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

• Lowered their health risks:  CDHP customers lowered their risk of developing or worsening a chronic condition. According to the study, when employers fully transitioned to offering only a CDHP option, individuals improved their health risk profile by 10 percent in the first year compared to customers in a traditional plan option.
• Reduced total medical costs:  CDHP medical cost trend was 16 percent lower than traditional plans during the first year. Over five years, cumulative cost savings averaged $9,700 per employee enrolled in a CDHP compared to employees who remained in a traditional health plan. Cost reductions were achieved without employers shifting out-of-pocket health expenses to their employees.
• Received higher levels of care:  CDHP customers had consistent or higher use of over 400 evidenced-based medical best practices (than their counterparts in traditional plans.  CDHP customers also sought preventive care, such as annual office visits and mammograms, more frequently than customers enrolled in a traditional plan.
• Were more engaged in health improvement: Through proper plan design plan and the use of incentives,  CDHP customers were more likely to have completed a health risk assessment and participated in their health coaching program than those enrolled in a traditional plan.
• Were more savvy consumers of health care:  CDHP customers enrolled in their pharmacy management program were more likely to choose generic medications and had 14 percent lower pharmacy costs compared to those in a traditional plan. In addition, CDHP customers used the emergency room at a 13 percent lower rate than individuals enrolled in HMO and PPO plans.
• More likely to compare cost and quality:  CDHP customers were twice as likely to use myCigna.com online cost and quality information to help them select a doctor or to review potential medical costs than customers enrolled in traditional plans.

“Each year the evidence increasingly shows that properly designed consumer-driven health plans can lower health risks, reduce medical costs and drive engagement,” said Cigna Chief Medical Officer, Dr. Alan Muney.

Please contact Gary Whiddon at Health Plans Online for more information on Consumer Directed Health Plans.  He can be reached at (888) 474-6627 or gary@hpo.biz.

 Now is the time to stay healthy with “FREE” preventive care services!

Preventive health care–including annual physical exams, screenings, and immunizations–is essential to good health. Yet many Americans don’t receive the regular preventive care they need, despite the fact that chronic diseases, which are responsible for 7 of 10 deaths among Americans each year and account for 75% of the country’s health care spending–are often preventable.

Why do so few Americans get the preventive care they need? Often, the reason is cost.

The Affordable Care Act (health care reform) attempts to address this problem by requiring all new group and individual health insurance plans as of September 23, 2010 to pay 100% of the costs for preventive care services ranked A and B by the U.S. Preventive Services Task Force (USPSTF) .

If your health plan qualifies, you can take advantage of a wide range of preventive care services to help you avoid illness and improve your health–at no cost to you, so long as you receive these services from a health care provider within your health plan’s network of doctors and hospitals.

You won’t have to pay a copayment at the office visit, and not a penny toward coinsurance or your deductible. Doctors and health care facilities continue to charge for these services. But now it’s the health insurance companies that pay the costs. Essentially, preventive care becomes ‘free’ for the policyholder, greatly increasing the incentive to take advantage of these services. The following lists outline the preventive care services covered by these rules for adults, women, and children.

Adults

Covered preventive services for adults include:

• Abdominal aortic aneurysm
• A one–time screening for men of specified ages who have ever smoked
• Colorectal cancer screening
• Depression screening for adults
• Type 2 diabetes screening
• Diet counseling for adults at higher risk for chronic disease 
• HIV screening for all adults at higher risk  
• Immunization vaccines for adults (recommendations vary):
• Hepatitis A
• Hepatitis B
• Herpes zoster
• Human papillomavirus
• Influenza (flu shot)
• Measles, mumps, rubella
• Meningococcal
• Pneumococcal
• Tetanus, diphtheria, pertussis
• Varicella
• Obesity screening and counseling for all adults
• Sexually transmitted infection (STI) prevention counseling for adults at higher risk 
• Tobacco use screening for all adults and cessation interventions for tobacco users 
• Syphilis screening for all adults at higher risk

Women

Women Covered preventive care services for women, including pregnant women, include:

• Anemia screening on a routine basis for pregnant women
• Bacteriuria urinary tract or other infection screening for pregnant women
• BRCA (breast cancer gene) counseling about genetic testing for women at higher risk
• Breast cancer mammography screenings every one to two years for women over 40
• Breast cancer chemoprevention counseling for women at higher risk
• Breastfeeding comprehensive support and counseling from trained providers, as well as access to breastfeeding supplies, for pregnant and nursing women*
• Cervical cancer screening for sexually active women
• Chlamydia infection screening for younger women and other women at higher risk
• Contraception : Food and Drug Administration–approved contraceptive methods, sterilization procedures, and patient education and counseling, not including abortifacient drugs*
• Domestic and interpersonal violence screening and counseling for all women*
• Folic acid supplements for women who may become pregnant
• Gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk of developing gestational diabetes*
• Gonorrhea screening for all women at higher risk
• Hepatitis B screening for pregnant women at their first prenatal visit
• Human immunodeficiency virus (HIV) screening and counseling for sexually active women*
• Human papillomavirus (HPV) DNA test : High–risk HPV DNA testing every three years for women age 30 or older* with normal cytology results
• Osteoporosis screening for women over 60, depending on risk factors
• Rh blood incompatibility screening for all pregnant women and follow–up testing for women at higher risk
• Tobacco use screening and interventions for all women, and expanded counseling for pregnant tobacco users
• Sexually transmitted infections (STI) counseling for sexually active women*
• Syphilis screening for all pregnant women or other women at increased risk
• Well–woman visits to obtain recommended preventive services for women under 65*

Note: Services marked with an asterisk (*) must be covered with no cost–sharing in plan years starting on or after August 1, 2012.

Children
Covered preventive care services for children include:

• Alcohol and drug use assessments for adolescents 
• Autism screening for children at 18 and 24 months 
• Behavioral assessments for children of all ages 
• Blood pressure screening for children 
• Cervical dysplasia screening for sexually active females 
• Congenital hypothyroidism screening for newborns 
• Depression screening for adolescents
• Developmental screening for children under age 3, and surveillance throughout childhood 
• Dyslipidemia screening for children at higher risk of lipid disorders 
• Fluoride chemoprevention supplements for children without fluoride in their water source 
• Gonorrhea preventive medication for the eyes of all newborns 
• Hearing screening for all newborns 
• Height, weight, and body mass index measurements for children 
• Hematocrit or hemoglobin screening for children 
• Hemoglobinopathies or sickle cell screening for newborns 
• HIV screening for adolescents at higher risk 
• Immunization vaccines for children from birth to age 18 (recommendations vary): o
• Diphtheria, tetanus, pertussis
• Haemophilus influenzae type B
• Hepatitis A
• Hepatitis B
• Human papillomavirus
• Inactivated poliovirus
• Influenza (flu shot)
• Measles, mumps, rubella
• Meningococcal
• Pneumococcal
• Rotavirus
• Varicella 
• Iron supplements for children ages 6 to 12 months at risk for anemia
• Lead screening for children at risk of exposure
• Medical history for all children throughout development
• Obesity screening and counseling
• Oral health risk assessment for young children
• Phenylketonuria (PKU) screening for this genetic disorder in newborns
• Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk
• Tuberculin testing for children at higher risk of tuberculosis
• Vision screening for all children

It’s important to keep in mind that while the health plan cannot charge you a copayment, deductible, or coinsurance when the primary purpose of the office visit is the recommended preventive care service and the service is NOT billed separately from the office visit, you may be required to share some of the costs if the preventive service is not the primary purpose of the office visit. And remember, preventive services are covered at 100% only when received from health care providers within the health plan’s network. For the most up–to–date list of covered preventive care services, please visit http://www.uspreventiveservicestaskforce.org

.

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.

 As an ERISA Plan Administrator (most private sector employers fall under ERISA law), you have the responsibility to comply with Federal Laws that govern your plan.  No matter who else you may hire to administer your plan, your Company is solely responsible to make sure things are done correctly.  As an employer offering benefits to your employees, there are many rules that you must comply with regarding the administration of employee benefit plans.  Below are some of the rules you must be careful to comply with in under law:

•  Make sure you define – in writing in an employee handbook- the definitions of eligible employees and dependents.  For example, do you only offer benefits to full time employees over 40 hours per week?  However you define eligibles, make sure you are consistent in benefits that you offer and monitor to make sure you remain consistent.   Make sure you also define leave policies and waiting periods as well.
• Make sure your plan complies with benefits mandate by state law and health care reforms.
• Benefit and eligibility information must be provided to eligible participants or be made available at their request.
• Make sure you file all necessary plan documents, such as 5500 reports.

Please remember that failure to follow the rules can be costly.  For example, the fine for failure to file the 5500 report is $1,000 PER DAY.

If we may be of any assistance to you or can help you organize a compliance process, please contact Gary Whiddon at (888)474-6627.

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.

• Health Savings Accounts (HSAs) .
• Medical Savings Accounts (MSAs)
• Flexible Spending Arrangements (FSAs) .
• Health Reimbursement Arrangements (HRAs)

On January 3, 2012, the IRS issued additional interim guidance on the W-2 reporting requirement that is part of health care reform. In this guidance, the IRS confirms that employers filing fewer than 250 W-2s are not required to report the value of health benefits. This guidance extends that relief until further guidance is issued.

Additionally, the release indicates that specialty coverage, if included with medical benefits, must be reported.

The guidance reaffirms that this is a reporting requirement only and does not impact employees’ taxable wages.

1. Employers may require that employees pass biometric screenings to receive discounts on their health insurance premiums. Those who don’t meet the necessary biometric levels would have to enroll in a wellness program and after achieving a healthy body mass index and other biometric numbers, would then be eligible for the discounts.

2. More employers may use the services of a health care advisor to teach employees how to make better treatment choices, find quality providers and make better use of their employers’ health management programs, thereby reducing health care costs.

3.Employers may begin to  use social media to reinforce healthy behaviors, such as  losing weight, exercising more and  becoming healthier.

4.In spite of the economic downturn, one-third of employers plan to increase their  spending on wellness programs  in order to reduce overall premium expenditures.

Our President, Gary Whiddon is well workplace certified from Welcoa University.  He would be happy to assist in the implementation of any employer wellness program.  Please call him at (888) 474-6627 x 116, or email him at gary@hpo.biz

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.

 Exemption for small employers. Employers filing fewer than 250 Forms W-2 for the preceding calendar year are not required to report the aggregate cost of coverage.

Stand-alone dental and vision plan reporting. The Notice clarifies that the standard for determining whether the cost of coverage under a dental plan or vision plan is included in the aggregate cost is the same standard for determining whether such coverage is an excepted benefit under HIPAA. Thus, certain stand-alone dental and vision plans may be exempt from the reporting requirement.

Excess reimbursement for highly compensated individuals. The reporting requirement does not apply to the cost of coverage includible in income under Section 105(h) of the Internal Revenue Code, or payments or reimbursements of health insurance premiums for a 2% shareholder-employee of an S corporation that is required to include the premium payments in gross income.

Coverage under employee assistance program or similar program. An employer that does not charge a premium for an EAP, wellness program or on-site medical clinic to COBRA-qualifying beneficiaries is not required to include the cost of such coverage in the aggregate reportable cost. For arrangements that are not subject to any federal continuation coverage requirements (such as church plans), the employer is not required to include the cost of such coverage on the Form W-2.

Optional reporting of exempted benefits. Employers may, for convenience, include in the aggregate reportable cost the cost of coverage that is not required to be included (e.g., cost of coverage under a Health Reimbursement Account, provided that certain conditions are satisfied.

Reporting non-applicable employer-sponsored coverage. Employers may use any reasonable method to determine the relative allocation of cost for benefit programs that make available both applicable employer-sponsored coverage (e.g., group health plans) and other coverage (e.g., long‐term disability programs).

Employee election changes after year-end. The aggregate reportable cost for a calendar year reported on a Form W-2 may be based on the information available to the employer as of December 31 of the calendar year, without regard to any election or notification made or provided in a subsequent calendar year that has a retroactive effect on a previous year’s coverage.

Payroll periods crossing two taxable years. The Notice provides employers with various options for reporting the aggregate reportable cost for a payroll period that spans two taxable years.

Hospital indemnity/specified disease insurance. Employers are required to include the cost of coverage in the aggregate reportable cost on Form W-2 if the employer makes any contribution to the cost of coverage that is excluded from the employee’s income, or if the employee purchases a policy on a pre-tax basis under a cafeteria plan. However, if the employer provides the opportunity for employees to purchase an independent, non-coordinated fixed indemnity policy and the employee pays the full amount of the premium with after-tax dollars, the cost of coverage provided under that policy is not required to be reported on Form W-2.

Third-party sick pay. The aggregate reportable cost is not required to be reported on a Form W-2 furnished by a third-party sick pay provider. However, a Form W-2 furnished by the employer to an employee must include the aggregate reportable cost, regardless of whether that Form W-2 includes sick pay, or whether a third-party sick pay provider isfurnishing a separate Form W-2 to report sick pay.

Plans that currently allow a health care FSA election of more than $2,500, must amend plan documents before Jan. 1, 2013, and change employee communications.

To simplify administration of this change, sponsors of non-calendar year plans may want to adopt the new limit as of the first day of the plan year rather than waiting until Jan. 1, 2013. For example, if the current plan year begins May 1 and ends April 30, the plan sponsor may:

• Communicate the change to employees.
• Amend their plan documents to implement the new $2,500 maximum election.
• Initiate  the changes to the contribution effective May 1, 2012, rather than wait until the mid-plan year in Jan. 1, 2013

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.

Happy Holidays to everyone.  May you and your family enjoy the best in 2012!!

In order to avoid the naughty list this season and possibly fit down the chimney, here are a few suggestions to avoid the tempting treats of the holidays:

1. Avoid all the candy, cakes and sweets that you may be sent.  instead, sample from the fruit basket or have a handful of almonds.

2. Limit the fattening meats and gravies on your holiday plate.  Why not have more vegetables instead?

3. Get up and move!  It is so hard to want to be outdoors in cold winter weather.  If you cant go outside, why not try a few laps around the office hallway or a few sit-ups at lunchtime?

4. Bring a healthy entree or salad to the next pot luck.  Your will be surprised how many people will really want to have something healthy as an alternative to all the heavy and fattening treats of the season.

5. When baking or cooking, try low fat or sugar alternatives such as Splenda or apple sauce instead of sugar or margarine instead of butter.

6. Try to de-stress and not expect so much of yourself.  It is so easy to fall off the healthy eating wagon when under stress.  Try yoga, walking or calling a friend instead of that cookie.

7. Don’t wait for a New Years resolution, don’t even make them! Just try your best to maintain a healthy diet and exercise program.  Even if you slip and don’t work out for a while or gobble down junk food during the season or the year, its important to try again.  Better to not maintain for two weeks than two years, right?

Beginning in 2011, insurers and HMOs must annually calculate their MLR and provide rebates to policyholders if their MLR (percent of premium revenue spent on claims/medical care) is less than 85 percent for large groups and 80 percent for small groups or individuals. The revised rules make important changes to the MLR calculation and rebate distribution requirements.

Rebate Distribution

To simplify the rebate distribution process for group insurance, the revised rules call for rebates to be paid to the group policyholder in the case of group plans sponsored by governmental entities and private employer-sponsored plans subject to ERISA.

At the same time HHS issued the revised regulations, the Department of Labor issued a Technical Release that describes how ERISA’s fiduciary rules respecting plan assets govern the distribution of rebates for employer-sponsored ERISA plans. Generally, employers are required to apply the proportion of the rebate attributable to employee contributions to the benefit of current plan participants either in the form of a cash payment or a reduction in future contributions toward the cost of coverage. Rebates can be paid to group policyholders of non-ERISA plans if the policyholder provides written assurance that the rebates will be used to benefit enrollees.

The revised regulations also clarified that consumers will not pay taxes on any rebates they receive.

Transparency

Insurers are required to provide individual policyholders and subscribers under group plans information about their MLR regardless of whether there is a rebate.

Mini-Med Plans

Special adjustments for limited medical (“mini-med”) plans with total annual benefit limits of $250,000 or less have been extended through 2014. The numerator will be multiplied by 2.0 in 2011, 1.75 in 2012, 1.5 in 2013 and 1.25 in 2014. Previously, this adjustment was available only for 2011.

Currently, experience for mini-med plans must be reported quarterly. For 2012, 2013 and 2014, mini-med experience will be reported annually.

Expatriate Plans

The final rule keeps the expatriate plan multiplier adjustment at 2.0 indefinitely in recognition of the higher administrative costs and special circumstances of international plans. The rule also changes the reporting period from quarterly to annually.

Quality Improvement Activities

For purposes of the MLR calculation, ICD-10 conversion costs related to improvements in coding of medical conditions of up to 0.3 percent of an insurer’s earned premium can be considered quality improvement activities in 2012 and 2013.

Community Benefit Expenditures

An issuer may deduct from earned premiums the higher of either the amount paid in state premium tax or actual community benefit expenditures up to the highest premium tax rate in the state.

HHS has solicited comments on the revised rules, particularly those regarding rebate distribution and quality improvement activities.

A plan may not, as a routine matter, approve significantly shorter stays for inpatient mental health and substance abuse treatment than it does for inpatient medical or surgical care, even if extensions of those stays are subject to review.

Plan sponsors should be aware of these interpretations of the rules not only in  regard to plan design, but with regard to their own (and their vendor’s) administrative practices.

All members

• Yearly preventive medicine visits (Wellness visits)
• All standard immunizations recommended by the American Committee on Immunization Practices

All members at an appropriate age or risk status

• Screening for colorectal cancer, elevated cholesterol and lipids
• Screening for certain sexually transmitted diseases and HIV
• Screening and counseling in a primary care setting for alcohol or substance abuse, tobacco use, obesity, diet and nutrition
• Screening for high blood pressure, diabetes and depression

Women’s health

Recently, the Department of Health and Human Services released new health plan coverage guidelines that will require health insurance plans to cover women?s preventive services without charging a copayment, coinsurance or a deductible effective for plans beginning or renewing Aug. 1, 2012, to now include:

• Well-woman visits
• Screening for gestational diabetes for all pregnant women
• Human papilloma virus DNA testing for all women 30 years and older
• Annual sexually transmitted infection counseling for all sexually active women
• Annual counseling and screening for HIV for all sexually active women
• FDA-approved contraception methods, sterilization procedures and contraceptive counseling
• Breastfeeding support, supplies, and counseling, including costs for renting breastfeeding equipment
• Domestic violence screening and counseling

The following guidelines were effective for plan years beginning on or after Sept. 23, 2010:

• Screening mammography and evaluation for genetic testing for BRCA breast cancer gene
• Screening for cervical cancer including Pap smears
• Screening for gonorrhea, Chlamydia, syphilis
• Screening pregnant women for anemia, iron deficiency, bacteriuria, hepatitis B virus, Rh incompatibility
• Promotion of and counseling for breast-feeding
• Osteoporosis screening (age 60 and older)
• Counseling women at high risk of breast cancer for chemoprevention

Men’s health

• Screening for prostate cancer for men (age 40 and older)
• Screening for abdominal aortic aneurysm in men (age 65-75)

Children

• Screening newborns for hearing, thyroid disease, phenylketonuria and sickle cell anemia
• Standard metabolic screening panel for inherited enzyme deficiency diseases
• Counseling for fluoride treatment
• Screening for major depressive disorders
• Vision screening
• Screening for developmental/autism screening
• Screening for lead and tuberculosis
• Counseling for obesity

In addition to these services, under the Preventive Benefit, UnitedHealthcare also provides screening using CT colonography, Prostate-Specific Antigen (PSA), and screening mammography without age limits.

Their final ruling could shape the outcome for Obama’s re-election as this decision to hear arguments in the spring sets up an election-year showdown over the White House’s main domestic policy achievement.

The justices announced they will hear an extraordinary five-and-a-half hours of arguments from lawyers on the constitutionality of a provision at the heart of the law and three other related questions about the act. The central provision in question is the requirement that individuals buy health insurance starting in 2014 or pay a penalty.

It is possible that whatever the Court decides, the debate may not end.  It may possibly take more time to determine if the final responsibility for health care lies with the individual or government.

Even if the court upholds the law, Republican leaders say “repeal and replace” remains their slogan. “Job-killing tax hikes on families and small businesses may well be constitutional — that doesn’t mean we would support them,” said Senate Republican Leader Mitch McConnell of Kentucky.

The 2010 health care overhaul law aims to extend insurance coverage to more than 30 million Americans, through an expansion of Medicaid, the requirement that individuals buy health insurance starting in 2014 or pay a penalty and other measures. The court’s ruling could decide the law’s fate, but the justices left themselves an opening to defer a decision if they choose, by requesting arguments on one lower court’s ruling that a decision must wait until 2015, when one of the law’s many deferred provisions takes effect.

The D.C. Circuit is now the second appeals panel to uphold the health reform law’s individual mandate. The law’s supporters are declaring victory because the opinion was written by a conservative judge, Laurence Silberman, who was nominated by former President Ronald Reagan. Silberman and Senior Judge Harry Edwards, who was nominated by former President Jimmy Carter, upheld a lower court ruling that the law was constitutional.  Judge Brett Kavanaugh, who was appointed by former President George W. Bush, dissented.

The D.C. Circuit Court is the fourth appeals panel to consider a lawsuit challenging the health reform law. The 6th Circuit upheld the law, the 11th Circuit struck the mandate and the 4th Circuit ruled that the Anti-Injunction Act which says Americans have to pay a tax before they can challenge it in court barred it from ruling on the mandate until at least 2014.

Part B pays for physician visits, hospital outpatient costs and certain other services.

Officials attributed the lower than expected premium increase to several factors, including lower-than-expected use of medical care and slower cost growth.

For more information please visit www.medicare.gov.

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.

Below are some suggestions to assist you and your employees in making the best decision(s) regarding plan choices at open enrollment:

• Allow employees adequate time to think about the choices and/or discuss the options with their family or providers.  One day or a weekend simply isn’t enough time.  Studies suggest that employees who are given three weeks to make a choice are 50% more likely to remain satisfied with their decision.
•  Hold open enrollment meetings as far in advance as possible to the plan or carrier change.
• Provide enough information regarding the plan choices available.  Research shows that employes can make an informed decision once they have an effective benefits education, with their personal questions addressed.  If at all possible provide printed information or access to information online.
•  Personalized benefit statements can also help an employee to determine the amount they spend on insurance, and if this needs to be adjusted in light of their health care needs.
•  Give employees the opportunity to ask personal or specific questions related to their health care needs.  Perhaps the enroller can remain on site to answer questions, or the employees can contact someone on their own time to ask questions.  Make someone available to your employees.

Our staff at HealthPlansOnline.com can assist you and your employees with health plan choices and enrollment.  Please contact us at (888) 474-6627.

Anthem Blue Cross of California has recently provided a checklist of key items employers may need to to make sure they are on target with Health Reform Rules.  This list can be found at:

http://www.makinghealthcarereformwork.com/healthcarereform/assets/library/681109304232_23771CAEENABC_HCR_Employer_2012_Checklist_SH_08_11.pdf

Please contact our office at (888) 474-6627 to verify what you may need to do as an employer to stay in compliance.

copyright Anthem 2011 used with permission.

U.S. health insurance, unlike other industrialized countries, is largely provided by employers. Although the latest Census found more Americans losing company-sponsored insurance, almost 170 million Americans were on employer-based plans in 2010.

Kaiser and the Health Research & Educational Trust surveyed 2,088 randomly selected public and private employers large and small earlier this year.

On average, employees are contributing 28%, or about $4,129, a year toward employer-sponsored family plans. That is 131% more than a decade ago.  Including employers’ contributions, the overall premium has increased 113% since 2001 to $15,073 a year.

Employees, especially those employed by smaller employers, continue to join high-deductible health plans. Thirty-one percent of covered employees this year have to pay at least $1,000 in single plans before coverage kicks in, up from 27% last year.

For more information on the survey please go to   http://ehbs.kff.org.

Since one of my favorite game shows is Jeopardy, it stands to reason that I just love quizzes.  Since I know that many of you also love Jeopardy, lets play round one with the only subject being COBRA.  You do not need to answer in the form of a question.

Q:. Can Continuants receive the same benefits they had while an active employee?

A: Continuees can have the the same benefits that are available to active workers. If an employer decides to change for active workers, then the new offerings must also be available to COBRA particpants.

Q: Can the COBRA spouse of a participamt continue on COBRA after divorce?

A: No.  If the husband was not on the active coverage, and he was added to COBRA after it started, then he is not eligible for a second qualifying event.

Q:  What are some common COBRA mistakes?

A:  They can include:

*Not sending the Initial Right Notice

*Not sending the Qualifying Event notice

*Not maintaining accurate archives

*Making a decision simply because it “feels right”

*Making exceptions

*Not maintaining an accurate, up to date policy and procedure manual

*Overlooking the COBRA continuants at annual enrollment

Q: Should an HR Manager answer an inquiry regarding COBRA prior to obtaining all the facts and answers?

A:  No.  This one is a trick question.  Anything the HR/benefits manager says before reviewing the worker’s COBRA files may be inaccurate, and that’s a compliance liability for the employer.  Many things changed in the COBRA world in 2004, especially with coverage election and general notice letters. The new regulatory guidelines improved, in part, how an employee was required to notify an employer about a qualifying event, such as a divorce or a child who is no longer eligible for coverage as a dependent.

For more information, please refer to www.dol.gov/ebsa or contact our office at (888) 474-6627.

Thank you for playing!

ABX1 21 – designed to fund a large chunk of the Healthy Families budget by extending by a year a tax on Medi-Cal managed care organizations;

AB 922 – designed to expand and move the Office of the Patient Advocate. It took on an amendment that also moves its parent agency, the Department of Managed Health Care. Those agencies currently reside under the Department of Business, Transportation and Housing.

SB 946 -  require private insurers to cover treatment for autism.

These bills now moves to Gov. Jerry Brown’s desk for review.

“Child obesity is impacting employers today and will into the future as these children become the workforce of tomorrow,” says Helen Darling, president and CEO of NBGH, whose members include 329 large U.S. employers. “Parents have an enormous impact on the childhood obesity epidemic. The good news is that employers can play a critical role in fighting the childhood obesity epidemic by helping families develop healthy lifestyles at work and in the home”.

A recent survey of 83 of the nation’s largest companies conducted by the National Business Group on Health identifies the following programs employers currenlty have in place to help fight childhood obesity:

- One third of employers (33%) offer online weight management tools to children.

- More than one in four employers (28%) offer telephonic or online coaching for weight management to children

Beyond promoting healthy lifestyles in the home, employers will soon face a growing demand for obesity treatment in children.

“With the new guidelines for screening under The Patient Protection and Affordable Care Act, many more children nationally will be identified as overweight or obese,” says LuAnn Heinen, vice president and director of NBGH’s Institute on Innovation in Workforce Well-being. “Employers can provide tools and resources to support and empower employees and work with health plans and community resources to develop and promote new approaches to childhood obesity prevention and treatment.”

Employer toolkit expanded

NBGH also announced that it has updated its employer toolkit, “Childhood Obesity:  It’s Everyone’s Business,” to include examples of family-focused wellness programs that four forward-thinking companies are doing to fight childhood obesity. The toolkit also includes a new section on how employers can design their benefit programs to ensure that they are in accordance with new screening guidelines required by PPACA and support obesitytreatment options for children.

The employer toolkit was developed and updated with support from the U.S. Department of Health and Human Services, Health Resources Services Administration’s Maternal and Child Health Bureau. It’s available free of charge and can be found at www.businessgrouphealth.org.

Gary Whiddon is a wellness consultant affiliated with WELCOA university and can assist you in forming a wellness program for your employees.  Please contact him at (888) 474-6627 for information on setting up a prgram for your employees.

All health plans and issuers would provide a summary of benefits and coverage, along with a glossary of terms to employees before enrollment.  Health plans and issuers will also provide notice at least 60 days before any significant modification is made in the plan or coverage during the plan or policy year.  The summary of benefits coverage would be some simple standard boxes for comparison shopping. If the exchanges are in place by 2014, this would allow an employee to compare employer sponsored coverage against other market-available options.

As these are merely proposed, there is nothing final and employers do not have to immediately act, nor can then act until the proposed
uniform definitions are drafted. But employers and plan sponsors should keep this information handy as a reference point for developing a long-term compliance strategy.

For more details about the proposed regulations, please go to the dol website at www.dol.gov.

The intent of Uniform Benefit Summaries is to provide individuals with standardized information so they can review medical plans, compare insurers and make decisions about medical plan choices.  The proposed rule provides additional guidance on the information that must be provided to all individuals enrolling in a medical plan on or after March 23, 2012.

This provision applies to individual and employer-sponsored medical plans, regardless of grandfathered status or funding. It does not apply to retiree-only plans or to standalone dental and vision plans.

What Information Must be Included

Insurers and self-insured employers must provide a Summary of Benefits and Coverage (also referred to as an ‘SBC’ in the proposed rule) to individuals who apply for and enroll in medical plans. The Summary of benefits and Coverage is a required document that must be provided in the standard format.

There are four standard components:

• A four-page Benefit Summary (double sided)
• Medical Scenarios called “Coverage Examples” that  are patterned after the Food and Drug Administration food labels. They estimate customer costs based on the specific plan’s benefits for three medical scenarios – Maternity, Breast Cancer Treatment and Managing Diabetes
• A standard glossary of medical and insurance terms
• A phone number and website where individuals can get additional information including documents such as Certificates, Summary Plan Descriptions (SPDs) and policies

HHS asked the National Association of Insurance Commissioners (NAIC) to propose a format for the four components in the Summary of Benefits and Coverage. Here is a link to the documents proposed by NAIC: http://www.naic.org/committees_b_consumer_information.htm

The information on the NAIC website is not a guideline or example. It is the exact wording, format and layout that must be used. Insurers and employers will just insert plan details into the predetermined rows and columns.

The Benefit Summary must be a freestanding document and may not be incorporated into any other document. Supplemental
communication materials may be provided with it. Currently produced documents will not satisfy the requirements of the regulation.

The Coverage Examples must include three pre-defined medical scenarios: Maternity, Breast Cancer Treatment and Managing Diabetes. These scenarios are intended to show typical services and cost sharing under the plan. The numbers would be based on client-specific plans and costs. The estimates are based on national average costs and in-network benefit levels.

Who is Responsible for Providing the Information

For fully insured plans and HMOs, the insurer is responsible for producing and distributing the summaries. For self-insured
plans, the responsibility lies with the employer.

What is the Required Timing

Summaries must be provided when an employer or individual requests information about a plan, applies for coverage or enrolls in
a plan. They must also receive a summary if there are plan changes or if the individual has a HIPAA special enrollment event that prompts a new enrollment opportunity.

People enrolled in a health plan must be notified of any significant changes to the terms of coverage reflected in the Summary of
Benefits and Coverage at least 60 days prior to the effective date of the change. This timing applies only to changes that become effective during the plan or policy year but not to changes at renewal (the start of the new plan or policy year).

How Benefit Summaries will be Delivered

Summaries are required both before and after enrollment and may be delivered in paper and/or electronic format. There are
specific requirements for group vs. individual plans.

Penalty for Non-Compliance

The penalty for ‘willful’ non-compliance is up to $1,000 per enrollee for each failure to comply.

Next Steps

Comments on this proposed rule – including the specific request for expatriate plans – are due 60 days from the published date.

Authorized under provisions of the Patient Protection and Affordable Care Act, these guidelines, developed by a committee of the Institute of Medicine of the National Academies, expand the previous list of preventive services that must be covered without charging a copayment, coinsurance or a deductible to include:

• Well-woman visits
• Screening for gestational diabetes for all pregnant women
• Human papillomavirus DNA testing for all women 30 years and older
• Annual sexually transmitted infection counseling for all sexually active women
• Annual counseling and screening for HIV for all sexually active women
• FDA-approved contraception methods, sterilization procedures and contraceptive counseling
• Breastfeeding support, supplies, and counseling, including costs for renting breastfeeding equipment
• Domestic violence screening and counseling

New health plans and non-grandfathered plans and issuers are required to provide coverage consistent with these guidelines in the first plan year (in the individual market, policy year) that begins on or after August 1, 2012.  It is possible that your current health plan covers these services now, but may have a copay or co-insurance percentage.

1. Bumps on the head- every new walking toddler (or those that are already walking or running) hit their heads and get a few bumps and bruises during the early years. If your child gets right back up after the impact and stops crying after some serious soothing, an ice pack and some TLC is probably all she needs. Go to the ERor call 911 if your child loses consciousness or has an indentation in her head for emergency medical attention.

2. Mouth injuries – Why do all parents panic over mouth injuries?  The mouth is rich in blood vessels, so cuts and scrapes bleed a lot (and it’s often hard to see where all that blood is coming from at first). Applying ice, having her suck on an ice pop or  drink some cold water will soothe and stop bleeding.  Go to the ER when there is a gaping wound or a cut that won’t stop bleeding after you’ve applied ice is a true emergency.

3. Fever – Most fevers, even high ones, are just a sign that your toddler is fighting off an infection, but many parents worry that a fever signals something worse.  The American Academy of Pediatrics says Moms and Dads need to make a feverish tot comfortable, instead of trying to bring the temperature down to normal. Don’t be alarmed if that pain reliever doesn’t bring down her temperature right away. Instead, keep giving your little one plenty of fluids (and hugs) and check in with your pediatrician.  Go to the Pediatrician when your child has a fever higher than 102.2°F or has had a fever for more than 24 hours (for a child younger than two) or 72 hours (for kids two and older). Go to the ER if your child’s fever is 102.2°F and she has a stiff neck, can’t stop crying or vomiting, is so lethargic it’s difficult to wake her up, or has a blue tongue or blue lips or nails (which means she’s not getting enough oxygen). Also go to the ER when a baby under three months has a fever of 100.4°F.

4. Vomiting-  Persistent vomiting is another common reason parents head to the ER. But vomiting is usually caused by a stomach bug or infection and isn’t serious in and of itself. A bigger danger is dehydration, so be sure to offer your tot extra fluids (or Pedialyte), even if she just takes a sip at a time, as well as liquid-based foods like soups, fruits, and fruit pops. Most stomach bugs that cause vomiting last only 24 hours, so if your child is throwing up for more than a full day, call your Doctor. Call the pediatrician or go to the ER if there are signs of dehydration, such as : dry mouth, lack of tears, and dry diapers (or not much pee in the potty). Call your doctor or 911 if your child is vomiting after she’s hit her head, or is throwing up greenish fluid, blood, or what looks like coffee grounds (blood mixed with stomach acid).

5. Skin Rashes – Most rashes are not dangerous.  Some are caused by allergies, while others are symptoms of viruses like fifth disease. It is recommended that your pediatrician  check out a nasty or weird-looking rash, most rahses are not a cause for alarm.  Go to the ER if your tot breaks out in a rash and has trouble breathing at the same time. Another rash that warrants an emergency room visit and a call to the doctor is petechiae, which is flat purplish dots caused by broken blood vessels that are usually a sign of a serious infection or bleeding problem.

Please always remember that there may be increased charges on your insurance coverage for emergency room visits.  Please consult your plan booklet for information regarding the benefits available.

“Given the economic recession of the past few years, this could be especially true for those who may not have had adequate protection when they were laid off,” says John Kmiec, Jr., a research associate in human capital development at The University of Southern Mississippi. He also acknowledged that the group that earned less than $50,000 and long-term unemployed people might not have cared as much about voluntary benefits; however, the survey did not break those numbers down.  Age plays a role in the needs of job seekers, according to Kmiec. Fifty percent of respondents were between the ages of 35 and 55, which might have influenced the answers and the desires of potential employees.

“We think it’s a trend. We’ve seen that employees–how much they value benefits–is increasing,” says Barbara Nash, vice president of corporate research at Unum. “They’re learning more about it than they have in the past; they’re seeing that benefits are an important part of what they get from their employer.”

Significantly, 74% of those surveyed rated a good benefits package as being “very important,” which historically, has been equated to monetary value if the benefits are actually used.  People still need jobs, but beyond that, potential employees also want to have a financial safety net.

“The monetary value of a benefit isn’t realized until it is used by the employee. This ties to the employees’ perception of the benefit’s worth,” Kmiec says. “Since many benefits are only occasionally used, it is important that employees know what they feel is important, and that employers are clearly communicating the value of the entire compensation package (pay and benefits) to their employees.”

Unum also surveyed HR executives, of which 21% represented larger companies with 2,000 or more employees and 39% with fewer than 100 employees. About two-thirds of HR leaders said that employees and prospective employees are more aware of benefits, are asking more questions and take benefits less than a few years ago.

“They contribute a large chunk of the benefits budget and a truly caring HR department will insist this benefit be available,” Andes says.

1. ASK YOUR FRIENDS AND WORK COLLEGUES WHO THEY SEE FOR MEDICAL CARE.  Your firends and work associates will often be the most honest, as they do not stand to gain from any recommendation, and will often care enough about your welfare to be honest about any faults or issues the provider may have.

2. ASK YOUR CURRENT PHYSICIAN.  This works best if you need a specialist, or if you ar transitioning a child from a pediatrician to an internist or GP.  Doctors usually know the scuttlebutt on who is the best in their fields.

3. CONTACT A TEACHING HOSPITAL.  As with #2 above, they usually know who is a good physician.

4. USE THE INTERNET.  There are many websites devoted to physician reviews, such as ratemds.com and vitals.com.  Keep in mind that most people comment on these sites when they are dissatisfied with a provider, and not to commend one.  It would be good to know if there are many complaints, so you can avoid this doctor.

5. CONTACT AN ADVOCACY GROUP.  Organizations such as The American Cancer Society will be able to advise who is the best in their field, as they work closely with physicians and are on top of the latest research and advancements.

6. DO A BACKGROUND CHECK.  Contact the Federation of State Medical Boards at fsmb.org  for information on licensing and complain history.  Also check out the American Board of Medical Specialties at abms. org to check board certification status.

7. GO WITH YOUR GUT. Since you may be spending a lot of time with this person, you have to feel that you are a team and that you can work together.  You know who you feel a kinship with, and who you dislike.  If you don’t like the doctor, don’t use him/or her as your provider!  Can you imagine being sick and vulnerable, having your health and future in the care of someone you don’t like?

Of course, any doctor you choose doesnt have to be your provider for the rest of your life.  As your needs change you may also want to reconsider your choices.  Do not be afraid to change doctors.  As in life, not every relationship is meant to be permanent.  If you were meant to stay with the same doctor all of your life, there would be many elderly patients at the pediatrician’s office. 

Searching for the “Best” Rx price has never been easier! Simply visit www.PillBot.com and type the name of the medication in a box like below and click submit. You may also conduct your search alphabetically at PillBot.com.

I did a search on the cholesterol drug, Zocor.  Here are the results.  The first line  shows 30 pills each 80 mg for $115.87 or $3.82 per pill.

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.

 Whether you’re choosing among group health plans offered by your employer or shopping for individual health insurance coverage, there are seven mistakes to avoid.

 1. Your doctor isn’t in the network. You’ll pay more to use health care providers who aren’t in your health plan’s network, so check to see if the doctors and other professionals you want are included. A plan that tightly restricts you to a local network might be sufficient if you need care only in your area, but it won’t benefit a kid away at college or meet all your needs if you spend a lot of time on the road.  Make sure any specialists you need are also covered by the plan.  Don’t assume a specialist is in the network just because your primary care doctor gave you the name.

 2. You pay huge insurance premiums to save a few bucks on the co-pay.  Don’t focus so much on getting a low co-pay and fail to look at how much extra premium you will pay for it.  Evalute the need for the extra premium cost.  If you go to the doctor only a couple of times a year, is it worth hundreds of dollars extra on the premium just to get a lower co-pay?

3. The drugs you take aren’t covered.  If the plan provides prescription-drug coverage, check to see if your medications are included on its formulary, which lists the preferred drugs that are either included or covered at a better copay.  Check to see if  the plan provides discounts if you mail-order prescription drugs in bulk.

4. You are overinsured.  In addition to comprehensive health plans, many employers offer supplemental insurance policies, such as cancer or critical illness insurance, that pay a lump sum of cash after diagnosis. Such policies can provide valuable protection, but they might not be unnecessary if you already have excellent under your medical insurance and short-term and long-term disability insurance plans. 

6. Your policy doesn’t cover maternity care.  Most employer-sponsored plans cover maternity and prenatal care, thanks to federal and state laws in place.  Individual plans do not require maternity coverage.  Starting in 2014, individual and small-group plans sold through state health insurance exchanges must include pregnancy and newborn care, along with other essential benefits.

 7. You don’t check your health plan for changes.  During your annual open enrollment, check the details of your current health plan to be aware of any changes that may impact your health care needs. Don’t assume the plan is still the same. Coverage levels, costs and networks could change from one year to the next, even if the plan is offered by the same insurer.

A good Health Insurance Advisor or Broker will help you sort through the plans available and help you find the plan that best suits your needs.  Please call our office at (888) 474-6627 and we will be happy to help you find the right plan for you and your family.

They looked at various optios to assist their employees, including weight loss management programs but decided to put a process together themselves, spearheaded by Management.  A a top-down approach is the key to success of any wellness program offered by organizations, but particularly for smaller companies the size of KimStaffHR, which has about 25 employees. ”

Their program was inspired by the  book: “ICount: 10 Simple Ways to a Healthy Lifestyle,” authored by Susan Parks and Patricia Bonavia. “ICount” argues that the failure to engage in an active lifestyle can result in a huge hit to organizations across the country in terms of health-related costs, lost productivity and employee attrition.  The premise of the book is that even with busy schedules and hectic lives, individuals can still engage in simple activities that will lead to a stronger mental and physical condition.

KimStaffHR used the apprach that walking would fit into the lives of their busy employees and would lead to health and wellness. They did not require any of its employees to take part in the program, recognizing that some might not feel comfortable.  They introduced the idea to their workforce and supported those who expressed interest. Weekly meetings were held to focus on not just weight loss alone, but on how employees could incorporate more movement into their day.  With the goal to march 10,000 steps daily, employees walked at home, at work and all points in between. The company recognized that it needed to incorporate this new wellness routine into the workday. To accomplish this, meetings are now held outside, with workers walking while discussing items that normally would be handled in a conference room setting. During the winter months, the halls of the office became the walking grounds, as the employees refused to let weather interrupt their wellness efforts.  Some workers tracked their progress with pedometers and walked with their families, fostering a healthy lifestyle in the home as well. And with members of employees’ families likely participating on the health plans of KimStaffHR employees, the cost savings from reduced health care claims can multiply time and again.

There has been significant weight loss noted, but their workforce has benefited from becoming a more cohesive healthier unit as a result of their program.

Though its wellness-by-walking program still is in the early stages, KimStaffHR is convinced the benefits of the simple, yet diligent, work of their employees will pay off in its own health care costs. For example, chronic illnesses such as high blood pressure are coming under control, and execs ultimately believe the program will lead to less office visits and medication needs.

“One of the key points is that you have don’t have to spend tons of money to start a program like this. We have a lot of clients, and we have to walk the walk, literally.” The enthusiasm has also spread to other businesses that surround KimStaff in its business complex. Seeing many of the same faces walking outside day after day has inspired other organizations to take the same steps toward physical and mental fitness. And employees have connected on social sites, such as Facebook, to build a community supportive of their goals and one another. “We’ve built a culture here, and it’s recognized here,” Dillard says. “It helps to build self-esteem. Our personalities are positive, and it goes from the top down. Walking is the easiest thing to do, there is no excuse. If people stay committed to it, this will change their lifestyle. It did not cost us money and was a simple, but effective change in the workplace.”

For more information or ideas on on wellness programs, contact Gary Whiddon at 888-474-6627 ext. 116.

Employers may adopt mini-med and similar health plans to provide limited health insurance coverage (for example, health benefits capped at $20,000 per year) to a segment of employees that otherwise would not have access to the employer’s standard health coverage.

Under the new procedures, previously granted waivers for mini-med and similar health plans are extended through 2013 if the applicants report certain information about their plans to HHS on an annual basis and disclose additional information to enrollees about the limits of their plans’ coverage. Recipients of existing waivers must apply to HHS to extend their waivers by September 22, 2011. Any plans that have not yet applied for waivers must also apply by September 22, 2011.

The Affordable Care Act generally prohibits group health plans from imposing lifetime and annual dollar limits on certain benefits, beginning with the first plan year that starts on or after September 23, 2010. The Affordable Care Act allows annual limits to be phased out gradually through 2014, with minimum annual limits of $750,000, $1.25 million, and $2 million for the 2011, 2012, and 2013 plan years, respectively.

As part of the transition process, HHS established in September 2010 a temporary program (for years prior to 2014) to permit individual mini-med and similar health plans to apply for a waiver of the restricted annual dollar limit if the plan could demonstrate that compliance with the annual dollar limit rules would result in either a significant decrease in access to benefits or a significant increase in premiums for the plan or policy. Under the original waiver program, the applicant needed to reapply for the waiver each year. The new procedures eliminate the annual reapplication process, but require applicants to take action by September 22, 2011, and satisfy certain additional requirements.

 Plan sponsors who forget to actually do discrimination testing run into all sorts of problems, including the possibility that their plan can be disqualified.

Employee health plans,  cafeteria plans and self-funded welfare benefit plans have to do annual discrimination testing to remain qualified. Insured health plans are not currently subject to  discrimination testing, but that will change in the future.

Size of the group doesn’t matter.

 To pass the Section 105(h) nondiscrimination rules an employer must meet two separate tests: The Benefits Test  and The Eligibility Test 

 The benefits test measures whether the plan is “offered in a manner that is discriminatory on its face” and whether the plan is operated “in a discriminatory manner.” All benefits provided for highly compensated employees (HCEs) must be provided for all other participants” and that “all the benefits available for the dependents of HCEs must also be available on the same basis for dependents of all non-HCE participants.” Required employee contributions must be the same for HCEs and non-HCEs for each benefit level and the same type of benefits that are available to HCEs must be available to non-HCEs. The “discrimination in operation” occurs, for example, if a plan added a benefit for a particular treatment for one plan year during which an HCE received coverage for that treatment, then terminated the benefits as soon as the HCE no longer needed the treatment.

For the Eligibilty Test, an employer passes the eligibility test if it passes any one of the three:

1. At least 70% of employees must benefit from the plan.

2.  All benefits provided for highly compensated employees (HCEs) must be provided for all other participants” and that “all the benefits available for the dependents of HCEs must also be available on the same basis for dependents of all non-HCE participants.”.

3. Required employee contributions must be the same for HCEs and non-HCEs for each benefit level and the same type of benefits that are available to HCEs must be available to non-HCEs. The “discrimination in operation” occurs, for example, if a plan added a benefit for a particular treatment for one plan year during which an HCE received coverage for that treatment, then terminated the benefits as soon as the HCE no longer needed the treatment. 

 Plans that fail will cause the employee benefits to become taxable as income.

WELCOA , the Wellness Council of America, is one of the nation’s leading non-profit organizations in workplace wellness, and provides resources to more than 4,000 member companies.  Located in Omaha, Nebraska, WELCOA has been in operation for more than 25 years.

 Congratulations Gary!

• Maximum annual HSA contribution for self only coverage will be $3,100 (up from $3,050)
• Maximum annual HSA contribution for family coverage will be $6,250 (up from $6,150)
• Annual maximum out of pocket for self only coverage will be $6,050 (up from $5,950)
• Annual maximum out of pocket for family coverage will be $12,100 (up fro,m $11,900)

 Amounts that are remaining at 2011 levels: 

• Age 55 catch-up contribution will continue to be $1,000
• Minimum HDHP deductibles will remain at $1,200 for self only coverage and $2,400 for family coverage.

These plans were created by the health overhaul that President Obama signed last year. They are meant to provide temporary aid to sick Americans until 2014, when insurance companies will no longer be allowed deny coverage to people who are sick.

The number of people signing up for these plans has lagged, in part because of high premiums and stringent eligibility guidelines.  Premiums in some states could come down as much as 40%, thanks to a more refined analysis of what the plans should charge.

The administration is directly slashing premiums in the District of Columbia and most of the 23 states that have elected to have the federal government run their health plans. The remaining 27 states, which each run their own plans, will be able to reduce premiums, as well.

The administration will no longer require applicants for these plans to furnish a letter from an insurance company showing they had been denied coverage. Instead, applicants will need only a letter from a doctor, nurse or physician’s assistant stating they have a medical condition.  Applicants will still have to show they had been without coverage for at least six months.

The expansion of preexisting condition insurance plans is made possible by $5 billion that was set aside in the new law.  Because just 18,000 people nationwide had signed up for a plan, much of that has not been spent, according to the Department of Health and Human Services.

Additional information about signing up for a preexisting condition insurance plan is available at http://www.pcip.gov or by calling (866) 717-5826.

WASHINGTON – U.S. Senator Orrin Hatch (R-Utah), Ranking Member of the Senate Finance Committee, today unveiled the Family and Retirement Health Investment Act of 2011, bicameral legislation to strengthen and expand Health Savings Accounts (HSAs) and Flexible Spending Arrangements (FSAs) for American workers and retirees. Companion legislation was introduced in the U.S. House of Representatives by U.S. Rep. Erik Paulsen (R-Minn.). “This legislation will provide American workers and retirees with a common-sense way of improving access to quality, affordable health care,” said Hatch. “These health plans empower Americans to take control of their health and well-being. Health Savings Accounts and Flexible Spending Accounts allow consumers to make informed decisions about their health care and will help restrain costs by putting people in charge of their health choices.” This year health care costs are expected to rise by eight percent, more than double the rate of inflation. HSAs and FSAs provide individuals with opportunities to put away tax free savings for everyday medical expenses. When Congress first made HSAs available, these plans only covered 454,000 lives. Today, more than 10 million people are covered under a health plan that is eligible for an HSA. The Family and Retirement Health Investment Act of 2011 will streamline these health care products and simplify them for American families, seniors, and entrepreneurs. Specifically, the legislation will: allow a husband and wife to make catch-up contributions to the same HSA remove the onerous new restrictions on the use of HSA and FSA dollars for the purchase of over-the-counter drugs allow individuals to roll-over up to $500 from their FSA accounts clarify the use of prescription drugs as preventive care that will not be subject to an HSA-eligible plan deductible reauthorize the use of Medicaid health opportunity accounts promote wellness by expanding the definition of qualified medical expenses to encourage more exercise and better diet allow seniors enrolled in Medicare Part A to continue contributing to their HSAs allow for the purchase of low-premium health insurance and long-term care insurance with HSA dollars

###

To see this press release on the Senate Committee on Finance website, click here.

  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.

Last week, Milliman released its annual Milliman Medical Index, and it shows that the average American family’s medical costs have doubled in less than nine years and increased 7.3 percent from 2010 to 2011. The results also show that hospital spending, which accounts for 48 percent of total health care spending, accounts for more than 60 percent of this year’s total increase. And, outpatient facility costs increased more than any other component. The medical index illustrates the complexity of the health care cost problem, while legislative remedies to date have focused principally on health plan rate review processes and medical loss ratio restrictions. Interestingly, a new Yahoo Finance analysis of quarterly financial data shows that the health plan sector of the health care system ranked only 143rd out 215 in terms of profit margin.

The study notes that even though hospital costs are only 48% of total health care spending, increases in facility spending accounted for 60% of this year’s total increase in costs. For the third year in a row, spending at outpatient facilities rose faster than any other component of patient care, climbing 10%. Milliman attributes the growth in cost to the fact that existing outpatient services have increased in price while new, more expensive services continue to emerge. Pharmacy costs also rose by 8%. Although a quarter of that increase came from broader usage of pharmaceuticals, most of the change came from higher average prices.

These rising costs present a challenge for insurers, which are facing more political pressure to keep premiums down. Indeed, the report calls health care reform “the elephant in the room” and predicts that insurers will become subject to greater scrutiny of their rates. “Premium rate reviews do nothing to directly influence the underlying drivers of health care cost, but can put pressure on insurers to find ways to keep medical costs down,” the report states.

Please contact our office for more information on this valuable benefit.

Democratic Representative Frank Pallone said the effort to deny federal grants to the states would not kill the exchanges. Rather, it would make it harder for cash-strapped states to establish their own marketplaces and give more power to the federal government, Pallone said.

The health care law calls for the federal government to set up exchanges for states that fail to establish their own.

The nonpartisan Congressional Budget Office said the House bill would delay establishment of state exchanges and save $14.6 billion over the next 10 years mostly because fewer people would purchase government-subsidized insurance.

About 500,000 people would be without health coverage in 2015 because of the delay, CBO said in a recent analysis of the bill.

Remember that 70% of health claims are “lifestyle driven”, so firms that establish “results-oriented” wellness plans that provide employees financial incentives for results, means thousands saved in lower health claims and improved on the job productivity.

As reported yesterday,  Medicare Part B premiums are tied to a seniior’s income history.  The most affluent seniors have been paying higher income threshold Medicare Part B premiums (doctor visits and outpatient services) since 2007. The surcharge was put in place by the Medicare Modernization Act of 2003. 

 This premium increase also  extends the income threshold formulas to Part D prescription drug enrollees for the first time. This will affect just 5% of Medicare enrollees this year, although that figure will rise to 14% by 2019 according to the Kaiser Family Foundation.

High-income seniors who pay both Part B and Part D premiums could see their combined premiums rise anywhere from $300 to $700 per month by the end of the decade, according to Juliette Cubanski, associate director of Kaiser’s Medicare Policy Project.

The new income thresholds also affect people who choose a Medicare Advantage plan (Part C), which often covers prescription drugs. Advantage enrollees typically pay the monthly Part B premium plus a supplemental premium to the Medicare Advantage plan; now, these premiums are being adjusted to factor in the higher-income amounts for Part B and Part D coverage, where applicable.

The policy aims to help offset the cost of health-care reform by reducing taxpayer subsidies on Medicare services for seniors who don’t really need the help.  Kaiser estimates that the higher premiums will save taxpayers $25 billion for Part B from 2010 to 2019, and $10.7 billion for Part D.

These changes will provide important new benefits to retirees that should at least take the edge off the higher expenses over time.

The Medicare D prescription drug doughnut hole will be closed. That’s the coverage gap that starts when a beneficiary’s annual drug spending hits $2,830, and resumes at the catastrophic level ($4,550). This year, pharmaceutical companies are providing a discount of 50% on brand-name drugs to low- and middle-income beneficiaries who find themselves in the gap. Then, the doughnut hole itself will shrink a bit every year, ultimately disappearing entirely in 2020.

These will also be important improvements to traditional Medicare aimed at boosting preventive care. Medicare patients now receive an annual wellness visit–with no co-payment or deductible–that includes a comprehensive health risk assessment and a long-term personalized prevention plan. Deductibles and co-payments also were eliminated for most preventive care services.

• employers issuing fewer than 250 Forms W-2 in the previous year;
• multiemployer plans;
• health reimbursement arrangements;
• stand-alone dental and vision plans (in other words, dental and vision plans that are not otherwise integrated or incorporated into comprehensive medical plans);
• self-insured plans that are not subject to COBRA or similar Federal requirements; and
• employers furnishing Forms W-2 mid-year to employees who terminate during that year.

For a fully-insured plan, the premium charged is the cost of coverage.  For a self-insured plan, the cost of coverage is the COBRA applicable premium.  In calculating this cost, the employer must be sure to comply with the requirements for calculating the COBRA premium provided in the COBRA statute.  If the employer subsidizes the cost of COBRA so that the premium charged to qualified beneficiaries is less than the COBRA applicable premium, the employer may determine the reportable cost based upon a reasonable good faith estimate of the COBRA applicable premium, if such reasonable good faith estimate is used as the basis for determining the subsidized COBRA premium.

 To prepare for this reporting obligation, employers should begin working with their payroll administrators to make sure that their systems are updated by the end of 2011, so that they can track the cost of any coverage provided in 2012 and report it on the Forms W-2 that will be issued in January 2013.

Most Medicare beneficiaries continue to pay the same $96.40 or $110.50 Part B premium amount in 2011. Beneficiaries who currently have the Social Security Administration (SSA) withhold their Part B premium and have incomes of $85,000 or less ($170,000 or less for joint filers) did not have an increase in their Part B premium for 2011. 

If your income is above $85,000 (single) or $170,000 (married couple), then your Medicare Part B premium may be higher than $115.40 per month.  Social Security will use the income reported two years ago on your IRS income tax return to determine your premium (if unavailable, SSA will use income from three years ago).  For example, the income reported on your 2009 tax return will be used to determine your monthly Part B premium in 2011. If your income has decreased since 2009, you can ask that the income from a more recent tax year be used to determine your premium, but you must meet certain criteria.

The chart below shows the Part B monthly premium amounts based on income. These amounts change each year. There may be a late-enrollment penalty.

If you are having trouble paying your premiums, you should call your State Medical Assistance (Medicaid) office to see if you qualify for some help. Some states refer to the Medicaid office as the Public Aid office, the Public Assistance office, or the State Medical Assistance office.

INCOME RELATED MONTHLY ADJUSTMENT AMOUNT (IRMAA)

The Internal Revenue Service supplies your tax filing status, your adjusted gross income, and your tax-exempt interest income to the Social Security Administration to determine if you have an income related monthly adjustment amount (IRMAA). The Social Security Administration will add your adjusted gross income together with your tax-exempt interest income to get an amount called the modified adjusted gross income (MAGI).

The income-related monthly adjustment amount is effective from January 1 through December 31 each calendar year. The Social Security Administration will refigure your Medicare Part B premium amount again next year when the Internal Revenue Service updates the information.

For more information, please refer to the Medicare website at www.medicare.gov.

• 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.

If you have a new health insurance plan or insurance policy beginning on or after September 23, 2010, the following preventive services must be covered without your having to pay a copayment or co-insurance or meet your deductible. This applies only when these services are delivered by a network provider. 

Covered Preventive Services for Adults

• Abdominal Aortic Aneurysm one-time screening for men of specified ages who have ever smoked
• Alcohol Misuse screening and counseling
• Aspirin use for men and women of certain ages
• Blood Pressure screening for all adults
• Cholesterol screening for adults of certain ages or at higher risk
• Colorectal Cancer screening for adults over 50
• Depression screening for adults
• Type 2 Diabetes screening for adults with high blood pressure
• Diet counseling for adults at higher risk for chronic disease
• HIV screening for all adults at higher risk
• Immunization vaccines for adults–doses, recommended ages, and recommended populations vary:
  • Hepatitis A
  • Hepatitis B
  • Herpes Zoster
  • Human Papillomavirus
  • Influenza
  • Measles, Mumps, Rubella
  • Meningococcal
  • Pneumococcal
  • Tetanus, Diphtheria, Pertussis
  • Varicella
• Obesity screening and counseling for all adults
• Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk
• Tobacco Use screening for all adults and cessation interventions for tobacco users
• Syphilis screening for all adults at higher risk

Covered Preventive Services for Women, Including Pregnant Women

• Anemia screening on a routine basis for pregnant women
• Bacteriuria urinary tract or other infection screening for pregnant women
• BRCA counseling about genetic testing for women at higher risk
• Breast Cancer Mammography screenings every 1 to 2 years for women over 40
• Breast Cancer Chemoprevention counseling for women at higher risk
• Breast Feeding interventions to support and promote breast feeding
• Cervical Cancer screening for sexually active women
• Chlamydia Infection screening for younger women and other women at higher risk
• Folic Acid supplements for women who may become pregnant
• Gonorrhea screening for all women at higher risk
• Hepatitis B screening for pregnant women at their first prenatal visit
• Osteoporosis screening for women over age 60 depending on risk factors
• Rh Incompatibility screening for all pregnant women and follow-up testing for women at higher risk
• Tobacco Use screening and interventions for all women, and expanded counseling for pregnant tobacco users
• Syphilis screening for all pregnant women or other women at increased risk

Covered Preventive Services for Children

• Alcohol and Drug Use assessments for adolescents
• Autism screening for children at 18 and 24 months
• Behavioral assessments for children of all ages
• Blood Pressure screening for children
• Cervical Dysplasia screening for sexually active females
• Congenital Hypothyroidism screening for newborns
• Depression screening for adolescents at higher risk
• Developmental screening for children under age 3, and surveillance throughout childhood
• Dyslipidemia screening for children at higher risk of lipid disorders
• Fluoride Chemoprevention supplements for children without fluoride in their water source
• Gonorrhea preventive medication for the eyes of all newborns
• Hearing screening for all newborns
• Height, Weight and Body Mass Index measurements for children
• Hematocrit or Hemoglobin screening for children
• Hemoglobinopathies or sickle cell screening for newborns
• HIV screening for adolescents at higher risk
• Immunization vaccines for children from birth to age 18 —doses, recommended ages, and recommended populations vary:
  • Diphtheria, Tetanus, Pertussis
  • Haemophilus influenzae type b
  • Hepatitis A
  • Hepatitis B
  • Human Papillomavirus
  • Inactivated Poliovirus
  • Influenza
  • Measles, Mumps, Rubella
  • Meningococcal
  • Pneumococcal
  • Rotavirus
  • Varicella
• Iron supplements for children ages 6 to 12 months at risk for anemia
• Lead screening for children at risk of exposure
• Medical History for all children throughout development
• Obesity screening and counseling
• Oral Health risk assessment for young children
• Phenylketonuria (PKU) screening for this genetic disorder in newborns
• Sexually Transmitted Infection (STI) prevention counseling and screening for adolescents at higher risk
• Tuberculin testing for children at higher risk of tuberculosis
• Vision screening for all children

While it’s easy to simply say that preventive care is covered at 100%, the actual administration of this benefit is exceedingly complex. Here are some common concerns and things you can do now to address them:

* Eligible expenses. Some items on the list of covered services are not currently covered under most medical plans, such as aspirin, fluoride and iron supplements.   We recommend providing the list of covered items to your insurer early and ask them about their plan to address these types of items. If they do not yet have a plan of action, request semi-annual updates on the status.

* Participant confusion. Finding a clear definition of the difference between preventive and routine care, and educating your participants, is also key.  Many services that a participant considers preventive are not, such as screening for skin cancer, follow-up care and colon cancer screenings for individuals under age 50.  We recommend requesting a list from your insurance company of the items considered preventive care and make this easily available internally to assist with minimizing confusion.

As a precaution, we recommend contacting either your carrier or insurance broker to determine how any of the above items will be covered by your insurance carrier.

One of the provisions of the PPACA law that is worrisome to small employer groups is the requirement that the cost of employer-sponsored group health plan coverage be included on an employee’s Form W-2.

This requirement was originally scheduled to be effective for taxable years beginning on or after Jan, 1, 2011, however, the IRS granted a one year extension in late 2010 so that the requirement now applies beginning with the 2012 Forms W-2.

While the general rule is that all employers that provide employer-sponsored group health plan coverage during a calendar year are subject to the enhanced Form W-2 reporting requirement, a limited exception now exists for small employers.

Specifically, in the case of the 2012 Form W-2 (which must be delivered to employees on or before Jan. 31, 2013), an employer is not subject to the enhanced reporting requirement for any calendar year if the employer was required to file fewer than 250 Forms W-2 for the preceding calendar year.

Consequently, if an employer files fewer than 250 2011 Forms W-2, the employer would not be subject to the enhanced reporting requirement for the 2012 Forms W-2.

This exception will be very helpful to those employers that do not reach the 250 Forms W-2 threshold. In addition, while the exception specifically applies with respect to the 2012 Form W-2, the exception is available until the issuance of further guidance.

Therefore, it is possible that this exception will be extended into later taxable years.

In any event, the earliest that such small employers would be required to comply is the 2013 Forms W-2 in January 2014. While the exception applies with respect to the 2012 Forms W-2, the determination of whether the 250 Form W-2 threshold has been reached is based on the prior year (i.e., 2011).

However, it is important that employers who may be eligible for this small employer exception in 2012 are aware of the exception throughout 2011.

Guidance on implementation is available in the IRS notice 2011-28 avaiable onthe IRS website.  Employers should consult with their employee benefits counsel and tax advisors to determine the impact that this guidance will have on their reporting obligations.

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 .

MetLife’s new Study of Employee Benefits Trends is full of the latest – and sometimes surprising – insights about employers and their employees think about benefits. And, it delivers unique perspective on how the benefits landscape is changing.

Download the Study

For example, you know that successful companies depend on a strong foundation of loyal and productive employees.

However, this year’s Study reveals:

• A workforce that has grown more dissatisfied
   and disloyal, to the point where a startling one in
   three employees hope to be working elsewhere
   in the next 12 months.
• Yet, employers, perhaps focused on expense
   control and lulled by a period of low turnover,
   assume employees feel as loyal today as they
   did three years ago.

Benchmarketing Tool

Quickly compare benefits objectives and offerings — as well as employee attitudes — to those of similar companies and employee populations. View, print and download your results for your next presentation.

Take the Benchmarking Tool Tour!  Then visit the tool 

Passage of the law was a major legislative victory for Obama and helped change the political landscape, but not always in the way Democrats had hoped. Republicans strongly opposed the law and successfully worked public skepticism about it into sweeping election victories in November.

Here’s a look at the uncertain future of the reform law.

REPEAL, DEFUND AND TAKE APART

Republicans, who say the law gives the federal government too much control and does little to reduce costs, have pushed a repeal bill through the U.S. House of Representatives after they took control in January. Full repeal, however, is unlikely unless Republicans successfully take control of the Senate and the White House in next year’s presidential elections.

The Democratic-led Senate will not go along with repeal and Obama would veto any such bill. Democrats argue the law’s reforms will slow the growth of healthcare costs while improving care and reducing the ranks of the uninsured.

A Republican move to withhold funds to stop implementation of the law will meet similar resistance from Senate Democrats.

That leaves Republicans the option of picking apart the law regulation by regulation. This strategy could be more successful.

Already, a revenue raising provision requiring businesses to file Internal Revenue Service forms on purchases and service totaling more than $600 a year is likely to be repealed with support from both parties.

The bill passed the House, and the Senate is expected to follow. The bill adjusts insurance purchase subsidies for middle income people as a way to cover the $22 billion cost of rescinding the so-called 1099 reporting provision.

COURT CHALLENGES

A number of states have challenged the constitutionality of the law’s requirement that most Americans obtain health insurance or pay a penalty. The rulings have been divided, and the issue is certain to end up before the U.S. Supreme Court.

A U.S. District Court judge in Florida ruled the entire law unconstitutional, while a U.S. judge in Virginia ruled the insurance mandate unconstitutional and upheld the rest of the law. Other courts have dismissed cases or have found the law’s mandate to purchase insurance constitutional.

The U.S. Supreme Court could decide as early as next year. Senate Finance Committee Chairman Max Baucus, who played a leading role in writing the healthcare law, and other healthcare advocates believe the law will be upheld.

Conservative critics give better than even odds that the Supreme Court will overturn the law.

If the court does decide that the coverage mandate violates the Constitution, many experts believe the judges would most likely strike down just that provision and leave the rest of the law intact.

A decision striking down the purchase mandate but leaving intact provisions requiring insurers to cover everyone regardless of medical history would wreak havoc on the insurance industry and send premiums soaring.

The law’s major provisions establishing state insurance exchanges, imposing coverage mandates and requirements that insurers can no longer exclude or charge more for preexisting conditions take effect in 2014. That would give lawmakers time to act on any court decision.

STATE ISSUES

Despite the court challenges and stiff Republican opposition, the federal government is moving ahead with implementation that mostly falls on the states.

A number of state governors, primarily Republicans, have balked at the added cost of the law to already tight budgets. States must set up insurance exchanges to help consumers and small businesses purchase insurance. States also have to maintain their Medicaid coverage for the poor until the program is expanded in 2014 to cover millions more low income people.

The Medicaid healthcare program is run by the states with federal financial aid, and many governors are looking to cut Medicaid spending to help balance budgets that took a huge hit during the economic recession.

The federal government will pick up the cost of expanded Medicaid coverage for three years, but many states worry about future added costs.

Some states are dragging their feet on establishing the insurance exchanges that are to go into effect in 2014, leaving it to the federal government to step in and operate them.

SAVING THE HEALTHCARE LAW

Democrats note the popular Social Security retirement and Medicare healthcare programs for the elderly also faced stiff political opposition from conservative Republicans and survived legal challenges.

If the healthcare law survives the constitutional challenge, most likely the current political opposition will begin to subside and the law will remain on the books.

Most Americans did not think the costly U.S. healthcare system was working well before the new law. Costs were soaring and millions were going without coverage.

Polling data show that while people are skeptical about the law, most do not want to see it scrapped entirely.

Republicans have yet to put forward a proposal to replace the current law and are not likely to take a comprehensive approach. Instead they most likely would take it step-by-step, starting with limits on medical malpractice lawsuits. They also would push to allow insurers, who are regulated at the state level, to sell policies across state lines.

© Thomson Reuters 2009 All rights reserved

What’s Changing

DE-6 and DE-7 forms have been replaced by new DE-9 and DE-9C forms.

• DE- 9  (formerly form DE-6) Quarterly Contribution Return and Report of Wages Form
  Employers will use this form to report Unemployment Insurance, Disability Insurance, taxable wages and contributions
• DE-9C (formerly from DE-7) Quarterly Contribution Return and Report of Wages Continuation Form
  Employers use this form to report employee wages and personal income tax withheld

For additional information, please visit the links below:

For FAQ’s regarding Payroll tax changes in 2011, click here.
http://www.edd.ca.gov/Payroll_Taxes/FAQ_-_2011_Payroll_Tax_Reporting_Changes.htm

To download Payroll tax forms and instructions, click here.
http://www.edd.ca.gov/Payroll_Taxes/Forms_and_Publications.htm#Forms

They will begin notifying members affected by the July 1 rate change as early as mid-April.  Anthem is doing so following the end of a 60-day postponement requested by the state insurance commissioner.   

As part of the agreement, they will delay certain benefit changes in our original filing from a July 1, 2011 implementation to a January 1, 2012 implementation. In addition, the average premium increase will be slightly lower, averaging 9.1%, vs. the 9.8% in the company’s original rate filing.  An estimated 80,000 California customers will receive rate decreases per the original filing.

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.

One of the main reasons so many people are so pessimistic about their retirement prospects is the simple fact that far too few workers are actually saving for retirement.  Most Americans can now expect an average retirement of about 20 years, and that number continues to expand as people live longer, while at the same time incur higher medical and cost-of-living expenses.

The survey found that people folks with savings of less than $25,000 are the most nervous about retirement and  resigned to the fact that they’ll either work throughout most of their retirement or never be able to retire at all. Forty-three percent of respondents with savings of less than $25,000 said they are not confident they’ll have enough money to afford a decent retirement, up from 19% in 2007. Meanwhile, 22% of those with between $25,000 and $100,000 in savings remained less-than-confident about their retirements, more than triple the 7% who felt the same way in 2007.

This changing perception reflects not only most Americans’ disinterest in saving for tomorrow, but also the stark reality that most people aren’t expecting things to magically improve between now and the time they hit retirement age.

“Sixty-two percent of workers said they can save more than they’re saving now,” said Greenwald. “Most said they could dine out less, cut back on entertainment and, in some cases, wouldn’t really need to cut back at all to increase their savings. And while the sacrifices wouldn’t be that great, many still haven’t formed the habit of doing it.” 

That so few have taken the time to reasonably figure out how much they’ll need to take that cruise to Alaska or keep them in prescription medications for 25 years or more speaks to just how invaluable retirement planning advice will be to this growing population of skeptical, unprepared workers.

Perhaps most depressing, the survey found that the percentage of workers who expect to retire after age 65 continues to increase, growing from 11% in 1991 and 20% in 2001 to a stunning 36% in 2011. Also, 74% of workers said they expect to have work for pay in retirement, more than triple the number (23%) of current retirees who are now working because they need the income. 

“Even those who have achieved the highest levels of accumulation already, with more than $100,000 in savings, won’t be able to maintain the lifestyle they’re currently enjoying in retirement,” Greenwald said. “High accumulators still haven’t come to that reality. And 70% of all workers say they’re behind schedule when it comes to saving for retirement.”

“The bigger problem is that most haven’t changed their behavior and turned this pessimism into action to catch up,” he said.

Kalamazoo County wellness success holds premium increases to zero 

 In an effort to curb rising dissatifaction and revolt by individual states, President Obama offered a compromise on Monday to states struggling to implement his health care law, offering support for a proposal that would give them some flexibility in carrying out its key parts.The Patient Protection and Affordable Care Act (PPACA) originally was designed  to lower costs and extend coverage to millions of uninsured Americans.  The law has divided Democrats and Republicans and handed states – more than half of which are suing over its constitutionality – a handful of bureaucratic challenges. The president acknowledged those issues during a meeting with state governors at the White House on Monday.  President Obama emphasized a part of the law that would allow states to tailor their own solutions to health care reform in 2017 if they fulfilled the same goals created by PPACA. “If your state can create a plan that covers as many people as affordably and comprehensively as the Affordable Care Act does – without increasing the deficit – you can implement that plan,” Obama told the governors. “And we’ll work with you to do it,” he said. 

More than half of the 50 states are suing to stop the plan in federal court, saying it usurps individuals’ and states’ rights, making it mandatory to purchase insurance coverage or pay penalties.

States must carry out many of the reforms, including establishing exchanges where individuals can buy health insurance. PPACA made more people eligible for Medicaid, the health care program for the poor that states operate with partial reimbursements from the federal government. When states balked at the huge price tag of larger Medicaid rolls, Congress agreed to pay 100% of the costs for new enrollees. Manystates are still concerned that they cannot afford to implement the plan after the financial crisis and recession induced an historic collapse in many states’ revenues. Additionally, Medicaid costs are rising as large numbers of laid-off workers turn to it for assistance (Medicaid on average takes up a third of states’ budgets).  Obama asked the governors to create a bipartisan commission to study ways to bring down costs. 

 Last week, the Health and Human Services Department announced a variety of grant programs to help fund state programs to review health insurance rates, pay for the administration of insurance regulation, and provide home healthcare to Medicaid enrollees.

Another benefit of self funding is that employers can avoid the increased costs associated with benefit mandates built in to the the Patient Protection and Affordable Care Act (PPACA).   Carriers are increasing their premiums to cover the costs of the increased benefits required by PPACA.   According to Aon Hewitt, premium increases will be, on average,         8.8% in 2011, the highest in five years.  

Self funded or co-operative plans will give employer groups the option to design their own plans to lower costs and maintain control over their benefit dollars.  A 2010  Kaiser Family Foundation survey found that these types of plans  sold for employers with less than 200 employees increased from 12% to 16% of the plans sold between 2008 and 2010, covering more than 70 million Americans.

A qualified benefits administrator will help an employer determine if this is the right approach for their employees, as well as funding options that would be beneficial to employ. 

While the state of PPACA remains unclear until all legal challenges are completed and all regulaltions implemented, it is clear that there will be a dramatic uptic in premium costs.   By exploring the options available through Self Funding or Co-operatives, it is possible for emplyer groups to regain control over their premum dollars and manage costs.

Four district courts have now heard challenges to the law, with two upholding the law and two ruling against it. Naturally, the judges deciding in favor of the law were both appointed by Democrats and the two ruling against it were appointed by Republicans. In all of the cases the central issue is the constitutionality of the individual mandate. Although the mandate’s infringement of personal liberty is what most upsets mandate opponents, the question the courts have focused on is the more mundane one of whether the mandate falls within the scope of the federal government’s power to regulate interstate commerce.

Under the Constitution, the federal government has only those powers specifically granted to it in that document, one of which is the power to regulate interstate commerce – known as the “Commerce Clause.” This authority has in the past provided the legal basis for a wide range of federal legislation. A key argument of the plaintiffs in the health reform legal challenges is that declining to purchase health insurance, which the federal government would penalize under the law, can’t be considered commerce because it doesn’t constitute activity of any kind. Someone who chooses not to buy health coverage is not engaging in commercial activity, they argue, and so is beyond the reach of the government’s regulatory powers under the Commerce Clause. In defense of the law, the government has argued that an individual’s failure to purchase coverage is economic activity because it’s a unique commodity.  Not buying coverage, they say, results in other Americans picking up the cost of their health expenses when they receive uncompensated care at an emergency room. Thus, failure to purchase coverage disrupts insurance pooling arrangements, causing higher costs for others, and so does represent commercial activity. 

A secondary, but hugely consequential, issue in these cases is what should happen to the rest of the law in the event that the mandate is deemed unconstitutional. On this point, the two courts ruling against the law parted company. Prior to the Florida court ruling, a Virginia District court found the mandate unconstitutional but also ruled that the rest of the law, including guarantee-issue and the other market reform provisions, should stand. Going way beyond his Virginia colleague, the Florida judge ruled the entire law invalid since it did not contain a severability clause – specific language stating that its provisions were severable and that if one should be stricken the others should nevertheless take effect.

The cases decided so far and others yet to come are all just a run-up to the final action, which will likely come within one to two years when the Supreme Court has its say on the matter. Unless and until the Supreme Court overturns any of its provisions, health reform will remain law.

We will keep you informed of any new developments.

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.

As so many American are leaving their jobs (voluntarily or otherwise), there is a need for alternatives to high priced COBRA coverage.  The best option in an individual plan.  There are so many options and plans available, and the task of finding the right one can be daunting.  These  tips can help you find a low-cost individual health insurance policy that fits your needs.

Find Out What’s Covered
 Before you choose a health plan, find out what’s covered. For instance, is your family doctor covered? What is the coverage for prescription drugs?  You want a health insurance policy that covers all your medical needs, so check the details before you buy.

Find Out What’s Not Covered
After you learn what’s covered, find out what ism’t. For instance, many policies won’t cover acupuncture or in-home nursing care. Others won’t cover treatment for depression, anxiety and other mood disorders.

If you have a specific condition that requires a specialist, make sure it’s covered under your prospective plan.

Choose Between an HMO or a PPO
For low-cost care, an HMO is best. HMO’s typically have low deductibles and co-payments, resulting in minimal out-of-pocket costs. However, HMO’s also require you to select an in-network doctor to coordinate all of your medical care, and you cannot visit a specialist without being referred by your primary care doctor.

PPOs, on the other hand, offer a much broader range of health care—but it comes at a price. Patients can see almost any doctor of their choice, provided they are part of the network. Plus, visits to specialists don’t require referrals. However, premiums and deductibles for PPO plans are generally higher than those of HMO plans.

Decide Whether You Want a Low Premium or Cheap Co-Pays
What’s better—low premiums or cheap co-payments? It depends entirely on your situation.

Healthy applicants who rarely visit doctors may opt for lower premiums and higher co-pays. However, those with chronic health conditions may save money with cheaper co-pays and higher premiums.

1. Lifetime Maximum Benefit
   A lifetime maximum is a cap on the amount of benefits you can receive, usually around $1 million. For most people that amount is adequate. However, if a chronic condition forces you into the hospital every few months, a $1 million cap may not be enough.
2. Make Sure Your Prescriptions Are Covered
   If you take prescription drugs, make sure your medication is covered. Many monthly prescriptions cost hundreds of dollars out-of-pocket, so make sure all your medication is covered before purchasing a policy.

Health insurance premiums can vary greatly by company—sometimes by as much as 50% for similar plans. So it pays to shop around.  Individual plan carriers can reject an applicant or increase the premium based on the health condions advised.

 Grandfathered Health Plans

The term “grandfathered plan” means an employer-sponsored health plan that was in existence on March 23, 2010. Grandfathered plans are exempt from some, but not all, of PPACA’s requirements. Employers can lose this grandfathered status if they make plan changes that significantly cut benefits or increase costs for employees. Employers with group health plans may change insurance carriers and still maintain their grandfathered status.

 Breaks for Nursing Mothers

Employers are to provide nursing mothers with reasonable breaks to express breast milk for their nursing children. Employers are required to provide these breaks for up to one year after a child’s birth and the breaks need not be paid. Employers are also required to provide a private space for expressing milk, other than a bathroom. 

 Age-26 Mandate and Pre-existing Conditions for Children

Effective with the first plan year beginning on or after September 23, 2010, employers providing dependent coverage are required to cover their employees’ adult children up to age 26, regardless of whether the child is a student, resides with the participant or is declared as a dependent on a parent’s income tax return. This provision does not apply to dependents that are eligible under another group plan. In addition, group health plans are not allowed to deny coverage to children under age 19 with pre-existing conditions.

 Rescission

Employer health plans are now prohibited from retroactively rescinding or canceling health care coverage, except in the case of fraud or intentional misrepresentation.

 Preventive Care Changes

Beginning in 2011, health plans are required to provide certain preventive care services without cost sharing, including some immunizations and annual or preventive exams for adults, infants, children and teens. In addition, patients can no longer be required to obtain authorization from a primary care physician before seeing an obstetrician or gynecologist.

 Lifetime and Annual Limits

Employer-provided coverage is now required to eliminate lifetime limits on essential benefits coverage, and may only place “restricted” annual limits on essential benefits for the time being.

 Over-the-Counter Medications

Beginning January 2011, individuals may no longer use funds from their Flexible Spending Accounts (FSAs), Health Savings Accounts (HSAs) or Health Reimbursement Arrangements (HRAs) for over-the-counter (OTC) medications unless prescribed. 

 HSA Penalty Increased

Effective January 2011, PPACA increases the penalty for withdrawing pretax funds from an HSA for non-eligible expenses from 10% to 20% in an effort to discourage unauthorized use.

Small Business Tax Credit

Health care reform provides for a tax credit for small businesses (those with fewer than 25 full-time employees and average wages less than $50,000) that provide employer-sponsored health insurance to their employees. Employers were able to apply for this credit beginning in 2010.

 Medical Loss Ratios

Beginning January 2011, health insurance companies are required to spend at least 80% to 85% (depending on the plan’s size) of premiums on medical care and quality improvements for patients.

 Health Insurance Exchanges

While exchanges are not required to be in operation until 2014, state health insurance exchanges have already received much attention. Many states have started to implement a state-wide insurance exchange system.

Businesses have complained that the new reporting rules would be too time-consuming for them to meet.  Baucus and Reid said this week they hope to pass a repeal of these rules with strong bipartisan support. They have attracted one Republican co-sponsor: Sen. Scott Brown of Massachusetts.

Last week, House Republicans passed a repeal of the overall health care reform bill, but an overall repeal of the health care reform law is not expected to go far in the Democratic-controlled Senate.

During his State of the Union address on Tuesday evening, President Obama indicated he was willing to fix the 1099 reporting requirements. “Now, I’ve heard rumors that a few of you have some concerns about the new health care law,” he said. “So let me be the first to say that anything can be improved. If you have ideas about how to improve this law by making care better or more affordable, I am eager to work with you. We can start right now by correcting a flaw in the legislation that has placed an unnecessary bookkeeping burden on small businesses.”

We will keep you apprised of any developments as they occur.

To date, 48 states and the District of Columbia have received planning grants of approximately $1 million each for HIEs, which are viewed as a key element of the Patient Protection and Affordable Care Act.

HIEs are designed to bring new transparency to the market so that consumers will be able to compare plans based on price and quality, giving American consumers insurance choices. They will also increase competition among insurers.

Those moving ahead with HIE plans can apply for multi-year funding. The option to states that are making progress in a step-by-step approach can apply for funding for each project year.

Private Health Insurance Cooperatives are also available as an option to HIE’s.

The current guidance modifies Notice 2010-59 and permits the use of FSA and HRA debit cards for OTC drug purchases provided:(1) a prescription is presented to the pharmacist;(2) the OTC medication is dispensed according to state prescribing laws and an Rx number is assigned;(3) records of the sale are maintained by the pharmacist and made available to the employer on request; and(4) the debit card system will not accept a charge for an OTC medication unless an Rx number has been assigned

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

As wellness incentives are now part of the Patient Protection and Affordable Care Act, this is a trend that should continue to gain attention.  According to a survey from the National Business Group on Health and Fidelity Investments, many employers have implemented these programs without first developing an integrated strategy that clearly outlines targets and goals.

The survey revealed three key findings:

1. Employers are investing in numerous health improvement programs.

2. Few employers set measurable goals or are able to calculate the return on their investment in these programs.

3. Employers underestimate the investments they make in health improvement programs.

The survey shows that employers have invested in an average of 21 different health improvement programs, administered by several different vendors.  Programs include disease prevention, lifestyle change, condition management and educational campaigns.

Employers are spending roughly the same on programs that help maintain and improve health, such as prevention and lifestyle efforts, as on programs that help manage health after onset of an illness or disease.

The challenge for employers is determining what the right mix of spending is. For example, a strategy focusing on condition management is logical if an employer has a large population that has particular chronic diseases or illnesses.  However, if the employer’s workforce is relatively healthy, then focusing more heavily on lifestyle modifications might be a wiser investment, considering the impact that likely lifestyle changes could have on the health of the workforce as it ages.

Measure The Program Goals

In the study 35% of employers indicated they have measurable goals and/or targets. As a result, few employers know the return on their investment across all their health programs, and many (42%) rely on a collection of vendor assessments to measure success.  As a result, it is difficult for employers to assess the success of their program.  Employers should consider determining the outcomes that they want before they decide on the programs. Knowing your intended focus should help to determine which types of programs you should implement.

Employers should include common sense metrics, such as number of health screenings, adherence to medications for chronic conditions or percentage of the population that is tobacco-free.  If you have a population with a high prevalence of a particular disease such as asthma, focusing on decreased emergency room visits among a constant population in the program is a logical program choice.

Track Your Investment

Accurately tracking the investment in health improvement is perhaps an employers greatest challenge, since many programs are often bundled with other services. The study quantifies the employer investment in health improvement, based on employer responses about which programs they offered and market data on the cost of these programs.

It is estimated that employers spend an average of 1.8% of medical claims on health improvement programs. These investments were consistent across companies of different sizes.

The 1.8% estimate represents the average level of investment that employers are currently making. However, the level and focus of investment that is right for one employer may not be appropriate for another employer, and individual company characteristics should be considered when deciding how to invest.

Investing in employee health has the potential to reap substantial benefits for employers, but there are numerous challenges – including coordination of multiple programs, communication to engage people in the program, and development of measurable outcomes and accurate financial calculations – that must be addressed before the best outcomes can be realized.

Employers who are able to identify desired outcomes, and implement strategies and programs to achieve these outcomes, will ultimately be the ones that see improvement in their workforce’s health profiles.

For additional information about implementation of Wellness Programs, please contact Gary Whiddon at (888) 474-6627 or at gary@hpo.biz.   Mr. Whiddon has received his well workplace certification from WELCOA (Wellness Council of America), and can assist you with any questions you may have.

Hello Amigos!  I have just returned from an eight day cruise on the Mexican Riviera.  Before you get too jealous, let me tell you I returned with a horrible case of the flu.   Feel better now?      

While on a bus tour of Mazatlan, our driver, Carlos, was speaking about many of the buidings we saw on our drive.  He mentioned the private hospital and the public hospital.  I already knew that  Mexico has socialized medical care for its citizens.  I asked Carlos why there were two hospitals and what were the differences.  He explained that the private hospital was for those people who could not wait at least a week for care or needed a greater level of medical care.  The public hospital was for “everyone else”.  Naturally, there were costs associated with using the private hospital.   

I found this really interesting.  I have Canadian relatives who do come here for medical care, since they do not want to wait for care under the Canadian system.  I have never heard about a private versus public hospital system in Mexico.  I have since done some research on this and have found that there are a few levels of care available to Mexican citizens based on their employment status.  While the quality of care on Mexico has improved greatly in the past 40 years, it still lags behind the care provided in the United States.  For those citizens who can afford the best care and those who want control over the care they receive, the private hospitals are an option.

So what did I learn on my winter vacation?  That there is no place like home.  They may have better weather and margaritas in mexico, but we still have a better health care system.  Yes there is still a long way we have to go in regards to our insurance and health care systems, but we are still better off  in this country than our neighbors to the South.  Viva USA!!

The annual survey, based on interviews with 805 California employee benefit managers,  includes the following findings:  

• Sixty-nine percent of California employers  offer health coverage, identical to the national rate.
• Health Insurance Premiums increased 8.1% in 2010, compared with a 1.8 percent increase in overall consumer prices.
• Since 2002, premiums have increased 134.4%, more than five times the 24.5% rise in California’s overall inflation rate.
• Single coverage premiums in California average $5,463 annually, a great deal higher than the national average of $5,049. Premiums for family coverage were $14,396.
• Twenty-four percent of the employers surveyed paid 100% of the employee premium costs.
• Twenty-eight percent of California firms either reduced benefits or increased cost sharing for employees in 2010 as a result of the economic downturn, up considerably from the 15% who did so in 2009.
• Four percent of California employers now say they are very likely to drop coverage completely, compared to just 1% as recently as 2008.

So what may happen in the future regarding health care for employees?  Some employers report that they are “very likely” to increase the portion of premiums paid by employees.  Four percent of respondents report that they probably will drop health coverage, compared with one percent of employers stating this in 2008.

For the complete survey click here

The Internal Revenue Service  released instructions on Friday December 19th to help employers implement the 2011 cut in payroll taxes that were included as part of the tax cut legislation passed by Congress, along with new income-tax withholding tables that employers will use during 2011. 

Notice 1036 contains the tax withholding tables and other information needed to implement the changes.  This notice, as well as Publication 15, the “Employer’s Tax Guide” should be available on the IRS website, www.irs.gov, by the end of this week.

Employers should start using the new withholding tables and reducing the amount of Social Security tax withheld as soon as possible in 2011 but not later than Jan. 31, 2011. Employees will not need to complete new W-4 forms for this change to occur.

We do suggest, however, that employers ask their employees to review their W-4 adjustments annually, in case their are changes to the family status that may effect the amount employees wish to withhold from taxes.

More information about the credit, including a step-by-step guide to claiming the credit and answers to frequently asked questions, is available on the affordable Care Act page at IRS.gov.

1. October 2010 – the application was completed online.   Long and complex.  On the plus side, easier to complete than most government forms.

2.  Telephone interview completed.  Confirmed that memory problems exist that were not requested on the application by virtue of having to try and remember every doctor visit for the last 10 years.  Telephone interview requested from 19 year old daughter.  Not sure if my friend wants to know about the daughter’s anwers on alcoholic beverages consumed….

3.  Called the unnamed carrier at the end of November for status.  Was advised that a request for medical records was issued at the beginning of November, but was not completed.  Doesn’t anyone follow up on these things???  My friend contacted her Doctor and had the records faxed to the carrier.  No help given by the carrier.  Thanks Dr. S.

4.  After a minor tantrum on the part of my friend the Broker, finally got ahold of a very nice person in underwriting who was able to expedite the application on a 3 day turnaround.   Received a verbal approval from the phone rep.

5.  The same day as #4,  received a letter requesting a signature for the 19 year old, and that her status was pended until this was received.  Made furious phone call to the unnamed carrier requesting clarification.   Faxed requested signature.

6.  Received call from Copy Service assigned by carrier for medical records faxed over 2 weeks ago.

7.  Called the next business day and spoke to a very nice rep named Rachel (my friend promised her a favorable mention in the blog)  who informed the red faced and frustrated applicant that it will be another 15 days at most until the signature is reviewed and processed.

In case you haven’t guessed by now, the frustrated applicant is me, and this is my tale of woe.  In the grand scale, this is a minor mess and will be resolved.  However, as I was going through all of this hassle I kept wondering how an applicant without knowlege of the system and having the leverage that a broker has deals with all of this.  Surely my experience can’t be all that unique.  In spite of the unfavorable reputation of brokers today (think of the movie Groundhog Day), we do serve a valuable purpose to insureds, and potential insureds.  We can save others from dealing with the messes dealt by the carriers.  We can save you the time and frustration of dealing with applications, benefit and claims questions.  We can help you, based on the experience ank knowledge we have of the industry. 

Isnt it better if we are red faced and frustrated and not you?

So what does this mean for consumers?

It is said in the industry that the more likely an event is to occur, the harder this is to insure.  In plain english (as my Mother used to say), this means that Met Life stopped selling the plans because of the high likelyhood that consumers will need to have long term care assistance.  This also means that us baby boomers will face the probablility that we will need to have either an LTC plan or a great deal of money in reserve for expenses related to aging. 

According to government figures, at least 70% of people over age 65 will eventually require some form of help with personal care such as dressing or using the bathroom and 40% will need a nursing home. Nursing homes now cost $80,000 a year on average. It is estimated that future costs vary widely, but may be around $250,000 for a 65-year old couple retiring today. Charles Farrell, an investment adviser with Northstar Investment Advisors in Denver, Colorado, calculates that a 55-year old couple should plan on a million for insurance costs and two years in a nursing home for two.

Given that one insurer has already “retired” (pun intended) from selling LTC care, we anticpate others may follow suit.  They cannot rescind policies already in effect. 

So what does this mean for you and I?     My daughter always tells me that she will put me in a nice nursing home when I am old(er).  She is, of course, kidding me, I hope.  If you dont have $250,000 or more in savings dedicated to future health needs it is in your best interests to contact your financial advisor to discuss LTC coverage.

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.

Prior to this ruling, any health plan that changed carriers after March 23, 2010 lost their Grandfathered status, meaning that provisions of the PPACA must be applied to the new plan.  This could result in greater premium charges due to benefits that must be impletmented under the law.   Under the new ruling, plans that retained similar benefits under a new carrier for premium savings would not lose their grandfathering status solely as a result of the change in carriers.

For complete information please refer to the Department of Labor website at http://www.hhs.gov/ociio/regulations/grandfather/factsheet.html

Parents can buy it for themselves to cover the costs for a lengthy nursing home stay, for assisted living or for a health aide at home a few hours each day.  Adult children of parents whose income is limited could buy policies for their parents in order to cover the expense of their parents future care.

Should be easy, but consumers aren’t purchasing the coverage.  According to the New York Times, there were fewer new individual buyers of the insurance in 2009 than in any year since Limra, a market research firm, began tracking the data in 1988. It was also the first year that the number of existing policies did not increase.

• Over-the-counter (OTC) medicines and drugs will no longer be eligible for tax-free reimbursement from an HSA without a doctor’s prescription. This includes pain relievers, sleep aides, and cough medicines.
• Certain OTC purchases, such as insulin, bandages, and medical devices, continue to be eligible for tax-free purchase from an HSA without a prescription. Accountholders should always keep their receipts and save doctor’s prescriptions for OTC purchases with their tax records.
• The tax penalty for non-qualified distributions from an HSA will increase from 10 percent to 20 percent (for accountholders under age 65 and not disabled).
• Family insurance coverage may be extended to children up to age 26 but HSA distributions can only be made for qualified expenses incurred by tax dependents. If a tax dependent is listed on an accountholder’s federal income tax, typically their qualified expenses can be paid from the HSA.

2011 contribution limits

The Internal Revenue Service (IRS) 2011 annual contribution limits for HSAs are the same as the 2010 annual contribution limits. The 2011 minimum deductible and maximum out-of-pocket limits for HSA-compatible health plans also remain unchanged.

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

What is the best way to get rid of old or unwanted medications?

It is not recommended that you either flush them down the toilet or down the sink drain.  Modern water treatment plants are not fully designed to deal with medication disposal. The long-term health risks posed by consumption of even minute quantities of these medications in drinking water and the full extent of environmental damage remains unknown. 

It is also not a good idea to throw them in the trash.  Safety experts strongly discourage throwing old medications into the trash where your children or pets can find them. Your trash will end up in a local landfill, where your medications could still have the potential to leach out.   Instead, many municipal or local trash services now have local household waste facilities where you can safely drop off your medications for incineration. Call your local trash service for options in your area.

There may be hazardous waste disposal facilities or drug recycling programs in your area.  Look online for this information. You could also contact your local pharmacy or physician’s office to see if they have disposal facilities available.

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!

No Change In Contribution Amounts from 2010

What Is changing effective January 1, 2011?

• Over-the-counter medicines and drugs will no longer be considered a qualified medical expense.
• The penalty for using HSA funds for other than a qualified medical expense increases from 10% to 20%.

The Treasury Department and the IRS have determined that this relief is necessary to provide employers the time they need to make changes to their payroll systems or procedures in preparation for compliance with the new reporting requirement. The IRS will be publishing guidance on the new requirement later this year.

The draft IRS form can be accessed at: http://www.irs.gov/pub/irs-utl/draft_w-2.pdf

The passage of the PPACA Health Reform could cause a loss of grandfathered status for plans that were in effect as of March 23, 2010 due to the following conditions: 

• Increase in employee contributions that are greater than 15% plus inflation
• Decrease in employer contributions by more than 5%
• Increase in coinsurance or copays that are greater than 15% plus inflation
• Reduction in or addition of annual dollar limits  

The passage of the PPACA Health Reform will affect plans renewing and effective after September 23, 2010.  If you have a plan that is renewing after that date your plan could lose its status as a grandfathered plan if there is a:

• Change in carrier
• Purchase of or merger with another plan to avoid compliance 
• Elimination of benefits to treat a specific condition

 Why would any group want to keep its grandfathered status?  Remember benefits that must be implemented due to PPACA Health Reform are not required to added prior to 2014.  Retaining grandfathered status to 2014 may prevent a larger increase in premiums due to benefits that must be added and restrictions that must be eliminated, which will probably increase the costs of the health plan.  Additionally grandfathered plans are not subject to discrimination rules, meaning higher levels of benefits for certain classes of employees can still be allowed. 

 Parts of the Health Reform legislation will be implemented over the next few years, with all plans to be in compliance by 2014.  It is highly unlikely that groups will be able to retain their grandfathered status until 2014, as increases in premiums and changes to employee expectations will force change.  For any renewals prior to 2014, carriers will most likely ask the employer to sign a letter verifying their status as either grandfathered or non-grandfathered. 

Certain changes must be made to all plans, regardless of grandfathering status, as of renewals after September 23, 2010, including: 

• Elimination of Lifetime Benefit Limits
• Elimination of annual limits for specific benefits, such as durable medical equipment
• Elimination of pre-existing condition limitations for children to age 19
• Children to age 26 must be considered as eligible dependents, unless they are covered by their employer plan
• Reporting the dollar value of benefits on an employee W-2

 Some of these changes have recently been signed into California state law by Governor Schwarzenegger.

 Please remember that all the legislation will be subject to revision as changes in Washington transpire.  We will, as always, keep you informed of changes as they occur.

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)

Having completed Level 1 and Level 2 training,  I plan on completing the last Level 3 courses before the end of the year.

As health insurance costs continue to rise, employers will place more emphasis on controlling future costs through wellness.  Moreover, in 2011 our government will be providing eligible firms “wellness grants” to promote wellness in the workplace.  This means that employers will look to find capable individuasl to help them build and monitor an ongoing wellness program.  A “results oriented” program instead of a “passive join 24 hour fitness if you want”.

Low participation does little to change health care costs, so employers must provide “financial incentives” to employees who reach their goals.  Employees will not be forced into a wellness program, but financially encouraged.  Since healthy lifestyles to not change overnight, employees will have to be educated  on an ongoing basis about diet, exercise, stress, smoking, obesity, plus benchmark their current way of life to show measurable lifestyle changes from participating in a wellness program.

Healthier employees do reduce health claims, workers’ comp claims, and sick days.  What about offering time off for “health days”, instead of “sick days”?  Get involved with wellness with me!

 What can be done for children who need              insurance now???

 For those children who are currently covered by a child only health plan, they will remain covered as long as premium payments are made on a timely basis.  The carriers will not rescind coverage.  For those children who will need coverage as of 9-23-10, Legislation has recently been passed in California that would block California insurers from denying coverage to children with preexisting conditions, but would let them charge significantly higher premiums to those who don’t sign up during open enrollment periods each year and impose surcharges on those who try to abuse the system by dropping coverage when children are healthy. This legislation would limit how much children with preexisting conditions would have to pay if they signed up during open enrollment.  Carriers that refuse to participate would face penalties.

 This bill, AB 2244, is pending signature by Gov. Schwarzenegger. He is expected to sign the bill.

Your help is urgently needed now! There are two bills pending now in the state legislature that would establish the California Health Benefit Exchange.  If signed into law, these bills, AB1602 and SB 900, could create major problems with the individual and small group markets in our state as well as cripple consumer choice and negatively impact our state’s already chronic budget deficit.

This pending legislation gives the California Exchange Board the authority to create the structure of the new agency with little guidance and no legislative oversight or accountability. This Exchange would:

·         Exempt senior staff from the state’s civil service laws, regulations and pay caps.

·         Provides no fiduciary duty to the Board or senior staff and allows them to make decisions without personal liability for their actions for an agency that could potentially handle coverage for 4-9 million Californians and premiums of $20-$40 billion annually.

 ·         Allows the Board to act without transparency and exempts the Exchange from the California Public Records Act and Administrative Procedures Act. 

 ·         The Board can meet in private and adopt rules without public comment and enter into contracts without following state procurement guidelines.

 ·         Allows the Board to establish a budget and raise revenue through assessments outside of the normal legislative budget process or controls.

 ·         Allows the Board to select how many and what kind of insurance products individuals and businesses may purchase.

 We urge you to contact Governor Schwarzenegger to oppose passing this legislation!  Please click  here to let our State Government know this legislation is NOT in the best interest of California citizens!

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.

Below are some ideas to help you work with your employees in creating a plan to help them WANT to adopt a healthier lifestyle.:

1. Create a sense of urgency. This is really the best way to start any program for change.  If you forcast your own company’s health care costs for the next 10 years using current trends, including the additional cost of complying with the health care reform., this will definitely show you that this is a program that shouldn’t be excluded.

2. Set up a guiding coalition.  In order for a wellness program to be successful, the management and leadership of the Company MUST believe in the benefits of a wellness program for all employees.

3. Develop a vision and strategy. Ask yourself what you want to accomplish and how you plan to initiate change.  A few samples questions are below:

* How have your employees’ behaviors changed?

* What foods are being offered in the canteen and in nearby restaurants?

* Are coworkers meeting over lunch to exercise?

* How has the changed work environment impacted you personally?

* Do you more effectively manage your own biometric values?

* How do employees use the benefits provided by the company and where do they find the best medical service at the lowest cost?

* Who is in charge of your health and well-being now?

4. Let your employees know what you want to change. Now that you know what you want to accomplish, let your employees know too!  Remember, nothing can be changed without awareness and cooperation.

5. Take action. Remove the barriers in place in order to start the process.  Look at the long range picture and gaols.  For example, there may be costs associated with promoting a healthier lifestyle, such as higher costs for healthier food in the vending machines, or the charges from a fitness trainer.  Ultimately, these costs will be less than they costs assicated with inactivity and obesity.

6. Look for gains but know that this may take time.  Creating a healthier lifestyle and seeing the results may take time.  There may be some measurable short term goals that you can find and promote in order to retain the momentum.  For example, can you track weekly weight loss?

8. Keep Going! Long-term success can only be accomplished if you continue to work on maintaining the successes you have achieved. 

A true measure of the creation of a culture of health is when the majority of the workforce is maintaining healthy lifestyle choices even in the absence of any company initiatives or incentives.

Adopting a healthier lifestyle benefits everyone in the workplace.  Employees are in better health, feel happier and are more productive.  As an employer you will benefit from the increase in productivity and the decrease in medical plan and Workers’ Compensation plan costs.  This truly is a benefit plan where EVERYONE benefits!

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.)

Like many, you may be wondering what impact the recently passed health care legislation will have on wellness promotion. In this exclusive interview, WELCOA President Dr. David Hunnicutt sits down with   Dr. Michael O’Donnell to discuss this issue.  Dr. O’Donnell covers the short and long-term benefits of the legislation as well as what health promotion practitioners and business leaders can do to prepare for the upcoming changes.

To access your copy at no charge, simply visit this WELCOA link.

The Pre-Existing Condition Insurance Plan exists to address “the challenges of people with pre-existing conditions… In general,” HHS said, “high risk pools provide coverage of last resort for people who, because of their health, are denied coverage by private insurers or are unable to purchase coverage in the individual market except at substantially surcharged premiums due to their health status, and are ineligible for public coverage.”

Currently, 35 states have high risk pools, which provide coverage to about 200,000 individuals, or about one percent of the individual market nationwide.

Key issues addressed in the interim final rule include:

Eligibility – Eligible individuals must:

• Be a U.S. citizen, a U.S. national, or be lawfully present in the U.S.
• Not have had insurance coverage for the previous six months.
• Have a pre-existing condition that an insurer refused to provide coverage for, or have a rider that excludes coverage for that condition.

Premiums – Must be set so they:

• Equal the standard rate for anyone in the population with the same health conditions.
• Do not vary by age by more than 4 to 1.

State role – States are given flexibility in how to implement high risk pools.

• They may operate a new high risk pool alongside their current state high risk pool.
• If they don’t already operate a high risk pool, they may establish a new one.
• They may build on other existing coverage programs designed to cover high risk individuals.
• They may contract with a current HIPAA carrier of last resort, or another carrier, to provide subsidized coverage.
• They may do nothing, in which case HHS will provide a coverage program.

Funding

• The law appropriates $5 billion in federal funding to support this program.
• The formula for allocating funds to each state is “almost identical” to what was used for the Children’s Health Insurance Program (CHIP): a combination of factors, including nonelderly population, nonelderly uninsured and geographic cost.
• Also like CHIP, funds will be reallocated after no more than two years, based on an assessment of actual enrollment.

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.

Future health care costs are affected by today’s lifestyle.  Since I have felt a responsibility to my clients, I realized the need to become a Wellness Facilitator during the next decade of my work.  Adopting “result oriented” wellness progarms will be recognized as a productive way to reduce future health insurance costs.

To truly help employers, I felt the need to learn as much as possible about implementing and managing workplace wellness.  WELCOA University provides three levels of  wellness certification, and is recognized as the place for wellness education.  Level 1 is now completed and I am pursuing Level 2.  If you have any questions about wellness or would like to set up a wellness program for your firm, please call me at (888) 474-6627 x116.

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.

In a study conducted by StayWell Health Management, a health promotion vendor, employee participants who completed a telephone-based health coaching program lost an average of 3 pounds, compared to 1 pound for those who did not complete the program.  Additionally, employees who followed the advice offered in the health coaching program were more likely to improve their overall eating habits and their physical activity levels.

In the study, the company examined the benefits of long-term weight management versus short-term weight loss. The final study sample size included 1,298 participants from 10 different employers and focused on clients who offered programs between 2004 and 2006.

Health experts believe that individuals who want to lose weight should focus on a lifetime goal of healthy eating and exercising and not on weight-loss challenges and programs aimed at dropping pounds over a short period.  Even a small amount of weight loss can contribute to an improvement in health, such as lower blood pressure and decrease in wear on knees and back.

StayWell points to hardware store giant Lowe’s Home Improvement as an example of how a health coaching program can promote weight manangement.

The company, which employs about 240,000 workers, rolled out a health coaching program that offered phone-based, mail-based coaching or a six-week interactive program to help workers identify and change unhealthy behaviors.  A total of 3,461 pounds was lost by participants with an average weight loss of 9.25 pounds per person; and the average body mass index among all participants decreased from 35.3 kg/m2 at pre-assessment to 33.9 kg/m2 at post-assessment; a decrease of 3.9%.

The recent Health Care Reform legislation offers a financial incentive of 30-50% off premium costs to employees for participation in approved wellness programs beginning in 2014.

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 Preventative Services include: 

Evidence-based preventive services,  such as breast and colon cancer screenings, screening for vitamin deficiencies during pregnancy, screenings for diabetes, high cholesterol and high blood pressure, and tobacco cessation counseling. 

Routine vaccines: those recommended by the Advisory Committee on Immunization Practices ranging from routine childhood immunizations to periodic tetanus shots for adults.

Prevention for children: including regular pediatrician visits, vision and hearing screening, developmental assessments, immunizations, and screening and counseling to address obesity and help children maintain a healthy weight as recommended under the Bright Futures guidelines, developed by the Health Resources and Services Administration with the American Academy of Pediatrics.

Prevention for women: Health plans will cover preventive care provided to women, with final guidelines for services covered to be issued by August 1, 2011.

I wish we all had thought about what might have happened to him well in advance of his final years.  I regret that none of us considered getting long-term care insurance before he could longer complete ordinary, daily living activities such as bathing, using the bathroom, preparing meals, and following medical directives — including taking prescription drugs.   We found out that paying for help with these activities can be very expensive. I know that my dad felt horrible that he, and by extension our family, was in this situation.  None of us think about aging and illness.  The fact is that we all get older, and most of us wind up with health issues as we age.  I strongly believe that everybody needs to have a plan  to address the possiblity of long-term care expenses.

Why would anybody possibly need long term care?   

When my parents moved to Florida they were in their sixties, and reasonably healthy.  My father’s health worsened as he entered his seventies.  My mother did the best she could to help him, and I came from California as often as I could to give her respite.  But I had my own children to care for and a job, so I was unable to help as much as I would have liked.  There were no other close relatives nearby to help.  After a few years of this, my father’s numerous medical conditions became too difficult for my mother, and we were faced with the difficult decision of how to best care for my dad.

A report last year by the National Alliance for Caregiving in collaboration with AARP found that just one in five caregivers had their care recipient living with them. So unfortunately, formal long-term care may be the only solution for people whose health has deteriorated and who have no family nearby.

Medicare will pay limited benefits for a nursing facilty following a hospital stay.  They do not pay for care facilities that help with common activities like dressing, bathing or using the bathroom.for long-term care expenses.   Since my parents didn’t have Long Term Care insurance, they had no choice but to apply for Medicaid to cover his expenses.    There are financial requirements and benefits can be hard to obtain. Moreover, Medicaid laws vary from state to state

Insurance company statistics advise that two-thirds of people aged 65 and over will need long-term care in their lifetime.  When my parents moved to Florida they certainly didn’t think my dad would be one of them.  Most of us don’t think about that real possibility – until they are actually in need of care.

Why buy Long Term Care insurance??

Because we all age.  Because most of us become less healthy as we age.  Because we all want to have control over the quality of our medical care.  Because none of us want to leave our children with  the regret and guilt of not being able to care for our parents.

Our new health reform bill focused on providing coverage to the uninsured, who account for $56 billion annually in  uncompensated care.  Three quarters of that care is financed by the government.  The remainder is paid by charity and cost-shifting to private health plans.  Hospitals demonstrate “cost-shifting” as well as anyone, they lose money on medicare and medicaid patients so they over charge private health plans to make up the loss.  If you are covered by a private health plan like me,  we are paying more that we should, and we may even pay more as the government further reduces what medicare and medicaid will pay doctors and hospitals.

To download the full report click here.

• Premiums
• Benefits to comply with changes in state or federal law or PPACA
• Changes to provider network or prescription formulary
• Changes to third party plan administrator
• Changes to plan structure, i.e. switching from insured to self funded

 Increases in co-insurance percentage, changing insurers, employee contributions by more than 5% or elimination of benefits to treat a particular condition are among the changes that would cancel a plans grandfather status. 

 For a full list please refer to: www.healthcare.gov/news/factsheets/keeping_the_health_plan_you_have_grandfathered.html – 47k – 2010-03-23

DON’T WAIT UNTIL THERE IS AN EMERGENCY TO FIND A DOCTOR

Maintaining a  relationship with a primary care doctor going for routine visits is the best way to stay healthy and avoiding the need for emergency care.  There are low cost or free clinics, check with your community or city health care system for more information, or look online at http://findahealthcenter.hrsa.gov/.  If you lost insurance coverage, tell your physician about the change in your status and perhaps discounts can be negotiated for cash payment.

EMERGENCY ROOM VISITS

Please use the ER only for true life threatening emergencies.  For routine medical care, please go to a physician’s office or urgent care center.  Emergency rooms are higher in cost for routine care.  If you must visit the ER, please contact the billing department of the hospital as soon as possible after the visit to ask them to renegotiate the billing for cash payment, or to set up a payment plan.

CHILDREN ONLY HEALTH COVERAGE

The federal government and some states, including California, offer coverage for children when their parents cannot afford private coverage.    There are income qualifications that have to be met.  For more information go to: http://www.insurekidsnow.gov/.

PRESCRIPTION DRUGS

Your physician may be able to provide you with samples of prescribed medications.  Community medical clinics may also have low cost medicines. Pharmaceutical Research and Manufacturers of America, the drugmakers’ trade group, provides free and low-cost drugs through its Partnership for Prescription Assistance http://www.pparx.org/. Individual drugmakers often have their own programs that offer free or reduced-cost drugs as well.

 What is a Cooperative (Co-op)?  It is an option to offer health insurance as a competitive alternative to the government run exchanges.  Co-ops are owned by the people who have their insurance with them, called “member-owned.” They are health insurance organizations owned by the patients they insure. They are comprised of thousands of members, meaning the costs of care get spread out across all those people, and this allows them greater bargaining power with providers. Since co-ops are not interested in profits, their costs are real costs, and not inflated by administrative costs. Additionally, because co-ops only collect what they spend, they have no tax liability, keeping costs even lower.   

A 3^rd party administrator is hired to oversee the plan, so employers would not have to handle claims, contracts or network negotiations.  According to the New York Times, Cooperatives for health insurance started in the 1930’s and were dominant in the Midwest.  In fact, Congress actively supported Cooperatives but withdrew support at the time insurance companies as we know them today were formed.

 For more information on Cooperatives, please contact Gary Whiddon at Health Plans Online.  Mr. Whiddon can be reached at (888) 474-6627, ext. 116 or gary.whiddon@healthplansonline.com.

No Pre-Existing Condition Exclusions for Anyone Under Age 19  

Plans are prohibited from denying coverage to anyone under the age of 19 based on a pre-existing condition. This ban includes both benefit limitations and coverage denials. These policies apply to all individual market and group health insurance plans. The requirement will be extended to all ages starting in 2014. Grandfathered individual plans are exempt from this requirement.

No Arbitrary Rescissions of Insurance Coverage

Insurers and plans will be prohibited from rescinding coverage – for individuals or groups of people, except in cases involving fraud or an intentional misrepresentation of material facts

No Lifetime Dollar Limits on Coverage

 Insurers and employers are prohibited from imposing lifetime dollar limits in all health plans and insurance policies issued or renewed on or after September 23, 2010.

Restricted Annual Dollar Limits on Coverage
The rules will phase out the use of annual dollar limits on “essential health benefits” over the next three years until 2014 when the Affordable Care Act bans them for most plans. The limits can only apply to essential health benefits; however, the rule does not provide any further detail on the definition of “essential health benefits” beyond that provided in the law.

• Plans issued or renewed beginning September 23, 2010, will be allowed to set annual limits no lower than $750,000
• Beginning September 23, 2011, minimum limit will be raised to $1.25 million
• Beginning September 23, 2012, minimum limit will be raised to $2 million
• Beginning January 1, 2014, all annual dollar limits on coverage of essential health benefits will be prohibited

These limits apply to all employer plans and all new individual plans, not grandfathered plans.  For more details and clarification, please refer to the HHS website at www.healthreform.gov.

Starting June 1, 2010, the newly unemployed aren’t eligible to get the subsidy at all. The proposal to extend subsidies to those laid off through the end of the year is languishing in Congress, a casualty of worries about the deficit in an election year.  Congress extended the subsidies four times since February 2009, but the latest effort stalled before the Memorial Day recess. Congress may again consider extending the subsidy when members return next week, but it’s unclear how long such a proposal would take to make its way through Congress and what support there would be for it.

So what you do now if you are newly unemployed?

• Remain on COBRA, paying the full cost;
• Condsider state HIPAA eligible plans; each state offers one for people with pre-existing conditions whose coverage on COBRA has expired.  The premiums are often very expensive, and in order to qualify people must meet exacting criteria- They must have had COBRA for 18 months, have been covered the entire time, have a pre-existing condition that would preclude them from getting other coverage and must be able to pay the higher premium such a plan would charge;
• State Funded assistance plans such as Medicaid or Healthy Families (subject to qualifications);
• Individual plans, it is suggested that you price the plans available in the marketplace to determine if one may be more affordable than COBRA. 

You may be able to combine any of the options above, for example, individual plans for some family members and COBRA for others.

One option we do not suggest is not having any health coverage.  In the event of an illness or accident, you are exposing yourself to a great financial risk.  This would be far more expensive in the long run.

The future of the subsidy is in doubt.  Should the ARRA subsidy be extended again, we will advise.

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.

Douglas Holtz-Eakin

Former CBO Director Douglas Holtz-Eakin comments on Obama Health Reform Costs in this must see video http://tiny.cc/holtzvideo.

The 2010 Milliman Medical Index (MMI)* has been released and shows that American families are paying more for their health care. The total medical cost for a typical family of four is $18,074 in 2010. That’s about $1,300 more than 2009. This is the highest dollar increase seen in the last 10 years since the index was created. While there are many factors to consider, the report reveals that these rising costs are largely driven by increases in the underlying costs of care.  

According to the report, “most of the hospital and physician cost increases identified in this year’s MMI have been driven by average unit cost, not utilization, which frames the effort to control costs.” Average unit cost reflects the negotiated charge for each service, as well as the mix of services delivered. This may be one reason the report suggests that “provider/payor negotiations will be more visible and intense in the reform environment and as regulators put more pressure on the premium rate-setting process.”  

Here are other key findings and observations:  

• This year, there was an increase in cost trend for inpatient and outpatient facilities, and a decrease in cost trend for physician, pharmacy and other services.
• Inpatient and outpatient facility services combined represent 48% of total annual medical costs vs. 47% in 2009. 
• The largest dollar increase this year was for inpatient facility care, which increased by $498.
• The 2009 to 2010 hospital inpatient annual rate of increase grew from 7.7% to 9.8%; most of the inpatient annual rate of increase is driven by “average unit costs.”
• Although physician costs are the largest component of the overall health care cost pie, their 2010 annual rate of increase is lower than that of other health care costs components. 
• There is large variation in health care costs across geographic regions. Costs vary from low to high by more than 35%, with the lower-cost areas generally being in the West and across some parts of the South.
• At $10,744, the average employer’s share of the cost nationwide for the typical family of four now surpasses $10,000 for the first time. 
• With reform now in place, some short-term reforms may shift costs further from employees to employers.
• Despite passage of federal health reform, the underlying drivers of increasing health care costs are not expected to immediately change.   

For more details, take a look at the 2010 Milliman Medical Index.

*The Milliman Medical Index is published annually by the respected global actuarial and consulting firm Milliman Inc. to report total annual medical spending for a typical American family of four covered by an employer-sponsored PPO. The MMI looks at key components of medical costs and charts the changes in these components over time, including cost changes for employers and employees. The MMI also includes results for 14 major American metropolitan areas to demonstrate the variance in medical costs by region.

 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.

As Medicare only covers limited nursing home care, many people are ill prepared for expenses relating to extended care following illness or accidents.  Only about 7 million people in the U.S. have purchased Long Term Care coverage.

 The CLASS program (Community Living Assistance Services and Supports) is not limited to the elderly.  Anyone who elects the payroll deduction can enroll and draw benefits.

The health care reform law requires the Department of Health and Human Services to set up a new, voluntary long-term care insurance program to take effect in January 2011. Participants will sign up through their employers, and the monthly premiums will be collected through payroll deductions.

After five years of enrollment, the policyholder will be eligible for benefits, regardless of age.  The program will not pay for the entire cost of nursing home care, which in some areas can reach more than $70,000 a year. Instead, it will pay cash benefits of $50 per day or more, depending on the degree of disability.

This is probably inadequate to fund possible future needs.  We recommend discussing additional coverage with your financial planner, or contact our office at (888) 474-6627.

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.

 Details of the PPACA are slowly being released and this week, the U.S. Department of the Treasury clarified that the tax credit will be extended to the dental and vision coverage as well as medical.

 All small businesses with fewer than 25 full-time employees earning less than $50,000 average annual wages and cover at least 50% of the employee-only monthly premium are eligible for the credit (dependent costs paid by employer are NOT part of the tax credit). 

 Employers who do not currently have group insurance in place can add it any time during 2010 to receive the tax credit.

 In order to promote wellness and decrease the costs associated with preventable illness, Congress has enacted the following legislation as part of the Health Reform Legislation: 

• Starting in September of 2010, Medicare, employer‐sponsored (and other) group health  plans and  health insurance issuers are prohibited from requiring co‐pays for certain  preventive services, such as cancer and mental health screenings and immunizations; 
• Beginning in 2014, certain most individual, employer and health insurance Exchange plans must cover “essential heath benefits”.  The Secretary of Health and Human Services (HHS) is to define the essential health benefits, however such benefits are required to include certain general categories, including: emergency services, hospitalization, maternity and newborn care, prescription drugs, laboratory services, mental health services, preventive and wellness services and chronic disease management(PPACA, Sec. 1302) 
• Previous legislation allowed employers to reward workers who maintained a healthy lifestyle via participation in wellness programs, such as smoking cessation and fitness programs, with reductions in premium.    Starting January 1, 2014, group health plans may give reductions of up to 30% of the cost of premiums to employees who voluntarily participate in wellness programs. This may be expanded to 50% subject to the discretion of the Secretary of Health and Human Services

  For additional information on this legislation,  please refer to the Democratic Policy Committee Senate website at http://dpc.senate.gov/healthreformbill/healthbill75.pdf

This information is subject to additional information/clarification from a Carrier.

Note that this would not include reinstatement of dependents who previously aged out of their plan. It also does not affect dental, vision, standalone pharmacy or other benefits.

For individual and small group medical plans (as defined in state law), Aetna will continue coverage effective June 1, 2010 for dependents under age 26 currently covered on a parent’s medical plan. Aetna will not change the plan’s premium until renewal.
For fully insured larger groups, and for all self-funded medical plans, Aetna will offer the option of expanding medical coverage for dependents under the age of 26 currently covered on a parent’s medical plan, effective on or after June 1, 2010. This would include dependents who would have aged out on May 31, 2010. Aetna will provide pricing for this plan design change, as appropriate, for plans that choose this option.

Blue Shield of California will allow existing covered Blue Shield dependents up to age 26 to remain on their parents’ plan starting June 1, 2010. This applies to IFP (Individual and Family Plans) and group coverage.

The extension applies to dependents covered on a Blue Shield plan who are scheduled to age out of their parent’s plan (or no longer full time student) as of June 1st or later. Blue Shield is not offering this extension for new dependents that enroll June 1st or later. This extension of coverage applies only to those who currently have Blue Shield coverage and would lose that coverage during the gap between June 1st and the effective date of the new law.

Blue Shield will not allow re-enrollment of dependents that have already dropped off the plan. If a dependent is not currently covered (as of June 1, 2010) by Blue Shield of California, he/she is not eligible for the continuation of dependent coverage to age 26. All other dependents will be offered this coverage when the new law takes effect beginning on or after September 23, 2010.

Employers have the option of continuing coverage for adult dependents up to age 26 who are currently enrolled on their parents’ health care policies.

The option of keeping adult dependents on their parents’ policies is effective immediately.

UHC will extend health coverage that graduating college students have under their parents’ fully insured plans until the new health reform provision requiring dependent coverage up to age 26 is fully implemented.The dependent college graduate must not have access to other employer-sponsored coverage. For fully insured members, if dependent spouses of graduating college seniors are covered under an existing UnitedHealthcare policy they are eligible for continuing coverage.

This offer to extend coverage applies to students who currently are covered under their parents’ fully insured plans through UnitedHealthcare, as well as those covered under UnitedHealthcare’s Golden Rule individual family health plans. UHC will work with fully insured clients to carry out the extension of coverage and to make sure these young adults have health coverage available to them. UHC will also work with self-funded customers to determine if they are going to offer this benefit to graduating seniors. Individual health plans from Golden Rule Insurance already allow all dependents to stay on the plan until age 26, so no action is necessary for those health plan enrollees.

Following is excerpted from the the Kaiser Family Foundation about Dependent Child coverage: http://healthreform.kff.org/

The health reform law will allow qualifying young adults whose parents have private group and non-group health coverage to remain on their parents insurance policy up to age 26. Both married and unmarried young adults can qualify for the dependent coverage extension. The law also specifies that young adults can only qualify for dependent coverage through group health plans that were in place prior to the dependent coverage provision taking effect if they are not eligible for another employer sponsored insurance plan. The Secretary of Health and Human Services will issue regulations that will further define who will be considered a dependent eligible to remain on a parents health insurance policy and will answer the following questions:

• Can working young adults qualify?
• Do qualifying young adults have to live in the same state as the parent whose insurance will be providing the coverage?
• Are you adults required to be students in order to qualify?
• Can married young adults qualify for he extension for dependent coverage through their spouse’s parent’s plan?

The dependent coverage extension takes effect on September 23, 2010. At that time, when insurance plans start a new plan year, they will have to abide by the new dependent coverage rules . The law stipulates that the dependent coverage extension is effective for new plans years beginning on our after September 23, 2010. Regulations that will be issued before the provisions takes effect in September 2010 will provide further clarification regarding enrolling in extended dependent coverage.

http://healthreform.kff.org/

 Insulin and all health related supplies (such as syringes) will continue to be an eligible expense.  Any OTC for which you have a physician’s prescription or letter of medical necessity will be covered as an exception.

According to a recent study, this change in law regarding FSA eligible expenses will not greatly impact the reimbursements for and tax advantages of FSA enrollment, as there will most likely be other expenses that could be used to fill any void. 

If you are enrolled in an  FSA or Health Savings Account, Health Reimbursment Account , please contact your health insurance broker or employee benefit advisor for information, or contact our office at (888) 474-6627.

The February edition of the journal Health Affairs says:

“Amid soaring health spending, there is growing interest in workplace disease prevention and wellness programs to improve health and lower costs. In a critical meta-analysis of the literature on costs and savings associated with such programs, we found that medical costs fall by about $3.27 for every dollar spent on wellness programs and that absenteeism costs fall by about $2.73 for every dollar spent.

“Although further exploration of the mechanisms at work and broader applicability of the findings is needed, this return on investment suggests that the wider adoption of such programs could prove beneficial for budgets and productivity as well as health outcomes.”

As an insurance consultant for over 25 years, I am prepared to health my clients develop ongoing wellness programs for their workforce.  Engaging the employees to lead healthier lifestyles will result in lower health care costs.  Safeway with 200,000 employees engineered a wellness program years ago that has resulted in four years without any additional cost to the employer or employees where other companies experienced a 38% increase.

• 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.

The summary reflects provisions of the new law, and changes made by subsequent legislation, including provisions to expand coverage, control health care costs, and improve the health care delivery system.

Summary (.pdf)