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Insurance coverageWhat is COBRA?

  • It is the Consolidated Omnibus Budget Reconciliation Act of 1985
  • COBRA is a law passed by the U.S. Congress in 1986 that mandates an insurance program to give eligible employees the opportunity to continue health insurance coverage after experiencing the loss of active coverage

What Employers are Subject to COBRA?

  • Almost all group health plans are subject to COBRA
  • Some small employer plans are not subject to COBRA
    • If a small employer has less than 20 employees employed on a typical business day during the previouscalendar year, then the group is exempt from COBRA the following year
    • If an employer has employed fewer than 20 employees on at least 50% of its typical business days during that year, then the group is exempt from COBRA the following year
  • If you have any questions regarding the group’s eligibility for COBRA, please contact legal counsel

What Plans are Subject to COBRA?

  • COBRA applies to group health plans that provide health care and are maintained by the employer
  • Group health plans may include:
    • Medical
    • Dental
    • Vision
    • Flexible Spending Account
    • Health Care Reimbursement Arrangement
    • Employee Assistance Program
  • Note: Health Savings Accounts are not subject to COBRA

What Qualifying Events Trigger the Obligation to Offer COBRA Coverage?

Qualifying Events trigger COBRA if they cause a loss of coverage. These possible events are:

  • Termination of a covered employee’s employment
  • A reduction of a covered employee’s hours of employment
  • The death of a covered employee
  • A divorce or legal separation from the covered employee
  • Ceasing to be a dependent child under the requirements of the plan
  • The covered employee becoming entitled to Medicare
  • Employer bankruptcy (this applies to retiree plans only)
  • Note: Not all events cause a loss of coverage
    • Coverage dropped during open enrollment is not a COBRA qualifying event

What is a Loss of Plan Coverage?

The general definition means to cease to be covered under the same terms and conditions as in effect immediately before the qualifying event

  • A loss of coverage includes:
    • Loss of group health coverage
    • An increase in required premiums
    • A reduction of benefits
    • Any other change in terms or conditions of coverage

How Long can COBRA last?

  • The maximum coverage period for a termination of employment or reduction of hours is 18 months
  • Other qualifying events (if a loss of coverage occurs) that extend the maximum period to 36 months for dependents include:
    • Death of employee
    • Divorce or legal separation
    • Child’s loss of dependent status
    • Employee’s entitlement to Medicare
  • If the employee is certified by the Social Security Administration to be disabled within the first 60 days of COBRA coverage, the maximum coverage period may be extended to 29 months if the participant notifies TPA within that first 60 days

Loss of Coverage/Election Notice Procedure

  • Employer has 30 days after the COBRA qualifying event to notify TPA. TPA has 14 days to mail a COBRA Election Notice to the Qualified Beneficiary
  • Complete a Termination Template for your respective Qualified Beneficiaries
    • Instructions are included on the ‘Instruction’ tab of the spreadsheet
  • Upload the Termination Template via TPAs secure File Transfer utility
  • TPA will mail a COBRA Election Notice to the Qualified Beneficiary
  • If Qualified Beneficiary elects COBRA coverage, TPA will reinstate coverage with the carrier(s) upon receipt of initial premium payment
  • Payments collected from COBRA Participants will be forwarded to the employer to pay for the insurance premiums
  • TPA will notify the carrier(s) when Participant terminates from COBRA coverage.

Procedure for Qualified Beneficiaries & COBRA Participants

  • Qualified Beneficiary will receive a COBRA Election Notice
  • Qualified Beneficiary elects COBRA by returning completed election form to TPA within 60 days from the date the Election Notice was postmarked or the loss of coverage date, whichever is later
  • TPA will mail courtesy payment coupons to the participant
  • Participant has an initial 45 days grace period, to pay premium/s
    • After initial 45 days grace period, premium due dates revert to the standard cycle with the due date on the first of the month of coverage and a 30 days grace period
    • Checks, money orders and/or online payments are accepted
    • Payment is mailed to: TPA
    • Detailed payment instructions are included with the payment coupons
  • Once participant remits initial payment, TPA will reinstate coverage with the insurance carrier(s)
  • If payment is not received within the grace period, carrier(s) will be notified to terminate COBRA coverage
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groupNefouse & Associates, Inc. is proud to be one of the chosen Insurance agencies to be able to offer the IU group health plans. We are especially excited to be able to offer this solution to small companies.

Since the inception of the IU group health plans, there has not been an outreach to the small companies. This has now changed and IU would like to offer these plans to all size companies.

The IU Health group health plan is not a traditional HMO. The group plans offer a dual network, which provides access to your employees outside IU Network. These plans even offer options to members inside the IU network. This gives companies great flexibility in offering their employees a competitive priced solution.

IU is offering a full line up of plan designs. From rich benefits with 1st dollar copays to health saving accounts. They are also offering a level funded option, which looks and feels like a full insured plan, but it has the ability to give the group a refund on a good year.

If your company is over 50 employees, then the case will be underwritten. IU underwriting is very aggressive, which can lead to lower premiums. With IU owning the medical network, this helps to control medical costs which can lead to a lower costing health plan.

In the last few years, there has not been a lot of competition in the small group market. With the IU health plans, we have one option to help companies of all sizes to offer a competitive employee benefit package.

Contact us today

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healthcare2017 individual and small group health plans have been submitted for review. There is very little good news to report about.

United Health Care exiting the market is the biggest blow to network access for Indiana. The UnitedHealth Choice & Choice plus were actually employer based networks. Off exchange was the last Individual PPO network with choice. On the exchange was an EPO network. These networks were designed for small groups, which gave members access to the majority of medical providers.

Why Did UHC pull out?

We have now seen multiple carriers pull out of Indiana and the rest of the country, this has to do with decision making based on pre ACA knowledge. Humana & Assurant both offered PPO plans similar to UHC’s. In a post ACA market, that leads to only one thing, higher medical costs. If a consumer has doctors in 3 different networks, there is a higher probability they will have higher claims. UHC had this knowledge, but were unable to act on it, until it was too late.

UHC took on a large national footprint for distribution of the individual plans. This led them into markets where there were extremely high risks and this risk was unknown.

The bottom line, leadership took on too much risk which lead to financial loss. Once the risk was on the books, they could not remove it. Actually they created adverse selection by being the most expensive in the market. This leads to only the high utilizers staying on the plan and no low utilizers joining because of the cost.

As with Humana & Assurant, the only move UHC could do was to drop out of the individual health insurance markets.

Impact to Indiana?

The loss of UHC will have a huge impact on Indiana residents. For those members that have doctors in multiple networks, you may not be able to replace that access. The Hoosiers that live on the border of another state, may experience a loss of access to those out of state providers. For those who want to able to get a second & third opinion, that option may be over.

For individual health insurance in Indiana, you have to elect an HMO. A family might have to choose to use one family doctor for everyone, the pediatrician will have to participate in that network and the OBGYN will also have to be in network.

When shopping for health insurance coverage, it may be more about the medical facility that the health plan is associated with. If you are eligible for tax credits, then your plan could be an even narrow network.

Silver Lining with limited access?

If you no longer have access to multiple health networks, then the insured might want to build a relationship with their doctors. Creating a relationship with one’s doctor may not only be a necessity, but a requirement to insure a higher level of awareness on your family’s health care.

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All health insurance policies must follow guidelines under the Affordable Care Act.

One guideline is the out of pocket maximum (OOPM). The OOPM is the most an insured can pay out of their pocket in one year. Also can be referred to as cost sharing.

For 2016, the OOPM cannot exceed $6,850 for a single and $13,700 for a family. This is the OOPM for in network services.  Out of network OOPM is significantly more, that is assuming your policy has out of network coverage. A lot of policies today, do not have coverage for out of network.

$6,850 is a significant amount of money to pay out of pocket for most Hoosier and US citizens/legal residents.

For a middle class family of 4, that does not qualify for tax credits and does not have access to group coverage.   Here in Indiana, let’s assume they elect a plan a bronze plan off the exchange.

Monthly premium is $918 x 12= $11,016 a year.

OOPM = $13,700 a year.

In a bad year, this middle class family could have a total cost $24,716.

An average Indiana family = $15,016 with premium and medical claims. This would be the savvy healthcare consumer that uses RX coupons and shops healthcare services.

For 2017:

Individual OOPM increase of $300 to $7,150

Family OOPM increase of $600 to $14,300

The OOPM under the ACA is absolutely getting unaffordable.

Even families that are eligible for tax credits, with reduced premiums, $7,150 is completely unaffordable!

$14,300 OOPM is well beyond affordability.

As an insurance brokerage, we are trying to address these OOPM for our clients. (Individual and Group Coverage)

One of the strategies we have used with group health plans is introductions of supplemental policies. These policies will help to offset the OOPM. We are now forced to find similar options in the individual health market. We now have to purchase additional insurance with our insurance to offset financial hardship. ACA is quickly becoming unaffordable to all.

Gap Coverage

Critical Illness

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02J80139The governor of Indiana signed House Bill 1263, which will official make telemedicine legal in Indiana.  Under the new law board-certified doctors, will be able to provide care for flu, colds, allergies, minor infections and more. They will even be able to prescribe medications online.

This is a huge step for Indiana when it comes to general care. We Hoosiers have utilized med checks and immediate care centers for these type of basic services. Now, with your smartphone and internet connection, you can go online and get treatment, without waiting in line.  This will change the way we get basic medical services. This will also lower the cost for treatment.

There are multiple telemedicine programs available through the insurance companies and independent companies.  Once you choose which telemedicine company you want to use, you will download the smart phone app. Once you open the app you will see a list of health care providers that are available. Click on the provider you want to use, then start discussing your case.  The provider then can diagnose the condition and recommend treatment.

This going to help a lot of people and save the insured money. Most Insurance policies in Indiana, have a larger copay for med checks, with Telemedicine you may only have to pay your general doctor copay.  We should have more information on Telemedicine options this summer.

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healthcareAs a decision maker, the philosophy that you form for employee benefits will have a huge impact on your company and employees.  There are many different approaches and benefit philosophy’s can also change over time, so they are not set in stone.

Co Pay Approach

A common approach is to offer benefits that are going to be utilized and appreciated the most. We will usually design a health plan with a high deductible, but have co pays on prescriptions and office visits. The view here, is I am going to cover the small claims but if a member has a large claim they are responsible for the larger upfront amount. This philosophy does work well because the cost is lower, but the employees get 1st dollar benefits.

Consumer Driven approach

You want your employees to be engaged in their health care. This approach will force the insured to look at the cost of care and become a consumer. Ask how much a procedure costs, shop out diagnostic services for the best deal. Research their health conditions and price shop prescriptions. There is a couple of different plan designs that can be used. The first one is Health Savings Account (H.S.A), this is where all the claims go towards the deductible. Some employers will offer incentives for their employees by funding the employee’s custodial account they use for claims. Once the money is given to the employee, this does lead to different behavior on medical services.

Multi Plan Approach

An employer will offer multiple plan selections and the employee will have to choose the best plan for their situation. With employees being in different stages of life, you may have young single employees choose a very high deductible plan, while other employees may choose plans specifically for a family planning. There may be employees that have up and coming treatments that will be very engaged in the process.

Defined Contribution

This scenario ties in with the multi plan approach. This is when the company will pay a set amount towards the premium and then allow the employee to either buy up or down in the benefit structure. Companies will use this approach to control costs, but still allow the employees to have choice.

High Benefit Offering

In certain industries, we see where a company wants to offer and pay the majority of a rich benefit plan. There are a few reasons for this. One is employee retention. The company does not want to lose any employee over benefits. Another might be, the company needs the tax deduction. This does happen! The most common is the employees are making the company extremely successful and leadership wants to take care of them. There are a lot of different options employers will use when it comes to plan designs. One of the most popular is to offer H.S.A. plans and then fully fund the H.S.A. Other options are to offer a platinum policy design, with a very lower out of pocket max. Along with health insurance, the company will offer disability, life, & vision.

Low Benefit Offering

Some companies that are being forced to offer group health, will go with the lowest costing plan on the market. The company may not have the resources to offer anything else. Common to see $6,500 upfront deductible plans. In other cases, a minimum essential coverage will be offered. These plans meet the requirements of the ACA but act more like supplemental plans. These plans will hurt employees and any company should know that going into it.

Wellness Philosophy

This is where a company wants to build a culture of wellness and healthy lifestyles. This approach does not always lead to savings, but there is value. Having employees engaging in healthy lifestyles can help to bring employees together. This approach will have a high deductible health plan, but will offer multiple tools for health and wellness. Employees having the ability to take health risk assessments and truly be engaged in the companies’ philosophy. We even see where gym memberships can have some reimbursements.

As you view think about the options, remember your philosophy is not set in stone. You have that approach for one year and really you are not even bound to that. Creating a benefits philosophy is just another step in leadership.

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healthIn today’s market of employee benefits, there are still multiple vehicles in which you can provide employer sponsored health insurance. The group health insurance industry both here in Indiana and the rest of the country have been impacted by the Affordable Care Act. There has been some positives impacts and some negative. For now, we still have a variety of options for any company to look at.

The first option and still the most common option, is a fully insured group health plan. Under this arrangement, there is a total premium and that is all the company & employees are responsible for. Under the ACA, there is no more underwriting for companies that have less than 50 employees here in Indiana. The rates are determined by the age of employees, geographical location of the company, type of plan design, and which carrier you use. Your company can be extremely healthy and will pay the same as a group that is unhealthy. There is still some competition in the small group fully insured market. The amount of companies offering small group products for Indiana, is less than 5.

If your company has over 50 employees, even if the majority of them are part time, you are eligible for underwriting. A group then must answer medical questions on their employee applications or pull claims data. Then the insurance carrier will underwrite the risk of your employees. Once risk is assessed, then a risk factor will be determined and that will impact your premiums. This can be a good thing for groups that have low risk, but a negative thing for groups with high risk. The other issue is it can take time for employees to complete applications when they are answering medical questions.

Partial Self Funded plans/ Level funded plans

When the ACA was passed, the insurance industry was concerned about guaranteed issues impacts on the small group market. The low risk groups will have a significant premium increase under an ACA plan. The industries answer has been partial self funded products that look and feel like a fully insured plan. Also called level funded. These plans are self funded so they do not have to comply with all the rules of the ACA. This opens the door to underwriting a small group, which can lead to a lower costing plan. The other potential benefit is a potential claims refund. On a self funded plan, underwriters will project what your expected claims are going to be. Then on the level plan, a portion of the monthly cost will go towards funding those claims. If your claims for the year are less than expected, then you may get a claims refund back. This approach can be very successful with groups that that have large dependent participation. The premiums dollars for family coverage can add up quick, which will add to your claims fund, which creates the potential for refunds. A company that has a culture of health and wellness should also entertain this arrangement.

One important aspect of the claims funds is what is called specific stop loss insurance. It means exactly what it sounds like, STOP THE LOSSES. On the level funded plan, you may have options on specific stop losses for each member of your plan. An example, the 1st $15K in claims comes out of the claims fund, then after that, the reinsurance pays the rest. If you have $100K in your claims fund, now you have $85K. The specific stop loss, is one of the most important aspects of the level funded insurance contract.

Claims fund refund

Every carrier treats the refund a bit different. Some carriers will give 100% of the refund back, others up to 2/3rds and some even less. These are the details that have to be address when entertaining this insurance plan.

Indiana has more carrier competition in the level funded market, than in the fully insured market. The reason for this is because of underwriting. The carriers are able to assess risk and decline to accept the risk. The approach is sophisticated so you should have a broker that you can trust.

PEO

Preferred Employer Organizations (PEO) is the another option for the group health insurance. This is a co arrangement with your company and a company that will take over all aspects of HR and accounting. Under this arrangement, your company agrees to list your employees under a larger group and lease them back to your company. By joining the larger group, this can create insurance premium reductions, Shifting HR responsibility, limiting risk for compliance along with having access to a larger benefit offering.

The PEO is not a new concept by any means, but the health insurance companies started to embrace that model after the ACA was put in place. Again this option creates the ability to underwriting the group health insurance, which can create savings. Another positive aspect of the PEO is shifting all reporting and compliance to the PEO company. This has been a popular idea as we fully understand the scope of the ACA reporting requirements.

For Indiana, we have a handful of PEO plans variable. Some of the PEO companies have even embraced the broker community for distribution channels. Not all PEO’s are the same. We have national PEO’s and then we have local PEO’s. There are benefits to both of them. One thing is certain you want to make sure the PEO you are looking at is taking on all the liability of the ACA reporting. So far we have only found one PEO that will do that.

Companies that may benefit from PEO arrangement:

The reality is a PEO can have significant admin fees. These costs can be anywhere from $600-$1,500 per employee. The companies that could benefit are the ones that do not have an HR infrastructure. A company that has multiple locations, but has no time to put in the right HR services. These type of situations can lead to the PEO being the best option. It’s not the lowest costing option, but the one that takes the least amount of ownerships time. There has been a need for all the services the PEO is offering to make the admin fee worth it. There are very few companies that will negotiate the admin fee, we have found one.

Association plans

Another move by the health insurance industry, was to create association plans. These are not the type of association plans of the past, these association plans allowed for the insurance company to underwrite the health insurance. For Indiana, we have the national association of manufacturing. If you qualified to join the association, then you could take your group health insurance to underwriting.  At first companies had great interest in the association plans in an attempt to lower their health insurance costs. What was realized very quickly, some of these associations had high risk which led to even higher rates than ACA group plans. The association plans should not be completely dismissed as some companies could benefit from the health savings along with being a part of the association.

HMO Come back

HMO’s are now making a comeback on all forms of health insurance. At one time, a HMO was viewed as a very negative health insurance arrangement. That is starting to change because of the cost savings they can bring to a company. In Indiana, we have hospital groups form their own HMO insurance products for large group, and now they are offering these plans to small groups. The HMO can create savings because of their narrow network and the way they reimburse medical providers.

The narrow networks are made up of doctors that are willing to except less in reimbursement with the change growing their practice with more patients. Today’s HMO are putting a large emphasize on care coordinators. This is where a member may have a serious condition and a coordinator reaches out to coordinate all the members care. This should lead to a better outcome of treatment, which leads to less cost. The HMO does not use the fee for service schedules to pay doctors. The doctor is paid the same amount no matter the amount of treatments the member receives.

The group hmo is another option that employers should look at. This can bring significant saving in premiums, but employees may have to switch doctors. The switching doctors can be a difficult because most people do not want to be told where they can receive care. If your company is debated on dropping coverage or need to reduce costs, the HMO may be the best option.

ACO

Accountable Care Organizations (ACO), this is a new concept introduced under the ACA. Under this arrangements, medical providers are rewarded for positive treatment outcomes. Think about it, who would not want to use a plan, where the doctor is paid on performance. What a concept!

The ACO has been slow to develop because of the medical community. Since the ACO reduces costs, that leads to a reduction in revenues. Many medical groups have built their practice on the fee for service schedules, so shifting to a ACO model, could be cost prohibitive.

This may be one of the best features of the ACA because it addresses the actual cost of care. Once these networks are established, group products will follow. At that time, I think everyone in Indiana should look at an ACO network.

Health Insurance through SHOP

SHOP, is the group health insurance option that can be purchased through the marketplace. The reason to go to the SHOP, is if the employer is going to qualify for tax credits. The way the tax works is you are eligible for up to 50% of what you contribute towards the employee’s premiums. That 50% is on a sliding scale that is impacted by what your average employees salary is. The SHOP has not had a lot of success in Indiana. For 2017, there are about 150 employees insured through the shop. There are a lot of reasons why we have not seen greater success. A few of the reasons are the network on the SHOP is limited vs the off the exchange plan and they cost the same amount. Why would an owner choose a plan that cost the same but has less options. Unless they are not understanding what they are buying. Another issue, why would an employer want to deal with the marketplace until is has proven itself and smooth running.

Shifting Group to Individual

This are options for many small Indiana companies. Certain small companies can benefit from this approach. If you are not looking to grow your company, if your employees qualify for large tax credits, if you have low turnover & if the individual plans have network access, then this can work. Indiana companies with less than 10 lives have taken advantage of this option and some have saved large amounts of money. The problem with this approach now, tax credits are smaller, smaller drug list, and larger out of pockets. It can still be an option but know all the facts so you can make an informed decision.

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workersGroup health insurance, employers sponsored health insurance, employee benefits, or group health, no matter what you call it, it’s in investment into the employees and the company.

In Indiana, we have been experiencing a large decline in group health insurance being offered for over a decade. The affordable care act has helped to increase that decline by creating guaranteed issue and tax credits, in the individual market.

Why offer group health insurance?

In today’s market, group health plans are able to offer better coverage than individual plans. The group plan, can give greater access to medical providers through PPO plans. These PPO’s can have national network access. We are now seeing better drug formularies vs the individual plans. The individual plans could have prescriptions going towards the deductible, where the group plan could have that same drug covered under a co pay. This can lead to significant savings when it comes to medical expenses.

Retention of employees can come from offering an employee benefits. If your company does not offer any health benefits, a good employee could leave and even go to work for your competition. All because they offer group health and you do not.

Employee Attraction

If you are looking to recruit higher skilled, more motivated, employees, it may be difficult without the investment into an employee benefit package.

With the decline of employee offered benefits in Indiana, this should create an advantage for any company that is offering benefits, to recruit and retain the best employees.

Employer mandate:

With the ACA, your company could be subject to the employer mandate where you have to offer group coverage or pay a penalty. If you meet the equation for the employer mandate, I am truly sorry because there is no great solution, it’s picking the best of the bad options.

We have a lot of experience with groups that have been forced into offering group health insurance. We know all too well, what you are going through. Your business model may not be built to afford to offer a group health insurance plan. You may be faced with making tough decision on your current business operations

The penalty for not offering coverage, is $2,000 a full time employee. You may be eligible to remove the first 30 full timers from that penalty, which is an important fact. Companies that have 100 + full time employees are being impacted the most. You may have to pay a $140,000 penalty or contribute $140,000 to an employers sponsored health insurance package. Either option, can put a financial strain on your business.

Now in Indiana, groups with over 50 employees are subject to underwriting. This means, your group will have to answer medical questions to lock in your health insurance rates.   Underwriting can be extremely frustrating to business owners that are looking at offering group benefits for the first time. Leadership decided to make a decision on offering group benefits based of non-underwritten rates. Quotes are exactly that, they can change. Do not make a decision off of quotes. Under the ACA, there is a affordability piece to offering group health insurance. No single employee, can contribute more than 9.5% of their income towards group health insurance premiums. If an employee does pay more than the 9.5%, this can open the door to another $3,000 penalty per.

If an employee is making $20,000 a year working for you, they cannot pay more than $175 a month towards group health insurance premiums. If you decide on a contribution amount on the lowest compensated employee with group health insurance quotes, those costs can go up after underwriting. So now you are an employer that has already announced to the employees they are getting a group health plan. After underwriting the rates may double, now what? This is a common mistake with companies being impacted by the employer mandate.

How do you make the plan affordable to both you and the employee?

This is a difficult goal and sometimes impossible. If you are a large group subject to underwriting, you may take significant risks taking the health insurance coverage. This will lead to your health insurance rates being much higher than what is deemed to be affordable to the company and employee. Some employee situations can have dependents that are diagnosed with serious health conditions that need a significant amount of medical treatment. In these situations, have a broker that not only understands group benefits, but also the individual market can create huge savings. We have the knowledge of both markets and leverage that benefit our clients.

When the premiums are affordable:

There are certain companies and situations where the premium is affordable to offer group health insurance. This situation occurs most often with business that have young employees. When we run the health insurance rates, we average the age, and that can determine your premium. In some industries we have been able to come in with premiums under $350 a month per employee. In this situation, you should be able to afford a group health package.

Another option to lower premiums is look at different plans designs and networks. Something we are using with 1st year benefit groups, is a gatekeeper plan.  A gate keeper is where the insured must choose a doctor and all of the insured care goes through that doctor. Its been proven that if your doctor knows you, there is a higher chance for more successful outcomes when treated. HMO offers the same type approach and can lower premiums even more by limiting the medical choices a member has.

Adding admin responsibilities

Another aspect of the employer mandate companies are having to adjust to is benefit administration. When putting the health insurance plan in place, someone has to take on the responsibility of collecting applications. This is the first step in taking on administration duties of the group health insurance plan. Once the plan is in place, now we need someone to take on more admin duties. Adding and deleting employees is a serious responsibility. It really does not require a lot of time but does entail someone being component. Cobra administration can and should be farmed out to a 3rd party, but you still need someone that inform the 3rd part that there is an employee termination. With all of the online technology, the administration of any group health plan is easy.

If you are a company that is impacted by the employer mandate, we can help you. We will walk you through the entire process. We will be honest with you, if we don’t think you need to offer a group health package, we will tell you. We may be one of the only brokers that would tell you not to buy something.

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afforableUnder the Affordable Care Act, once open enrollment has ended, an individual may still be able to purchase though a special enrollment period (SEP). The SEP usually occurs when that individual has a qualifying life event (QLE). Involuntary loss of health insurance coverage, marriage, child birth, and move to a new state are all examples of QLE’s.

In the past, when a Indiana resident, U.S. citizen or legal resident went to the market place for a new policy, there was almost no reporting requirements to prove you had a QLE. Essentially people would enroll into health plan whenever they wanted. Most situations occurred when they needed medical attention. This segment of enrollments has become a serious issue with the insurance industry.

The first issue, is the high utilization of claims that these members accounted for. These enrollments represents less than 1/3rd of total membership, but they account for 50% of total claims. The health insurance industry has been scrambling to try to stop these losses.

The second issue, which is far more complicated is the insurance carriers assessing risk to their membership. Under the ACA, insurance companies have to estimate what their risk is and report that to the government. This is an extremely complicated equation. If the insurance company is wrong on the risk, they could end up paying or receiving money from the risk corridor program. With the SEP enrollments, the insurance companies are having a hard time assessing risk to report to the government. The insurance industry needs/wants a full 12 months of coverage to determine that risk. Without accurate risk assessment, the insurance companies are losing money/funding from government programs.

SEPS Data

Out of the SEP enrollments for 2014 & 2015, the data that has been analyzed has shown a large amount of enrollments that were not qualified. This is not a small amount, it is estimated that 45% of SEP enrollments were not qualified enrollments. A step deeper, shows that 20% of the SEPs may have been flat out fraud.

Insurance Industry Actions

The health insurance companies participating in Indiana and the rest of the county, have tried to slow down enrollments. They have actually been successful. They have limited their distribution channels to only healthcare.gov. Carriers have stopped compensation on all channels and even removed their in house agents.

The large insurance companies have petitioned CMS to allow them to police the SEPS enrollments from the exchange. It remains to be seen if CMS will allow them to do this. Government officials may not have a choice, if they wish for the large carriers to stay in the exchange markets. The insurance companies have processes for SEP proof for off the exchange policies. You have to send them the proof that you had prior coverage and when it ended. Where there might be issues is on unusual circumstance, where there is not a clear definition if the situation is QLE or not.

The Market Place

The federal exchange has started to require proof of QLE. The issue for the insurance companies, is the poof of the QLE is not required until after the policy is in place. Usually supporting documentation is not due until 90 days after the policy is in place. This could create more abuse of the system and leave the insurance industry holding the bill.

With the insurance companies currently losing money in the individual exchange market, they are scrambling to stop the losses. If CMS refuses to address the SEP issue, we could see insurance companies drop out of the exchange market.

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texIRS Notice https://www.irs.gov/pub/irs-drop/n-16-4.pdf  2016-4  extends the deadline for large group and self-funded groups for reporting under section 6055 & 6056.

Under the law applicable large employers or self funded plans:

Must provide to individuals the 1095-B and 1095-C forms. This was originally due by Feb. 1st and now has been extended to March 31st of 2016.

Must file with the IRS the 2015 forms:

  • 1094-B, 1095-B, 1094-C and 1095-C has also been extended to May 31st 2016.

The 1094-B and 1095-B will be used by groups that have self-funded plans, but are not considered a large group. These fillings are to report plan information to the IRS and to covered employees.

Applicable large group employers will use forms 1094-C and 1095-C to report info to the IRS and employees.

If your company is both a large group and self-funded, use forms 1094-C & 1095-C, this will satisfy both reporting requirements.

Employers that do not comply with the ACA reporting will be subject to penalties.

Confirm all information with your trusted advisors! If you can’t trust them, then call us.

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