King Ruling Awaiting Supreme CourtThe King Ruling awaits As Supreme Court schedules more decision days. The decision is expected to be possibly on Thursday on the legality of the Health care subsidies. ISSUE RECAP: At issue is whether subsidies that 8.7 million people receive to help pay for their insurance are available in all 50 states, or only those that set up their own health insurance exchanges. (more…)
2/12/15
Last days for 2015 Individual Open Enrollment is ending this week. This deadline applies to both On and Off Exchange!
If you’re wondering about the penalty for not having insurance: yes, there is one, and no, you can’t really get out of paying for it. You’ll pay the penalty when you file your taxes for 2015. Even if you get coverage midway through the year, you’ll still need to pay a penalty for the months you weren’t insured. So get covered!
You can check here at the New York State of Health Marketplace calculator. If you are eligible or think you might be eligible, you can contact the marketplace directly to purchase a plan or ask questions about financial assistance.
Please remember that during open enrollment you are permitted to switch carriers. Choose wisely because after February 15, one cannot switch plans until open enrollment 2015, unless you have a “qualifying event,” such as marriage, divorce, birth or adoption.
Open enrollment for the 2015 New York individual market season is right around the corner. Below are answers to commonly asked questions pertaining to individual market coverage for residents of New York State:
Q: What is the New York State of Health (NYSOH) exchange website?
A: NYSOH provides NYS residents living between 139%-400% of the Federal Poverty Level, access to lower cost health insurance by supplying them with tax credit premium subsidies. Additional Cost Sharing subsidies are available to those living between 139%-250% of the FPL. All subsidy programs are subject to eligibility requirements. Additionally, NYSOH is where individuals can enroll in Medicaid (for those living below 139% of the FPL).
Q: Is the NYSOH government health insurance? Is that what “Obamacare” means?
A: No. Individual health insurance is a relationship between a consumer, and a private health insurance company. NYOSH slips in between this relationship by forwarding tax credit money to the carrier on behalf of the subsidy-eligible consumer, and then the carrier bills the consumer for the difference in premium owed. “Obamacare” is simply the nickname of the new health insurance law, which (in part) assists individuals in obtaining health insurance.
Q: Do I have to have health insurance?
A: Yes. As part of the individual mandate, all US citizens must enroll in Affordable Care Act-compliant health insurance…be it through your employer, the individual market, Medicare, or Medicaid. Citizens not enrolled in coverage will be fined by the IRS (less those who qualify for exemptions).
Q: What is the fine for not having health insurance?
A: In 2015, the fine is 2% of household income per uninsured month. In 2016, this increases to 2.5% of household income per uninsured month.
Q: Do I have to enroll in individual coverage through NYSOH?
A: No. Only people in need of tax credit subsidy assistance must enroll through the NYSOH exchange website.
Q: What if I don’t earn enough income to qualify for subsidy assistance for on-exchange health plans?
A: People in NY living below 139% of the FPL will be eligible for Medicaid. Medicaid enrollments are conducted on the NYSOH website.
Q: If I am over the subsidy income limit threshold, how do I apply for coverage outside of the NYSOH website?
A: You can enroll directly with a carrier, or, by contacting a licensed insurance broker for assistance. Off-exchange carrier applications are extremely simplified, requiring only a 1-2 page paper/PDF application to be completed in most cases, and with no government intervention.
Q: Can brokers assist me with my individual coverage written through the NYSOH website as well?
A: Yes. Licensed brokers, who are also certified to write health plans on the exchange, can be found in the Broker directory on the NYSOH website. You can search using a specific broker’s first and last name, by selecting a specific Agency from the drop down list, or you can enter your ZIP Code to find one in your region.
Q: Do brokers charge fees for helping me secure an individual health plan?
A: Brokers are not allowed to charge fees for assisting individuals with writing their health insurance.
Q: How do brokers get paid?
A: Every time you pay your health insurance bill, a portion of your payment is allocated towards compensating a broker (just like with your auto or homeowners insurance). Most carriers pay broker commissions on the back end, which is completely transparent to the consumer. If no broker is utilized by the consumer, the carrier retains the commission. This means that whether you use a broker or not, you’ll be paying for one anyway.
Q: Don’t Navigators already provide these broker services?
A: No. Sometimes referred to as “in person assistors” or “experts” by the NYSOH, Navigators are not licensed to write health insurance. They are trained employees or contracted agencies of the NYS government (funded by Federal grant money) to help individuals navigate the enrollment process on the NYSOH website only. They are not required by federal law to undergo criminal background checks, nor are they licensed by the NYS Department of Financial Services, which means they cannot make plan recommendations to health insurance consumers.
Q: Can a certified broker process my NYSOH enrollment for me?
A: Yes. Brokers that are certified to write business on the NYSOH exchange website can drive the entire online enrollment process for the consumer. You just need to authorize a broker through your NYSOH account by logging in, and then clicking “Find a Navigator/Broker” towards the bottom left side of your NYSOH account home page. Once authorized, the broker you have selected will receive an email from the NYSOH that you are in need of assistance, and can now enroll you on your behalf.
Q: When can I enroll in individual health insurance?
A: Like Medicare, the individual health insurance market is setup to have an open enrollment season. The individual market open enrollment window is from 11/15/14 through 2/15/15.
Q. Are there any exceptions to the open enrollment period?
A. Enrollment in Medicaid, Child Health Plus and the Small Business Marketplace continues all year.
Find us on the Health Insurance Marketplace where you may qualify for help to pay for your health insurance. Qualifying Events for Exchange Marketplace. 76 percent of the uninsured are unaware of the looming March 31 sign-up deadline. Contact us at (855)667-4621.
Q: Can I enroll in coverage outside of the open enrollment season?
A: Consumers can enroll in individual coverage outside the open enrollment season so long as a “Qualifying Life Event” exists. Examples of such events include the loss of a job, marriage, divorce, birth of a child, a change in subsidy eligibility, and others. Written proof of the QLE will be required when enrolling outside of the open enrollment season as established by the US Department of Health and Human Services.
Q: If I am subsidy eligible, and my income changes, what do I do?
A: Consumers enrolled through the exchange who receive tax credits must notify the NYSOH Marketplace whenever a change of income is experienced. You can contact the marketplace call center at 855-355-5777 to update your income information.
Q: Am I limited to certain insurance companies if I am subsidy-eligible?
A: No. Consumers who are subsidy-eligible may pick any plan they wish that is available on the NYSOH exchange website. However, subsidy-eligible individuals may not apply those tax credits towards health plans written outside of the NYSOH website (for example, Oxford Liberty plans, which are only available outside of the NYSOH Marketplace).
Q: I have completed the income portion of my on-exchange application, and I’m now ready to pick a plan. How can I find out more specific information pertaining to the available options in the market?
A: A licensed insurance broker can help you understand the available health plans in the market, and can make plan recommendations specific to your needs and financial situation.
Q: I started my current individual plan in July 2014. Do I have to renew my plan on January 1st 2015?
A: Yes. All individual market plans have calendar year deductible and maximum out of pocket accumulation periods, which resets on January 1st of any given year. So for example, if you lost your job (and your health insurance) effective 12/1/14, and then you enroll for individual coverage effective 12/1/14, you must renew your individual plan the following month (for 1/1/15) at the new carrier plan structures and rates.
Q: I already have individual market based health insurance. Can I change plans during the open enrollment season?
A: Yes. Existing individual health insurance policyholders may change their plan during the open enrollment season. You may also change carriers should you wish to find a better solution for your needs. Talk to your licensed insurance broker about the available plan options in the market for 2015.
Q: My employer is offering me a health plan that I am not interested in. Can I waive my employer health plan and replace it with an individual plan, and receive tax credit subsidy assistance?
A: The answer to the first part of the question is yes. Employees can choose to opt out of employer-sponsored health insurance, and can replace their coverage in the individual market.
With regards to receiving tax credit subsidies in these situations, yes, an individual can receive tax credit subsidies to help pay the cost of individual health insurance. However, in addition to the employee needing to meet tax credit eligibility requirements as discussed earlier, one of two additional conditions must be met to be eligible to receive subsidy assistance: 1) The employer’s health plan does not meet the minimum actuarial value of 60%, or 2) The employee’s single rate cost (self-only coverage, no dependents) for employer-sponsored coverage exceeds 9.5% of their household adjusted gross income (defined as “unaffordable” under the health care law).
Q: I’m applying for a tax credit subsidy. How do I determine my adjusted gross income?
A: Your adjusted gross income can be found on line 37 of your 1040 tax return. Subsidy applicants who have a steady income can use this figure as a guide when determining tax credit eligibility for the upcoming tax year.
Those that do not have a steady income (e.g. sole proprietors, freelancers, single-person businesses, etc.) should speak with their accountants to determine their estimated adjusted gross income for the upcoming tax year.
Q: I was determined Medicaid eligible after applying for tax credit subsidy on the NYSOH website. However, my doctors do not take Medicaid. Can I opt out of medicaid and get a subsidized individual health plan instead?
A: You may choose to opt out of Medicaid if you wish. However, those who are Medicaid eligible will not qualify for tax credit subsidies for individual health plans. You can enroll in a health plan, but you must pay the full price of the plan.
Q: I was determined subsidy eligible, and I want to pick a plan to enroll in through the NYSOH website. Can I put my children on my health plan with my spouse and I?
A: No. Those who are subsidy eligible must insure their dependent children through a Child Health Plus plan. CHP (or “chip”) plans are selected during the plan check out process at the end of the NYSOH application. Only the applicant and spouse will qualify for a private health plan with subsidy assistance. If you choose to opt your children out of CHP, you and your spouse will lose subsidy eligibility for your private health plan.
Q: How can I find out if my doctors take a particular health plan?
A: Your licensed insurance broker can provide you with carrier-specific tools to look up providers in particular networks.
Q: How can I get a copy of the full benefit summary for a particular health plan I’m interested in?
A: Your licensed insurance broker can provide you with electronic benefit summaries for most health plans upon request.
Q: How can I find a licensed broker to assist me?
A: Licensed insurance brokers, and who are also certified to write on-exchange plans, can be found in the Broker directory on the NYSOH website. You can search using a specific broker’s first and last name, by selecting a specific Agency from the drop down list, or you can enter your ZIP Code to find one in your region.
Congratulations – you just signed up successfully for Obamacare! You made it right before the March 31st deadline and avoided the individual penalty and getting blocked out for 2014. Don’t relax just yet. If you’re one of the many people who applied on the first open enrollment it’s smart to expect some bumps over the next few weeks. Shifting deadlines and technical glitches have left many insurance companies scrambling to catch up to the flood of requests. To make sure you start things right, here are some easy ways to stay vigilant:
Obamacare 2014 Deadline Nearing. You are now more knowledgable than most after reading this article. Given all the new changes thanks to the new insurance plans, new enrollees, and changing deadlines, being aware of these simple tips will help you avoid unnecessary headaches. And remember, if you are still shopping for insurance, you only have until March 31st to enroll in a plan.
Federal government health care site: www.healthcare.gov
Kaiser Health Reform Subsidy Calculator:http://healthreform.kff.org/subsidycalculator.aspx
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.
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.