Accidents happen without any notice. Life insurance helps those you leave behind pay bills, education cost, and funeral expenses among other things. Nothing can replace you in their hearts, but life insurance can make things easier for them when your gone.
This is an essential part of financial planning. One reason most people buy life insurance is to replace income that would be lost with the death of a wage earner. The cash provided can also can help ensure that your dependents are not burdened with significant debt when you die. The insurance proceeds could mean your dependents will not have to sell assets to pay outstanding bills or taxes. An important feature is that generally no income tax is payable on proceeds paid to beneficiaries. The death benefit of a life policy owned by a C corporation may be included in the calculation of the alternative minimum tax.
How much Insurance do I need?
Before buying life insurance, you should assemble personal financial information and review your family’s needs. There are a number of factors to consider when determining how much protection you should have. These include:
any immediate needs at the time of death, such as final illness expenses, burial costs and estate taxes;
funds for a readjustment period, to finance a move or to provide time for family members to find a job
ongoing financial needs, such as monthly bills and expenses, day-care costs, college tuition or retirement.
Although there is no substitute for a careful evaluation of the amount of coverage needed to meet your needs, one rule of thumb used is to buy life insurance that is equal to five to seven times annual gross income.
Sign up for latest news updates. Please contact us for immediate information on how to implement these initiatives for your group-specific needs at info@medicalsolutionscorp.com or Call (855) 667-4621.
Our Compliance Education Center takes the communication of compliance materials to the next level. Our Benefits Counsel partners actively monitors the progress of health care reform and legislative news to provide insightful bulletins to help simplify complex issues. This unique resource acts as a hub for all compliance information and bulletins as well as including brief videos that summarize each topic. The Compliance Education Center is automatically updated with the health care industry’s latest news, alerts, and important information.
Compliance Experts on your side.
Our team understands the changes taking place in healthcare reform and how they affect your business. From explaining regulations to detailed analysis of your compliance standards, we’ll help you stay compliant and plan for the future.
Great news for families with HSA and high deductible plans. Individual out of pocket maximums will apply EVEN UNDER A FAMILY POLICY. New federal health care reform law regulatory guidance ends lingering uncertainty on how much in out-of-pocket costs employers with high-deductible plans can require employees to pick up.
The guidance, leaves intact the maximum out-of-pocket expenses employers can require employees to pay before health plan coverage kicks in: $6,850 for single coverage and $13,700 for family coverage when the rules go into effect in 2016.
An example illustrates how the HHS-imposed “EMBEDDED” limit on out-of-pocket expenses will work:
An employee and his or her spouse enroll in family coverage with an annual cost sharing limit of $13,000, and during the 2016 plan year, $10,000 of cost sharing payments are attributable to the spouse and $3,000 of cost sharing payments are attributable to the employee. Prior to the HHS’s clarification, the full $13,000 would be payable by the covered individuals because the $13,000 plan limit had not been reached on an aggregate basis. However, with the new EMBEDDED self-only limitation, the cost sharing payments attributable to the spouse must be capped at the self-only limit of $6,850, with the remaining $3,150 being covered 100% by the group health plan. The employee would still be subject to cost sharing, however, until the $13,000 plan limit is reached.
The biggest impact on the new cost-sharing rules will be on employers with high-deductible plans.
For the FAQs, visit: http://www.dol.gov/ebsa/pdf/faq-aca27.pdf
For more information and a free renewal evaluation please
HDHP Minimum Annual Deductible (No change from calendar year 2011):
Single – $1,300 (NONE, $1,300 in 2015)
Family – $2,600 (+$100, $2,500 in 2015)
HDHP Out-of-Pocket Maximum:
Single – $6,550 (+$100, $6,450 in 2015)
Family – $13,100 (+$200, $12,900 in 2015)
Age 55 Catch Up Contribution
As in 401k and IRA contributions, you are allowed to contribute extra if you are above a certain age. If you are age 55 or older by the end of year, you can contribute additional $1,000 to your HSA. If you are married, and both of you are age 55, each of you can contribute additional $1,000.
HSA/HDHP Market Growth
HSA holders own the assets in the accounts and can build up substantial sums over time. Enrollment in HSA-compatible insurance plans has increased to 10 million earlier this year, from 1 million in March 2005, according to, America’s Health Insurance Plans (AHIP), a trade group.
HSAs were authorized starting in January 2004. Since then, AHIP has conducted a periodic census of health plans participating in the HSA/HDHP market.
The number of people with HSA/HDHP coverage rose to more than 11.4 in January 2011, up from 10.0 million in January 2010, 8.0 million in January 2009, and 6.1 million in January 2008.
30 percent of individuals covered by an HSA plan were in the small group market, 50 percent were in the large-group market, and the remaining 20 percent were in the individual market.
14% of all workers in the private sector that have access to a Health Savings Account acc. to Bureau of Labor Statistics.
States with the highest levels of HSA/HDHP enrollment were California, Ohio, Florida, Texas, Illinois and Minnesota.
HSA Advantages:
Opportunity to build savings – Unused money stays in your account from year to year and earns tax-free interest. The HSA also gives you an investment opportunity.
Tax-free contributions and earnings – You don’t pay taxes on contributions or earnings.
Tax Free Money allowed for non traditional Medical coverage– As per IRS Publication 502, unused moneys can be used for dental,vision, lasik eye surgery, acupuncture, yoga, infertility etc. Popular Examples
Portability – The funds belong to you, so you keep the funds if you change jobs or retire.
Our overall experience with HSAs have been positive when employer funding is at minimum 50% using either the HSA or an HRA (Health Reimbursement Account-employer keeps unspent money). Traditional plans trend of higher copays and new in network deductibles has also led to the popularity of an HSA.
(Note that a health plan will not fail to qualify as a high deductible health plan merely because it provides certain preventive health services without a deductible, as required under Health Care Reform.)
Is your HSA compliant? Which pre-tax qualified HSA, FSA, HRA spending card is right for you? Please contact our team at Millennium Medical Solutions Corp (855)667-4621 for immediate answers.. Stay tuned for updates as more information gets released. Sign up for latest news updates.
With first new star rankings released yesterday by CMS (Center for Medicare & Medicaid Services) this will be a little easier for consumers. The role of Government in medical transparency have long been touted as a qualitative and cost factor. The patient experience Star Ratings will make it easier for consumers to use the information on the Hospital Compare website and spotlight excellence in health care quality.
The Hospital Compare star ratings relate to patients’ experience of care at almost 3,500 Medicare-certified acute care hospitals. The ratings are based on data from the Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS) measures that are included in Hospital Compare. HCAHPS has been in use since 2006 to measure patients’ perspectives of hospital care, and includes topics like:
• How well nurses and doctors communicated with patients
• How responsive hospital staff were to patient needs
• How clean and quiet hospital environments were
• How well patients were prepared for post-hospital settings
Only 251 hospitals–or 7 percent of those ranked–received a five-star rating under the new system, Kaiser Health Newsreported. The largest share of hospitals (40 percent) received three stars, including highly respected institutions such as Cedars-Sinai Medical Center in Los Angeles, NewYork-Presbyterian Hospital in Manhattan and Northwestern Memorial Hospital in Chicago. Only 3 percent of hospitals netted one star.
Consumers will now see 12 HCAHPS Star Ratings on Hospital Compare, one for each of the 11 publicly reported HCAHPS measures, plus a summary star rating that combines or rolls up all the HCAHPS Star Ratings. These star ratings will be updated each quarter. Also, the Nursing Home Compare site already uses star ratings to help consumers compare nursing homes and choose one based on quality.
The first massive data breach of 2015 hit one of the country’s largest insurance issuers, Anthem, Inc., including Empire Blue Cross and Blue Shield and other related entities (Anthem). The incident reportedly affected over 80 million persons who are or were covered under a policy or program insured or serviced by Anthem. Th Anthem Facts or FAQs seek to provide helpful information to the millions of individuals affected. These communications address what is known about the incident, describe the kinds of information compromised, warn affected persons about potential email attacks, and advise that there is more information coming.
But there is not much information at this point for employers that are plan sponsors of group health plans. Is this really only Anthem’s problem? How well protected is YOUR business? In the event of a hack would you even realize this before its too late? We know that long before the attack the malware may have been sitting there latent as early as December. Even if you have IT service agreement will they insure and cover you in case of compromise hacks?
A critical component of combating the risks to your business represented by cyber crime and unintentional data breaches is to purchase a cyber liability insurance policy. Cyber coverage isn’t exactly new, but the need for it is increasing as the rate of cyber crimes rises.
FBI Executive Assistant Director Kenneth Bixby, the agency’s “point man” for cyber fraud, recently presented testimony before Congress regarding the bureau’s efforts to combat computer fraud. While attacks on large corporations like Target, Neiman Marcus, and Home Depot make the evening news, Bixby emphasized that smaller companies (those with fewer than 250 employees) are the targets of almost one third of all cyber attacks.
Last year, according to FBI statistics, federal agents informed over 3,000 U.S. businesses that their data had been hacked. In nine out of ten cases, these companies didn’t even know their computer systems had been breached until they were informed by the government.
Symantec estimates that attacks on small businesses increased 91 percent from 2012 to 2013, and experts believe the increase in software as a service and cloud storage solutions suggests that the problem is only going to get worse. As one security expert puts it: “Either you have been data breached or you just do not know that you have been data breached.”
The Cost of Data Breaches
In a separate Symantec-sponsored study, researchers identified the major direct and indirect expenses associated with business data breaches. They include:
Direct Costs: engaging forensic experts, providing customer hotline support and consumer credit monitoring subscriptions, discounts for future products and services.
Indirect Costs: in-house investigations and communication, the extrapolated value of customer loss resulting from turnover or diminished acquisition rates.
The same study pegs the per-record cost of a data breach at $188—32 percent for direct costs and 68 percent for indirect. This is just an average, however. According to researchers, the cost per record for data lost or exposed due to employee errors and system glitches is (on average) “cheaper,” coming in at $159 and $177 per record, respectively. In contrast, the cost associated with data loss or exfiltration from malicious cyber attacks is much more “expensive” at $277 per record.
A separate 2014 study by Kaspersky Lab tallied business losses for a given data breach “from $66,000 to $938,000 per organization, depending on the size of the company.” In addition, the Kaspersky study found that, in data breaches that involved business-to-business accounts, 43 percent of businesses terminated a business relationship following a reported fraud on their account, while 82 percent of companies indicated they would consider ending a business relationship with a company that suffered a data breach.
Cyber Liability Insurance
A critical component of combating the risks to your business represented by cyber crime and unintentional data breaches is to purchase a cyber liability insurance policy. Cyber coverage isn’t exactly new, but the need for it is increasing as the rate of cyber crimes rises. Also, many business owners don’t realize that cyber insurance often needs to be purchased as its own policy. As you begin looking into getting this crucial insurance for your company, it’s important to note that pricing and coverage will depend in large part on the details of your business, your data, your security measures, and your online presence.
Policies and coverages vary, but a cyber liability insurance policy generally covers the following:
Coverage for actual costs associated with a data breach: these can include consumer notification, customer support, and contracted credit monitoring services for those affected.
Liability for security/privacy breaches: protection from lawsuits and other actions resulting from the exposure of confidential customer information.
Asset recovery and restoration: the cost to restore, update, and/or replace hardware, software, or data assets damaged through cyber crime or by an unintentional loss or release of data.
Business interruption costs: coverage for additional expenses incurred and losses sustained as a result of a data breach.
Reputation management: protection from liability related to slander, libel, copyright claims, and other harm to your reputation resulting from activity on a business website or in social media.
Some policies also cover additional items, such as cyber extortion, cyber terrorism, and the cost of regulatory penalties or sanctions that may result from a breach of data.
If you think your existing business liability policy will protect you in the event of a breach of your company’s data, you’ll want to think again. Many business policies specifically exclude this type of risk because of the extreme variability between different companies’ risks and assets. If you’re not sure whether you’re covered, schedule an appointment to talk to your insurance advisor so you can be protected in the likely case of your company suffering a data breach.
Some of the elements of cyber-liability coverage may be interconnected or overlap with coverage from existing products, including those for business continuity, third-party supply chain issues, and professional indemnity. Even if this overlap does exist, a decent cyber-liability policy is not expensive and will save you headaches in the long run.
Talk with our cyber liability partner Mordy Littman and check if your business is protected at (855) 667-4621.
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Consumer complaints about receiving inadequate reimbursement from their insurers for medical services that they received outside of a provider network have been answered by New York’s “Emergency Medical Services and Surprise Bills” law. As of March 31, 2015, consumers will have protection from “surprise” medical bills for emergency medical services and certain out-of-network medical services.
The state of affairs today for small business plans offering both in and out of network is an exception with only 2 insurers in Downstate covering out of network at catastrophic high deductible levels. For Individual Marketplace it is even more dire with NO OUT OF NETWORK coverage at all.
The Problem. This has been a pattern in recent years and posted in Out of Control Out of Network Charges (March 2012). According to an investigation report commissioned by Governor Cuomo recognizing the unexpected out-of-network claim problem. Officials say that this is now “an overwhelming amount of consumer complaints.” Some examples cited in the report An Unwelcome Surprise – “a neurosurgeon charged $159,000 for an emergency procedure for which Medicare would have paid only $8,493.” Another example: ” a consumer went to an in-network hospital for gallbladder surgery with a participating surgeon. The consumer was not informed that a non-participating anesthesiologist would be used, and was stuck with a $1,800 bill. Providers are not currently required to disclose before they provide services whether they are in-network.” The average out-of-network radiology bill was 33 times what Medicare pays, officials say.
The blog post goes on to say “Today, 90% of SMB members have in network only benefits but the few remaining consumers are paying for eroding out of network benefits with little transparencies and necessary protection from new out of network billing practices. The NY Dept of Financial services is calling for providers in non-emergency situations to disclose whether or not all services are in-network, what out-of-network charges will be and how much insurers will cover.”
Balance Bill Protection. The long awaited bill passed last April protects patients from out-of-network providers from “balance-billing” consumers for emergency care or when patients can’t choose their doctors. Balance-billing occurs when health workers who don’t accept a patient’s insurance try to collect the difference between their charge and the insurer’s reimbursement.
Provider Disclosure Requirements. Hospitals will now be required to disclose anticipated charges. Patients most often receive these surprise bills in emergency cases, when they can’t choose the doctors who treat them. Its not unusual for a Provider to come into the picture who may read your tests or touch you thats not in network. Under the new law all medical providers will have to notify patients before treatment if they don’t take their insurance. If not, patients will be required to pay only a regular co-pay as if the provider was in network.
Providers will need to provide patients with disclosures of the health plans with which they participate and the names of the providers that may be billing them. They are also required to disclose procedures to follow with the an independent dispute-resolution entity (IDRE) which will be the arbiter of disputes under the law if a patient feels that a bill is inappropriate.
Network Adequacy. While the Affordable Care Act didn’t address surprise bills, the government has imposed network adequacy requirements that prevent health plans from having too few providers, which may reduce the number of cases where patients find themselves inadvertently out-of-network. New York will now require doctors and hospitals to disclose their network status before treatment in non-emergency procedures. Insurers will have to update online provider directories within 15 days of a change.
Prior to the Surprise Bill Law, these network adequacy rules only applied to health maintenance organizations (HMOs) and other “managed care” plans. HMO’s normally have more Provider/Insurer responsibility shifting form the patient. As with most non-HMO plans, however, the responsibility rests with patient to make sure everything is pre-authorized and in network is possible. Starting next month Health plans that are also based on more comprehensive PPO and EPO are also required to be certified as having provider networks that can meet the health needs of their members without having to rely on more expensive out-of network services.
A patient protection law is a welcome respite form the unfair unwelcome surprises out of one’s control. Common sense finally prevails!
WestMed Medical Group has now joined the North Shore LIJ’s insurance – CareConnect Network! This is not a purchase. This partnership expands their footprint and makes CareConnect a compelling fit for individuals and groups located in Westchester. In addition, CareConnect has just announced CareConnect’s Network Expansion! Yale-New Haven Health and all their facilities are now in-network with CareConnect. Tools are available to search for providers with updated expansion to be added shortly.
A combined Hospital Insurance system is an intriguing concept thats not all that new. Pittsburgh’s UPMC has been delivering the same model in Western PA successfully. In NYS an integrated medical approach is new on the other hand and challenging in an open competitive loop. A high quality smaller network that is priced affordably and can offer Patient Concierge like service may be what the market is asking for. They may also be in a better position to manage patient health and Preventative Medicine. For Jan 2015, NSLIJ CareConnect will have a 20% reduction in most regions such as Westchester and NYC. For new rates, benefits and provider listings click – CareConnect NSLIJ
For more information, please
Press Release#
Award-Winning WESTMED Joins CareConnect!
We’re pleased to announce our continued network expansion with the addition of WESTMED Medical Group. With this practice, CareConnect members now have more access in Westchester County:
• 289 physicians in eleven office locations • On-site laboratory and radiology services • Four urgent care centers • Three NCQA recognized programs including the patient-centered medical home and diabetes Stay tuned as we continue to add access for your groups around the CareConnect service area
On November 6th, the government issued their 22nd set of FAQs on ACA. This FAQ makes it clear that an employer cannot offer employees cash to reimburse the purchase of an individual policy.
Such an arrangement may be subject to a $100/day excise tax per applicable employee (which is $36,500 per year, per employee tax).
FAQs about Affordable Care Act Implementation (Part XXII)
November 6, 2014 Set out below are additional Frequently Asked Questions (FAQs) regarding implementation of the Affordable Care Act. These FAQs have been prepared jointly by the Departments of Labor (DOL), Health and Human Services (HHS), and the Treasury (collectively, the Departments). Like previously issued FAQs (available at http://www.dol.gov/ebsa/healthreform/ and http://www.cms.gov/cciio/resources/fact-sheets-and-faqs/index.html), these FAQs answer questions from stakeholders to help people understand the new law and benefit from it, as intended.
Compliance of Premium Reimbursement Arrangements On September 13, 2013, DOL and the Treasury published guidance on the application of the market reforms and other provisions of the Affordable Care Act to health reimbursement arrangements (HRAs), certain health flexible spending arrangements (health FSAs) and certain other employer health care arrangements.(1) HHS issued contemporaneous guidance to reflect that HHS concurs in the application of the laws under its jurisdiction as set forth in the DOL and Treasury Department guidance.(2) Subsequently, on May 13, 2014, two FAQs were made available on the IRS website addressing employer health care arrangements.(3)
The Departments’ prior guidance explains that employer health care arrangements, such as HRAs and employer payment plans, are group health plans that typically consist of a promise by an employer(4) to reimburse medical expenses up to a certain amount. The Departments’ guidance clarifies that such arrangements are subject to the group market reform provisions of the Affordable Care Act, including the prohibition on annual limits under Public Health Service Act (PHS Act) section 2711 and the requirement to provide certain preventive services without cost sharing under PHS Act section 2713.(5) The Departments’ guidance further clarifies that such employer health care arrangements will not violate these market reform provisions when integrated with a group health plan that complies with such provisions. However, an employer health care arrangement cannot be integrated with individual market policies to satisfy the market reforms. Consequently, such an arrangement may be subject to penalties, including excise taxes under section 4980D of the Internal Revenue Code (Code). Q1: My employer offers employees cash to reimburse the purchase of an individual market policy. Does this arrangement comply with the market reforms? No. If the employer uses an arrangement that provides cash reimbursement for the purchase of an individual market policy, the employer’s payment arrangement is part of a plan, fund, or other arrangement established or maintained for the purpose of providing medical care to employees, without regard to whether the employer treats the money as pre-tax or post-tax to the employee. Therefore, the arrangement is group health plan coverage within the meaning of Code section 9832(a), Employee Retirement Income Security Act (ERISA) section 733(a) and PHS Act section 2791(a), and is subject to the market reform provisions of the Affordable Care Act applicable to group health plans. Such employer health care arrangements cannot be integrated with individual market policies to satisfy the market reforms and, therefore, will violate PHS Act sections 2711 and 2713, among other provisions, which can trigger penalties such as excise taxes under section 4980D of the Code. Under the Departments’ prior published guidance, the cash arrangement fails to comply with the market reforms because the cash payment cannot be integrated with an individual market policy.(6)
Q2: My employer offers employees with high claims risk a choice between enrollment in its standard group health plan or cash. Does this comply with the market reforms? No. PHS Act section 2705,(7) which was incorporated by reference into ERISA section 715 and Code section 9815, as well as the nondiscrimination provisions of ERISA section 702 and Code section 9802 originally added by the Health Insurance Portability and Accountability Act (HIPAA), prohibit discrimination based on one or more health factors. Offering, only to employees with a high claims risk, a choice between enrollment in the standard group health plan or cash, constitutes such discrimination. While the Departments’ regulations implementing this provision(8) permit more favorable rules for eligibility or reduced premiums or contributions based on an adverse health factor (sometimes referred to as benign discrimination), in the Departments’ view, cash-or-coverage arrangements offered only to employees with a high claims risk are not permissible benign discrimination. Accordingly, such arrangements will violate the nondiscrimination provisions, regardless of whether (1) the cash payment is treated by the employer as pre-tax or post-tax to the employee, (2) the employer is involved in the selection or purchase of any individual market product, or (3) the employee obtains any individual health insurance.
Such offers fail to qualify as benign discrimination for two reasons. First, if an employer offers a choice of additional cash or enrollment in the employer’s plan to a high-claims-risk employee, the opt-out offer does not reduce the amount charged to the employee with the adverse health factor. Rather, the employer’s offer of cash to a high-claims-risk employee who opts out of the employer’s plan effectively increases the premium or contribution the employer’s plan requires the employee to pay for coverage under the plan because, unlike other similarly situated individuals, the high-claims-risk employee must accept the cost of forgoing the cash in order to elect plan coverage. For example, if the employer’s group health plan requires all employees to pay $2,500 toward the cost of employee-only coverage under the plan, but the employer offers a high-claims-risk employee $10,000 in additional compensation if the employee declines the coverage, for purposes of discrimination analysis, the effective required contribution by that high-claims-risk employee for plan coverage is $12,500 – that is, the $2,500 required employee contribution for employee-only coverage under the employer’s plan plus the $10,000 of additional compensation that the employee would forgo by enrolling in the plan. Because a high-claims-risk employee must effectively contribute more to participate in the group health plan, the arrangement violates the rule that a group health plan may not on the basis of a health factor require any individual (as a condition of enrollment) to pay a premium or contribution which is greater than the premium or contribution for a similarly situated individual enrolled in the plan. Second, the Departments’ regulations generally permit providing, based on an adverse health factor, enhancements to eligibility for coverage under the plan itself but not cash as an alternative to the plan. In particular, the regulations permit providing plan eligibility criteria that offer extended coverage within the plan and subsidization of the cost of coverage within the plan based on an adverse health factor.(9) An example in the Departments’ regulations illustrates that a plan may have an eligibility provision that provides coverage to disabled dependent children beyond the age at which non-disabled dependent children become ineligible for coverage.(10) Another example in the regulations illustrates that a plan may provide coverage free of charge to disabled employees, while other employees pay a participant contribution towards coverage.(11) However, in the Departments’ view, providing cash as an alternative to health coverage for individuals with adverse health factors is an eligibility rule that discourages participation in the group health plan. This type of arrangement differentiates based on a health factor and is outside the scope of the Departments’ regulations on benign discrimination, which permit only discrimination that helps individuals with adverse health factors to participate in the health coverage being offered to other plan participants. The Departments intend to initiate rulemaking in the near future to clarify the scope of the benign discrimination provisions. Finally, because the choice between taxable cash and a tax-favored qualified benefit (the election of coverage under the group health plan) is required to be a Code section 125 cafeteria plan, imposing an effective additional cost to elect coverage under the group health plan could, depending on the facts and circumstances, also result in discrimination in favor of highly compensated individuals in violation of the Code section 125 cafeteria plan nondiscrimination rules. Q3: A vendor markets a product to employers claiming that employers can cancel their group policies, set up a Code section 105 reimbursement plan that works with health insurance brokers or agents to help employees select individual insurance policies, and allow eligible employees to access the premium tax credits for Marketplace coverage. Is this permissible? No. The Departments have been informed that some vendors are marketing such products. However, these arrangements are problematic for several reasons. First, the arrangements described in this Q3 are themselves group health plans and, therefore, employees participating in such arrangements are ineligible for premium tax credits (or cost-sharing reductions) for Marketplace coverage. The mere fact that the employer does not get involved with an employee’s individual selection or purchase of an individual health insurance policy does not prevent the arrangement from being a group health plan. DOL guidance indicates that the existence of a group health plan is based on many facts and circumstances, including the employer’s involvement in the overall scheme and the absence of an unfettered right by the employee to receive the employer contributions in cash.(12) Second, as explained in DOL Technical Release 2013-03, IRS Notice 2013-54, and the two IRS FAQs addressing employer health care arrangements referenced earlier, such arrangements are subject to the market reform provisions of the Affordable Care Act, including the PHS Act section 2711 prohibition on annual limits and the PHS Act 2713 requirement to provide certain preventive services without cost sharing. Such employer health care arrangements cannot be integrated with individual market policies to satisfy the market reforms and, therefore, will violate PHS Act sections 2711 and 2713, among other provisions, which can trigger penalties such as excise taxes under section 4980D of the Code. Footnotes 1. See DOL Technical Release 2013-03, available at http://www.dol.gov/ebsa/newsroom/tr13-03.html, and IRS Notice 2013-54, available at http://www.irs.gov/pub/irs-drop/n-13-54.pdf. 2. See Insurance Standards Bulletin, Application of Affordable Care Act Provisions to Certain Healthcare Arrangements, September 16, 2013, available at https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/cms-hra-notice-9-16-2013.pdf. 3. Available at: www.irs.gov/uac/Newsroom/Employer-Health-Care-Arrangements. 4. These arrangements may be sponsored by an employer, an employee organization, or both. For simplicity, this section of the FAQs refers to employers. However, this guidance is equally applicable to HRAs sponsored by employee organizations, or jointly by employers and employee organizations. 5. Section 1001 of the Affordable Care Act added new PHS Act §§ 2711-2719. Section 1563 of the Affordable Care Act (as amended by Affordable Care Act § 10107(b)) added Code § 9815(a) and ERISA § 715(a) to incorporate the provisions of part A of title XXVII of the PHS Act into the Code and ERISA, and to make them applicable to group health plans and health insurance issuers providing health insurance coverage in connection with group health plans. The PHS Act sections incorporated by these references are sections 2701 through 2728. Accordingly, these referenced PHS Act sections (i.e., the market reforms) are subject to shared interpretive jurisdiction by the Departments. 6. See DOL Technical Release 2013-03, available at http://www.dol.gov/ebsa/newsroom/tr13-03.html, and IRS Notice 2013-54, available at http://www.irs.gov/pub/irs-drop/n-13-54.pdf. See also Insurance Standards Bulletin, Application of Affordable Care Act Provisions to Certain Healthcare Arrangements, September 16, 2013, available at https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/cms-hra-notice-9-16-2013.pdf. 7. Prior to the enactment of the Affordable Care Act, Titles I and IV of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law 104-191, added section 9802 of the Code, section 702 of ERISA, and section 2702 of the PHS Act (HIPAA nondiscrimination and wellness provisions). Affordable Care Act section 1201 also moved those provisions in the PHS Act from section 2702 to section 2705. 8. 26 CFR 54.9802-1 (g); 29 CFR 2590.702(g);146.121(g). 9. 26 CFR 54.9802-1 (g)(1)(i); 29 CFR 2590.702(g)(1)(i);146.121(g)(1)(i). 10. 26 CFR 54.9802-1 (g)(1)(ii), Example 1; 29 CFR 2590.702(g)(1)(ii), Example 1;146.121(g)(1)(ii), Example 1. 11. 26 CFR 54.9802-1 (g)(2)(ii), Example; 29 CFR 2590.702(g)(2)(ii), Example;146.121(g)(2)(ii), Example. 12. See 29 CFR 2510.3-1(j).
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.
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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.
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.
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