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.
Yesterday, NYS 2018 Health Insurance Rate Filing were released. The total weighted average increases were 11.5% small groups and 16.6% individual market. This early filing request deadline request requirement is not an Obamacare requirement. As per NY State Law carriers are required to send out notices of rate increase filings to groups and subscribers.
These are simply requests and the state’s Department of Financial Services has authority to modify the final rates. But they are the first indication of what New Yorkers can expect when shopping for health insurance on the individual marketplace at the end of this year. The news comes as insurance companies across the country brace consumers for another year of large rate hikes, owing in part to the composition of the individual market, and in part to the uncertainty over the future of the law under the Trump administration.
Background:
By comparison last year NYS 2017 Rate Request early filings were higher at 12.3% small group and 19.3% for individuals. The final filing rates were lower NYS 2017 Final Rates were 8.3% small group and 16.6% for individuals. The NYS 2016 Rates final rates were 9.8% small group and 7.1% for individuals. Using these past figures one projects a 2018 Final Rates of 7% small groups and 14% individuals.
With only 3 months of mature claims in 2017 to work of off Insurance Actuaries have little experience to predict accurate projections. Simply put the less credible information presented to actuarial the higher the uncertainly and higher than expected rate increase. The national rate trend, however, has been much higher than in past years due to higher health care costs and the loss of Federal reinsurance fund known as risk reinsurance corridor.
Individuals:
Individual rates are expected to be higher than small group. The national rate trend, however, has been much higher than in past years due to higher health care costs Like other states throughout the nation, the 2018 rate of increase for individuals in New York is higher than in past years partly due to the termination of the federal reinsurance program. The lost of the program’s aka federal risk reinsurance corridor funds accounts for 5.5 percent of the rate increase.
This is one of the reasons why the individual market is significantly more costly to operate than small group as per recent Aetna and United Healthcare pull out of most State Individual Exchanges. Another local example was last year’s Oscar Health Insurance which had lost $105 million and is asking for up to 30% rate increase. The 3 year old company said the increase was necessary because medical costs have risen, government programs that helped cover costs are ending, and its members needed more care than expected. For 2018, with successful pivotal changes Oscar is asking below average 11% individual increase and a decrease of 3.2% small group next year.
Small Groups:
While small group rates are better risk and naturally lower rates. There is some rate shock with notably Careconnect. CareConnect, the financially struggling health insurance arm of Northwell Health, has asked the Cuomo administration to allow an average 30 percent premium hike on the individual market in 2018. The company, which lost $157 million in 2016, is asking for small group increases that range between 9 and 24 percent.
THE THREE R – RISK CORRIDOR, RISK ADJUSTMENT & REINSURANCE designed to mitigate the adverse selection and risk selection. The problem, according to many insurance companies, is that the formula is flawed, and CareConnect executives have consistently complained that they are at an unfair disadvantage. The Cuomo administration has taken steps to ameliorate some of those problems, giving the DFS the authority to essentially overrule the federal numbers. In its first-quarter financial report, executives made clear that the risk adjustment penalty was a threat to its business.
Instead, the correct approach for a small business in keeping with simplicity is a Private Exchange. This is a true defined contribution empowering employees with 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 OUTLINED ABOVE ARE HIGHER FOR INDIVIDUAL MARKETS THAN SMALL GROUP PLANS.
You may view the NYS 2018 Rate Requests DFS press release, which includes a recap of the increases requested and approved by clicking here.
For a custom analysis comparing PEO with YOUR upcoming 2017-2018 renewal please contact our team at 36PEO (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 onour site.
Summary of 2018 Requested Rate Actions
INDIVIDUAL MARKET
Company Name
2018 Requested Rate Action
Affinity
23.5%
Care Connect
29.7%
CDPHP
15.2%
Crystal Run Health Plan, LLC
8.7%
Emblem (HIP)
24.9%
Empire **
N/A
Excellus
4.4%
Fidelis
8.5%
Healthfirst Insurance Company, Inc.
13.0%
Healthfirst PHSP, Inc.
22.1%
HealthNow New York
47.3%
IHBC
25.9%
MetroPlus
7.9%
MVP Health Plan
13.5%
Oscar
11.1%
UnitedHealthcare of New York Inc
38.5%
Total Weighted Average
16.6%
SMALL GROUP MARKET
Company Name
2018 Requested Rate Action
Aetna Life
14.2%
Care Connect
19.3%
CDPHP
21.1%
CDPHP UBI
8.6%
Crystal Run Health Insurance Company
0.0%
Crystal Run Health Plan, LLC
3.9%
Emblem (HIP)
8.5%
Empire Healthchoice Assurance
12.9%
Empire Healthchoice HMO
13.8%
Excellus
8.0%
Healthfirst Health Plan, Inc.
10.0%
Healthfirst Insurance Company, Inc.
10.0%
HealthNow New York
8.9%
IHBC
14.5%
MetroPlus
5.1%
MVP Health Plan
8.5%
MVP Health Services Corp
11.7%
Oscar
-3.2%
Oxford Health Insurance Inc
11.4%
UnitedHealthcare Ins Company of New York
15.2%
Total Weighted Average
11.5%
*These averages may change based on DFS’s review of the rate applications.
** Empire submitted a filing that DFS is evaluating.
