Living in Chicago and choosing a plan of Health Insurance

Choosing a plan of health insurance coverage can be very frustrating and confusing.  That is why The Health Insurance Shoppe opened its doors in 2009.

When you search your options in Chicago, online or through The Shoppe, you will be presented with about 6 carriers to choose from dependent on your search provider.  The Shoppe markets 6 carriers for you to choose from.

In Chicago, the 2 most competitive health insurance carriers are going to be Celtic and Blue Cross and Blue Shield of Illinois (BCBSIL).

Celtic is a carrier that markets only individual and family plans, not large or small group...reducing the amount of risk on their books.  Typically Celtic will beat out BCBSIL in rates when you are under 35 years old.  Celtic uses the Private Health Care Systems (PHCS) network, one of the nations largest.  The only downside to Celtic is that after the first year of coverage your plan will renew semi annually while all other carriers are annually.

• premiums can increase based on height and weight and current treatment
• specific medical conditions can be excluded from coverage
• 12 month pre-existing medical condition waiting period

BCBSIL offers the largest network of providers in Illinois, great customer service, simple plan designs and the best ER benefits available. BCBSIL is not for anyone.  If you do not have a current Blue Cross and Blue Shield (BCBS) plan for at least 12 months without a gap greater than 63 days prior to application, BCBSIL will impose a 12 month waiting period for pre-existing medical conditions; conditions that were treated (meds) consulted or diagnosed within the 12 months prior to application.  This means that all current treatment will not be covered for the first year.  If you have current BCBS coverage than the waiting period will be waived.

• premiums only increase if you smoke (25%) or if you are above or the height and weight guidelines (25%)
• specific medical conditions can be excluded from coverage
• rates are age banded every 5 years...a 25 year old will have the same rate as a 29 year old

Next in line are Humana UnitedHealthCare (UHC) and Aetna.  If you take current prescription medication or have a medical condition that BCBSIL will exclude from coverage than these carriers are the route to go.

Humana is next in line after BCBSIL when it comes to premiums.  Medical conditions that are disclosed on the application will be covered from day one as long as they are not excluded from coverage. For some medical conditions, Humana will issue a separate condition specific deductible in addition to the plan deductible.  When it comes to exclusions, Humana is  more lenient than BCBSIL.

• 2 tier rating system; Preferred and Standard
• dependent on cost of current treatment, premiums can increase up to 100%
• specific medical conditions can be excluded from coverage
• contraceptives are not covered
• HSA plan design may be less in premium than BCBSIL

After Humana is UnitedHealthCare (UHC), who is just about the same in medical underwriting guidelines as Humana.  Like Humana, UHC will cover conditions that are disclosed on the application as long as they are not excluded from coverage.

• 4 tier rating system; Preferred, Preferred II, Standard and SubStandard
• dependent on cost of current treatment, premiums can increase up to 100%
• specific medical conditions can be excluded from coverage

Finally there is Aetna, who only waives the 12 month pre-ex if you have had 12 months of prior coverage, not dependent on prior carrier.  Aetna is unique as they do not place exclusions.  Aetna can increase your premium up to 100% or decline coverage.

Assurant is the last carrier The Shoppe markets and will be the most expensive option available with no special benefit about their coverage.  If coverage can not be placed with any of the above carriers, it would be more cost effective to apply to the state plan ICHIP than Assurant.

For further information about your options in Chicago, please contact The Shoppe.

Understanding Your Deductible

Specific to private plans of coverage

Q: What is your plan deductible?

A:  The amount of money the insured must pay for the below expenses prior to the insurance carrier beginning to cost share, usually paying 80% of future expenses.

• Diagnostic Testing and Lab Work performed at a physicians office that is not related to preventative care, copay does not cover these expenses
• Prescription Drugs if you do not have copay option
• Outpatient Procedures
• Inpatient Procedures
• Hospitalization
• Emergency Room; carriers may provide a richer benefit
• X-rays
• Therapy; some carriers impose waiting periods

Now...the most important thing you must understand is the value of your deductible.  For example, if a $2,500 deductible is selected, do not assume that you are paying out the first $2,500 before the insurance carrier begins to cost share.   The #1 benefit you receive by having a plan of coverage is access to the carriers network of providers.  When services are rendered in-network, the insured should be responsible to pay anywhere between 30-70% off of retail cost.  This final responsibility is known as the contracted rate.  An outpatient procedure could cost $1,500/retail, with the final insured's responsibility between $350-$500.  The final responsibility is what is applied against the plan deductible.

When you look at choosing a plan, please keep in mind that having covered services applying towards the deductible is a good thing, as you begin to chip away at your total financial liability if faced with a large claim.

For further questions on benefits please contact The Shoppe.

Thanks,

Jordan

Top 3 Differences Between Carriers

Each carrier the shoppe represents has their own place in the market, behind monthly premiums.  Below are the 3 key differences per carrier the shoppe represents.

BCBSIL

1. ER is offered at 3 coverage levels, dependent on plan  to either cover the bill 100%, waive the deductible, requiring the insured to pay 20% or subject the bill toward the plan deductible (HSA plans)
2. There are no prescription copay's unless a $500 or lower deductible is selected to then receive a $10 copay for generics.  All other plans have the insured paying the contracted rate towards the plan deductible to then be covered at 80% or 100% once satisfied
3. 12 month waiting period for pre-existing medical conditions; waived if insured has 12 months of credible coverage with another BCBS plan

Humana

1. ER is subject to the plan deductible with optional SAB benefit to be purchased which will reduce ER bill by $1,000 or $2,500, and will only reduce for accident, not illness
2. All plans other than HSA provide an immediate $15 copay for generic drugs and have a separate $500 and higher prescription drug deductible that the insured pays the contracted rate towards for Preferred and Brand Name drugs before copay's are received
3. Waives the 12 month pre-ex waiting period for conditions that are disclosed on application, leading to a possible premium increase to cover risk from day one of coverage

UnitedHealthCare

1. All plan deductibles, no matter the plan, are considered "decreasing"...meaning that each calendar year the deductible has not been met it will reduce by 20%
2. Many optional benefits such as SAB rider, lower prescription drug deductible and limited office visit copays (to reduce premium)
3. Waives the 12 month pre-ex waiting period for conditions that are disclosed on application, leading to a possible premium increase to cover risk from day one of coverage

Aetna

• 90% of the time, Aetna will be the most expensive in plan premium
• Aetna does not place condition specific exclusion riders and will increase premium to cover medical risk
• 12 month waiting period for pre-existing medical conditions to be waived if insured has prior credible coverage for 12 months, not carrier specific

Celtic

• 80% of the time, Celtic will be the lowest in monthly premiums for applicants 19-35 years old
• Limited office visit copay plans
• After 1st year of coverage, plan will renew semi-annually

Assurant

• 90% of the time, Assurant will be the most expensive in plan premium
• Offers 3 networks to choose from to reduce monthly premium
• Non HSA plans start with a $700 facility fee copay in addition to the deductible that does not apply to the plan

I hope this has been helpful.  Please contact the shoppe with further questions.

Sincerely,

Jordan

Contraceptive Coverage for Women, effective 8/1/2012

This week the U.S Department of Health and Humana Services (HHS) announced that new health insurance plans that are in compliance with The Affordable Care Act (ACA) must provide contraceptive coverage to females at 100% with no cost obligation.


New health plans will need to include these services without cost sharing for insurance policies with plan years beginning on or after August 1, 2012.  The rules governing coverage of preventive services which allow plans to use reasonable medical management to help define the nature of the covered service apply to women’s preventive services.  Plans will retain the flexibility to control costs and promote efficient delivery of care by, for example, continuing to charge cost-sharing for branded drugs if a generic version is available and is just as effective and safe for the patient to use.

For more information on the HHS guidelines for expanding women’s preventive services, please visit:http://www.healthcare.gov/news/factsheets/womensprevention08012011a.html. The guidelines can be found at:www.hrsa.gov/womensguidelines/.

To learn more about the Affordable Care Act, please visit www.healthcare.gov.

-The Shoppe

Maternity Coverage

For those unaware of maternity benefits and availability, let me explain.

With employer provided coverage, also known as group health insurance, maternity is an immediate benefit without restrictions to waiting periods.  There is no additional cost with limitations applying to infertility and fertilization.

When it comes to private coverage for individuals and families options are scarce and limited to one carrier, Blue Cross and Blue Shield of Illinois (BCBSIL) and includes civil unions.  Maternity is an optional benefit (additional premium) and imposes a 12 month waiting period before maternity services are covered.  Additional premium for benefit is paid until delivery.  This benefit can only be taken at time of application or at plan anniversary.  The only time premium is not required is when a male takes coverage to add a spouse later down the road.  This can begin elimination of the waiting period and once a spouse is added, additional premium will be required for the maternity benefit.

BCBSIL and all other carriers will cover complications of pregnancy.

All other options for maternity are with the 4 state plans ICHIP , IPXP, Moms and Babies and Illinois Healthy Women.

ICHIP has been around for a long time and is administered by BCBSIL and utilizes their network of providers.  Coverage is extremely expensive for health insurance and additional premium is required for maternity that imposes a 9 month waiting period.  To be eligible for coverage you must have been declined by a private carrier or have a plan that currently costs more than the state.

IPXP is from Obamacare (health reform) and utilizes the Healthlink network of providers.  This is an affordable option with maternity included at no additional cost and no waiting periods.  To be eligible for coverage you must go without health insurance for 6 months and have a qualifying pre-existing medical condition or have received an offer of coverage (not accepted) that placed exclusion riders on specific medical conditions.

Moms and Babies covers healthcare for women while they are pregnant and for 60 days after the baby is born. Moms & Babies covers both outpatient healthcare and inpatient hospital care, including delivery.  To be eligible you must be within a certain income range and will need to utilize a provider that accepts Medicaid. 

The last option, Illinois Healthy Women, is not health insurance but covers family planning (birth control) and certain services provided at the family planning visit, such as the physical exam, pap tests, lab tests for family planning, testing and medicine for sexually transmitted infections found during a family planning visit, and sterilization. Illinois Healthy Women also covers mammograms, multivitamins and folic acid if they are ordered by the doctor during the family planning visit.


For further information on your options please contact the shoppe.


Thanks,


-Shoppe

NEW 2012 HSA Inflation Adjustments

Applicable to all that are currently enrolled in an HSA qualified plan.

The Internal Revenue Service (IRS) recently announced the 2012 inflation adjustments for High Deductible Health Plans (HDHPs) and Health Savings Accounts (HSAs). These adjustments include maximum HSA contributions, minimum deductible amounts and maximum out-of-pocket limits.

High Deductible Health Plans In 2012, an HSA-compatible HDHP is a health plan with:

An annual deductible that is not less than $1,200 for self-only coverage (no change from the calendar year 2011) or $2,400 for family coverage (no change from the calendar year 2011), and The annual out-of-pocket expenses (deductibles, copayments and other amounts, but not premiums) do not exceed $6,050 for self-only coverage or $12,100 for family coverage. 2012 Requirements The following adjustments apply to the calendar year 2012, as compared to 2011: 2012 Requirements for HSAs & HDHPs Single Coverage Family Coverage Minimum Aggregate Deductible     2012 2011 $1,200 $1,200 $2,400 $2,400 Maximum Out-of-Pocket Limit     2012 2011 $6,050 $5,950 $12,100 $11,900 HSA Contribution Maximum     2012 2011 $3,100 $3,050 $6,250 $6,150 2011/2012 Catch-up Contributions (age 55 and older): $1,000 Note:  Minimum embedded deductible is $2,400 individual and $4,800 family.

What is a DEDUCTIBLE?

Knowing what a plan deductible means, was the first thing that I had to understand when I began marketing health insurance plans.  A deductible is the key element in every health insurance plan, other than HMOs.

When prospects come in or call the shoppe for service and are currently covered through COBRA or private coverage, 99% are unaware what their plan deductible is...even if they are paying over a $1,000/m for coverage.  The most common answer to an inquiry on current benefits is the amount of office visit and prescription drug copays.

Another benefit prospect are unfamiliar with is the negotiated/contracted rate.  No matter if you are paying $100/m for coverage or $2,000/m, one common element is that the insured has access to the network of providers through their insurance carrier.  This is known as a PPO.  When services are rendered at a participating provider, the insured receives maximum plan benefits with services being discounted between 30-70%.  This discount is known as the negotiated/contracted rate.  This is the amount that the provider is allowed to bill since they have a contract with your insurance carrier.  Expenses that apply to the deductible are paid for at this contracted rate.


So...as for the plan deductible, this is the amount that the insured must pay in covered expenses at the negotiated/contracted rate, prior to the insurance carrier beginning to pay the selected coinsurance (percentage). If there are more than one member on a plan (spouse, family), than there will be a separated deductible per member, with majority of carriers requiring up to 3 deductibles to be met.

What are deductible expenses?

• Outpatient Procedures
• Inpatient and Outpatient Diagnostic Testing
• Emergency Room (dependent on insurance carrier and plan)
• Inpatient Hospitalization
• Durable Medical Equipment (DME)
• Prescription Drugs (dependent on insurance carrier and plan)
• Office visits when there is not a copay
• Outpatient Therapy
• Chiropractic (limited benefit with each carrier with $1,000 max in annual benefits)

When searching for plans carriers offer many deductible options, some that even decrease if not satisfied.  Choosing a lower deductible is the more expensive plan as you are asking the carrier to begin payment quicker as the insured's liability is much lower.  Choosing a higher deductible lowers premium as more expenses are onto the insured prior to the carrier beginning payment.

Choosing a plan with office visit copays will cost more than plans without and if office visits are frequent, the amount paid in copays has not applied to the deductible.  Saving premium to go without a copay, will have the insured paying the negotiated/contracted rate, that is applied towards the deductible...chipping away at the annual exposure on can have on a large claim.

Plans that are compatible with a Health Savings Account (HSA) have a different type of deductible than traditional plans of coverage.  With HSA compatible plans, the deductible is collective for a family instead of separate per member.  Once the deductible is met all members of the plan are covered at 100%.

It can be confusing and the shoppe is here to help :)

Jordan

Domestic Partnership Update

Implementation Update: Illinois Religious Freedom Protection and Civil Union Act  Beginning today, June 1, 2011, the Illinois Religious Freedom Protection and Civil Union Act (PA 96-1513) takes effect. In light of this non-insurance law being passed on Jan. 31, 2011. All carriers that offer private individual plans are currently working out details with the state to make sure they comply when offered with products. For further info please contact the shoppe. Thanks, Jordan

Boomer's and Medicare cont...(MED Supp)

Welcome back...I hope everyone had a nice Memorial Day weekend :)

Following up to the prior blog on Medicare Parts (Part A, Part B and Part D), this email will go over Medicare Supplement plans that pay for expenses Medicare leaves a beneficiary to pay.

As stated prior, Medicare leaves the following for a beneficiary to pay:

Part A :  $1,162 deductible for days 1-60 in the hospital then moving to a fixed dollar amount per additional day

Part B:  $162 deductible to then pay 20% on all Medicare approved amounts with excess charges not covered

To help beneficiaries cover these expenses, private insurance carriers offer Medicare Supplement plans that either;

• pay 100% of above amounts, including excess  (Plan F)
• pay 75% of above amounts (Plan K)
• pay 50% of above amounts  (Plan L)
• pay 100% of above and require beneficiary to pay copays for office visits  (Plan N)
• require the beneficiary to pay the first $2,000 before plans pays 100% including excess  (Plan F High Deductible)

In order to be eligible for a Medicare Supplement a beneficiary must currently have Medicare Part A and Part B.  Medicare Supplements do not cover prescription drugs.

If you currently have private coverage while being eligible for Medicare, please make sure to check with your current providers to see if they accept Medicare.  If not, then it will be best for you to stay current if possible.

For more information on Medicare and Medicare Supplements please contact the shoppe.

Thanks,

Jordan

Boomer's and Medicare

Do you know much about Medicare?  Are you turning 65 soon?

Medicare can be difficult to understand and The Health Insurance Shoppe is here to help.

The only part of Medicare that is free is Part A, which is either entitled to a beneficiary at age 65 or requires a premium if the beneficiary has not paid Social Security Taxes.

Part A covers hospital services and leaves the beneficiary to pay up to the $1,162  deductible for days 1-60 in the hospital.  This covers all facility services that are covered by Medicare.  After 60 days the beneficiary is responsible to pay a fixed dollar amount for the remainder of the year.

Medicare Part B, covering physician services is not entitled and requires a monthly premium that can be deducted from a beneficiaries Social Security check.  The standard monthly Part B premium if you are single and filed an individual tax return with a Modified Adjusted Gross Income (MAGI) $85,000 or less, or married and filed a joint tax return with a MAGI less than $170,000 is $115.40.  For incomes that are above there will be an increase in premium up to $253.70, bringing the highest monthly total to $369.10 per beneficiary.


Part B benefits require the beneficiary to pay the first $162 (deductible) in Medicare approved amounts before paying 20%, leaving Medicare to pay 80% with no out-of-pocket maximum.  Part B does not cover the excess charges physicians charge above Medicare, leaving this expense to the beneficiary.


Now, when a beneficiary turns 65 and current private coverage (employer provided, individual) is in place, Medicare Part B does not need to be elected as current coverage is considered credible for Part B.  At this time the beneficiary will want to compare the cost of Medicare Part B premiums to their current, making sure that current coverage is considered credible.  If credible coverage is not in place a penalty will be imposed for each month that goes by and the beneficiary did not enroll when eligible for Part B.


***Both Medicare Part A and Part B are provided by the Center of Medicare and Medicaid Services (CMS).


Lastly, there is Medicare Part D, providing coverage for prescription drugs that is obtained in the private market.  A penalty fee can be implied when a beneficiary does not enroll when eligible, provided there is no credible prescription drug coverage.  Part D premiums begin can start at $30/m and be as high as $90/m, still leaving the beneficiary with out-of-pocket costs.  ***As with Part B, additional premium is required dependent on the beneficiaries MAGI.  At the most, $69.10 can be added to the monthly Part D premiums.


So....When a boomer hits 65 they can be expected to pay at least $145/m for Part B and Part D coverage, with $468/m on the high end.


All of the above was discussion on parts of Medicare.  Please look for the next blog on Medicare Supplements, also known as plans.


I hope that this was informative and all questions can be directed to the shoppe.


-Jordan

Vail

Enjoy :-)

Emergency Room Coverage

This blog will detail ER coverage amongst the 6 carriers marketed.

Emergency Services are covered with all plans and are considered  a plan deductible expense unless noted otherwise.

Blue Cross and Blue Shield of Illinois (BCBSIL) is the only carrier that offers 100% coverage (you owe nothing) at the ER or waives the plan deductible, requiring the insured to pay 20% of the bill towards the plans out-of-pocket expense limit...dependent on plan with 6 out of 8 including this benefit.

All other carriers will slap the insured on the wrist with a copay or access fee before subjecting the bill to the plans deductible.

Certain carriers offer a Supplemental Accident Benefit (SAB) rider that can be purchased for additional premium for benefit amounts of $1,000, $2,500, $5,000 and $10,000.  This benefit will reduce the bill on an accident by the benefit amount selected.  Dependent on the carrier, the amount that paid out by the SAB does not apply towards the plan deductible or out-of-pocket.

Unfortunately with private plans you can not walk into the ER and only owe a copayment.

For further information on benefits please contact The Shoppe.

Thanks,

Jordan

The Importance of The Shoppe

When it comes to choosing a health insurance plan you have 2 choices to make, choosing a benefit package and an Insurance Carrier.  All premiums that are presented by the carrier are subject to change at time of application based on the following factors:

• height and weight
• smoking status
• was their prior coverage in the past without a break greater than 63 days
• some carriers have different rating tiers based on prior coverage
• quotes are presented at preferred rates and then change when answering medical questions YES and to how the prior coverage section is answered
• medical conditions (ongoing or within past 5 years)
• current treatment
• cost of prescription drugs being taken

In order to find out where you fall in eligibility you would need to inquire within each carrier you are interested in.  This can be a dreadful process and being declined coverage after application will take away time from desired coverage and leave you further stressed on what to do next.

Working with The Shoppe (free) will provide you access to 6 private carriers in the Illinois market with one personal contact providing you with information.  The Shoppe knows the ins and outs of the health insurance market and will be able to place you in the most appropriate coverage needed based on your current medical needs and hopefully budget.

Please stop in or call for further information.

Thanks,

Jordan

Blue Cross's 2 most popular plans

BCBSIL announced their 2 plans that are sold the most in Illinois...For those that are clients about 95% are in the HSA plan!

Sales Tip: Most Popular Individual Under 65 Plans
The most popular Under 65 health plans sold in 2010 were BlueEdge^SM HSA and SelectBlue Advantage^SM. The two products that had the highest percent change in sales from 2009 to 2010 were BlueEdge HSA and BlueChoice^SM Value.

Negotiated/Contracted Rate..what does this mean?

In paying a premium to the insurance carrier, whether the lowest or the highest...one benefit that is universal is having access to the provider network of your health insurance carrier.

When services are rendered through a provider that is considered "in-network" the insured is not responsible to pay the retail cost of services.  The provider has a contract with each insurance carrier that they are deemed "in-network" with.  The contract states that the provider can only bill the insured the negotiated/contracted rate of service, which can be anywhere from 30-70% off the retail cost.  The negotiated rate is applied towards all covered expenses including prescription drugs.

When a plan has co-payments for office visits and or prescription drugs, this pre-fixed payment is to cover the negotiated rate, which may be only $20-$40 greater than the requested co-payment.

When a plan has a separate prescription drug deductible, say $500...the insured pays the negotiated rate of the medication until $500 is spent.  Once the prescription deductible is satisfied the insured will then only owe a co-payment.

So... a prospective plan that does not offer office visit or prescription copays, NO, the insured will not owe the full cost of service.  Physicians do not know the negotiated rate at time of service.  They must submit a claim to the insurance carrier to find out the allowable amount the insured can be billed.  Payment will not be due at time of service.  The insured will receive an explanation of benefits (EOB) outlining the date of service and the amount that may be owed to the provider.

For further questions on plan benefits please contact the shoppe!

Thanks,

Jordan

Legislative Update

Special Legislative Update

Health care spending addressed in long-term deficit reduction plans

In a speech Wednesday, President Barack Obama unveiled his deficit reduction plan, which included several measures that seek to address health care spending. According to a White House fact sheet, the President's plan will build on policies put in place by the Affordable Care Act (ACA) and would save an additional $340 billion by 2021, $480 billion by 2023 and at least an additional $1 trillion in the subsequent decade.

The House Budget Committee released the GOP deficit reduction proposal last week, which President Obama has said he will oppose. Both the President's and GOP’s proposals have indicated that their deficit reduction plans include Medicare and Medicaid spending cuts.

Federal budget deal targets ACA measures

Late last Friday night, a bipartisan budget agreement was reached to avoid a federal government shutdown. The agreement is now known as H.R. 1473. If H.R. 1473 becomes law, it would continue to fund the federal government through the end of the fiscal year (Sept. 20, 2011), and according to the latest Congressional Budget Office's estimate, would cut between 20 to 25 billion dollars in spending over the next 10 years.

The package went to Congress for passage this week as H.R. 1473. The bill was passed by both the House of Representatives and Senate yesterday. It now goes to the White House for the President's signature.

The budget agreement contains several provisions that would affect the ACA. Most notably, H.R. 1473 would:

1. Eliminate ACA's Free Choice Voucher program
   
   H.R. 1473 repeals the health benefits exchange-related Free Choice Voucher program that would have allowed employers to provide vouchers for eligible employees to use in purchasing health insurance coverage on a health exchange beginning in 2014. They are different from the premium tax credits and cost-sharing subsidies that will be provided by the federal government to individuals purchasing health insurance coverage on a health exchange.
   
   Proponents of the Free Choice Vouchers believe that the vouchers provide eligible employees with more choice and flexibility, increase competition, and reduce costs. Opponents believe they are too costly for employers, especially those that offer both low-cost and high-cost coverage, or employ large numbers of younger employees who do not make large salaries. They also say the vouchers have the ability to create adverse selection, which could increase employer costs.
   .
2. Reduce $2.2 billion in funding for ACA's CO-OP Program
   
   The Consumer Operated and Oriented Plan (CO-OP) program of the ACA directs the federal government to support the creation (through issuance of federal loans and grants) of member-owned, nonprofit insurers (CO-OPs) that will offer qualified health plans on the exchanges and possibly in the off-exchange individual and small group markets. Some $2.2 billion of the $6 billion in appropriated budget for the (CO-OP) will be permanently cut.
   .
3. Require auditing, reporting on various aspects and effects of ACA
   
   H.R. 1473 directs the General Accounting Office, the federal government's "watchdog" over how taxpayer money is spent, to issue a report on ACA implementation; to perform an audit of requests for essential health benefit annual limit waivers; and to audit the comparative effectiveness research funding (comparing the effectiveness of different treatments for the same illness).
   
   In addition, the bill directs the Chief Actuary of CMS to conduct an actuarial analysis of projected premium impacts as a result of a number of the ACA provisions, including guaranteed issue, guaranteed renewability, and community rating.

President Signs Repeal of ACA's 1099 Reporting Requirements

Thursday, President Obama signed H.R. 4, which repeals the expanded 1099 reporting requirements included in the ACA. As we previously reported, the Senate approved the measure on April 5, and the House approved it on March 3.

The new reporting requirements would have compelled businesses to file a Form 1099 for all payments of goods and services aggregating $600 to a single payee, including corporations.

Repeal of the expanding requirements is expected to reduce revenue by $24.7 billion from 2011 to 2021. H.R. 4 offsets this cost by requiring recipients of the premium assistance tax credits included in ACA to repay a greater share of any overpayments of the tax credits.

friday afternoon

Vail

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Preventative Care Benefits under Reform

Under the Affordable Care Act, you and your family may be eligible for some important preventive services—which can help you avoid illness and improve your health—at no additional cost to you.

What This Means for You

If your plan is subject to these new requirements, you would not have to pay a copayment, co-insuranceor deductible to receive preventive health services, such as recommended screenings, vaccinations and counseling.

For example, depending on your age, you may have free access to preventive services such as:

• Blood pressure, diabetes, and cholesterol tests
• Many cancer screenings, including mammograms and colonoscopies
• Counseling on such topics as quitting smoking, losing weight, eating healthfully, treating depression and reducing alcohol use
• Routine vaccinations against diseases such as measles, polio or meningitis
• Flu and pneumonia shots
• Counseling, screening, and vaccines to ensure healthy pregnancies
• Regular well-baby and well-child visits, from birth to age 21

Some Important Details

• This preventive services provision applies to people enrolled in job-related health plans or individual health insurance policies created after March 23, 2010. If you are in such a health plan, this provision will affect you as soon as your plan begins its first new “plan year” or “policy year” on or after September 23, 2010.
• If your plan is “grandfathered,” these benefits may not be available to you.
• If your health plan uses a network of providers, be aware that health plans are only required to provide these preventive services through an in-network provider. Your health plan may allow you to receive these services from an out-of-network provider, but may charge you a fee.
• Your doctor may provide a preventive service, such as a cholesterol screening test, as part of an office visit. Be aware that your plan can require you to pay some costs of the office visit, if the preventive service is not the primary purpose of the visit, or if your doctor bills you for the preventive services separately from the office visit.
• If you have questions about whether these new provisions apply to your plan, contact your insurer or plan administrator.  If you still have questions, contact your State insurance department.
• To know which covered preventive services are right for you—based on your age, gender, and health status—ask your health care provider. 

Please call the shoppe with any questions....

Thanks,

Jordan

What Does Having a "Grandfathered" plan mean under reform?

The Affordable Care Act exempts most plans that existed on March 23, 2010--the day the law was enacted--from some of the law’s consumer protections. This will preserve consumers’ rights to keep the coverage they already had before health reform.

What This Means for You

If you have health coverage from a plan that existed on March 23, 2010--and that has covered at least one person continuously from that day forward--your plan may be considered a “grandfathered” plan.

This is true whether you are covered by an individual health insurance policy that you had on that date, or you are covered by a job-based health plan that your employer first established before March 23, 2010. This is true even if you enrolled in that job-based plan sometime later.

A grandfathered health plan isn’t required to comply with some of the consumer protections of the Affordable Care Act that apply to other health plans that are not grandfathered.

Here’s a look at which consumer protections do and don’t apply to grandfathered plans.

Consumer Protections in the Affordable Care Act that DO Apply to Grandfathered Plans

Many of the Act’s consumer protections that took effect on September 23, 2010 apply to all plans, whether or not the plans are grandfathered.

Please note that these consumer protections will be added to your plan when it begins a new plan year orpolicy year on or after September 23, 2010.

All health plans:

• Are prohibited from applying lifetime dollar limits to key health benefits.
• Are not permitted to cancel your insurance coverage solely because of an honest mistake that you or your employer made on your insurance application.
• Must extend dependent coverage to an enrollee’s adult children until they turn 26 years old (with one temporary exception: Click here for more details).

Consumer Protections in the Affordable Care Act that DO NOT Apply to Grandfathered Plans

Unlike other health plans, job-based plans and individual insurance policies that are grandfathered arenot required to:

• Provide certain recommended preventive services at no additional charge to you.
• Offer new protections for consumers who are appealing claims and coverage denials.
• Protect your choice of health care providers and your access to emergency care.

Consumer Protections in the Affordable Care Act that DO NOT Apply to Grandfathered INDIVIDUAL Plans

Grandfathered individual health insurance policies are not required to adopt the provisions of the law that:

• Phase out annual dollar limits on key benefits.
• Eliminate pre-existing condition exclusions for children under 19 years old.

Some Important Details

Grandfathered plans can lose their grandfathered status if they make certain significant changes that reduce benefits or increase costs to consumers. (Read more about changes that will cause a health plan to lose grandfathered status).

Although grandfathered plans can make only limited changes to the percent of the premium the employer contributes, grandfathered plans may still increase their total premium amount without losing grandfathered status.

If your plan loses its grandfathered status, all of the Affordable Care Act consumer protections would apply to you when your plan begins a new plan year or policy year.

To find out if your health plan is grandfathered:

• Check your plan’s materials. Beginning with the first plan or policy year starting on or after September 23, 2010, health plans must disclose their grandfathered status in any plan materials describing the plan’s benefits that are distributed to beneficiaries or primary subscribers. These materials must also contain contact information for questions and complaints.
• Check with your employer and/or your health plan’s benefits administrator. If you are in a group health plan, the date you joined may not reflect the date the plan was created. New employees and new family members may be added to a grandfathered group plan after March 23, 2010.

For additional questions please contact the shoppe.

Thanks,

Jordan

Insurance Protection for Children

Under the Affordable Care Act, health plans cannot limit or deny benefits or deny coverage for a child younger than age 19 simply because the child has a “pre-existing condition”—that is, a health problem that developed before the child applied to join the plan.

What This Means for You

Until now, plans could refuse to accept anyone because of a pre-existing health condition, or they could limit benefits for that condition. Now, under the new law, health plans that cover children can no longer exclude, limit or deny coverage to your child under age 19 solely based on a health problem or disability that your child developed before you applied for coverage. This new rule applies to all job-related health plans as well as individual health insurance policies issued after March 23, 2010. The rule will affect your plan as soon as it begins a plan year or policy year on or after September 23, 2010.

Some Important Details

• This rule applies whether or not your child’s health problem or disability was discovered or treated before you applied for coverage.
• The new rule doesn’t apply to “grandfathered” individual health insurance policies. A grandfathered individual health insurance policy is a policy that you bought for yourself or your family (and is not a job-related health plan) on or before March 23, 2010 (the date that the new law was passed).
• These protections will be extended to Americans of all ages starting in 2014.

Example

On October 1, 2010, Sally purchased a new individual health policy for herself and her 13-year-old child, Miranda, who has been treated for asthma in the past. The new health policy excludes coverage for treatment of pre-existing conditions for all enrollees. On November 1, 2010—one month after coverage began for Sally and Miranda—Miranda is hospitalized for an asthma attack. Her insurance company denies payment for the hospitalization, because under the policy Miranda’s asthma is considered a pre-existing condition.

Under the new law, the insurer can’t deny payment for the hospitalization based on Miranda’s pre-existing asthma condition. Miranda is under the age of 19; Sally’s policy is new and therefore subject to the pre-existing condition rules of the new health care law. Sally’s policy year began after September 23, 2010, when the law’s rules on pre-existing conditions began to take effect.

Please call the shoppe with questions.

Thanks,

Jordan

Appealing a decline in coverage

Your Benefit Appeal Rights Under the Affordable Care Act

If your health plan was created after March 23, 2010, the Affordable Care Act ensures your right to appeal, or to ask that your plan reconsider its decision to deny payment for a service or treatment. New rules, now in effect, govern how your plan itself must handle your initial appeal. If your plan upholds its decision after its internal review, the law permits you to appeal to an independent reviewer who does not work for your health plan.

What This Means for You

• When an insurance plan denies payment for a treatment or service, you can appeal to the plan to review its own decision. Your plan must explain how to appeal when it informs you of the denial.

• When you appeal, your plan must give you its decision within:
  • 72 hours for denials of urgent care.
  • 30 days for denials of non-urgent care you have not yet received.
  • 60 days for denials of service you have already received. 

• If the plan still denies your request, it must explain why and tell you how to appeal for an independent review of the decision. In some cases involving urgent care, you may be able to have the internal and external review take place at the same time.

• If you do not speak English, you may be entitled to receive all appeals-related information in your native language.

Some Important Details

• The appeals provision applies to all health plans created or purchased after March 23, 2010  and affects each plan as that plan starts a new “plan year” or “policy year” on or after September 23, 2010.
• How much the law will change your appeal rights depends on the State you live in and the type of plan you have.  
• Some employers’ plans may have more than one internal review before you’re allowed to seek an external review.
• If you have questions about whether the appeals provision applies to you, ask your health plan orState insurance regulator. Your State may also have a health care consumer assistance program that can help.

Please call the shoppe with any questions...

thanks,

Jordan