On September 1, 2022, Empire BlueCross BlueShield will begin partnering with CareMount Medical, the largest independent, multi-specialty group in New York State, to provide access to affordable care throughout New York City, Westchester, Putnam, Dutchess, Columbia, and Ulster counties.
CareMount will now be part of Empire’s Blue Access and Connection Networks for all Large Group and Small Group members. This will mean greater access to more affordable care throughout Westchester and surrounding markets.
Contact us to learn how Empire can fit your employee’s needs.
Learn more about how we are successfully helping navigate SMB for 25+ years. If you have any questions or would like additional information, please contact us at 855-667-4621 or info@360peo.com.
Good news Bronx/Westchester. Oxford and Montefiore Health System announced moments ago that they have reached an agreement effective December 1, 2021 for UnitedHealthcare and Oxford employer-sponsored plans, as well as UnitedHealthcare’s Medicare Dual Special Needs Plan.
This resolves a split since Jan 1, 2021 which affected a significant percentage of local residents as both companies have a critical size of the market. Westchester and Bronx populations total nearly 2.5 million people. While this contract is resolved with titanic and a few Hospital Systems and Insurers left in the market we expect to see this trend to continue.
See below the official press release.
UnitedHealthcare and Montefiore Health System Renew Relationship
UnitedHealthcare and Montefiore Health System have reached a multi-year agreement that restores access to Montefiore’s hospitals and physicians for people enrolled in UnitedHealthcare and Oxford employer-sponsored plans as well as UnitedHealthcare’s Medicare Dual Special Needs Plan, effective Dec. 1, 2021.
We recognize that the care Montefiore provides is not only important but also personal to our members and we also know the negotiations process may have been difficult for them. Our top priority throughout this process was ensuring the people and employers we’re honored to serve in New York have access to quality, more affordable health care, and this new agreement helps accomplish that goal.
We thank our members and customers for their support and patience throughout this process. We are honored to continue supporting the more than 3.7 million individuals across New York who depend on us for access to quality and affordable health care.
Montefiore Hospitals & Health System
Facility Name
County
Montefiore Hospital (Moses Campus)
Bronx
Children’s Hospital at Montefiore
Bronx
Garnet Health MedJack D. Weiler Hospital (Einstein Campus)ical Center
Bronx
Montefiore Wakefield Hospital (Wakefield Campus)
Bronx
Burke Rehabilitation Hospital
Westchester
Montefiore Mount Vernon Hospital
Westchester
Montefiore New Rochelle Hospital
Westchester
Montefiore Nyack Hospital
Rockland
Montefiore St Luke’s Cornwall Hospital
Orange
White Plains Hospital
Bronx
Montefiore Hutchinson Campus
Bronx
Montefiore Medical Group
Westchester
Montefiore Medical Specialists of Westchester
Westchester
Neighboring Hospitals
Facility Name
County
Bon Secours Community Hospital BronxCare Hospital Center Garnet Health Medical Center Good Samaritan Hospital of Suffern New York Presbyterian Hudson Valley Hospital New York Presbyterian Lawrence Hospital NYC Health + Hospitals Jacobi NYC Health + Hospitals Lincoln NYC Health + Hospitals North Central Bronx St. Anthony Community Hospital St. Barnabas Hospital St. John’s Riverside Hospital Westchester Medical Center
A little-known requirement but most important under Affordable Care Act (ACA) is for Health Insurers must waive their minimum employer-contribution and employee-participation rules once a year. ACA requires a one-month Special Open Enrollment Window for January 1st coverage.
The special open enrollment period occurs November 15th through December 15th of each year, allowing eligible small group employers to enroll for coverage effective January 1st of the following year.
Background
The ACA has a section in it called the “guaranteed issuance of coverage in the individual and group market.” It stipulates that “each health insurer that offers health insurance coverage in the individual or group market in the state must accept every employer and individual in the state that applies for such coverage.” The section also states that this guaranteed issuance of coverage can only be offered during (special) open enrollment periods, and that plans can only be offered to applicants that live in, work in, or reside in the plans’ service area(s).
Participation and Contribution Requirements
In many states (including California and Nevada), carriers can decline to issue group health coverage if fewer than 70% of employees elect to enroll in coverage. Some carriers may have even tighter participation requirements.
Generally speaking, employees with other coverage (Medicare, other group coverage, individual coverage through the Exchange, etc.) are removed from the participation requirement calculation – though it varies by insurance carrier.
Furthermore, employer contribution rules require employers to contribute a certain percentage of premium costs for all employees in order to attain group health coverage. Some businesses struggle to meet these contribution requirements for a variety of financial reasons.
Problem Solved: Special Open Enrollment Period
Many employers want to offer coverage to their employees, but are denied because they struggle to meet participation and/or contribution requirements. Employers cannot force employees to enroll in coverage unless the employer pays for 100% of the employees’ premiums, which many employers cannot afford. Even with moderate to generous employer contributions, many employers still find young and lower-income employees waiving coverage. This was even more evident in 2019 with the ACA’s federal Individual Mandate non-compliance penalty reduced to $0.00.
The U.S. Department of Health & Human Services provides final guidance on this in regulation 147.104(b)(1): “In the case of health insurance coverage offered in the small group market, a health insurance issuer may limit the availability of coverage to an annual enrollment period that begins November 15 and extends through December 15 of each year in the case of a plan sponsor that is unable to comply with a material plan provision relating to employer contribution or group participation rules.”
If your employer groups are struggling with participation and/or contribution, the Special Open Enrollment Window is the time to enroll them in coverage.
The New York State Department of Financial Services (DFS) announced the updated Paid Family Leave premium rate and covered payroll limit for 2019. The NY DFS publishes a new employee contribution rate and wage cap each September 1st for the upcoming year to accommodate the graduation of benefits in from 2018 to 2021.
The following chart can be used to help explain these changes to your employees:
Year
Max Annual Covered Payroll
Premium Rate
Maximum Annual EE Contribution
Benefit %
Max Weekly Benefit
Benefit Duration
2018
$67,908
.00126
$85.56
50%
$652.96
8 Weeks
2019
$70,570*
.00153
$107.97
55%
$746.41
10 Weeks
HOW TO CALCULATE CONTRIBUTIONS?
• EMPLOYEE EARNING: $200,000 OR $3,846.15 WEEKLY WAGE.153% x $3.846.15 = $5.88 (Paid up after 19 weeks) *
• EMPLOYEE EARNING: $100,000 OR $1,923.07 WEEKLY WAGE.153% x $1,923.07 = $2.94 (Paid up after 37 weeks) *
• EMPLOYEE EARNING: $70,569 OR $1,357.10 WEEKLY WAGE.153% x $1,357.10 = $2.08 (Paid up after 52 weeks) *
• EMPLOYEE EARNING: $38,812.80 OR $746.40 WEEKLY WAGE.153% x $746.40 = $1.14 (Paid up after 52 weeks) *
Note: Employers may not collect contributions in excess of $107.97 * Such employee will have satisfied their maximum annual contribution
NYS has approved 2019 Final Rates last Friday. Small group rates will increase 3.8% and 8.6% for individuals.
As per NY State Law, Health Insurers are required to send out early notices of rate request filings to groups and subscribers see original –NYS 2019 Rate Requests. Despite only 3 months of mature claims data experience for 2018 health insurers’ original requests were noticeably below average 7.5% for small group and 24% for individuals. Ultimately NYS reduced this request substantially by approximately 50%.
Experts are concerned over the long term effects. Example, the Individual mandate was removed last December by Presidential order. Without the Mandate anyone can drop insurance without penalty. A comparable take away for similar auto insurance industry would be something like this -Drivers ought not be mandated to buy auto insurance as its a profit scheme by Insurers. While a popular decision this will hardly bend the curve long term and reduce competition. Furthermore, the new order of Selling Across State lines makes NYS most unwelcoming.
OTHER STATES
Insurers have been filing to sell Obamacare plans that will go into effect in 2019, and in some states they appear to be pricing in for the fact that the mandate is going away next year. Other states are seeing mild increases, but that is in part because they saw significant hikes for the previous year.
Insurers have concluded that fewer people will enroll without the mandate than otherwise, so in some places they are pricing their plans higher based on the assumption that sicker people will be left behind, which will increase medical costs for those left. It is well worth pointing out that in recent years the loss federal risk reinsurance corridor funds account for 5.5 percent of the rate increase.
How are neighboring States doing?
In NJ, not that bad. Last year the average increase were 5.5% for small groups and some popular plans such as Horizon Blue Cross Blue Shield’s OMINA increasing only 4.8% increase. This year the increase is only 5.2. Other insurers offering EPO and HMO plans in the individual market for 2019 include Oscar Health and Oxford Health Plans.
With individual mandate repeal fewer people will buy health insurance raising the prices for those who do. NJ Banking and Insurance Department officials said premium prices would have increased, on average, by 12.6 percent.
For CT market, on the other hand, things are much worse at least for the individual marketplace with average 25% rate increases last year. The 2019 proposed rate increases for both the individual and small group market are, on average lower, than last year: The proposed average small group rate increase request is a 10.22 percent and ranges from -5.0 percent to 21.1 percent. This compares to the average increase request of 18.06 percent requested last year.The proposed average individual rate increase request is 12.3 percent and ranges from -10.9 percent to 31.0 percent. This compares to the average increase request of 25.51 percent requested last year.
Final plan rates in New Jersey & CT will be finalized and released in the fall, state officials said. ACA open enrollment begins Nov. 1
Trend: Trend is a factor that accounts for rising health care costs, including the cost of prescription drugs, and the increased demand for medical services.
Uncertainty in Washington:
Removal of penalty for individual mandate: The elimination of the penalty means that individuals who are typically younger and healthier would have no inducement to participate in the insurance pool, which could further destabilize the market. Lack of participation shrinks the pool and increases the cost of insurance to the remaining members.
Short-duration health plans and Association Health Plans: Still pending are final federal regulations on non-ACA compliant short-duration plans, which may have implications for the ACA risk pool. Also, Connecticut along with other state insurance regulators, are awaiting clarification from the federal government on new federal regulations allowing association health plans, which could further shrink the ACA risk pool.
A bipartisan group of congressional representatives has discussed an agreement to extend and guarantee the payments, but it’s unclear whether they could do so by the new filing deadline of Sept. 5. A lawsuit filed by Congress against the Obama administration to challenge the payments is still pending. In addition, Trump has repeatedly threatened to withhold payments to insurers that reduce cost-sharing – deductibles, copays and coinsurance – paid by low-income customers. More than half of New Jersey’s marketplace customers receive that assistance, and without it, most would be unable to afford coverage.
Finally, a tax on health insurance premiums has been reinstated in 2018 after a one-year “tax holiday” approved by Congress for 2017. That contributed 2.3 percent to the rate hikes that insurers requested for 2019 and for 2019
SMALL GROUP MARKET VS. INDIVIDUAL MARKET
Importantly, small group market is still more advantageous than individual markets unless one gets a sizable low-income tax credit. Overall, about 350,000 individual plan consumers will be affected by the price hike, while more than a million users will be hit by higher small group fees. Last year, Blue Cross Blue Shield released a study showing Obamacare user costs were 22 percent higher than people with employer-sponsored health plans, while UnitedHealthplans to exit most Exchanges see – Breaking: Oxford Exits Metro Indiv & Oxford Liberty HMO 2017.
The correct approach for a small business in keeping with simplicity is a Private Exchange and with our large buying group PEO partnerships. This is a true defined contribution empowering employees with a choice of leading insurers offering paperless technologies integrating HRIS/Benefits/Payroll. Both employee and employers still gain tax advantage benefits under the business. Also, the benefits, rates and network size are superior under a group plan as the risk are lower for small group plans than individual markets.
Learn how a PEO Partnership can help your group please contact us at info@360PEO.com or (855)667-4621.
HealthPass New York will start offering OSCAR Health Plans effective Sept 1, 2017 to small employers. Oscar will offer eight plans with varying benefits package with 1 to 100 employees. The plans are available to small businesses located in New York City, Long Island, Westchester and Rockland counties. NJ residents can also access Hospitals & physicians through the NJ Qualcare PPO Network
HealthPass New York, a private insurance exchange for small employers. The addition of Oscar gives small businesses access to 3 health networks – Oxford, CareConnect and Oscar. Also, Guardian is the insurer of record for the ancillary benefits comprising dental, vision, life insurance, disability and accident insurance
Oscar entered the NY market on Jan 1, 2014 and had around 16,000 members. In 2015, it expanded coverage to New Jersey and grew to about 40,000 members. In 2016, Oscar had 145,000 members in New York, New Jersey, California, and Texas. Oscar’s cutting edge technology and pioneering benefits have simplified the consumer health insurance experience propelled easier access and understanding of health plans. Examples of success have been ease of physician locator, online appointment setting and no cost telemedicine 24/7. Additionally, some plans have $0 Copay generics and annual 3 free office visits
Why a Private Exchange? The advantage of a Private Exchange is the ability to empower employees with choice. Much like a 401K your employees can use a defined contribution allocation for benefits. As affordable health plan networks are increasingly smaller with specific coverage areas the one size show for all approach to benefits no longer works.
If you’re a small business owner who has concerns about payroll, filing paperwork, and complying with government regulations, co-employment may be the service you’ve been looking for. In some cases, a Private Exchange may NOT be right for you. With Health Care Reform your company may qualify for a small business tax credit or a be eligible for a large group discount under a PEO.
Try us on a custom demo, contact us at (855)667-4621.
