Final 2017 Marketplace Guidance
Health and Human Services had released earlier this year the final version of its 2017 Notice of Benefit and Payment Parameters. Under the Affordable Care Act (ACA) this is issued annually. While the guidance is mostly relate dot the individual marketplace itt does, however, include several items relevant to employers and group health plans, specifically:
- Annual limits for cost sharing (out-of-pocket limits)
- Marketplace eligibility notifications to employers
- Marketplace annual open enrollment period
- Small Business Health Options (SHOP) Exchange
ANNUAL LIMITS FOR COST SHARING:
The annual out of pocket limits for plan years beginning on or after January 1, 2017 are $7,150 for individual coverage and $14,300 for family coverage. These cost sharing limits apply to in-network essential health benefits offered under non-grandfathered health plans, both fully and self-insured. Annual deductibles, in-network co-insurance and other types of in-network cost sharing accumulate toward the out-of-pocket limit, including prescription drug copayments. Not included are premium payments, out-of-network cost sharing and spending on non-essential health benefits.
MARKETPLACE ELIGIBILITY NOTIFICATIONS TO EMPLOYERS:
Beginning in 2017, the Marketplace will notify an employer as soon as possible when one of its employee’s first enrolls in subsidized Marketplace coverage. Since some employers may be liable for a penalty under the ACA’s employer mandate when an employee qualifies for a subsidized Marketplace coverage, this change to a more proactive notification process will hopefully provide employers with the opportunity to work with CMS in cases where an improper subsidy has been provided.
MARKETPLACE ANNUAL OPEN ENROLLMENT PERIOD:
Open Enrollment in the Health Insurance Marketplace, Healthcare.gov, for 2017 and 2018 will take place from November 1, 2016 through January 31, 2017 and November 1, 2017 through January 31, 2018, respectively.
SMALL BUSINESS HEALTH OPTIONS (SHOP) EXCHANGE:
Beginning in 2017, small employers electing coverage in the SHOP Exchange will have the option of “vertical choice,” offering plans across all metal levels (platinum, gold, silver and bronze) from one insurer. States who opt out of the vertical choice option will continue to offer employers the choice of selecting health plans that are available at one single metal level of coverage.
Stay proactive and contact us today for a custmozied consult on how your organization can prepare ahead for ACA, Benefits, Payroll and HR @ (855) 667-4621 or email@example.com.
Licensed Brokers vs Navigators
With less than 45 days before the first Affordable Care Act Open Enrollment set to end its important to understand the role of both Brokers and Navigators. The Patient Protection and Affordable Care Act (PPACA) requires States to establish a “Navigator” Program to help educate consumers about Health Exchange marketplace. With the new health insurance exchanges a broker can act either as a traditional broker or a navigator (but not both). The info-graph below illustrates how navigators will differ from brokers.
Specifically, agents and brokers play a vital role in the developing health insurance exchanges nation wide. As the individuals with the education and expertise to advise and help select health insurance products for families and businesses large and small, health insurance agents, brokers and consultants occupy a unique place in the health care coverage system.
We educate consumers on their health care coverage choices, help them select the most appropriate plans for their specific needs, and serve as their advocate if problems should arise. Subject to strict state licensing laws and education requirements, agents, brokers and consultants are critical to not only the health insurance enrollment process, but also in serving the healthinsurance coverage needs of individuals and employers after the point of sale.
Benefit specialists design benefit plans, explain coordination issues of public and private benefits to individuals and employees, and solve complex claims and billing issues. We help design and implement cutting-edge health promotion and wellness programs and help our clients comply with state and federal laws like newly enacted PPACA, HIPAA, COBRA and ERISA.
Professional agents, brokers and consultants continue to assist individuals and small businesses with their coverage needs long after the point of sale. Whereas a travel agent is finished with a client after the travel is completed, benefit specialists continues to serve as compliance experts, health and wellness promoters and the prominent contact for complex claims and billing issues. Health insurance coverage is a longstanding commitment for American consumers and often requires guidance from benefit specialists when dealing with a complex healthcare system. For more information regarding both Exchanges – Individual Exchanges or SHOP please contact our team at Millennium Medical Solutions Corp (855)667-4621. We work in coordination with Navigators to assist with medicaid, CHIP Child Health Plus, Family Health Plus and Medicare Dual Eligibles. We have Spanish, Russian, and Hebrew speakers available. Quotes can also be viewed on our site.
Are You Losing Your Health Insurance?
There have been plenty of reports in the media of employers having their group insurance plans canceled by health insurance carriers due to health care reform. While there have been plenty of issues, complications, and confusion in regard to group health insurance plans as a result of health care reform…cancelation of group health insurance plans is not one of them.
There are many circumstances where a specific health insurance plan design is being terminated by an insurance company and an employer’s plan is being “routed” to a new plan design. While this may be viewed as problematic for an employer and their employees, it has been happening for years. This issue is most likely not being caused by health care reform, but is likely being exacerbated by it.
The reasons for these routings of plans are several and include:
- Normal year to year changes that insurers implement based on many circumstances.
- Restructuring of plans so that they can be classified in an appropriate Metal Level category (Platinum, Gold, Silver, Bronze).
- Pricing – some plans were not going to be able to continue in the present format.
Employers now have a new alternative if they are being routed to a new health insurance plan for which they are not comfortable. The new alternative is individual health insurance. While there are many items that need further clarity (i.e. circumstances in which an individual may enroll mid-year, pre-tax / post tax, employer deductibility, etc.), it is clear that in many situations the individual health insurance plans are comparatively priced to other small group plans. In addition, the new individual health insurance plans are now Guaranteed Acceptance with no pre-existing condition qualifications.
We’re here to help!
Employers should still seek qualified professional benefits guidance if they considering moving their health insurance programs to an individual platform. Planning, implementation, and ongoing support are just as important as with a traditional group plan. Benefit Consultants that are adapting their practices to the Health Care Reform law such as Millennium Medical Solutions Inc. will be able to help. For more information on individual health plans, please call us as 1-855-667-4621.
States Pushing Back Against Smaller Networks
From Kaiser Health News:
Officials in at least a half dozen states are pushing back against health plans in the new insurance markets that limit choice of doctors and hospitals in a bid to control medical costs.
The plans don’t start offering coverage until January but they’re facing regulatory action, possible legislation, and in at least one case involving a high-profile children’s hospital, litigation.
The pushback against “narrow” provider networks recalls the backlash against managed care and health maintenance organizations in the 1990s. Protests from consumers and hospitals eroded those attempts to restrain expenses by narrowing provider networks.
Now criticism of limited networks has risen as consumers realize that, despite President Barack Obama’s pledge that they could keep their doctors, their Affordable Care Act insurance may not include the physicians or hospitals they’ve been seeing.
The critique feeds into the politically damaging outcry over the millions of people whose health plans were cancelled. It’s unclear whether the limited choice of doctors and other providers will be as much of a concern to uninsured people who will be gaining subsidized coverage through the state-based marketplaces.
Still regulators and elected officials in a few states have already forced changes. Others are weighing legislation that could expand the networks. Legal fights are brewing. In some cases, the officials are responding to complaints of health care systems or providers that were excluded.
In Maine, state regulators prohibited Anthem BlueCross BlueShield from switching some customers to a network sold through the Affordable Care Act’s marketplace that excluded six of the state’s hospitals.
In Washington State, the insurance commissioner initially banned several health plans from the online exchange for what he called inadequate caregiver networks. Some of the plans have broadened networks; the dispute continues with others.
In New Hampshire Anthem’s 2014 marketplace plans exclude more than a third of the state’s hospitals. Lawmakers have written legislation that would force insurers to expand choice.
Anthem will “use the excuse, ‘Well, we’re going to save money by having a narrow network,’” said State Rep. Bill Nelson, a Republican who sponsored the bill pendingin the New Hampshire legislature. “Sure that could happen for some people, but other people are going to be losers. Imagine having to change the doctor you’ve had for years.”
South Dakota, Pennsylvania and Mississippi are discussing measures similar to Nelson’s, known as “any-willing-provider” laws that would force insurers to accept more participants in the networks.
Broader choice comes with a price. The ability to sell less-expensive plans with limited choices of doctors and hospitals helps contain medical inflation, health economists argue. Looser networks could. mean higher prices.
“We had narrow networks in the ‘90s. Health-care prices not only moderated, but actually there was one year where they fell,” said Northwestern University professor David Dranove, who specializes in the health care industry. “Then we had the HMO backlash and we had broad networks [again], and health care prices went through the roof.”
In a typical narrow network, offered in many states under the new ACA rules, caregivers agree to lower prices in expectation of more patients. Insurers pass some of the savings to consumers. Done correctly, limited networks can also save money because family doctors, specialists and hospitals who are all part of the same network do a better job of coordinating care, many health policy experts believe.
Excluding certain hospitals from Anthem’s New Hampshire narrow plan would allow premiums to be 25 percent lower than they otherwise would have been, a company spokesman said. Anthem’s narrow Maine plan would save 12 percent, he said.
Insurers are supposed to compete side-by-side in the health law’s subsidized, online exchanges. Under the ACA, they must all now offer certain basic health benefits and they must cover anyone, regardless of pre-existing conditions.
On this new legal terrain, they compete by offering their best combination of price and providers directly to individuals and families who lack other coverage. Adjusting caregiver rosters is one of the few remaining ways insurers can lower costs, limited-network advocates say.
But others argue that these narrow networks can force patients to switch doctors or drive long distances for care if a key hospital is left out of the plan, especially in states such as Maine and New Hampshire with few insurers selling through the ACA marketplace.
“Whenever you have an extremely narrow network there are potential problems for patients with cancer and for patients with any chronic condition, particularly when it requires the patient to go out of network,” said Kirsten Sloan, senior director of policy for the American Cancer Society Cancer Action Network.
Leaving a network to seek specialized care can lead to enormous out-of-pocket bills, she said.
In extreme cases networks could be too small to serve all the plan members they sign up.
“It’s no good making a narrow network that nobody can get in to see,” said Sander Domaszewicz, a senior benefits consultant at Mercer.
Insurers began unveiling ACA marketplace plans with narrow networks in recent months for coverage that starts in January 2014. Policymakers soon challenged them in several states, often pushed by excluded hospitals and their patients.
Maine Insurance Superintendent Eric Cioppa blocked Anthem from switching several thousand existing subscribers to a plan that excluded Central Maine Medical Center and partner doctors and hospitals. Anthem argued that shrinking its network would provide less-expensive but still high-quality care.
This summer Washington Insurance Commissioner Mike Kreidler blocked five insurers from selling through the exchange, in several cases because of network problems. One plan, he said, would have required people to drive nearly 50 miles to see a cardiologist and more than 100 miles to see a gastroenterologist.
Four plans protested Kreidler’s ban. Three reached settlements, some by adjusting networks. An administrative judge ruled in favor of another, Coordinated Care, whose network doesn’t include a children’s hospital.
Seattle Children’s Hospital, left out of networks including Coordinated Care’s, then sued Kreidler, alleging he failed to ensure adequate access to care.
In New Hampshire, Anthem’s decision to leave hospitals out of its network has prompted at least one to threaten litigation, and Nelson to introduce his bill. Anthem’s network could force some patients in his district to drive a dozen of miles or more to get routine care, he said
In few places has the fight over networks been fiercer than in Mississippi. BlueCross Blue Shield of Mississippi cancelled in-network contracts over the summer with Health Management Associates, a for-profit chain with 10 hospitals in the state.
Blue Cross isn’t selling insurance in 2014 through Mississippi’s federally run ACA marketplace, but many expect it to come on board later.
In response HMA took to the airwaves in protest and pitted the insurance commissioner, who wanted only four hospitals reinstated, against the governor, who ordered the insurer to take back all 10.
“I’ve been practicing law for 36 years and I have never seen as aggressive an effort to sway public opinion as these guys engaged in,” said David Kaufman, an outside lawyer for BlueCross BlueShield of Mississippi said of the hospital chain. “You could not go to your mailbox, pick up a newspaper, watch TV, listen to the radio or answer your home phone without hearing that Blue Cross is the devil.”
Blue Cross sued Gov. Phil Bryant, arguing the order was unconstitutional, noting that his daughter works for HMA’s law firm and pointing out that HMA is one of his top campaign contributors. Bryant backed off but ordered Insurance Commissioner Mike Chaney to hold hearings. He refused. Bryant and Cheney, both Republicans, have clashed repeatedly over the federal health law.
Now Mississippi, too, is talking about an any-willing-provider law, which typically requires insurers to take any hospital, clinic or doctor under terms accepted by other participants.
Such a rule would tell Blue Cross that “it can’t kick somebody out of the hospital of their choice,” HMA executive Paul Hurst told WFMN radio’s Paul Gallo on a show broadcast statewide.
But in any state, making every insurer accept every hospital, “is going to throttle competition,” said Dranove, the Northwestern professor who specializes in the health industry. “And this is a healthcare reform that depends entirely on competition. So the people who are fighting for broad networks… are ultimately fighting for the demise of Obamacare.”
Millennium Medical Solutions Inc. will continue to monitor and report on narrow net- work plans and other efforts by insurers to control costs in the PPACA environment.
NYS Health Exchange FAQ Jan 1 Enrollments. NYS of Helath has provided a helpful Frequently Asked Questions for recent enrollees. We have attached the document for your use.
IMPORTANT: How can I pay my premium bill for January 1st coverage?
You need to pay your health plan – not NY State of Health – no later than 10 days after you receive your invoice (bill) from your plan. You can pay your bill by mail. Some plans may accept payment online or over the phone. Plans must accept the following forms of payment: paper checks, cashier’s checks, money orders, electronic funds transfer (EFT), and all general-purpose pre-paid debit cards. Contact your health plan for more information about payment options or if the due date is a problem for you.
For more information regarding both Exchanges – Individual Exchanges or SHOP please contact our team at Millennium Medical Solutions Corp (855)667-4621. We have Spanish, Russian, and Hebrew speakers available. Quotes can also be viewed on our site.
- FAQ Using Coverage January 1, 2014
Jan 1 Deadline is Today. Attention last minute health insurance shoppers you have until midnight to purchase a policy on the Health Exchange.
NYS Health Exchange is down again. Not surprisingly a large volume of late comers trying to beat t0morrows deadline for Jan 1, 2014. Last week a 34% enrollment spike in 1 week alone. Despite the 1 week extension the enrollments are still falling short of the original 600,000 projection. A significant percentage have instead been qualified under expanded Medicaid in NYS. At the same time many New Yorkers have had sole prop and husband/wife groups shut out of the small group market place. In addition, popular programs such as Healthy NY have been increased by 25-35% and new $600/single or $1200/family deductibles.
- Some people mistakenly believe they have until Dec. 31 to enroll in a plan that takes effect on Jan. 1. Others don’t realize they could pay a federal tax penalty if they don’t have health insurance in place by March 31.
- Under the Affordable Care Act, most adults will pay a $95 penalty — or 1 percent of income — in 2014 if they don’t have health insurance coverage. The penalty rises to $695 — or 2 percent of income — by 2016.
- To avoid the penalty, people must enroll in a plan by Feb. 15 or qualify for an exemption from the penalty.
- Consumers who sign up by Dec. 23 and pay the first month’s premium by Jan. 10 will have coverage on Jan. 1, the industry group America’s Health Insurance Plans announced Wednesday.
- If you make under $45,960 or your family makes under $94,200, you could get a real break on health insurance costs More low-income people will also be eligible for free coverage under Medicaid For those eligible, the subsidies will cap the amount you pay for your exchange policy at between 2% and 9.5% of your income (on a sliding scale, based on your income). To find out how much you would pay, estimate your income for this year and plug it into any health subsidy calculator. You can also see estimate subsidies with these ”health subsidy charts”.
- Health Exchange Marketplace Top Ten List
Need help with your insurance application?
Important: If the web site is down we can sign up via paper application to avoid the penalty. A surge of 34% enrollments in one week caused some technical delays last week.
For more information regarding both Exchanges – Individual Exchanges or SHOP please contact our team at Millennium Medical Solutions Corp (855)667-4621. We have Spanish, Russian, and Hebrew speakers available. Quotes can also be viewed on our site. [contact-form-7 404 "Not Found"]