may preempt the future assessment of penalties by the IRS, in that it alerts the exchange to the fact that the employee may not be eligible for subsidized exchange coverage. At worst, the appeal will help create documentation to be used in the event that the IRS does attempt to assess penalties with respect to the identified individual. It is our understanding that some payroll vendors and third party administrators are willing to assist employers with this process, typically for an additional fee, if the employer does not have the resources (or interest) to manage this process in-house.
For notices from a Federal exchange or one of the state-based exchanges listed above, employers will have 90 days from the date of the notice to file an appeal. The appeal can be filed in one of two ways:
By filling out an Employer Appeal Request Form, currently available at this link:https://www.healthcare.gov/downloads/marketplace-employer-appeal-form.pdf, or
By submitting a letter with the following information:
Business name, EIN, The employer's primary contact name, phone number, and address,
The reason for the appeal, and Information from the notice that was received, including date and employee information.
Mail the form or letter described above to:
Department of Health and Human Services Health Insurance Marketplace
465 Industrial Blvd.
London, KY 40750-0061
According to the HHS website, once the appeal is received by HHS, the employer should receive a letter acknowledging its receipt that will provide a description of the appeals process, as well as instructions for submitting any additional materials, if needed.
If the employer identifies that any employee was inadvertently not offered coverage while working through the steps above, it should make an offer as soon as possible, so that it can at least limit the potential IRS penalty that may be applied on a going forward basis. As a reminder, the Affordable Care Act penalties are applied on a monthly basis, so acting quickly to remedy any coverage errors can have a significant impact on any potential penalties that might otherwise apply.
Note that the exchange notices will generally be sent to the address the employee provides when applying for exchange coverage. As a result, the employer may also want to think about communicating with individual office locations other than corporate headquarters (if any), to make sure that managers and other personnel are aware that they need to route these to your preferred department/contact as soon as possible following receipt. Similarly, it may be necessary to put your mail department on notice of where these notices should be routed, so that the chance to appeal a notice is not missed due to the notice being inadvertently misdirected.
Communicating with Employees
As you may know, employers are required to provide a notice to new hires explaining the availability of exchange coverage (please see the following link for more information: https://www.dol.gov/ebsa/newsroom/tr13-02.html). One step employers could consider taking to help direct any exchange communications to the correct address and contact would be to include that contact information in this notice when it is provided to new hires in the future. Although this would not guarantee that employees will use the correct address, it may increase the chances that, when inputting information online while enrolling in an exchange, an employee will use employer preferred contact information, rather than an individual location (or incorrect address). There may also be other employment or benefits communications routinely provided to employees that could be revised to accomplish the same result.
If you chose to also notify the employee of the appeal you are filing, below is sample wording you can use:
The Affordable Care Act exchange where you purchased health insurance for 2016 notified us they granted you a government-paid advance premium tax credit to help pay for the insurance. Usually, a person receives these credits only if his or her employer did not offer him or her affordable health insurance coverage of a minimum value.
We are committed to providing competitive wages and benefits, including health insurance, to full-time employees. We regularly review our health insurance program in order to provide valuable coverage at a cost that is as reasonable as possible. We believe the health insurance we offered you for 2016 meets the Affordable Care Act guidelines for being affordable and providing minimum value.
We are appealing the notice from the Affordable Care Act exchange because if the government believes we did not offer our full-time employees health coverage that met or exceeded the Affordable Care Act requirements for affordability and value, the Internal Revenue Service (IRS) could charge us large fines. We believe the health insurance we offer our full-time employees meets the government requirements.
We wanted to let you know we are appealing. The government will also notify you and, depending on its final decision, you might have to make a repayment to the IRS for an advance premium tax credit if they find you were not eligible. We want to assure you we are not accusing you of any wrongdoing and this does not affect your employment relationship with us in any way. We value all our employees, and we realize the Affordable Care Act is a very complicated law for both employers and employees.
If you have questions on how the premium tax credits and cost-sharing subsidies are credited or repaid, please see questions 20 through 25 on the IRS Questions and Answers on the Premium Tax Credit webpage. You can also visit HealthCare.gov's premium tax credit page or questions and answers section.
If you have any questions about the health insurance we offer here at _________, please contact an employee benefits team member at _______ or visit our company website at __________.
Your company name here
The information provided is for educational purposes only. This information is from sources we believe to be reliable, but we cannot guarantee or represent that it is accurate or complete. The opinions are those of the writer, and the opinions and information presented are subject to change without notice.
August 8, 2016
The Affordable Care Act amends the Social Security Act by creating the Patient-Centered Outcomes Research Institute (PCORI). The Institute will be responsible for setting national research priorities and establishing an agenda to carry out such research.
The provision also amends the Internal Revenue Code by creating the Patient-Centered Outcomes Research Trust Fund (PCORTF) that will be used to support the PCORI. In addition to specified appropriations and transfers from the Medicare Trust Fund, the Affordable Care Act also imposes a fee on fully-insured health insurance policies (individual and group) and self-funded health plans that together will fund the PCORTF. This fee is commonly referred to as the PCORI fee.
This article is provided for general use. Employers and other plan sponsors with specific questions about the PCORI fee should contact their legal counsel or tax professional.
In addition to a plan sponsor's legal counsel or tax professional, the Internal Revenue Service (IRS) provides several resources through its PCORI web page. Information includes:
Final Rule provides the details for calculating the fee, among other pertinent information
IRS Notice 2015-60 provides updated PCORI fee amounts
Questions and Answers addresses common questions about the fee and its payment
Summary Chart a chart of common types of insurance coverage or arrangements, and the party responsible for paying the fee
Form 720 the form to be used to report and pay the fee.
Payment is Due by July 31
For members enrolled in fully-insured group plans and individual policies, BlueCross is responsible and liable for calculating, reporting, and paying the fee to the IRS.
For self-funded plans including Health Reimbursement Arrangements (HRAs) the plan sponsor is responsible and liable for calculating, reporting, and paying the fee to the IRS. The final rule provides guidance to determine the plan sponsor and methods for calculating the number of members on which the fee is based.
Fees for plan years ending in 2015 are due by July 31, 2016. The amount of the fee is based on plan year timing as follows:
For plan years ending Jan. 1, 2015 through Sep. 30, 2015, the fee is $2.08 per member per year
For plan years ending Oct. 1, 2015 through Dec. 31, 2015, the fee is $2.17 per member per year
Please refer to the IRS website for other information about reporting and paying the fee, especially if you have to file Form 720 for other purposes.
The PCORI fee and HRAs
Several questions have been asked about the application of the PCORI fee to HRAs, particularly for groups with a fully-insured medical plan. As mentioned above, BlueCross is responsible for paying the fee for members enrolled in its insured business. However, HRAs and the plan sponsor of an HRA plan will also be responsible for paying a separate fee on this portion of the plan, unless the plan meets the requirements to be treated as an excepted benefit. BlueCross does not pay the PCORI fee for self-funded plans, including HRAs that are integrated with fully-insured medical plans.
The following excerpt from the IRS summary chart may provide clarity:
"Special rule for coverage under multiple applicable self-insured health plans:
Generally, separate fees apply for lives covered by each specified health insurance policy or applicable self-insured health plan.
However, two or more applicable self-insured health plans may be combined and treated as a single applicable self-insured health plan for purposes of calculating the PCORI fee but only if the plans have:
The same plan sponsor; and The same plan year.
"For example, if amounts in an HRA may be used to pay deductibles and copays under a specified health insurance policy, the HRA (an applicable self-insured health plan) and the policy would be subject to separate PCORI fees. However, an HRA that may be used to pay deductibles and copays under the applicable self-insured health plan is not subject to a separate fee (and the fee will apply only to the applicable self-insured health plan) if both the HRA and the applicable self-insured health plan have the same plan sponsor and the same plan year.
There is no similar rule for lives covered by more than one insurance policy subject to the PCORI fee.
"Special counting rule for HRAs and FSAs:
Plan sponsors are permitted to assume one covered life for each employee with an HRA.
Plan sponsors are permitted to assume one covered life for each employee with an FSA."
Available Reporting for Self-funded Plans
While BlueCross cannot report or pay the PCORI fee on behalf of self-funded plans, we are providing a variety of resources that may assist plan sponsors. BlueCross provides information to self-funded plans for Form 5500 reporting, including the number of participants at the beginning and end of the year for plans that we administer.
In addition, BlueCross has reports available through the Self-Service Reporting tool under our BlueAccess secure portal. These reports may be of assistance if the plan sponsor determines it to be appropriate. Two reports are available:
Demographic Breakdown of Members Report This report provides the number of members by month. For each complete month, the membership information returned is as of the last day of the month.
To access the report:
Log-on to BlueAccess
Select Interactive Reports
Select Launch Enter Client (group) name if prompted (group administrators will have access only to their specific group information)
Select the "Demographic Breakdown" option listed under the Member Information section
The current reporting date is the default. If you are looking for the most recent information, select "View Reports". This will return all member demographics for the group. Run the report for the month you need. Print or download/export the results for your records.
Enrollment Report This report provides the number of subscribers by month. For each complete month, the enrollment information returned is as of the last day of the month and presented as a breakdown by contract type.
To access the report:
Follow the first three steps for accessing the Demographic Breakdown of Members report as outlined above
Select the "Enrollment by Group by Month" option listed under the Member Information section
The current reporting date is the default. Run the report for the period that you wish to see. The results will be separated for each month within the time period specified. You can print or download/export the results for your records.
These reports provide information about all subscribers or members enrolled under a group number based on the information in our database at the time the report is compiled. Data for any given month is usually available for reporting ten days after the month end. The reports will not reflect any additions or terminations that have not yet been reported and/or processed by BlueCross.
The reports can be customized to be run on the entire group population or parts of it as identified by subgroup, plan ID or Department. They can be run on any study period between 1 and 48 months.
This information is provided for general use. If you are an employer or self-funded plan sponsor and have specific questions regarding the calculation, reporting, or payment of the PCORI Fee, please consult with your attorney or tax professional.
 The Patient Protection and Affordable Care Act, Public Law 111-148, was enacted on March 23, 2010. The Health Care and Education Reconciliation Act, Public Law 111-152, was enacted on March 30, 2010. They are collectively known as the Affordable Care Act.
 The Patient Protection and Affordable Care Act, Public Law 111-148, was enacted on March 23, 2010. The Health Care and Education Reconciliation Act, Public Law 111-152, was enacted on March 30, 2010. They are collectively known as the Affordable Care Act.
Across the country carriers cannot seem to collect enough premium dollars to fund the ever increasing claims brought on by Obamacare and Government subsidized heath plans. I don't have a national tally of how much was lost in the individual market over the past 2 1/2 years but its safe to say they are losing hundreds of billions. Thus, the only way to stop the bleeding is to collect more premium.
Before ACA plans (guarantee issue, no pre-x, community rates, mandated benefits) carriers could predict and set prices fairly based on each persons specific risk. Today with millions of previously uninsured gaining access to mostly/nearly free insurance with immediate comprehensive coverage. We have seen it in our office, people need an expensive procedure and put it off because they could not get coverage under the old rules. Now, they sign up and can have the expensive procedure or prescription immediately and if they want to drop the coverage when their treatment is done, so be it.
Group coverage on the other hand while managed under pretty much the same rules is managing quite well. The main reason is most had prior coverage so there are very few who would have been in the previous scenario. Here are some other interesting facts from JD Hickey, president of BCBST.
They analyzed 2015 claims data for marketplace members and compared it against members who get their coverage at work. Their marketplace members had:
- Higher rates of chronic conditions, including diabetes and cardiovascular disease.
- 42 percent higher rates of impatient hospital admissions with 15 percent longer stays.
- 14 percent higher rates of emergency room utilization.
- 67% higher rates of behavioral health visits.
BCBST's marketplace members had on average, 43% higher medical claims costs and 58% higher pharmacy claims costs.
These facts are from JD Hickey, MD's editorial in the Tennessean, June 13, 2016