Here is what SeeChange is saying  . . .

Rate Adjustment (Small Group Plans Only)
We’re not using the term “adjustment” just to avoid the word “increase.” Premiums are going down for some products and some rating areas (pending Department of Insurance approval, of course).

• The average unweighted increase (the average premium change based on all our plans in all our rating areas) is 1.3%
• The average weighted increase (the average premium change our existing groups will experience) approximately 7%
• Rates will now be based on the employee’s residence, not the employer’s location. This could impact rates for specific groups whose employees reside in a different rating area than the one in which they work.
• These are averages: the rating changes vary significantly by product and area. Please see our Rating Matrix at www.SeeChangeHealth.com/brokers

Benefit Improvements (For Both Small and Large Group Plans)
Our value-based benefit approach rewards members who take steps to improve and manage their health. We’ve increased the reward for some of our plans.

• Classic Plans (2200, 3500 and 5000):
  We’ll now contribute $500 to the Health Incentive Account for employees who complete their Preventive Health Actions—and another $500 when their spouse or domestic partner completes theirs. That’s a total of $1,000 per couple, up from the $200 per person contribution we make today.
• No-Deductible 3.0:
  We’ve improved the co-insurance levels by 10%:
  - Standard in-network benefit is improving from 60/40 to 70/30.
  - Enhanced in-network benefit is improving from 70/30 to 80/20.

For details concerning the rate adjustments rate adjustments and benefit improvements please see our new Rate Tables and Benefit Summaries at www.SeeChangeHealth.com/brokers.

Alliance Plan Highlights

Alliance HMO plans come with built-in health and wellness programs, at no
additional cost, to help your clients’ employees take steps toward an overall
healthier lifestyle. They can get information on their specific health needs and
enroll in online health coaching or other motivational programs for improving
their health. UnitedHealthcare will also send personalized messages and
reminders for preventive care and screenings. Their disease management and case
management programs offer support and guidance to members who are looking for
treatment options for chronic conditions.

Plans also include prescription drug benefits based on clinical quality and
evidence-based medicine, which may lead to potentially better health outcomes
and cost savings. Members can also receive personalized messages to help them
make more informed decisions and save money at the pharmacy.

Alliance Network Overview

Alliance HMO provides coordinated care to members with access to more than
26,000 physicians and specialists and more than 90 hospitals. With
UnitedHealthcare SignatureValue Alliance, members choose a Primary Care
Physician (PCP) from a network of highly acclaimed medical groups in the state,
which consists of:

• HealthCare Partners Medical Group
• Heritage Provider Network
• Monarch HealthCare Medical Group
• PrimeCare Medical Group
• Santé Community Physicians
• Scripps Health

Alliance HMO Plan Line-up

• SignatureValue Alliance 15-30/300a
• SignatureValue Alliance 20-40/300d
• SignatureValue Alliance 30-40/500d
• SignatureValue Alliance 40-60/800d
• SignatureValue Alliance 40-60/60%
• SignatureValue Alliance 20-40/70%/1500ded
• SignatureValue Alliance 40-60/70%/2000ded
• SignatureValue Alliance HRA 30-45/90%/1500ded
• SignatureValue Alliance HRA 35-50/80%/2000ded
• SignatureValue Alliance HRA 40-55/70%/3000ded
• SignatureValue Alliance HSA 1500/90%
• SignatureValue Alliance HSA 2000/80%
• SignatureValue Alliance HSA 3000/80%

Guidelines

The Alliance plans may be offered standalone or as part of a multi-choice
package, allowing employers to pair the HMO Alliance network alongside specific
PPO plan designs. Premier Source Alliance is also available for employers who
wish to offer HMO Alliance plans alongside another carrier.

• 2-50 Product Grid
• Alliance Brochure
• Flex Brochure   – Video

Network Information

• PPO Network: 56% of dentist locations in California. PPO
  Dentists are considered In-network for all PPO, PPO Plus Premier, and
  Premier plans.
• Premier Network: 90% of dentist locations in California. Delta
  Premier dentists are considered Out-of-Network for all PPO and PPO plus Premier plans, and are considered In-Network for Premier plans.

Dentist Reimbursement by Plan

• PPO: Ina Classic or OPTIONS PPO plan, all dentists (PPO, Premier, and Non-contracted) are reimbursed at the lesser of the submitted charge or the PPO provider’s contracted fee.
• PPO Plus Premier: If a member visits a PPO dentist, charges are reimbursed at
  the lesser of the submitted charge or PPO contracted fee.  If visiting a Premier dentist, charges are reimbursed at the lesser of the submitted charge or the Premier provider’s contracted fee.
  If a Delta Dental member goes to a Non-contracted dentist, charges are reimbursed at the lesser of the submitted charge OR the fee that satisfies a majority of dentists with the same training and geographical area.
• Premier: If a member visits a PPO or Premier dentist, charges are reimbursed at the
  lesser of the submitted charge or the Premier provider’s contracted fee. Non-contracted dentist charges are reimbursed at the lesser of the submitted charge OR the fee that satisfies a majority of dentists with the same training and geographical area.

For more information, view the following:

• Delta Dental PPO and PPO Plus Premier Network Information
• Delta Dental Online – About PPO and PPO Plus Premier
• Delta Dental Online – About Premier

New 2012 Summary of Benefits

• Click here for the CoPower ONE Summary of Benefits
• Click here for the Delta Dental Summary of Benefits
• Click here for the Vision Service Plan (VSP) Summary of Benefits
• Click here for the UNUM Summary of Benefits

UHC has a great online tool to help us identify prescription costs.  You can access it here.  This is only an example of costs through Medco, so your costs will differ depending on your insurance plan and pharmacy.  It also shows you the cost for mail order compared to filling your prescription at a retail pharmacy.

I looked up 80mg tabs of Zocor, a common cholesterol drug.  A 30 day supply from a retail outlet showed $163.59, whereas the generic Simvastatin costs only $12.05.  Yikes, the brand name was 1300% higher!

Why not check your costs.

This change is due to the addition of atorvastatin, a new generic for the brand name Lipitor, on their covered drug list.

This change impacts all of the commercial and individual business in California and New York. Medicare Part D and state-sponsored business are not impacted.

All of these new plans build on rates and benefits that brokers and plan sponsors have requested. 

More on the new plans: 

• The new plans were designed to help employers and employees save on health care costs while getting a plan that meets their needs.
• All of the HMO and MC/PPO plans alongside each other.
• Plan sponsors can set their contribution rates on the lowest priced plan, and their employees can “buy up” to different plans if they wish to do so.

Just look at some of the key benefits these plans offer your employees:

IMPORTANT PLAN CHANGES: In addition to introducing new plans, some changes were made to existing plans. Look at the Renewal guide for details about the changes to specific plans. Please note: There are changes to every plan — so it is important for you to review the changes. You can also view the new Plan Guide here. 

Other plan highlights include:

• Vision benefit now included with all plans — One exam every 24 months. Includes refractive testing. 
  
• Wellness/health incentive benefit — Employees and their spouses/domestic partners can earn up to $100 for completing a wellness program through simple steps.
• Brokers and employees can complete adds and terms online.
• As of March 2012, an employer can obtain a new employee’s member ID right in the on-line enrollment tool as soon as the enrollment has been processed.

Item 1: Health Net SmartCare – first innovation for 2012

• Convenient CVS MinuteClinics;
• Acupuncture and chiropractic services included as valued-added benefits; and
• Health incentives to help employees be well and productive.

More relevant to your clients:

• Easy-to-understand, choose, and use HMO plans keep decision making clear and simple.
• Sets employers up for the long-term. SmartCare is built to flex over time with planned expansions for 2012 (and beyond) in geographic coverage, prominent participating provider groups and other resources to match evolving employer and employee needs.

Health Net SmartCare is the health care solution that employers can afford, employees will use, and both will value.

Creating an easy migration from Bronze to SmartCare
Effective March 1, 2012, Health Net will no longer offer Bronze or Bronze Choice to new groups. Groups currently enrolled in a Bronze plan will be:

• Notified 90 days in advance of their renewal date by letter that explains the change.
• Offered the option to choose any one or more of the new SmartCare plans (six for SBG, five for Large), or any other Health Net group plan.

If a group wants to keep their plan design exactly as it is under their Bronze plan, they may do so by pairing those benefits with Health Net’s full HMO or Silver network.

Health Net has the Health Net SmartCare broker guide including a crosswalk and plan overviews available to support you and your brokers in client conversations.

Click here for SmartCare HMO Plans.

Item 2: Lower SBG PPO Advantage plan rates – San Diego
In conjunction with introducing SmartCare in San Diego (region 7), Health Net is also lowering rates for its PPO Advantage plans.

Item 3: Salud expands into Kern county
Health Net is expanding its Salud network with the addition of IPA Hispanic Physicians, which has eight PCPs and 74 specialists. The expansion makes Salud HMO y Más and Salud Mexico available to groups – both SBG and Large – in parts of Kern county effective March 1, 2012. More information and details about materials will be sent soon.

SAN FRANCISCO, CA–(Marketwire -01/24/12)- SeeChange Health (www.seechangehealth.com), an innovator in value-based benefit design solutions to improve health and reduce health care costs, today announced that the company’s growth is accelerating and is on pace to exceed $50 million in revenue over the next 12 months.

SeeChange Health offers value-based benefit design solutions to meet the needs of businesses of all sizes. SeeChange Health Insurance provides value-based benefit plans to fully insured employer groups in California and is the first to bring this unique approach to small and midsize companies. SeeChange Health Insurance is now the fastest-growing health plan in the market, as brokers and employers alike are embracing the value-based model. Read full article here.

EmployeeElectTotal

• PPO 3.2%
• HMO 6.9%
• CDHP 12.8%

EmployeeChoice – 7.9%
BeneFits – 3.5%
Total – 5.0%
(These rates are for Small Group ONLY, the EmployeeElect 51-99 portfolio as well as the Small Group MHP compliant plans have slightly different rates than the Small Group portfolio.)
*These rate adjustments are averages and will vary by plan and region..

HMO Rate Adjustments –April 2012
The HMO plans within the Small Group EmployeeElect Portfolio will see a new business average increase of approximately 6.9%*.   All HMO plan families will receive an approximate 6.9% quarterly increase on average.

Quarterly increases on the HMO plan families will be as follows*:

• HMO 100% – 7.6%/Select HMO 100% – 3.8%
• Classic HMO – 7.5%/ Select Classic HMO – 3.8%
• Saver HMO – 7.5%/ Saver HMO – 3.7%

“Renewal” increases are as follows:

• HMO 100% – 15.2%/Select HMO 100% – 11.1%
• Classic HMO – 16.3%/ Select Classic HMO – 12.1%
• Saver HMO – 15.2%/ Saver HMO – 11.4%

*These rate adjustments are averages and will vary by plan and region.

PPO Rate Adjustments –April 2012
The PPO plans within the Small Group EmployeeElect Portfolio will see a new business average increase of approximately 3.2%*.

The PPO Increases will be as follows (quarterly/renewal)*:

• The PPO Premier Plans will receive an average increase of 3.5%/12.1%
• The PPO Copay Plans will receive an average increase of 3.5%/12%
• The Solution PPO Plans will receive an average increase of 3.3%/7%
• The GenRx PPO Plans will receive an average increase of 2.5%/3.2%
• The Elements Hospital PPO Plans will receive an average increase of 2.7%/2.9%
• The EPO Plans will receive an average increase of 3%/10.3%

*These rate adjustments are averages and will vary by plan and region.

RAF Promotion Update
The basic promotion will remain intact, however, Anthem will also now allow for the following:

• Groups with 6 or more enrolling subscribers, with a minimum of 50% participation in either the Gen Rx PPO plans and/or any of the Select Network HMO plans will receive an automatic .90 RAF –There will be no qualifying renewal RAF required on those groups.

• Groups with 6 or more enrolling in our BeneFitsplan portfolio will also receive an automatic .90 RAF -There will be no qualifying renewal RAF required on those groups.

UnitedHealthCare

Per AB 1672, groups with 51% of the eligible employees employed in the State of California are considered guaranteed issue groups. 

Groups with more than 49% of the eligible employees employed outside the state of California are considered non-guaranteed issue in California. These groups require health statements and are not eligible for the RAF promotion. 

Underwriting will approve or decline these groups in accordance with the underwriting guidelines.

Suppose you are an Anthem small group employer and you receive your January 1, 2012 bill for your employee health insurance. California small group employers have always been accustomed to having a 30 day grace period past the due date to pay their bill and that has not changed.  What has changed is the willingness of a carrier to extend the grace period for longer than 30 days.

In the past when clients went past their 30 day grace period, we would call Anthem and tell them that our client promises not to do that again and to please reinstate coverage for their employees as our client will overnight the check.  I can’t remember a time where Anthem did not approve the reinstatement.  If you read the recently released “Notice of Grace Period and Right to Request Review“, Anthem may no longer be accommodating.

What I do know is that Anthem pays out more in claims that what the State of California will allow them to charge some businesses.  Why would Anthem want to be accommodating to a business that loses them money?

Here is another question:  If a group plan is cancelled for non-payment and the employees and/or dependents incur claims, who is expected to pay those claims? 

Answer: Injured employees would seek their employer.

Our advice to employers: 

Please pay early as you may not receive a reminder from the insurance company.

Once thing that can also help you is knowing more about the following common dental procedures:

Extractions

Teeth may need to be pulled in the event of dental pain or infection.  A certain amount of blood and pain is to be expected, so anesthesia can be used to reduce pain.  You can also use an MP3 player to deaden any sound.  Remember that any blood you se is mixed with your saliva, so it actually looks like you are bleeding more than you actually are!

Fillings

Cavities are small holes in teeth caused by germ-containing plaque, is treated by removing the surrounding area and filling the hole with materials to rebuild the tooth.  If cavities are not treated early, the bacteria will continue to eat away at the tooth, possibly resulting in a need for a root canal.  One way to lessen fear of the drilling and filling is to bring an MP3 player or similar device to listen to music while your dentist is working.

Root Canal

During a root canal, damaged tissue is cleaned out from inside a tooth. It’s a long procedure (sometimes lasting about two hours), but it can save your tooth. You can also bring along an MP3 player or you can break the treatment down into more manageable time periods.

X-Rays

X rays are designed to help your dentist find little problems before they become worse.  It can become a problem is you have a strong gag reflex or fear of radiation exposure.   Your dentist can use a little topical anesthesia to help control your gag reflex during this short dental procedure. It also may help to remember that the actual radiation exposure from dental X-rays is relatively minimal compared with the radiation exposure you get naturally each day.

Crowns

Crowns are used to protect a worn-out or weakened tooth.  The worst part of the procedure is the gag-inducing mold made of your tooth to shape the crown.  One way to alleviate this problem is to sit upright and use a faster-setting mold.

Dental Implants

Implants are used to replace missing teeth. They look natural and are stable as they are molded to your bone below your gums.  If you are afraid you can consider anesthesia.

Small Group Medical

After reasonable January and April increases, as well as a rate pass on most plans in July, Anthem is pleased to announce another low trend increase for October.

Small Group Rate change Overview*

The rate increases for Anthem’s 51–99 EmployeeElect portfolio are identical to Small Group for October. However, the total rates for these plans will vary slightly.

Rate Adjustments—EmployeeElect Portfolio

HMO Plans:

Anthem’s HMO plans will experience a new business average increase of approximately 4.9%.*

• The HMO 100% plans will receive an average increase of 4.5%.
• The HMO Classic plans will receive an average increase of 5.5%.
• The HMO Saver plans will receive an average increase of 4.5%.

PPO Plans:

Anthem’s PPO plans will experience a new business average increase of approximately 2.7%.*

• The PPO Premier plans will receive an average increase of 4.5%.
• The PPO Copay plans will receive an average increase of 4.5%.
• The EPO plans will receive an average increase of 2.5%.

These plans will not experience a rate increase:

• Solution PPO
• GenRx PPO
• Elements Hospital PPO

Lumenos Plans:

Anthem’s Lumenos Health Savings Account (HSA)-compatible plans will experience a new business average increase of approximately 3.4%.*

• The Lumenos HSA 80% plans will receive an average increase of 3.5%.

The Lumenos HIA+ plans will not experience a rate increase.

Fourth Quarter Renewal Increases

The October through December renewal increases will vary due to the rating changes Anthem Blue Cross has gone through in the past year. Anthem has had variances by product and region; however, they are pleased to announce an average renewal increase on their EmployeeElect plans for these three months of 10.6%.

New HRA Plans

Effective October 1, 2011, Anthem Blue Cross will have four Health Reimbursement Account (HRA) plans in their EmployeeElect portfolio.

• 3,000C and 5,000C plans—High-deductible HRA offerings with $20 or $30 copay amounts with the deductible waived for office visits.
• 3,000D and 5,000D plans—High-deductible HRA plans with 80% coinsurance amounts after the deductible is met.

Highlights:

• The employer may allocate up to 50% of the annual deductible dollar amount.
• The minimum amount recommended is no less than 10% of the annual deductible.
• The plans will allow for flexible rollover options.
• These plans promote healthy living with employer-sponsored incentives for employees.

Benefit Changes**

Effective October 1, 2011, all of Anthem’s Small Group plans will experience some benefit changes.

Highlights of Benefit Changes:

HMO Plans:

• Increase individual and family out-of-pocket maximums.
• Increase Emergency Room copays.
• All HMO plans will have a specialist copay.
• Durable Medical Equipment (DME)—Increase co-insurance from 20% to 50% (Exception: Co-insurance for special footwear and prosthetics remain unchanged.)

PPO Plans:

• The Emergency Room copay for all PPO plans increased to a $150 copay.
• Increase out-of-pocket maximum.
• Apply deductible to out-of-network office visits.

Elements Plans:

• Deductible and Out-of-Pocket Maximum:
  • Increase deductible and out-of-pocket maximum.
  • Separate in-network and out-of-network deductible, and out-of-pocket maximum.
  • Apply deductible to the out-of-pocket maximum.
  • Family maximum a flat dollar family maximum.
  • Deductible will apply to the following services (previously waived):
    • Out-of-network office visits
    • In-network and out-of-network Lab/X-ray
    • Out-of-network preventive care
• Infertility:
  • Additional $500 deductible will now apply to infertility services. It will not apply to out-of-pocket maximum and will continue to be required after the out-of-pocket is met.
• Specialty Drug Program:
  • Specialty drugs provided by a provider must be obtained through the Specialty Pharmacy Program.
• Behavioral Health Preservice Review:
  • Elements, BeneFitsPreferred, and Plus (except Basic)
  • Behavioral health out-patient visits require a preservice review after the twelfth visit.

To get details on the new Elements Hospital plan design, please contact us, your local LISI sales team.

Saver HMO Plans:

• Deductible replaced by predictable copays.
• In-patient admissions now subject to a per day copay, up to 3 days.
• Out-patient surgery now subject to a flat dollar copay.
• All other out-patient services now subject to a copay equal to the specialist copay.
• Specialist copay added to all plans.
• Out-of-pocket maximum increased.
• Pharmacy copays increased.

To get details on the new Elements Hospital plan design, please contact us, your local LISI sales team.

Pharmacy Plans

• Drug Tier Definition—Pharmacy drugs are now defined as:
  • Tier 1—Lowest copay; applies to most generics.
  • Tier 2—Medium copay; applies to most formulary.
  • Tier 3—Highest copay; applies to most non-formulary.
  • Tier 4—Coinsurance copay; applies to Specialty drugs and includes all forms of administration (self-injectable, oral, and inhaled).
  • In the future, generics and brands may be placed in any tier, depending on the appropriateness of the drug.
  • New Formulary.
• Increased Copays changed to 10/30/50.
• Tier 4 copay maximum increased to 30%, up to $150.
• Preventive care—Coverage for flu/pneumonia vaccine at retail pharmacy.
• EPO—Change to four-tier pharmacy copays.

Plan Discontinuation

In an effort to streamline Anthem’s HMO portfolio, they are discontinuing and migrating members off the Select HMO plans.

Ninety-day discontinuation notices will merge with the Lumenos Plan Discontinuation schedule beginning with October 1, 2011 Renewals.

Important Dates

• July 11:RAF engines and rate guides are available on Anthem’s sites; rating are available through general agencies and quoting vendors.
• July 12:Online renewals are posted for October.
• July 13:Broker renewals for October will go out.
• July 15:A webinar will be offered to Anthem’s general agents.
• July 27:Group renewals for October will go out.
• August 1: Rating goes live on Anthem’s Web site.

Effective October 1, 2011, these new plans include:

• NEW BC Exclusive PPO plans — offers HMO-like benefits using the BlueCard PPO provider network for non-California employees.
• NEW Advantage Plus HMO plans – an additional option for Advantage HMO on the Select Plus HMO Network
• Lumenos HIA plans — available to Pooled business in addition to Non-Pooled.
• NEW Premier PPO plans to offer more choice.
• NEW pharmacy plans to complement certain medical plans in Pooled business. (Non-Pooled business continues to have a choice of pharmacy plans).

Some of their other changes include:

• Adjusted benefit structures to their HMO and PPO-type plans to make their plans more cost-effective.
• Simplified plan choices — to meet today’s needs.
• Logical product downgrade options.
• Demarketing of non-competitive, duplicative plans.
• Benefit changes — to maintain affordability and consistency between plans

Highlighted links are pdfs that show their HMO plans, PPO plans, CDHP plans and the RX plans that are effective October 1, 2011 And a Benefit Modification Grid that explains what benefit changes they are making to their plans.

As theye have demarketed some of their plans and have also renamed some, attached is a crosswalk brochure Quick Reference Guide illustrating the demarketed plans and corresponding suggested replacement plans, as well as the former and new plan names.

  U.S. health insurance carriers will have to justify big premium rate hikes effective September, 2011  under new rules issued by the U.S. Health and Human Service Department   Insurers will have to publicly post proposed rate increases for the small group and individual markets. Any increase of 10% or more will have to undergo review by independent experts at the state or federal level, the agency said.

These rules were signed into law last year under health care overhaul.  HHS Secretary Kathleen Sebelius said her department will provide greater scrutiny of health insurance premium rises at a time when insurers are demanding premium increases, even as they enjoy lower costs and huge profits.

“Even though insurers are seeing lower medical costs as people put off care and treatment in a recovering economy, insurance companies continue to raise their rates. Often these increases come without any explanation or justification,” she added.

Results of reviews will be posted on the HHS Website, and insurers will be required to post that information on their sites as well, she said.

While federal regulators cannot set health insurance rates, Sebelius said a growing number of states have this authority.  Sebelius said her agency was working closely with states to undertake the review process. HHS will take over in cases where a state does not take up the responsibility.

The 10% threshold will be replaced in September 2012 by a state-specific threshold that takes into account trends in a state’s health care market.

Steve Larsen, director of HHS’s Center for Consumer Information and Insurance Oversight, said the current rule applies only to the individual and small group market but that the agency was seeking comment on applying the rules to groups that purchase coverage through associations.

• February 18  a rate pass for new second quarter business. In addition, Blue Shield offered renewal date change options for your second and third quarter new and renewing groups.
• The second and third quarter renewing groups may choose between two specific medical contract/policy (“contract”) terms. New business has contract term choices as well.
• For the July 2011 rate cycle, your small group rates will increase, however, the average increases are lower than previous cycles with rate actions. Below are some highlights of this quarter’s rate increases¹ :

• Detailed rates can be found obtained by contacting Health Plans Online.
• By popular demand,  the RAF program is extended until December 15, 2011.
• There will be no new benefit changes to medical or specialty products for third quarter 2011.

For the latest information on our July 2011 rate cycle, please contact your Health Plans Online.

It’s important to understand what constitutes a “rescission” for federal health care reform, as opposed to another type of coverage termination. A rescission is broadly defined as a retroactive termination of a member’s coverage. There are some important exceptions from this broad definition. For example, termination of coverage because of nonpayment of premium or contribution (either by the group or the member) is not a rescission. It is not considered a “rescission” when the member’s coverage is retroactively canceled to the last paid-to date if the member pays no premiums or contribution for periods of time after termination of employment or eligibility. The member’s coverage can be retroactively canceled to the last paid-to date.

 If a group health plan or carrier is faced with a “rescission,” certain restrictions apply for plan years that start on or after September 23, 2010.   The federal health care reform law does not allow the plan or carrier to rescind coverage, except in cases of fraud or intentional misrepresentation of material fact as specified in the contract. Examples of this include intentional misrepresentations of marital status or dependent eligibility.  When a policy or coverage is rescinded due to intentional misrepresentation of material fact or fraud, the plan or issuer must:

o Provide notice of the rescission 30 days in advance

o When providing notice carriers must inform the group or member of the opportunity to appeal the determination to rescind (as outlined in regulations for the appeals provision)

For group health plans, group policyholders control otice of membership eligibility. Therefore, when a member is removed from coverage, a carrier must be notified by the group .

Today Blue Shield has an update for your impacted small group clients.

Second Quarter Renewing Clients – Changed Renewal Period

For small groups currently scheduled to renew in the second quarter of 2011 ONLY, Blue Shield is extending their current contract/policy term and changing their renewal period. Your second quarter renewing clients will receive an endorsement/amendment that will extend their 2010 contracts/policies from 12 months to 15 months, under the current contract rates. So this year, they will renew in the third quarter and not in the second quarter.

• Members will be able to add dependents in their original renewing month as well as the extended renewal month.
• At their original open enrollment, employees may add or cancel dependents (including adult age dependants), late enrollees may enroll and members would be able to cancel their coverage.
• Group level changes (including plan changes) will be deferred to their new open enrollment 7/1, 8/1, or 9/1.  Members will be able to change plans at this time.

 The renewal contract/policy that is offered to these groups in 2011 will be for a term of 9 months, returning them to their original renewal month in 2012. However, the group may elect to receive a 12 month renewal contract/policy in 2011 and have their renewal month change permanently to the third quarter. If your clients would like to opt for this, please contact RBG who will notify Blue Shield of your clients’ election prior to their 2011 renewal date.

 Third Quarter Renewing Clients – Renewal Period

Small groups that already have a renewal date in the third quarter of 2011 will be offered a 12 month contract/policy. However, in 2011 ONLY, third quarter renewing groups may elect to receive a 9 month contract/policy and have their renewal month change permanently to the second quarter in 2012. Groups must notify Blue Shield of their election for a 9 month contract/policy prior to their 2011 renewal date. 

Second and Third Quarter New Business – Renewal Periods

New small group clients with effective dates in the second and third quarter of 2011 can receive a standard 12-month contract/policy. However, new second quarter accounts may elect to receive a one-time 15-month contract in 2011 only, and new third quarter accounts may elect to receive a one-time 9- month contract in 2011 only. New second and third quarter accounts must affirmatively select their preferred 2011 contract/policy period. Please contact your RBG representative who can provide you with the contract/policy term election form when it’s available.

Groups with Vision Coverage

Please note that groups with Vision Standard, Vision Plus, or Vision Deluxe plans have an initial contract term of 24 months.

Small business clients will be able to offer a selection of full network and tailored network plans to their employees.

1. Pick one or more of four new full network HMO plans. These plans were  modeled after those most favored by Health Net’s small business groups.  The chart below shows a summary of the difference in benefits.

2.      Once you’ve selected the full network HMO plan(s), you can bundle them with either the Silver Choice or Bronze Choice portfolio.

These plans are now available for quoting. For more details on the new plan designs, click on the PDFs below.

More Standard and Value Designs
Health Net is also expanding their Standard and Value plan collections with more coverage/cost combinations for today’s small business owner.

• Standard PPO Plans: four new choices
• HMO and EOA: four more of each with choice of network
• Value PPO Plans: four new choices
• New $50 copayment plan in either an HMO or EOA

HRA Plan Benefit Enhancement
Also new for May 1, 2011, Health Net is enhancing their HRA plans. Members now have benefit coverage for in-network doctor visits at a set 50% coinsurance after their deductible is met.

New, Lower-cost PPO Dental Plans
Three of them to be exact. Healthy teeth are important, and so is making it easy and affordable for employers to provide dental coverage for their employees. For example, the Essential Value plan delivers savings by including endodontics, periodontics and major oral surgery under major benefits. Plus, all of the new plans include health promoting features like extra services for pregnant women.

Rates are effective May 1, 2011 through July 15, 2011 effective dates.

 This document is not intended to be authoritative, and its accuracy is not guaranteed. It is believed to be correct at the time of its printing. Any questions about official interpretations of the law should be directed to legal counsel.

They provide the  self insured employer HSA or HRA plans down to 2 lives.  They can cover voluntary groups as long as there is 100% participation and employer sponsored groups with as little as 50% of the employee only costs paid by the employer.  For groups with less than 5 employees, 100% of the employees not covered elsewhere need to be included.  For groups of 6 to 10 employees 100% less one of the employees not covered elsewhere need to be included.  For groups with 10 or more employees 75% of the employees covered elsewhere need to be included. 

They offer medical claims administration, TPA functions, pharmacy, dental and vision, stop loss reimsurance COBRA administration, Health Coaching and Wellness programs designed to reduce claim expenses.

They can provide carve out plans for specific classes of employees, such as management only plans.

For more information please contact Gary Whiddon at gary.whiddon@healthplansonline.com.

 *Provided under a separate policy, certificate or contract of insurance (for insured plans)

 * Is otherwise not an integral part of the health care plan.
 For dental or vision benefits to be considered not an integral part of the plan (whether insured or self-insured), participants must have a right not to  receive the coverage and, if they do elect to receive the coverage, must pay
an additional premium  Accordingly, if a plan provides its dental or vision benefits pursuant to a
separate election by a participant and the plan charges even a nominal employee contribution toward the coverage, the dental or vision benefits would constitute excepted benefits, and the PPACA group health plan mandates and insurance market reform provisions would not apply to that coverage.

To put this in “plain english”  If the dental and vision plans are provided by a separate carrier than the medical and if an employee can make a separate election and premium payment for the dental and vision without having to have these benefits mirror the medical,  then the carrier does not have to offer dependent benefits to age 26.  Many dental and vison carriers are offering to continue benefits to age 26 as a courtesy, please check with the carrier to determine their position.

EmployeeElect Total
PPO 2.1 %
HMO 2.0 %
CDHP 8.2 %

EmployeeChoice – 7.3%
BeneFits – 4.4%
Total – 3.3 %

The Rate increases for the 51-99 EmployeeElect portfolio is identical to Small Group for April.  However, the TOTAL rate for these plans will vary slightly.
*These rate adjustments are averages and will vary by plan and region.

The Increases will be as follows: 

   The HMO Plans will receive an average increase of 2.0%
   The PPO Premier Plans will receive an average increase of 1%
   The PPO CopayPlans will receive an average increase of 1.7%
   The Solution PPO Plans will receive an average increase of 3.5%
   The GenRxPPO Plans will receive an average increase of 3.3%
   The Elements Hospital PPO Plans will receive an average increase of 3.8%
   The EPO Plans will receive an average increase of 1.0%
   The LumenosH.S.A. 100% Plans will receive an average increase of 9.5%
   The LumenosH.S.A. 80% Plans will receive an average increase of 7.6%
   The LumenosHIA+Plans will receive an average increase of 5%

The April, May & June 2011 renewal increase on EmployeeElect plans will average 13.1%.

…………………………………………………………………………………………………………………………………………………………………………………………

New PPO Plans added April 2011

Los Angeles County: no rate increase for HMO; 1.2% for PPO/HSA

Orange County: no rate increase for HMO; 1% for PPO/HSA

San Diego County: no rate increase for HMO; 3% for PPO/HSA

For renewing customers, the average statewide rate increase is approximately 7% for HMO and 13% for PPO. 

UHC introduced a new plan, Choice Plus Balanced Value 40/5000/70% (Plan Code J3-U) which comes with per-occurrence deductibles of $500 for outpatient surgery and $1,000 for inpatient hospital services. In addition, UHC are providing Substance Use Disorder supplemental coverage, offered with our HMO plans through an arrangement with U.S. Behavioral Health Plan.

See the Small Business 2-50 Product Catalog and Rate Guide for more details.

Employers will need to submit written confirmation about their contribution levels in order to maintain grandfathered status of their plan(s).  The written confirmation at each renewal will need to state that their contribution levels have not dropped by more than 5% since March 23, 2010. 

In the next few weeks, Blue Shield will provide their groups with an attestation letter. The attestation letter will be sent via mail, then the employer will need to complete it and fax back to Blue Shield. Their contracts will also be modified to state that employers must notify Blue Shield  if they plan to reduce their contribution levels. An attestation letter will also be sent to grandfathered groups that have already renewed with Blue Shield, as they continue to incorporate HHS guidance.  Grandfathered custom large group plans attest to this requirement at renewal and will not be sent the attestation letter.

Another responsibility focuses on W-2 reporting – which will be optional for 2011.  On October 12, the IRS issued a notice that makes benefits value reporting by employers optional for the 2011 tax year. (Note – this will be the W-2 issued in January of 2012 for the tax year of 2011.)

The ACA W-2 mandate requires that employers report to their employees the dollar value of their health coverage under employer-sponsored health plans. The Treasury Department and IRS have decided to make this an option for 2011 – giving employers more time to make payroll system changes and better prepare for and communicate the W-2 mandate.

We will, of course, provide you with updates as soon as they become available.

For more information please visit the Blue Shield of California website at https://www.blueshieldca.com/producer/news/health-reform/

The ID theft service assigns a fraud resolution specialist to members for an entire year to work closely with creditors, collection companies, collection law firms and credit reporting agencies in the event of an identity theft.

January 2010 – 4.0%
April 2010 – 4.7%
July 2010 – 1.9%
October 2010 – 2.8%

Renewal Increases:  

The January through March renewal increases will vary greatly due to the rating changes Anthem Blue Cross has gone through in the past year. We have had a large variance by product and region, however, we are pleased to announce an average renewal increase for these three months of 14.5%.   

EmployeeElect Total   Total – 4.7 %  

The PPO increases will be as follows

• Premier Plans will receive an average increase of 3.5% 
• PPO COPAY Plans will receive an average increase of 3.5%
• Solution PPO Plans will receive an average increase of 4.4%
• GenRx Plans will receive an average increase of 4.6%
• Elements Hospital Plans will receive an average increase of 5.0%
• EPO Plans will receive an average increase of 4.0%

The Lumenos HSA & HIA plan increases will be as follows

• HSA 100% plans will receive an average increase of 8.5% 
• HSA 80% plans will receive an average increase of 8%
• HIA+ plans will receive an average increase of 8%

 The HMO increases will be as follows

• All HMO plan families will receive an average increase of 3.5%

Definition of a “Wrap Plan”

A “wrap plan” includes any employer-sponsored plan, which is:

(1) Paid for or funded in whole or in part by the employer and/or the employee;

(2) (a) provides reimbursement for health plan deductibles, copayments, coinsurance, or medical expenses, or (b) provides for the payment of set amounts in the event of hospitalization.

Examples include: an employer-funded flexible spending account (FSA), a health reimbursement account (HRA), self-funding of the deductible, an IRS Section 105 plan, a medical expense reimbursement plan (MERP), or a hospital confinement policy. As defined herein, a wrap plan does not include a health savings account (HSA) or employee-funded general purpose flexible spending account (FSA).

CARRIER “WRAP GUIDELINES 

Aetna

Only allows the following to be wrapped:

• HMO Deductible plan
• MC HRA 3000

For all other Aetna MC plans, including the HRA 5000 and the MC 10,000 plans, the only funding allowed is through Aetna’s HealthFund HRA. The maximum amount of the deductible the employer can contribute is 50%

NOTE: existing business currently funding through a qualified HRA other than Aetna HealthFund can continue to do so provided no plan changes are made. If plan changes are made, the HRA administration will need to transition to Aetna HealthFund HRA

Blue Shield

Only allows the following plans to be wrapped:

• Shield Savings Plan 2250/4500
• Shield Savings 1800/3600
• Shield Spectrum 3000

No rules to how much of the deductible is funded 

HealthNet

Only allows the following plans to be wrapped:

• HRA 3000
• HRA 5000

No rules to how much of the deductible is funded  

UHC

Only allows the following plans to be wrapped:

• Definity HRA 1500/80%
• Definity HRA 2000/70%
• Definity HRA 2500/80%
• Definity HRA 3000/70%

May use United HealthCare or another HRA administration company

The maximum amount of the deductible the employer can contribute is 50% 

Sharp

No plans at this time are HRA compatible and/or allow HRA self fund wrapping

But I digress.  I used to think that the only benefit to dental insurance is the discounts provided by either the access to the PPO  network  or by the selection of an HMO dentist.  This still is true, the discounts are worthwhile.  I now know that the $50 or so dollars I spend each month for dental coverage is far less that the amount I would have to pay on the full charges for the dental care I am now in process of receiving.  Since I still have my wisdom teeth (pun intentional), I will illustrate how having dental insurance will save me money on the bridge now being made to replace the teeth pulled or ground down yesterday. 

Monthy Cost of Dental Insurance $50

Annual Cost of Dental Insurance $600

Maximum Annaul Benefit $1,500

Full Charge for Bridge $1,500

PPO Discounted Charge $1,200

50% Patient Responsiblity (my cost) $600

The amount I will have to pay for the bridge is the same amount I will pay for my dental coverage for this year.  If I didn’t have the coverage I would be reponsible for the full cost of the bridge, or $1,500.  Almost as painful as the abscess.

So to answer the question, yes I do think dental insurance is important.  I think people dont realize the sense of having either dental insurance or auto insurance – both are considered as useless until something goes wrong. 

Yes I am feeling better now.  I am grateful I have insurance – and the pain pills!

The research shows the 2011 projected trend rates for preferred provider organizations (PPOs)/point-of-service (POS) plans are expected to hit 10.6%, compared to 10.5% in 2010.

Please refer to the stuudy for details.

Effective 10/1! Health Net has made the following changes: 

• Stanislaus County – Silver rates will go from a 15% discount to a 25% discount
• HSA 4000 rates will be lowered 10% statewide
• HSA 4500 rates will be lowered 15% statewide
• PPO 40-V rates will be lowered 15% in Los Angeles, Inland Empire, and Orange counties (rating regions 5,6, and
• HRA rates will be lowered 10% statewide
• Salud HMO rates will be lowered 5%
• PPO plan rates in Los Angeles County (rating region will be lowered 8% (this excludes PPO 40-V, HSA 4000, and HSA 4500 whose rates will drop 10-15%) 

Effective 11/1! Health Net is making the following area changes:  

• El Dorado PPO (split between rating regions 1 and 2 – El Dorado and Marin, Merced, Nevada, etc.) will move to rating region 9 – Alameda, Fresno and Santa Clara counties
• Marin PPO (rating region 2 ) will move to rating region 7 – San Diego and Imperial counties
• Contra Costa, Placer and Sacramento PPO (rating region 3) will move to rating region 9
• Yolo HMO and PPO (rating region 2) will move to rating region 9
• Fresno (rating region 9) and Tulare (rating region 1) HMO will move to rating region 7 – San Diego
• Santa Cruz Silver Network (once created) rates will be discounted 25% off the full network

SIC 10% Discount

 PPO MEDICAL RATING REGIONS 

Region 1          Includes the following El Dorado ZIP codes: 95613-14, 95619, 95623, 95629, 95633-36, 95643, 95651, 95656, 95664, 95684, 95709, 95720-21, 95726-27, 95735, 96142, 96150-58 only, and Amador, Butte, Calaveras, Colusa, Glenn, Humboldt, Lake Mendocino, Monterey, Napa, Plumas, Shasta, Sierra, Sutter, Tehama, Tulare, Tuolumne and Yuba counties 

Region 2          Includes the following El Dorado ZIP codes: 95667, 95672, 95682 and 95762 only, and Marin, Mariposa, Merced, Nevada, San Benito, San Joaquin, Santa Cruz, Solano, Sonoma, Stanislaus and Yolo counties 

Region 3          Contra Costa, Kings, Madera, Placer, Sacramento, San Francisco and San Mateo counties 

Region 4          Kern, Santa Barbara and Ventura counties 

Region 5          Includes the Los Angeles ZIP codes beginning with 906-912, 915, 917, 918, and 935 only, Riverside and San Bernardino counties 

Region 6          Orange and San Luis Obispo counties 

Region 7          San Diego and Imperial counties 

Region 8          Includes the Los Angeles ZIP codes beginning with 900-905, 913-914 and 916 only 

Region 9          Alameda, Fresno and Santa Clara counties 

HMO MEDICAL RATING REGIONS 

Region 1          Includes the following El Dorado ZIP codes: 95613-14, 95619, 95623, 95629, 95633-36, 95643, 95651, 95656, 95664, 95684, 95709, 95720-21, 95726-27, 95735, 96142, 96150-58 only, Napa and Tulare counties 

Region 2          Includes the following El Dorado ZIP codes: 95667, 95672, 95682 and 95762 only, and Marin, Merced, Nevada, San Joaquin, Santa Cruz, Solano, Sonoma, Stanislaus and Yolo counties 

Region 3          Contra Costa, Kings, Madera, Placer, Sacramento, San Francisco and San Mateo counties 

Region 4          Santa Barbara and Ventura counties 

Region 5          Includes the Los Angeles ZIP codes beginning with 906-912, 915, 917, 918, and 935 only, Riverside and San Bernardino counties 

Region 6          Kern and Orange counties 

Region 7          San Diego

Region 8          Includes the Los Angeles ZIP codes beginning with 900-905, 913-914 and 916 only

Region 9          Alameda, Fresno and Santa Clara counties This document is not intended to be authoritative, and its accuracy is not guaranteed. It is believed to be correct at the time of its printing. Any questions about official interpretations of the law should be directed to legal counsel.

Just because a company “says” they lead the industry, doesn’t make it true, but when other Independent Organizations say that Assurant Employee Benefits . . . it is easy to understand they earned it! 

• is “Significantly above the Industry Average for timeliness” (JHA Disability Broker Study, 2009)
• is “A Model Carrier for the establishment of an online claims management system that enables us to better serve claimants”  (Celent, 2008)
• has a Dental Claims Center that is “Recognized as a ‘Center of Excellence’ …an award that goes to the top 10 Percent of 20,000 call centers through measurements of efficiency and effectiveness” (Purdue University, 2006)
•  ”Among True Group Carriers, AEB ranked #1 in Overall Satisfaction…in Providing Service that exceeds Expectations…In being Easy to do Business with…and in Percentage of Policyholders willing to recommend us” (LIMRA Plan Administrator Satisfaction Study, 2009)
• is Significantly Higher than Average in Overall Experience”  (JHA Disability Broker Study, 2009)

If you have a preexisting condition and can’t qualify for the high-risk pools, it’s a smart idea to at least check out the plans available within the private insurance market. “Don’t assume if one insurer rejects you that they all will,” says Anthony Wright, executive director of Health Access California, a statewide advocacy group.   By being a smart consumer you can improve your changes of obtaining coverage. Below are suggestions that we hope will help you in finding individual coverage:

Eligibility Laws
If you’ve exhausted your  COBRA and or CAL COBRA benefits available after leaving a job, federal law guarantees you a HIPAA policy from private insurers if you apply for one within 63 days from loss of other coverage.  Please make sure to retain a copy of the prior carrier’s “Certificate of Creditable Coverage” as proof that you did have coverage and that the loss of coverage occurred within 63 days of the application date.

Underwriting

In California carriers can review your health history, age and gender in order to determine the premium to be charged if you have a history of certain medical conditions.    The carriers are looking for those applicants that may potentially charge a large amount in claims costs.   The carriers also subscribe to a service that tracks your prescription drug records, the MIB Group.  You can request a copy of your 5 year usage history at http://www.mib.com/html/request_your_record.html.

Carefully answer the application

In order to determine the premium to be charged, the carrier’s application will ask many questions about your health.  Please remember to fully answer only the question asked.  Underwriters are looking to see if a medical situation has been resolved, or there are upcoming charges or procedures that may indicate a large expense.  Remember that omitting information may actually cause the coverage to be rescinded.  Sometimes the carriers will schedule a telephone interview in order to gain a better understanding of your medical history, so it is best if you have a copy of your medical records with you during the call, so you don’t have to try to remember all the details, which may be a costly mistake.

Manage your health

Of course it is always best for you to try to maintain optimum health, not only for obtaining health insurance, but to maintain your quality of life.  If a medication is working don’t change it unless there is a generic available.  Lose weight, exercise. Commit to a healthy lifestyle.  

Ask your medical provider to review your records and correct any inaccuracies and update your health history.  Not only will this effect a health insurance application, it is important to have all records be accurate for medical and legal reasons.

Work with a knowledgeable agent

The current insurance atmosphere is in a state of flux, with many changes to happen over the next few years.  Talk to someone in the field for help.  You can contact the National Assn. of Health Underwriters’ website, http://www.nahu.org or you can contact our office at (888) 474-6627   for assistance with the application process.

Plan participants will submit their park receipts directly to SeeChange Health for reimbursement. California State Parks boasts 278 parks across 1.4 million acres.

Plan participants can also receive up to $400 when they complete a personalized Health Action Plan, such as having an annual check-up, completing a health questionnaire and participating in a biometric screening (basic lab tests).

In addition to the $400 reward, SeeChange Health members who select the new value-based insurance plans and complete their personalized Health Actions will enjoy richer benefits and will see a significant reduction in out-of-pockets medical costs.

Earlier this year, SeeChange Health successfully launched its value-based insurance plans in California, beginning with the Fresno area. The company recently expanded into Monterey, Santa Clara and San Benito counties. Over the upcoming months, SeeChange Health will have value-based insurance plans available in various locations throughout the state.

Please review information from the websites below and develop your own communication pieces to advise your employees of the changes.  Sample language, and other resources are available at http://www.dol.gov/ebsa/

Annual and lifetime limit changes: http://www.dol.gov/ebsa/lifetimelimitsmodelnotice.doc

Revised dependent eligibility for older kids: http://www.dol.gov/ebsa/dependentsmodelnotice.doc

Primary care physician designation and OB/GYN self referral change: http://www.dol.gov/ebsa/patientprotectionmodelnotice.doc

Please also contact our office at (888) 474-6627 for any assistance we can provide.

What does that have to do with overall physical health? Plenty.

Eye exams play a crucial role in supporting overall health because the eyes provide the only non-invasive and clear view of blood vessels without puncturing skin.  

Because optometrists can (and do) look at blood vessels during an eye exam, they can help identify symptoms of – and manage – a variety of conditions that might not otherwise be detected until there are other symptoms.

In particular, an eye doctor can detect signs of more than 30 chronic diseases by seeing changes in blood vessels, as well as representative brain cells in the optic nerve.

By examining the eyes, an optometrist can often detect symptoms of chronic conditions such as hypertension, high cholesterol and diabetes. Indeed, in some cases, an eye exam can lead to the detection of a diabetic condition up to seven years sooner than with standard testing.

The total average quarterly increase is 2.8%.

Please note that these rates are for Small Group only. The 51-99 EmployeeElect and Small Group mental health parity compliant plan rates will no longer match small group rates. This is due to Anthem Blue Cross’ compliance with the Mental Health Parity Act, effective July 1, 2010. 

Here are the breakdowns:

• EmployeeElect PPO plans will see a new business average increase of 2.0%
• EmployeeElect HMO plans will see a new business average increase of 1.5%
• EmployeeElect CDHP plans will see a new business average increase of 7.0%

• EmployeeChoice plans will see a new business average increase of 3.6%

• BeneFits plans will see a new business average increase of 1.2%

In addition, there will be no rate or benefit changes for Small Group Dental, Life and Vision products.

Important Healthcare Reform Benefit Changes

Anthem Blue Cross has updated their benefits to comply with federal and state requirements, including applicable provisions of the recently enacted federal healthcare reform laws.

The following benefits have been updated to comply with the law:

• Removal of Lifetime Maximum on PPO plans
• Removal of Annual Dollar Maximums
• Preventive Care will now be covered at 100%

Grandfather Status:

• Effective October 1, 2010, Anthem Blue Cross will be making all of their EmployeeElect plans eligible for Grandfather Status
• The EmployeeChoice and BeneFits portfolios, as well as the Indian Tribes plans, will not maintain Grandfather Status

Specialty Product Discounts:
Anthem Blue Cross has lowered the rates on their most popular Dental Blue Gold Plus 100-80 plan by 8.5% in April…combine that sale with $25,000 of Life and the group receives an additional 6% off the rate for a total savings of 14.5%.

 And don’t forget the 1% RAF savings when a group buys at least $25,000 of Life coverage (down to a .90 RAF). In many cases, the 1% RAF savings can cover the entire cost of the life premium.

RAF Promotion Update:
Anthem Blue Cross is continuing with their current RAF promotion program through December 15th effective dates:

Groups with 6 or more enrolling medical subsribers with a renewal of 1.06 or less (with their current carrier) will receive an automatic .90 RAF.

There is one notable change for PEO groups:

Anthem Blue Cross will include PEO groups with 15 or more enrolling medical subscribers in the fourth quarter (assuming they meet all other eligibility requirements.)

For taxable years beginning after December 31, 2010, employers will be required to calculate and report the aggregate cost of applicable employer-sponsored health insurance coverage on employees’ Form W2s. 1 This new reporting requirement applies for employees’ tax years beginning after December 31, 2010. Because employees are entitled to request their Form W2 early if they terminate employment during the year, payroll systems need to be updated for this change by January 2011.

While most W2s for tax year 2011 will be issued in January 2012, W2s reflecting the new health insurance information must be available no later than February 1, 2011 for any terminating employee. It is important to note that the aggregate cost of an employee’s health benefits will not be included in the employee’s taxable income. The W2 reporting will be a way to track coverage values for the 40% excise tax (starting in 2018) on “high cost” employer based medical coverage above certain thresholds (the so called “Cadillac plan tax”) The coverage costs (whether under an insured or self insured plan) that must be reported under the new requirement include:

• Medical plans

• Prescription drug plans

• Dental and vision plans, unless they are “stand alone” plans (i.e., an employee may elect only dental or only vision and is not required to also enroll in medical coverage)

• Executive physicals

• Onsite clinics if they provide more than de minimis care (The term de minimis means (as provided by IRC Sec. 132(e)(1)) any property or service, the value of which is (after taking into account the frequency with which similar fringe benefits are provided by the employer to the employer’s employees) so small as to make accounting for it unreasonable or administratively impracticable. In other instances where the IRS was interpreting whether a medical clinic provided de minimis benefits, an on-site nurse who provided emergency services was considered a de minimis benefit, while a clinic at a hospital that provided full scale medical treatment was not considered de minimis).

• Medicare supplemental policies

• Employee assistance programs

If an employee enrolls in employer sponsored health insurance coverage under multiple plans, the aggregate value of all such health coverage (except certain benefits, discussed in section below) must be disclosed. For example, if an employee enrolls in employer-sponsored health insurance coverage under a major medical plan, a dental plan and a vision plan, the employer is required to report the total value of the combination of all of these health related insurance policies. For this purpose, employers generally use the same value for all similarly situated employees receiving the same category of coverage (such as single or family health insurance coverage).

Employers will not be required to provide a specific breakdown of the various types of coverage, but must only report an aggregate cost. For example, if an employee enrolls in medical, dental and prescription drug coverage, the employer only has to report the total value of all coverage, not a value for each individual benefit.

Benefits Exempt from Form W2 Reporting Requirements

The following employer provided benefits are not required to be reported on Form W2 under the new health care law:

• Long term care, accident or disability income benefits

• Specific disease or illness policies (such as cancer policies), and hospital (or other) indemnity insurance

policies where the full premium is paid by the employee on an after  tax basis

• Archer MSA or HSA contributions of the employee or the employee’s spouse

• Salary reduction contributions to a Health FSA

To determine the value of health insurance coverage, the employer will calculate the applicable premiums for the taxable year for such health coverage for the employee under the rules for COBRA continuation coverage under IRC Sec. 4980B(f)(4) (and accompanying Treasury regulations). The value that the employer is required to report is the aggregate premium calculated under the COBRA rules, not the portion of the premium that the employee has to pay. If the employer’s plan provides for the same COBRA continuation coverage premium for both individual coverage and family coverage, the employer plan would be required to calculate separate individual and family premiums and the employer would report the value of the coverage the employee received. For example, if one employee received family coverage, the employer would report the premium amount for family coverage for that employee. For another employee that receives individual coverage, the employer would report the premium amount for individual coverage.

This information is for educational purposes only.  Please refer to your tax advisor for additional infirmormation or guidance.

There are four levels of benefits available with different out of pocket expense choices.  The  Bronze tier plans will cover at least 60 percent of costs; silver plans 70 percent; gold plans 80 percent; and finally, rich platinum plans will cover at least 90 percent of costs. Catastrophic plans will be available to individuals who are exempt from the individual mandate because no affordable plan is available to them or they are under the age of 30.. To encourage health plans to participate fully in the exchange, each plan that wants to  become a qualified health plan must offer at least one plan in both the silver and gold benefit tiers.

While the federal Department of Health and Human Services (HHS) must provide guidance on how exchanges will be established, each state that chooses to institute an exchange must create two different exchanges that must  be operational by Jan. 1, 2014. The American Health Benefit Exchange will serve individuals, including those receiving premium reduction and cost-sharing subsidies. Small businesses will be able to purchase coverage through Small Business Health Options Program (SHOP) exchanges. Initially, only firms with up to 50 employees will be eligible to purchase coverage through SHOP exchanges. Beginning in 2016, they will be expanded to allow larger employers with up to 100 employees to participate. In parts of the country with separate and distinct insurance markets, states will be allowed to form geographically distinct sub-exchanges, or even partner with neighboring states to structure regional exchanges. States have also been granted the authority to merge their individual and small-group markets to enhance the size and strength of their risk pools.

An option that may is available to groups with 50-450 employees are Health Insurance Cooperatives.  Cooperatives are plans that are run by the member groups, with the claims paid by funds held by the member group.  Any funds left will be retained by the member group, instead of the carriers or government.  Wellness features and cost controls are included in coverage.  For more information on our Cooperative please call our office at (888) 474-6627.

Here’s the breakdown:

EmployeeElect HMO plans will see a new business average increase of 4.8%. 

• HMO 100% plans, Classic $20, Saver $20 and EmployeeChoice Saver HMO will receive an average increase of 5%.
• Classic $30 and $40 plans, Saver $30 and $40 plans and both Select HMO plans ($25 and $35) will receive an average increase of 4%.

 EmployeeElect PPO plans will see a new business average increase of 4.3%.

Premier PPO Plans:

• Premier PPO Copay $10/$20/$30 will receive an average increase of 4%.                       

PPO Copay Plans:

• PPO Copay $20/$30/$40 will receive an average increase of 4%.

PPO GenRx Plans:

• PPO Copay $25/$35 will receive an average increase of 4%.
• GenRx PPO $45 will receive an average increase of 2%.

 Solution PPO Plans:

• Solution 2500 and 3500 PPO will receive an average increase of 5%.
• Solution 5000 will receive an average increase of 4%.  

Elements Plans:

• Elements Hospital/Hospital Plus and Hospital Preferred will receive an average increase of 5%. 

EPO Plans:

• EPO plans will receive an average increase of 5%. 

EmployeeElect Lumenos HIA+ Plans will receive an average increase of 5%.

• Lumenos HIA+ 750 and Lumenos HIA+ 500 will receive an average increase of 5%. 

EmployeeElect Lumenos HSA Plans will see a new business average increase of 6.1%.

•  Lumenos HSA 2000/3000/5000 (100/70) will receive an average increase of 8%.
•  Lumenos HSA 1500 (80/50) will receive an average increase of 6%; Lumenos HSA 2500 (80/50) will receive an average increase of 3%; Lumenos HSA 3500 (80/50) will receive an average increase of 2%.

 EmployeeChoice plans will see a new business average increase of 7%. 

 BeneFits plans will  see a new business average increase of 4.7%.

Specialty April 2010 Rate Announcement

Anthem Blue Cross is lowering the rates on some of their most popular Dental Blue plans effective 4/1/10. 

• 10% reduction on Dental Blue Silver 100-80
• 11% reduction on Dental Blue Silver Plus 100-80
• 5% reduction on Dental Blue Gold 100-80
• 8.5% reduction on Dental Blue Gold Plus 100-80 

The Dental Blue Gold Plus 100-80 plan was their #1 selling Dental Blue plan in 2009. 

There will be a slight increase to the Dental Blue Platinum rates effective 4/1/10: 

• 2.5% increase on Dental Blue Platinum 100-80
• 5.6% increase on Dental Blue Platinum Plus 100-80

 There will be no changes to rates for their other dental plans on 4/1/10. 

Benefit change:

There is one benefit change for all Dental Blue members. Effective 4/1/10, pregnant women and diabetics will have access to a third cleaning per calendar year as deemed necessary by their dentist. The cleaning will not count towards their annual maximum benefit.  This document is not intended to be authoritative, and its accuracy is not guaranteed. It is believed to be correct at the time of its printing. Any questions about official interpretations of the law should be directed to legal counsel.

• EmployeeElect PPO plans will see a new business average increase of 1.4%
• EmployeeElect HMO plans will see a new business average increase of 1.1% 
• EmployeeElect CDHP plans will see a new business average increase of  5.2% 
• EmployeeChoice plans will see an average new business increase of 3.5% 
• BeneFits plans will see an average new business increase of 3.5%

 July – September Renewal Increases  

The July through September renewal increases will vary greatly due to the rating changes Anthem Blue Cross has gone through in the past year. There has been a large variance by product and region, however, the average annual renewal increase for groups renewing during these three months is approximately 10%.

 Ancillary product changes  

Dental:

Small Group dental rates will have no rate increases with the exception of the Indian Tribes who will receive a 5% trend increase affecting approximately 1,000 members.

 Vision:

The Blue View Vision and Vision Plus plans will be receiving either a rate pass or a $1.00 increase depending on the rating tier of each plan.   

 Vision benefit enhancements include: 

• Transition lens coverage for both children and adults. Children under age 19 may purchase transition lenses at no copay and adults may purchase them for a $75 copay
• Factory scratch coating on eyeglass lenses will now be standard coverage
• Tiered pricing for progressive lenses and anti-reflective coatings

 Life:

There will be no Life rate increases. This document is not intended to be authoritative, and its accuracy is not guaranteed. It is believed to be correct at the time of its printing. Any questions about official interpretations of the law should be directed to legal counsel.

Under the Patient Protection and Affordable Care Act (PPACA), the interim final rule requires group health plans and insurers to establish a comprehensive appeals process for patients who appeal decisions on coverage, services and claim payments. The interim final regulations apply to self-funded health plans, but not to grandfathered plans under the PPACA.

The Departments of Health and Human Services, Labor and the Treasury issued the interim final rule, which will take effect on Sept. 21, 2010.

Health plans and insurers that are subjected to the regulations are required to establish an internal appeals process that:

• Allows consumers to appeal when a health plan denies a claim for a covered service or rescinds coverage;

• Gives consumers detailed information about the grounds for the denial of claims or coverage;

• Requires plans to notify consumers about their right to appeal and instructs them on how to begin the appeals process;

• Ensures a full and fair review of the denial; and

• Provides consumers with an expedited appeals process in urgent cases.

Under the regulations, a patient can have the case reviewed by an independent reviewer  if the appeal is denied by the health plan or insurer. 

Most states currently have external appeals handled by an independent agency, however, governing the process varies from state to state.  The interim final rule encourages a federal standard for external reviews.  For external appeals, federal regulators are encouraging states to adopt the guidelines created by the National Association of Insurance Commissioners. The interim final rule calls for states to implement the NAIC standards before July 1, 2011. The NAIC rules require:

• External review of plan decisions to deny coverage for care based on medical necessity, appropriateness, health care setting, level of care, or effectiveness of a covered benefit.

• Clear information for consumers about their right to both internal and external appeals – both in the standard plan materials and at the time the company denies a claim.

• Expedited access to external review in some cases – including emergency situations or cases where their health plan did not follow the rules in the internal appeal.

• Health plans must pay the cost of the external appeal under State law, and States may not require consumers to pay more than a nominal fee.

• Review by an independent body assigned by the State. The State must also ensure that the reviewers meet certain standards, keep written records, and are not affected by conflicts of interest.

• Emergency processes for urgent claims, and a process for experimental or investigational treatment.

• Final decisions must be binding so, if the consumer wins, the health plan is expected to pay for the benefit that was previously denied.

Benefits and highlights of Kaiser Small Group plans in California

Call us (888) 474-6627 to get a free quote for your company

Plans for businesses with 2 to 50 employees, including the following: 

• Copayment plans
• Deductible plans
• Health savings account (HSA) plans
• Health reimbursement account (HRA) plans
• Point-of-service (POS) plans
• Preferred provider (PPO) plans

Get the plan rates and summary of plans for small business. 

• 2010 Summary of Plan Design
• 2010 Plan Rates for Small Business

Chiropractic & Acupuncture Rider 

Dental Benefits & Rates July 2010  

• Delta Dental PPO plans
• Delta Dental plans and rates—Bay Area
• Delta Dental plans and rates—Coachella Valley
• Delta Dental plans and rates—Kern County
• Delta Dental plans and rates—North Valley
• Delta Dental plans and rates—San Diego County
• Delta Dental plans and rates—Southern California

Health and productivity tools—build a wellness program step by step with the HealthWorks workbook, health tips, third-party research, promotional materials, and more.

The CDA states that $8.1 billion in long-term disability insurance claim payments was paid to disabled individuals in 2009.  This is a 2.9% increase over 2008 claim payments.

Most claims payers have found that the recession has not effected claims in any significant way. Most companies report little change in claim incidence or termination rates., however  insured lives declined by 2.2% from 2008 to 2009, reflecting job losses and layoffs in the broader economy and 1.2% fewer employers providing group long-term disability programs in 2009.  The economy has created an awareness on the part of employees to save and plan for a possible financial loss due to disability.

Currently, about 100 Million of the workforce do not have private disability insurance.  Of those with private insurance, there was a slight increase in claim payments in 2009 as compared to 2008.  The majority of claim payments were not work related, and the majority of claimants were over age 60, divided equally between men and women.  Fewer new claims were reported in 2009, reflecting the decrease in employed individuals.

For those individuals without private disability insurance, the Social Security Administration offers disability payments to those individuals who meet the strict criteria for claim payments. 7.8 million workers are currently receiving disability benefits under the SSDI program. This represents a 12% increase in the last decade.  SSDI benefits applications swelled in 2009: more workers are applying for SSDI claim payments than at any time in history. Applications for SSDI benefits rose to 2.8 million in 2009, 21.4% higher than the previous record in 2008. Over the past 10 years, the number of applications for SSDI benefits rose by 135% while the percentage of applications approved (the approval rate) dropped from 52% in 1999 to 35% in 2009. The upward trend in new claim applications is expected to continue in 2010.

SDI claim approval rate continues to decline: The SSDI percentage approval rate for applications has been trending downward since the late 90s. (The approval rate is the percentage of workers who apply for SSDI benefits whose initial claims are approved.) 35% of workers applying for SSDI disability claim payments in 2009 were approved; 10 years ago, the approval rate for workers applying for disability was 52%. Approval rates in the past 5 years (ranging between 35% and 39% during 2005–2009) represent the lowest five out of the past 15 years. The highest approval rate in the past 15 years was the 52% in 1998. The 15-year median approval rate is 44.6%.

The overall rate of disability is increasing among both men and women workers; in 1999, 3.6% of covered workers were receiving SSDI payments, while in 2009, 5.1% were receiving SSDI payments. The reasons cited for this increase include the aging of the U.S. workforce and the recent poor economic conditions. The rate of disability is rising faster for women than men, with a total of $110 billion paid in 2009, more than two times the amount paid in 1999.

2008 Social Security “Quick Facts”

• 52: this is the average age of a disabled worker receiving SSDI benefits.
• 2.8 million: this is the number of disabled workers in their 20s, 30s and 40s receiving SSDI benefits.
• 1.9 million: this is the number of disabled workers’ spouses and children who also received SSDI payments in 2008.
• $1,064: this is the average monthly SSDI benefit for all disabled workers.
• More than 90%: this is the amount of disabled workers receiving SSDI who do not qualify for workers’ compensation.
• 3 in 10: these are the chances of a young worker today becoming seriously disabled before reaching retirement.

According to a study conducted by a large health debit card provider, losing the tax-deductible status for OTC medicines will affect only a small percentage of employee medical FSA reimbursements.  It is suggested that participants continue to make their elections as conservatively as possible, and not drastically reduce their contributions

For more information contact the IRS at www.irs.gov

The new rules place new requirements on employers that have health plans. These plans (commonly referred to as “grandfathered” plans) were in operation when the president signed the new healthcare law on March 23.  Employers   have an incentive to retain this grandfather status because it exempts them from some of the healthcare law’s new mandates, as they were in existence before the reform laws were passed.    Employers with “grandfathered” plans will now be able to charge more for health benefits,  but with some limits.

 The rules limit how much companies could raise co-pays, deductibles and other employee contributions.  Co-pays, for example, could not be raised more than $5 or a percentage equal to 15 percentage points plus the rate of medical inflation, whichever is greater.  Employers also could not lower their contribution to their employees’ premiums by more than 5 %. Employers would also be able to adjust benefits, but not eliminate them entirely.  As an example, if a plan currently covers prescription drugs, it could not remove this coverage  although it could change the covered prescriptions available.

An employer can choose to give up grandfathered status and still offer health benefits, however the company’s health plan would then be considered a new plan and would be subject to new regulations. Such as covering  cancer screenings with no co-pays or other cost sharing.

There will be more changes coming  in 2014. Businesses then will have to offer plans with a minimum standard of health coverage, which will be outlined by the federal government. Grandfathered plans would not have to meet this standard.

Both new and grandfathered plans are already subject to some mandates starting next year, including a prohibition on lifetime benefit limits and a requirement that plans cover dependent children to age 26.

Beginning in 2014, small businesses will be able to shop for benefits for their employees in new insurance exchanges designed to improve coverage options.  Large employers could face penalties if they do not offer coverage to their employees.

The health reform law includes a mandatory requirement for oral health care benefits for children under the age of 21, referred to as the pediatric dental benefit.   Unfortunately, the health reform law does NOT include the elimination of annual and lifetime maximums and expansion of dependent child definition to age 26 as mandated for medical plans.

So for those with a stand-alone dental plan, it looks the health reform plan is, in effect, toothless.

 Employer based group health plans will remain in place and may include tax advantages to the employer. Any employer group with more than 50 employees will face a penalty beginning in 2014 for not offering health coverage to their employees. Offering or retaining coverage can actually foster employee loyalty and longevity, as well as decreased absenteeism and Workers’ Compensation costs.  Any changes to group health insurance system will be incremental and will not be fully completed until 2014. 

There really is no way to predict any possible cost increases as a result of the reform.  Employers will continue to enjoy tax advantages from offering coverage to employees, and it is predicted that there will be growth within the marketplace.  It is the role of the Insurance Broker or advisor to continue to educate employers on the changing healthcare system.  

Please contact us at 88VISIONARY (888-474-6627) for additional information or updates on health care reform.

 According to the study, 15% of employees at most companies account for 78% of all medical costs. By increasing participation in  preventive healthcare programs, companies can start decreasing the costs for employees.

According to a study by The American Journal of Health Promotion, employers who invested in worksite heath promotion saw a 28% reduction in sick leave absenteeism, 26% reduction in use of health care benefits and a 30% reduction in workers’ comp claims and disability management.

CNA offers competitive pricing for automotive repair shops and will write BOP, Auto and Workers’ Compensation.

Other key features with CNA for this class include:

• Mechanics Tools and Equipment Coverage
• Garagekeepers Coverage
• Hired and Non-Owned Liability with or without Physical Damage

Automotive repair classes include:

Travelers and OneBeacon will also write BOP and Auto for these classes.

Monoline Workers’ Compensation is available with the Hartford, ACE, AIG and Zurich.

• July 2009 – 0%

• October 2009 – 0% or slight decrease  

• January 2010 – 4.0%

• April 2010 – 4.7% 

July 2010 “Employee Elect”  

• PPO 1.4%  
• HMO 1.1%  
• CDHP 5.2%  

EmployeeChoiceTotal 3.5%  

BeneFitsTotal 3.5%  

Total Average Quarterly Increase: 1.9% 

There will be no benefit changes to current Small Group Medical Plans.

*These rate adjustments are averages and will vary by plan and region. 

Most Qualified High Deductible Health Plans (QHDP) eligible for Health Savings Accounts (HSA) do not have the separate (embedded) individual deductible per person like conventional PPO plans.  Employees who just cover themselves are not affected by “aggregate” family deductibles, however those who cover any dependents should take a close look whether their health plan will require their family to meet the full family deductible before benefits are payable.  When given a choice, “embedded” deductibles provide better coverage for those covering dependents assuming all other benefits are the same.  Below is a list of California small group HSA compatible plans identifying whether they have embedded or aggregate deductibles.  I hope this helps!

Effective May 1, 2010

Definitions:
Embedded Deductible: Each covered family member only needs to satisfy his or her individual deductible, not the entire family deductible, prior to receiving plan benefits. 

Aggregate Deductible: For Family coverage, the entire Family Annual Deductible must be met before co- pay or coinsurance is applied for any individual family member.

Aetna
MC HDHP $2000 80/50 - aggregate
MC HDHP $2500 80/50 - embedded
MC HDHP $3000 100/50 - embedded
MC HDHP $3300 80/50 - embedded

Blue Shield
Shield Savings Plan 1800/3600 - aggregate
Shield Savings Plan 2000/4000 - aggregate
Shield Savings QS 2000/4000 - aggregate
Shield Savings Plan 2250/4500 - aggregate
Shield Savings Plan 2500 - embedded
Shield Savings Plan 3000/6000 - aggregate
Shield Savings QS 3000/6000 - aggregate  
Shield Savings Plan 4800 - embedded
Shield Savings QS 4800 - embedded

HealthNet
Standard HSA 2000 - aggregate
Standard HSA 3000 - aggregate
Standard HSA 4000 - aggregate
Value HSA 1500 - aggregate
Value HSA 2500 - aggregate
Value HSA 3500 - aggregate
Value HSA 4500 - aggregate 

United Healthcare
Choice Plus Definity HSA 1500/80% Plan Z6-Q – aggregate
Choice Plus Definity HSA 2000/100% 5E-N – aggregate
Choice Plus Definity HSA 2000/80% Q3-M – aggregate
Choice Plus Definity HSA 3000/100% – 5E-O – aggregate
Choice Plus Definity HSA 3000/80% – 5E-L – aggregate
Choice Plus Definity HSA 4000/80% – 5E-M – aggregate
Rx 15/35/60 Plan - 0IV - Applies to all UHC HSA’s

Machine Shops

(SIC 359900)

Machine Shops, also called metal job shops, perform the machining of cold metal to the precise size and shape with or without assembly into more complex and customized products. 

There are over 22,000 machine shops nationwide with net sales over $26 billion for shipped products.

Operations involve cutting, drilling, punching, shaping, shearing, planing, grounding, machining, welding, heat treating and tooling materials into the necessary size and shape.  The cutting, bending, shaping or stamping of aluminum may also be involved.

Ineligible operations include:

• Machinery manufacturing, repair or re-building
• Foundries that do casting, molding, forging, or extrusion work

BOP. Auto and Workers’ Compensation are available with the Hartford, Travelers, Main Street America and Zurich.