Affordable Private Exchange

Premier Carriers ApplaudCaliforniaChoice for its Broad Selection, Affordability and Focus on CustomerService
As government-run healthcare exchanges continue to grab the national spotlight, employers in California are increasingly seizing the opportunity to enroll in the...

California rejects Obama plan to extend canceled healthcare policies Los Angeles Times | November 21, 2013 | 2:15 PM California's health insurance exchange voted unanimously Thursday against an extension of canceled health policies affecting about 1 million consumers in the state. The decision ends a weeklong drama over what would happen for policyholders who will lose their existing coverage Dec. 31 and face finding replacement insurance that may cost more. The 5-0 vote by the state exchange marks a break with the president since California has been a strong supporter of the Affordable Care Act. For the latest information go to

IRS change could make health FSAs more popular

The Internal Revenue Service has altered the "use-it-or-lose-it" rule for medical flexible spending accounts, allowing workers to roll over $500 from year to year, write Robert Bloink and William Byrnes. FSAs could become more valuable than ever under the Affordable Care Act because of greater out-of-pocket expenses for many people, Bloink and Byrnes write.

Sorting out ACA subsidies and credits

People with incomes higher than 400% of the federal poverty level may purchase health insurance plans from an Affordable Care Act marketplace, but they will not qualify for federal subsidies, and people whose incomes rise might have to pay back any subsidies they received the prior year. People who have health insurance through an employer do not qualify for subsidies unless that insurance meets the definition of unaffordable, and subsidies are calculated based on the cost of a silver-level plan but may be applied to a lower- or higher-tier plan. Subsidies to help with deductibles and copays are available to people making less than 2.5 times the poverty level, but they apply only to silver-level plans.

Section 125 rule change

The Internal Revenue Service announced last week in IRS Notice 2013-71 additional loosening of rules around cafeteria plans, all size employers with non-calendar year cafeteria plans have the option to amend their cafeteria plans and allow for one off-year election change. Generally, Section 125 cafeteria plan elections must be made before the start of the plan year, and are irrevocable during the plan year, with limited exceptions, including certain changes in status. Under existing regulations, the availability of health plan coverage through an Exchange beginning with 2014 calendar year does not constitute such a change in status. As a result, employees would not be able to change their salary reduction elections for health coverage during a plan year in order to, for example, cease their salary reductions and Section 125 cafeteria plan coverage and purchase coverage through an Exchange. The original transition rule allowing for one off-year election change was published in the employer mandate regulations and only applied to applicable large employers. IRS Notice 2013-71 expands the transition rule to all size employers.

California SB 639 Signed by Govenor effects Health Plans

On September 20, 2013, Governor Jerry Brown signed SB 639 into law.

The bill, introduced by Senator Ed Hernandez (D-West Covina), goes into effect January 1, 2014 and addresses annual deductible and out-of-pocket limits for all non-grandfathered health plans in the individual, small and large group markets.

Essentially, the bill states that any non-grandfathered plan in the individual or small group market that becomes effective or renews on or after January 1, 2014, must limit annual deductibles to $2,000 for individual coverage or $4,000 for families.

Any non-grandfathered plan in the individual, small group or large group market that becomes effective or renews on or after January 1, 2014, must limit annual out-of-pocket costs (for Essential Health Benefits) to $6,500 for Individual coverage, or $12,700 for family coverage.

The exception to this is pediatric care, which will have its own limits. When a non-grandfathered health care service plan or a health insurer in the individual or small group market provides a pediatric oral care benefit meeting the definition as specified in the ACA, the out-of-pocket maximum for the pediatric oral care benefits is $1,000 for one child and $2,000 for more than one child.

Carriers who are not in the Exchange, cannot offer a catastrophic (higher deductible) plan in the Individual market. However, the law allows the DMHC or the CDI higher deductibles for small group products at the bronze level of coverage in order to meet Minimum Value.

Catastrophic plans or policies are defined as “A health care service plan contract or health insurance policy that provides no benefits for any plan year until the enrollee has incurred cost-sharing expenses in an amount equal to the annual limit on out-of-pocket costs, except requires the plan provide coverage for at least three primary care visits.” Catastrophic plans can only be offered if either of the following apply:

• The individual purchasing the plan has not yet attained 30 years of age; or,
• The individual has a certificate of exemption from the federal individual mandate because the individual is not offered affordable coverage or because the individual faces hardship.

The Notice of Exchanges and Subsidies Deadline is Today-By October 1, 2013

Virtually all US employers (regardless of size or whether the employer offers a health plan) are required to distribute a Notice of Exchanges and Subsidies to each employee (regardless of part-time, temporary, full-time or health plan enrollment status). Additionally, beginning on October 1, 2013, this notice must be provided to each new employee within 14 days of the employee’s start date.

There are two model notices available, one for employers that offer a company-sponsored health plan to some or all employees, and one for organizations that do not offer an employer-sponsored health insurance plan. Both of these model notices are available for download in the HR Support Center “Essentials” tab under the “HR Forms” section. (Simply type “Notice of Exchanges and Subsidies” in the Search Box.) There is also an FAQ document regarding this requirement housed in the same location. The purpose of the Notice of Exchanges and Subsidies is to inform employees of the existence of Health Insurance Exchanges (also called Health Insurance Marketplaces) as well as potential federal subsidies available to them in 2014.

Should an employee opt to shop in the Exchange, the employee may use this Notice provided by the employer to enter certain information on the application. The Exchanges are government-provided virtual marketplaces intended to offer individuals and small groups “one-stop shopping” to find and compare private health insurance options.

Open enrollment for health insurance coverage through the Health Insurance Marketplaces begins October 1, 2013 and coverage is available beginning on January 1, 2014.  On September 11, 2013, the DOL announced that there is no specific fine or penalty for failing to provide the notice by October 1, 2013.  However, the DOL or plan participants may bring a civil action against an employer for failure to comply with this notice requirement.
 

Press Release
FOR IMMEDIATE RELEASE

AMSINSURE.COM Receives 2013 Best of Torrance Award

U.S. Commerce Association's Award Plaque Honors the Achievement
NEW YORK, NY, September 10, 2013 -- For the fifth consecutive year, AMSINSURE.COM has been selected for the 2013 Best of Torrance Award in the Employee Benefits Health, Dental, Vision, Pension Insurance category by the U.S. Commerce Association (USCA).
The USCA "Best of Local Business" Award Program recognizes outstanding local businesses throughout the country. Each year, the USCA identifies companies that they believe have achieved exceptional marketing success in their local community and business category. These are local companies that enhance the positive image of small business through service to their customers and community.
Nationwide, only 1 in 1000 (less than one-tenth of 1%) 2013 Award recipients qualified as Five-Time Award Winners. Various sources of information were gathered and analyzed to choose the winners in each category. The 2013 USCA Award Program focuses on quality, not quantity. Winners are determined based on the information gathered both internally by the USCA and data provided by third parties.

About U.S. Commerce Association (USCA)

U.S. Commerce Association (USCA) is a New York City based organization funded by local businesses operating in towns, large and small, across America. The purpose of USCA is to promote local business through public relations, marketing and advertising.
The USCA was established to recognize the best of local businesses in their community. Our organization works exclusively with local business owners, trade groups, professional associations, chambers of commerce and other business advertising and marketing groups. Our mission is to be an advocate for small and medium size businesses and business entrepreneurs across America.
SOURCE: U.S. Commerce Association

CONTACT:
U.S. Commerce Association
Email: PublicRelations@uscaaward.com
URL: http://www.uscaaward.com
###

Don Wachtel was determined to take care of his family

by LIFE Happens

Don Wachtel was determined to take care of his family, and purchased a term life insurance policy. As fate would have it, the policy ended up taking care of him. When he was diagnosed with an inoperable brain tumor, he was able to access a portion the death benefit early to help with his care and his family's transition.   view here

Hospitals supersize, fueling rising cost of care, AHIP says

From www.amsinsure.com
Hospitals and medical systems are increasingly merging with or buying competitors, potentially driving up health care prices as they gain negotiating power over payers, experts say. "The rhetoric is all about efficiency. The reality is all about higher prices," said AHIP President and CEO Karen Ignagni. Some 20% of U.S. hospitals are likely to seek mergers within the next five to seven years, Booz & Company analysts say. The New York Times (tiered subscription model)

Eating for Optimal Health now availale

Available now...

The 2013 Wellness Report:
Eating for Optimal Health

With thousands of books ... articles ... websites ... reports ... and clinical studies on eating for optimal health, no single person can keep up with all of the new developments in nutritional research. It would be a full-time job--and you probably already have one of those!

realLIFEstories

LIFE Happens has uploaded realLIFEstories | Life Insurance | Boomer Esiason

Boomer Esiason, retired NFL quarterback and current TV analyst, has a passion for life insurance. His mother died when he was just 7, and money was tight growing up because of it.


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Obama administration launches ACA support tool for businesses

A new government website called the Health Care Wizard gives employers customized information about how the Affordable Care Act applies to them based on company location, size and health insurance plans offered. The tool returns formulas for calculating penalties, compliance dates and new regulations. NEW SITE     AMSINSURE.COM

Easy access tool on Health Care Reform for Business

Health Care Changes: A New Tool for Small Business Owners

We're excited to announce a new, streamlined health care tool , housed at Business USA,  to help you find out exactly what you and your employees need to know about the Affordable Care Act. In a few quick steps, you'll understand the essentials of new insurance options and other health care changes.

> Try the new health care tool

Government site to help employers with Health Care Reform

http://business.usa.gov/healthcare

The Obama administration just launched Business.USA.gov/healthcare, which is intended to be a one-stop-shop website that will provide employers of all sizes educational materials on how the Affordable Care Act may affect businesses and help them compete. The site includes a wizard tool that is tailored based on size and location, so businesses can learn how the law helps them provide affordable coverage options to their employees while still meeting their bottom line.

Health Care Changes Wizard | BusinessUSA

business.usa.gov

Health Care Changes Health Care Changes Affordable health care is a top concern for businesses. In a few quick steps, this wizard can help you understand what you need to know about new insurance options and other health care changes as well as find health

realLIFEstories | Life Insurance | Brigette Hunter - Keeping a Family an...

Comedy website looks to make health insurance a laughing matter

Writers for the comedic video website Funny or Die are working on video scripts to encourage the site's audience to enroll in health insurance coverage. The material will not be political and instead will "focus more on the positive stuff and really how it relates to young people who aren't thinking about health care in a serious way," said Mike Farah, president of production. The Hill/Healthwatch blog (7/25)

SHOP tax credits explained

Firms with fewer than 25 employees can get up to a 50% tax credit next year if they join the Small Business Health Options Program, Small Business Administration Senior Policy Adviser Meredith Olafson said during a webcast. Some of the SHOP exchanges will offer only one plan next year, but employers should have multiple plans from which to choose in 2015, Olafson said. Average annual wages at qualified businesses must be $50,000 or lower, excluding owner, partner and family income; and employers must cover a certain percentage of employees' premiums. InvestmentNews (free registration) (

Can an Assisted Living Community Transfer my Mother without my Approval?

 

Question: My question is whether an Assisted Living Facility can transfer my mother to another facility without my approval, her financial and health care Agent. Apparently, Mom, who is 87 years old and has dementia, has been somewhat rowdy recently and apparently because of this behavior/acting out, the Assisted Living Facility has made a unilateral decision (without my input at all) to transfer her to another facility on the other side of town. Can this be done and what is my recourse?

Answer: In Florida, a resident in an assisted living facility has the right to at least 45 days’ notice of relocation or termination of residency unless a physician certifies that the resident requires an emergency relocation to a facility providing a more skilled level of care or the resident engages in a “pattern of conduct that is harmful or offensive to other residents.”. So, in your particular case, if the ALF has provided proper notice, they can transfer her for any reason or no reason. If they have not provided proper notice and it is not an emergency transfer as described above then you may have recourse. I suggest that you contact the Long Term Care Ombudsman Program through the Department of Elder Affairs for more specific guidance in your mother’s case. They can be reached at 1.888.831.04040 or at http://ombudsman.myflorida.com. There is no charge for these services.

- See more at: http://www.eldercarematters.com/eldercareanswers/2013/07/26/todays-qa-can-an-assisted-living-community-transfer-my-mother-without-my-approval/#sthash.3670sl0E.dpuf

Health Insurance Exchanges and how people buy Healt Insurance

Excerpt from a survey where people accessed the Health Insurance Exchanges and how they would purchase health insurance from the Washington Post 7/14/13.
                                                             

Still, the focus on price, including the effect of subsidies, is a constant. Consulting firm Booz & Co.'s pretend exchanges showed that premiums were the most important factor in plan selection, followed by cost-sharing features like deductibles. McKinsey & Co., which tested about 150,000 consumers, found most would opt for smaller arrays of doctors and hospitals to achieve discounts.
 

If you are wondering, then I will tell you that this is no different than how people have shopped for health insurance prior to Health Reform. All the fuss and muss over explaining options to most people has nothing to do with how the will shop and buy health insurance on the exchanges.
 

If this happens then it is my best guess that things won't go well and all insures who have higher prices will eventually cut their prices trying to compete or exit the exchange.

5 compliance considerations for employers

Business owners and health care providers should take steps now to comply with the next phase of the Affordable Care Act, attorney Pepper Crutcher writes. Employers should monitor forthcoming IRS guidance on the penalties and taxes it will and will not collect. Employers with "grandfathered" plans should determine the benefits and drawbacks of staying with those plans or making even small changes and losing grandfathered status, determine whether self-insurance is the best option, and consider offering scaled-back options. American City Business Journals/Birmingham, Ala.

§  The crucial difference between ACA tax credits and subsidies
People with incomes between 100% and 400% of the federal poverty level might qualify for tax credits to offset health insurance premiums, and people with incomes between 100% and 250% of the poverty level may also qualify for subsidies to offset out-of-pocket costs. Consumers can apply in advance for the tax credit based on estimated income, and the funds will be sent to the insurer, but if income was underestimated and too much was paid to the insurer, consumers may owe the difference at tax time. Cost-sharing subsidies are also paid directly to insurers, but they need not be paid back if the consumer's income rises or was underestimated. Kaiser Health News/Capsules blog (7/10)        

Cadalic Plans under Health Care Refom

Cadillac insurance plan - Wikipedia, the free encyclopedia

en.wikipedia.org/wiki/Cadillac_insurance_plan‎

 

 

<sup>Informally, a Cadillac plan is any unusually expensive
health insurance plan, usually arising in discussions of medical-cost
control measures in the United States.[1][2][3][4] The term derives from
the Cadillac automobile, which has represented American luxury
since its introduction in 1902,[1]and as a health care metaphor dates
to the 1970s.[1] The term gained
popularity in the early 1990s during the debate over the
Clinton health care plan of 1993,[1] and was also widespread during
 debate over possible excise taxes on "Cadillac" plans during the
health care reforms proposed during the Obama administration.[1]
(Bills proposed by Clinton and Obama did not use the term
"Cadillac".)

The Patient Protection and Affordable Care Act
(as amended by the
Health Care and Education Reconciliation Act of 2010) imposes an
annual excise tax on plans with premiums exceeding $10,200 for
 individuals or $27,500 for a family (not including vision and dental
benefits) starting in 2018.[4]

Criticisms of these plans generally center on the small or
nonexistent co-pays, deductibles, or caps that encourage the
overuse of medical care, driving the cost up for the uninsured or
those on other plans, which some say necessitates a Cadillac tax.[citation needed]

A study published in Health Affairs in December 2009 found that
high-cost health plans do not provide unusually rich benefits to e
nrollees. The researchers found that only 3.7% of the variation in the
cost of family coverage in employer-sponsored health plans is
attributable to differences in the actuarial value of benefits.

Only 6.1% of the variation is attributable to the combination of
benefit design and plan type (e.g., PPO, HMO, etc.). The employer's
industry and regional variations in health care costs explain part of t
he variation, but most is unexplained. The researchers conclude
"…that analysts should not equate high-cost plans with Cadillac
plans, but that in fact other factors—industry and cost of medical
inputs—are as important in predicting whether a plan is a high-cost
plan. Without appropriate adjustments, a simple cap may exacerbate
rather than ameliorate current inequities."[5]</sup>

Healthcare Reform Update: Employers – Controlled Groups and Related Entities

Healthcare Reform Update: Employers – Controlled Groups and Related Entities

March 06, 2013

The Affordable Care Act (“ACA”) provision also known as Employer Shared Responsibility, mandates that employers who generally employ 50 or more full-time equivalents must offer group health insurance benefits to its full-time employees and their dependents or potentially pay a penalty. Employers can determine whether they meet the 50 or more full-time equivalent threshold for January 1, 2014 by using selected information from 2013. An important note, if two or more companies are “related” then the companies may be combined by the government for purposes of determining if the companies are subject to the Employer Shared Responsibility provisions.
Control group and related entities’ rules can be found in the Internal Revenue Code, including but not limited to, sections 414(b) and 414(c), which generally provide that employees of all companies which are members of a controlled group of entities and employees of trade[s] or business[es] (whether or not incorporated) which are under “common control” are to be treated as employed by a single employer. Companies with as little as 20% of common ownership may be considered part of a control group, while companies with 80% common ownership are usually presumed to be “related”. Another area that needs to be considered is affiliated service groups which provide integrated services to the public, parent-subsidiary, brother-sister entities and “family members” with ownership that may be attributed to a related person’s individual ownership interests. In addition, smaller entities with five or fewer persons which could include trusts are also legal entities which should be considered when deciding on who is part of a “control” group.
Lastly, the IRS has proposed anti-abuse provisions which will penalize employers who attempt to avoid the mandates of ACA. As always, please speak with competent legal and accounting professionals to address your specific circumstances.
http://www.irs.gov/uac/Newsroom/Questions-and-Answers-on-Employer-Shared-Responsibility-Provisions-Under-the-Affordable-Care-Act

Obama Administration delays

	Importan Notice, Obama Administration Delays Tax on employers with 50 or more employees as required under ACA.

 

The Washington Post by Sarah Kliff - July 2, 2013: The Obama administration will not penalize businesses that do not provide health insurance in 2014, the Treasury Department announced Tuesday. Instead, it will delay enforcement of a major Affordable Care Act requirement that all employers with more than 50 employees provide coverage to their workers until 2015. The administration said it would postpone the provision after hearing significant concerns from employers about the challenges of implementing it. “We have heard concerns about the complexity of the requirements and the need for more time to implement them effectively,” Mark Mazur, Assistant Secretary for Tax Policy, wrote in a late Tuesday blog post. “We recognize that the vast majority of businesses that will need to do this reporting already provide health insurance to their workers, and we want to make sure it is easy for others to do so.” The Affordable Care Act requires all employers with more than 50 full-time workers provide health insurance or pay steep fines. That policy had raised concerns about companies downsizing their workforce or cutting workers’ hours in order to dodge the new mandate. In delaying the enforcement of that rule, the White House sidesteps those challenges for one year. It is also the second significant interruption for the Affordable Care Act, following a one-year delay on key functions of the small business insurance marketplaces. Together, the moves could draw criticism that the administration will not be able to put into effect its signature legislative accomplishment on schedule.

Individual Penalty Transition Relief for Those Eligible to Enroll in Employer-Sponsored Coverage with a Plan Year That Begins in 2013 and ends in 2014

 

Because many employer-sponsored plans have non-calendar plan years, brokers have questions regarding how to advise clients with employees and/or dependents who waived employer-sponsored coverage but would need to have minimum essential coverage beginning January 1, 2014 in order to avoid the Individual Shared Responsibility Payment (i.e. individual penalty).   IRS Notice 2013-42, issued Wednesday 6/26/2013, addresses these questions and provides an employee, or an individual with a relationship to the employee, who is eligible to enroll in a non-calendar year employer-sponsored plan with a plan year beginning in 2013 and ending in 2014 will not be liable for the individual penalty until the end of the 2013-2014 plan year. Thus, employees and dependents that choose to wait until the 2014-2015 plan year to enroll in coverage will not be subject to the individual penalty for the months in 2014 that are part of the 2013-2014 plan year.

For your easy access, we posted IRS Notice 2013-42 in the Health Reform Updates & News section of our Health Reform Resource Center; where you also will find an abundance of helpful resources like our ACA Calculators http://ca.wordandbrown.com/HRRC/ACANews.aspx.

Employer notice to employees on Health Insurance Market Place

EMPLOYER EXCHANGE NOTICE- Federal regulators have moved back the date in which ALL EMPLOYERS must provide a written notice about the health insurance exchanges , known in CA as “COVERED CALIFORNIA”.  A copy my be obtained from the Department of Labor for Employers WITH and WITHOUT plans and in English and Spainish.  See below for the information contained in the letter.

Form Approved

OMB No.

New Health Insurance Marketplace Coverage

Options and Your Health Coverage

PART A: General Information

When key parts of the health care law take effect in 2014, there will be a new way to buy health insurance
: the Health Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic information about the new Marketplace.

What is the Health Insurance Marketplace?

The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The Marketplace offers "one-stop shopping" to find and compare private health insurance options. You may also be eligible for a new kind of tax credit that lowers your monthly premium right away. Open enrollment for health insurance coverage through the Marketplace begins in October 2013 for coverage starting as early as January 1, 2014.

Can I Save Money on my Health Insurance Premiums in the Marketplace?

You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or offers coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends on your household income.

Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace?

Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible for a tax credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may be eligible for a tax credit that lowers your monthly premium, or a reduction in certain cost-sharing if your employer does not offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your employer that would cover you (and not any other members of your family) is more than 9.5% of your household income for the year, or if the coverage your employer provides does not meet the "minimum value" standard set by the Affordable Care Act, you may be eligible for a tax credit.
1

Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your employer, then you may lose the employer contribution (if any) to the employer-offered coverage. Also, this employer contribution -as well as your employee contribution to employer-offered coverage- is often excluded from income for Federal and State income tax purposes. Your payments for coverage through the Marketplace are made on an after-tax basis.

How Can I Get More Information?

The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the Marketplace and its cost. Please visit HealthCare.gov for more information, including an online application for health insurance coverage and contact information for a Health Insurance Marketplace in your area.

1 An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs.

Retail Clinics Expand Health Care Services

In a move that caught the attention of the American Academy of Family Physicians (AAFP), Walgreens' Take Care ClinicsSM have begun offering assessment, treatment and management for chronic conditions such as hypertension, diabetes, high cholesterol, asthma, and more ... READ MORE

Self–compliance Tools for Health Benefits Laws

Self–compliance Tools for Health Benefits Laws

There’s no denying it — numerous provisions of Health Insurance Portability and Accountability Act (HIPAA) and Affordable Care Act (ACA) are complicated and confusing. To help with this confusion, the Department of Labor (DOL) now provides two tools on its website that group health plans, plan sponsors, plan administrators, and health insurance issuers can use to test their compliance. These tools, or checklists, deal specifically with group health plan requirements (Part 7) of ERISA.

The first checklist focuses on HIPAA portability and other law provisions, such as pre–existing conditions exclusions, certificates of creditable coverage, special enrollment rights, wellness programs, and more. The questions and explanations of applicable statutes and other regulatory/administrative interpretation materials assist those involved in operating a group health plan in understanding the laws and their related responsibilities.

The second checklist focuses on ACA provisions, including a plan’s status as a "grandfathered" plan exempt from some ACA requirements, and such ACA requirements as limitations on rescission and annual and lifetime limits, and more. The various sets of questions and answers allow users to assess their plan's compliance with the ACA provisions that have already taken place, or will take place in the near future

Do you no someone who needs help with buying Health Insurance, let them know that in starting in October they will be to look for help to begin Jan1, 2014!

Two types of financial assistance will available through the Marketplace for individuals: one reduces your monthly insurance premium, and the other helps with out-of-pocket expenses for care. Applicants may qualify for one or both depending on household income. If you qualify, the federal government will pay any financial assistance to Kaiser Permanente on your behalf. Learn more about federal financial help.

Watch a short video from the U.S. Department of Health and Human Services that explains the Marketplaces.

The Facts about the Marketplaces

• Marketplaces are federal or state-run marketplaces where consumers can compare and buy health insurance plans.
• The individual Marketplaces will open on October 1, 2013, with coverage available beginning January 1, 2014.*
• All plans available through the Marketplaces will provide comprehensive benefits – from visits to the doctor or hospital, to prescriptions, to screenings for cancer and other conditions.
• To help consumers compare plans from different insurance companies, several standard levels of coverage will be offered. These include Bronze, Silver, and Gold plans. Platinum plans and high cost share/low premium plans will also be available in some states for some people.
• The Marketplaces will also help determine if consumers are eligible for a reduced premium, lower cost-sharing, or for Medicaid or other publicly subsidized health benefits coverage.

Question: Next year, based on the new Health Care Reform regulations, may our company still require a 90-day waiting period (60 days in California) before new employees become eligible to enroll in the health plan?

Answer: Yes, your company may still impose a waiting period of up to 90 days for new employees entering your group health plan. However, it is important to note that beginning with an employer’s first plan year starting on or after January 1, 2014, an organization may not use a waiting period that exceeds 90 days (60 days in California). This restriction applies to all employers, regardless of size, that sponsor a group health plan, as well as to both grandfathered and non-grandfathered plans. The proposed guidance does not permit the employer to wait to offer benefits until the first of the month following 90 days of employment. (However, many employer advocacy groups have submitted comments asking for the allowance of a “first of the month following 90 days” waiting period, so it is still possible that the federal government may institute a safe harbor to allow this calculation method in its final guidance.) As the proposed regulations currently read, the employer must count all calendar days when calculating the 90-day waiting period (60 days in California), including weekends and holidays. If the 91st day (61st day in California) is a weekend or holiday, the organization may set a policy permitting coverage to be effective earlier than the 91st day of employment, but it may not make the effective date of coverage later than the 91st day (61st day in California). If your current health insurance plan utilizes a longer waiting period, it may need to be adjusted in 2014 in order to comply with the new regulations. These adjustments may include the authorization of mid-month enrollments if your organization opts to use a 90-day waiting period (60 days in California). There are some exceptions to this rule when the employer is unable to determine if a new employee’s average hours will be sufficient to qualify for health plan participation. When this occurs, the plan may take a reasonable period of time to determine whether the employee meets the plan's eligibility requirements, which may include a measurement look-back period of up to 12 months.

Employers that offer Health Coverage need to send a letter regarding the exchanges.

http://www.dol.gov/ebsa/pdf/FLSAwithplans.pdf

New Health Insurance Marketplace Coverage
Options and Your Health Coverage

PART A: General Information
When key parts of the health care law take effect in 2014, there will be a new way to buy health insurance: the Health Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic information about the new Marketplace and employment­based health coverage offered by your employer.

What is the Health Insurance Marketplace?

The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The Marketplace offers "one-stop shopping" to find and compare private health insurance options. You may also be eligible for a new kind of tax credit that lowers your monthly premium right away. Open enrollment for health insurance coverage through the Marketplace begins in October 2013 for coverage starting as early as January 1, 2014.

Can I Save Money on my Health Insurance Premiums in the Marketplace?

You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or offers coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends on your household income.Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace?

Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible for a tax credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may be eligible for a tax credit that lowers your monthly premium, or a reduction in certain cost-sharing if your employer doesnot offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your employer that would cover you (and not any other members of your family) is more than 9.5% of your household
income for the year, or if the coverage your employer provides does not meet the "minimum value" standard set by the Affordable Care Act, you may be eligible for a tax credit.1

Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your employer, then you may lose the employer contribution (if any) to the employer-offered coverage. Also, this employer contribution -as well as your employee contribution to employer-offered coverage- is often excluded from income for Federal and State income tax purposes. Your payments for coverage through the Marketplace are made on an aftertax basis.

How Can I Get More Information?

For more information about your coverage offered by your employer, please check your summary plan description or contact . The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the Marketplace and its cost. Please visit HealthCare.gov for more information, including an online application for health insurance coverage and contact information for a Health Insurance Marketplace in your area.

1 An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs.

Form Approved
OMB No.

Notice to employers that do not provide health coverage

http://www.dol.gov/ebsa/pdf/FLSAwithoutplans.pdf

New Health Insurance Marketplace Coverage
Options and Your Health Coverage

PART A: General Information

When key parts of the health care law take effect in 2014, there will be a new way to buy health insurance: the Health Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic information about the new Marketplace.

What is the Health Insurance Marketplace?

The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The Marketplace offers "one-stop shopping" to find and compare private health insurance options. You may also be eligible for a new kind of tax credit that lowers your monthly premium right away. Open enrollment for health insurance coverage through the Marketplace begins in October 2013 for coverage starting as early as January 1, 2014.

Can I Save Money on my Health Insurance Premiums in the Marketplace?

You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or offers coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends on your household income.

Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace?
Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible for a tax credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may be eligible for a tax credit that lowers your monthly premium, or a reduction in certain cost-sharing if your employer does not offer coverage to you at all or does not offer coverage that meets certain standards.

 If the cost of a plan from your employer that would cover you (and not any other members of your family) is more than 9.5% of your household income for the year, or if the coverage your employer provides does not meet the "minimum value" standard set by the Affordable Care Act, you may be eligible for a tax credit.1 Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your employer, then you may lose the employer contribution (if any) to the employer-offered coverage. Also, this employer contribution -as well as your employee contribution to employer-offered coverage- is often excluded from income for Federal and State income tax purposes. Your payments for coverage through the Marketplace are made on an aftertax basis.

How Can I Get More Information?

The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the Marketplace and its cost. Please visit HealthCare.gov for more information, including an online application for health insurance coverage and contact information for a Health Insurance Marketplace in your area.  1 An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs.

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How does the individual subsidy for the purchase of Health Insurnance work and who qualifies.

Subsidies: Who is eligible and how do they work?

June 5, 2013
Starting January 1, 2014, some of your individual clients may be able to get subsidies or tax credits when they buy health coverage. So who can get these subsidies or tax credits, and how do they work? We’ll break it down for you.
Subsidies for individuals
In 2014, people who qualify may be able to get a tax credit from the government to help them buy health coverage and pay their premiums. Or they may qualify for subsidies from the government to help them pay for their out-of-pocket health care costs. And they don’t have to wait until tax time to get it. The tax credit can be used for any individual plan sold on the exchange, or health care marketplace.
Who qualifies

• Tax credit:
  • People who are U.S. citizens or legally live in the U.S.
  • People earning between 100% and 400% of the federal poverty level if they are not eligible for other sources of minimum essential coverage, including government-sponsored programs such as Medicare and Medicaid or Medi-Cal in California.
  • Single people with household modified adjusted gross incomes from 100% to 400% of the federal poverty level would earn from $11,490 to $45,960 each year.
  • A family of four with household modified adjusted gross income from 100% to 400% of the federal poverty level would earn from $23,550 to $94,200 each year.
• Subsidy:
  • People with incomes up to 250% of the federal poverty level may also get an extra subsidy when they buy a silver level plan. These subsidies are lower cost shares for services covered by the silver plan. The federal government subsidizes the higher benefits provided by the insurer.

Who doesn’t qualify

• People who can get Medicare or Medicaid (Medi-Cal in California)
• People who can get a plan of a minimum value at work with premiums that cost less than 9.5% of their earnings

What Small Business with 2 to 50 employees have to know about Health Care Reform?

How is employer size defined?

A large employer is defined as having 50 or more full-time equivalent employees during a testing period that can be from six to 12 months. Full time is defined by the government as 30 hours per week.

The term equivalent is used to account for those who work less than 30 hours per week. For example, if an employer has 30 full-time employees working 30 hours each week and three part-time employees working 20 hours each week, it has 32 full-time equivalent employees. The part-time hours per month are added, then divided by 130 to determine additional full-time equivalent employees.

There is some relief for seasonal workers.

How does PPACA apply to small employers?

The employer penalties are just one piece. All employers are subject to certain rules if providing a health insurance plan, such as:

• Waiting periods for eligibility cannot exceed 90 days, beginning in 2014.
• Continuing to cover dependents of employees until age 26, in most cases.
• Providing a Summary of Benefits and Coverage to each employee at specific events, such as open enrollment.
• Supplying 60-day notification for any plan changes, except at renewal.

What are some other considerations?

If a plan is not grandfathered — hasn’t changed since the law went into effect in 2010 — then it must continue to waive all cost sharing for preventive care services, which includes women’s preventive care for plans renewing on or after Aug. 1, 2012.

Employers also must offer employees information on the public insurance exchange whether providing health coverage or not. The law requires this notice be distributed each March; however, it has been delayed in 2013, pending Department of Labor guidance.

In 2014, all non-grandfathered small group plans will have limits on the deductibles charged in-network. The maximum deductible will be $2,000 per individual and $4,000 per family. There also will be out-of-pocket limits that apply to all non-grandfathered plans. These limits are the same as those for high deductible health plans, which this year is $6,250 for an individual and $12,500 for a family.

How will the pricing methodology change?

The biggest change for small employers will be the pricing methodology applied to group insurance plans. Insurance companies will be unable to use gender, industry, group size or medical history, and therefore are limited to family size, geography, tobacco use and age. The companies can charge the oldest ages no more than three times what they charge the youngest ages. Many insurance companies use a ratio of 7:1 or higher, so this should result in higher rates for younger, healthier groups and better rates for older, less healthy groups. In addition, there will be new taxes and fees passed through to the employer in 2014.

Where do small employers have flexibility?

A small employer, with fewer than 50 full-time employees, has more flexibility in determining how many hours an employee must work to be benefits-eligible. For example, a small employer can establish 37.5 hours as the minimum to be eligible for the company health plan, so employees regularly working less than 37.5 hours aren’t eligible. Those employees most likely are eligible for a subsidy to purchase coverage in the public insurance exchange. But, as a small employer not subject to the employer penalties, there are no financial consequences.

Because of the complexities, employers are encouraged to review their employee count and other pending health care reform legislation with a qualified advisor.

 

 

The high cost of U.S. health care

The cost of hip replacement surgery in the U.S. is up to four times higher than what's paid in Switzerland or France, while charges for cesarean section births were more triple the cost of the same procedure in New Zealand or Britain, according to a Commonwealth Fund report. Meanwhile, colonoscopies alone contribute more than $10 billion in annual costs. This report explores the drivers behind high costs in the U.S. using the colonoscopy example as a case study for understanding why 18% of U.S. gross domestic product goes to spending on health care. The New York Times (tiered subscription model)

Covered California Announces Health Plans & Rates

 

California Broker Magazines Insurance Insider News: Thirteen health insurance plans will offer health care coverage through the Covered California health exchange in 2014. The plans are a mix of large non-profit and commercial plan leaders, along with well-known Medi-Cal and regional plans.

The rates for individual plans through the exchange vary from 2% above to 29% below average 2013 premiums for small employer plans in California’s most populous regions. Additionally, exchange plans limit annual out-of-pocket costs to $6,350. Covered California plans include the largest health insurers in the individual market as well as new entrants, regional plans, and local MediCal plans.

The following health plans will participate in the exchange:
• Health Net
• Kaiser
• Anthem Blue Cross
• Blue Shield
• Alameda Alliance for Health
• Chinese Community Health Plan
• LA Care Health Plan
• Molina Healthcare
• Sharp Health Plan
• Valley Health Plan
• Ventura County Health Care Plan
• Western Health Advantage

Three of the nation’s largest players in the employer-sponsored insurance market – UnitedHealthCare, Cigna, and Aetna – will not be selling plans through the California exchange.
Brokers will be able to sell any plan in the exchange, according to Michael Lujan of Covered California who spoke at the LAAHU conference in Los Angeles last week. He urged brokers to get familiar with the plans in order to be ready for open enrollment in October. Renee Casserly of Blue Shield said that, as a broker, you should maintain contact with your clients and let them know that you are able to help them purchase plans under the exchange. She noted that carriers will begin sending out information about the exchange to individual policyholders in September.
Consumers will have a choice of HMOs, PPOs, and exclusive provider organizations (EPOs). Plans that were chosen for the exchange agreed to reduce profit margins down to 2% and 3% and embrace ACOs and medical homes.

In Los Angeles, Orange, San Bernardino, San Diego and Riverside counties, Health Net expects to offer its new tailored-network HMO exchange product, “CommunityCare,” which will be built around local health care providers. Steve Sell, president of Health Net’s Western Region Health Plan said the company will work to ensure that the medical groups, individual physicians and hospitals are committed to comprehensive care coordination and offer freedom of choice in selecting eligible in-network primary care physicians. Health Net Life expects to offer individuals PPO exchange products in the Northern California counties of Contra Costa, Kern, Marin, Mariposa, Merced, Monterey, Napa, San Benito, San Joaquin, San Francisco, San Mateo, Santa Clara, Santa Cruz, Solano, Sonoma, Stanislaus and Tulare.

Molina Healthcare will participate in Los Angeles, San Diego, Riverside, and San Bernardino counties. “Our goal is to work with low-income or uninsured,” said J. Mario Molina, MD, president and chief executive officer for Molina Healthcare.
Kaiser Health news reports that nearly three dozen health plans submitted bids to sell their products in the competitive marketplace, and 13 were selected. Exchange officials rejected bids that were priced too high or failed to have robust networks of doctors and hospitals.

Premiums vary depending on the geographic region, the consumer’s age, and the richness of benefits. For example, a 25-year-old in Los Angeles could choose a Health Net catastrophic plan for $117 a month or choose a Bronze plan for $147 a month from L.A. Care, the nation’s largest public health plan. If the 25-year old earns less than about $45,600 per year, they would qualify for a subsidy to bring the cost of the premium down further.

More than half of Californians will be eligible for federal income tax credits for exchange plans. A 40-year-old in Los Angeles who earns $1,915 a month, or 200% of the federal poverty level, would pay a monthly premium of $90 for a Health Net HMO Silver plan in 2014.
The monthly premium would be $332 to $476 for a Silver plan for a 40-year-old individual in Sacramento. That includes federal subsidies, on a sliding scale, for a man or woman with income up to $45,960. Individuals who are eligible for the highest subsidy ($276 per month) would have out-of-pocket premium costs as low as $56 per month. Californians would receive federal subsidies on a sliding scale, extending to a family of four earning up to $94,200. For more information info@amsinsure.com

What happens when a loved one in a nursing home is not receiving proper care?

Question:  3 months ago my sisters and I reluctantly placed our mother (who is 81 years old) in a local nursing home.  Now she is about 30 pounds thinner, doesn’t speak, smells terribly and has bed sores.  We believe that this is the result of poor care provided by the nursing home.  Is there anyone we can contact to “check out” this nursing home and to help us resolve these quality of care issues?  Several of our friends have suggested that we contact the State Long Term Care Ombudsman’s office.  We are not sure what the role of the Ombudsman’s office is.  Can you please educate us on this elder care agency?

Answer:  The Long Term Care Ombudsman program is administered by the Administration on Aging (AoA), and each state (plus the District of Columbia, Puerto Rico and Guam) has a Long Term Care Ombudsman program. 

Long Term Care Ombudsmen are advocates for the residents of long term care facilities, including nursing homes, board and care homes and assisted living facilities.  They are trained to help residents (and the families of residents) resolve problems that they may be experiencing with long term care facilities.

Long Term Care Ombudsmen can help families address the following long term care concerns:

• Violation of  the resident's rights or dignity
• Physical, verbal or mental abuse
• Poor quality of care
• Inappropriate use of restaints