Whether you're evaluating your company's current dental benefits or preparing to offer a plan for the first time,
choosing the best program can be a bit of a balancing act. The challenge of achieving this balance is made more difficult when you consider the options available in the dental benefits marketplace today.Dental carriers typically offer one or more of three basic types of plans:
1. Fee-For-Service (or Indemnity) Plan
The original dental benefits plan and the one which continues to dominate the market is the fee-for-service plan. Under this type of plan, employers and/or their covered employees pay a monthly premium to an insurance carrier, which is responsible for reimbursing dentists for the services they provide. Fee-for-service plans allow employees the most freedom in choosing their dentists, which is why they remain a popular choice. If the main concern for you or the employees you’re covering is the ability to choose a certain dentist, a fee-for-service plan is probably your best choice.
2. Dental PPO
Dental preferred provider organizations (PPOs) are a good option for groups seeking lower cost advantages while providing enrollees with a high level of freedom of choice in selecting providers. Enrollees have the freedom to visit any dentist who is part of a network
Preventive Care Usually Includes:
Annual bite wing x-rays.
Semiannual cleaning, polishing, and possibly semiannual fluoride.
Treatment for employees and their dependents 18-years-old and younger.
Basic Dental Care Includes:
Restorations and basic oral surgery.
Major Care Includes:
Crowns, root canals and prosthetics.
Complex restorations and advanced oral surgery.
established by the dental benefits company or, for higher out-of-pocket costs, can visit any non-network dentist.
3. Dental HMO
Dental health maintenance organizations (DHMOs) give subscribers access to a select group of dentists, with even greater cost savings. This type of program is a good choice for groups seeking lower costs with an emphasis on prevention and a pre-selected network of dentists from which to choose.
Whether it’s a fee-for-service, PPO or DHMO plan, coverage of specific services can vary. Some dental benefits programs cover diagnostic and preventive services only. Others cover the full range of dental services, from preventive to basic and major care. (See right-hand box.)
Riders:Many insurers also offer riders for popular extras, like coverage for orthodontics or cosmetic dentistry. For a little additional cost, riders enable you to customize or supplement a basic dental benefits package.
In the end, finding the right dental benefits program is a combination of many factors. In addition to matching a plan with your company and employees, look closely at other issues such as cost management, rate stability, the network of participating dentists, ease of administration, customer service and company reputation.
Knowing what to ask and how to communicate your company’s wishes makes it more likely your dental insurance will do what it’s meant to do — attract good employees and help them preserve their oral health.
IMPORTANT: A great value is a discounted dental plan. Our very own Bonus Card extends the Aetna Dental Access PPO negotiated rates to members. There are NO pre-existying conditions, NO annual deductibles & NO annual maximums. Cosmetics such as orthodontia and implants are covered. The Bonus Card also covers Vision with Coast to Coast, Rx discount and Telemedicine for $10/month!
Sample Discounted Fees and Savings
Procedure Description
Usual Fee
Discounted Fee
Member Savings
% Savings
Routine 6 Month Check-Up
$43
$24
$19
44%
In Depth Check-Up
$69
$37
$32
46%
Full Mouth X-Rays
$114
$65
$49
43%
Four Bitewing X-Rays
$55
$25
$30
55%
Panoramic Film
$97
$50
$47
48%
Adult Teeth Cleaning
$83
$44
$39
47%
Child Teeth Cleaning
$62
$32
$30
48%
Protective Sealant / Tooth
$46
$26
$20
43%
1 Surface White Filling
$135
$71
$64
47%
Single Crown Porcelain
$981
$566
$415
42%
Molar Root Canal Treatment
$919
$522
$397
43%
Perio Scaling and Root Planning
$217
$123
$94
43%
Full Upper Denture
$1,353
$725
$628
46%
* Actual Costs and savings vary by provider and geographical area. * Dental benefit not available to Vermont residents.
Insurance Versus Dental Cost Examples
The following is a comparative example between a typical insured dental plan versus the Aetna Access Dental discount plan. This illustrates the possible out of pocket costs for each.
Insurance Charges
First 12 Months Premium (Family)
$627.12
Adult Cleaning
$5.00
Child Cleaning
$5.00
Routine Check-Up
$5.00
Four Bitewing X-Rays
$5.00
Composite (white) Filling
$10.00
Crown
$878.00
Molar Root Canal
$855.00
Extraction (single tooth)
$11.00
Total Insurance Charge:
$2,401.12
Total Savings:
$988.12
Discount Charges
Annual Member Fee
$33.00
Adult Cleaning
$54.00
Child Cleaning
$38.00
Routine Check-Up
$28.00
Four Bitewing X-Rays
$32.00
Composite (white) Filling
$78.00
Crown
$604.00
Molar Root Canal
$474.00
Extraction (single tooth)
$72.00
Total Discount Charge:
$1,413.00
Percent Savings:
41%
The select regional average fee represents the average fees for the procedures listed above in Los Angeles, Orlando, Chicago and New York City, as displayed in the Estimate the Cost of Care tool as of November, 2005.
* Insurance plan based on the Aetna DMO Plan. * Actual costs and savings vary by provider and geographical area. Numbers given are regional average fees.
Sources: http://newbenefits.com – New Benefits Dental Care and Aetna Dental Access® Marketing Materials and FAQ
http://cdc.gov/OralHealth – Centers for Disease Control and Prevention (statistics)
http://moreinformationplease.com – Dental Care Program Information
http://adha.org – Oral Health Statistics and Facts
http://dentalplans.com – Aetna Dental Access® Nationwide Dental Discount Program (savings information)
There have been plenty of reports in the media of employers having their group insurance plans canceled by health insurance carriers due to health care reform. While there have been plenty of issues, complications, and confusion in regard to group health insurance plans as a result of health care reform…cancelation of group health insurance plans is not one of them.
There are many circumstances where a specific health insurance plan design is being terminated by an insurance company and an employer’s plan is being “routed” to a new plan design. While this may be viewed as problematic for an employer and their employees, it has been happening for years. This issue is most likely not being caused by health care reform, but is likely being exacerbated by it.
The reasons for these routings of plans are several and include:
Normal year to year changes that insurers implement based on many circumstances.
Restructuring of plans so that they can be classified in an appropriate Metal Level category (Platinum, Gold, Silver, Bronze).
Pricing – some plans were not going to be able to continue in the present format.
Employers now have a new alternative if they are being routed to a new health insurance plan for which they are not comfortable. The new alternative is individual health insurance. While there are many items that need further clarity (i.e. circumstances in which an individual may enroll mid-year, pre-tax / post tax, employer deductibility, etc.), it is clear that in many situations the individual health insurance plans are comparatively priced to other small group plans. In addition, the new individual health insurance plans are now Guaranteed Acceptance with no pre-existing condition qualifications.
We’re here to help!
Employers should still seek qualified professional benefits guidance if they considering moving their health insurance programs to an individual platform. Planning, implementation, and ongoing support are just as important as with a traditional group plan. Benefit Consultants that are adapting their practices to the Health Care Reform law such as Millennium Medical Solutions Inc. will be able to help. For more information on individual health plans, please call us as 1-855-667-4621.
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.
NYS Health Exchange FAQ Jan 1 Enrollments. NYS of Helath has provided a helpful Frequently Asked Questions for recent enrollees. We have attached the document for your use.
IMPORTANT: How can I pay my premium bill for January 1st coverage?
You need to pay your health plan – not NY State of Health – no later than 10 days after you receive your invoice (bill) from your plan. You can pay your bill by mail. Some plans may accept payment online or over the phone. Plans must accept the following forms of payment: paper checks, cashier’s checks, money orders, electronic funds transfer (EFT), and all general-purpose pre-paid debit cards. Contact your health plan for more information about payment options or if the due date is a problem for you.
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.
The holiday season is approaching and you may be wondering whether your company is required to provide time off or holiday pay. Here’s a look at some frequently asked questions and answers
.1. Are employers required to provide employees time off for a holiday?Although not generally required by federal or state law, many employers choose to grant employees time off for certain holidays or to close the business altogether on those days.Companies with 15 or more employees are subject to federal religious discrimination laws and may need to allow employees time off for religious observance. Employers should also consult their state’s nondiscrimination laws to learn if there are similar requirements for time off related to religious observances for employers of fewer than 15 employees.
2. Do employers have to pay their employees if the business is closed for a holiday?
Federal law and most state laws do not require employers to pay employees if time off for holidays is granted. Whether or not employees are paid for holidays is generally a matter of company policy. Employers need to be careful when it comes toexempt employees, though–as a general rule, if an exempt employee performs any work during a workweek, he or she must be paid the full salary amount
.3. What about employees scheduled to work on a holiday if the business remains open?
Extra compensation (above and beyond an employee’s regular rate of pay) for work on holidays is also generally a matter of company policy, although employers must comply with any specific state law requirements regarding holiday pay. Although some companies pay employees at a special rate (such as time-and-a-half) for holiday shifts, generally an employee is only entitled to his or her regular pay, plus any overtime.Remember that states will generally enforce an employer’s written policy regarding holiday pay, so it’s important to follow company policy and to apply the rules consistently and fairly to all employees. For questions about the specific requirements in your state, contact your state labor departmentor a knowledgeable employment law attorney. Our section on Leave and Time Off features more information on both mandatory and voluntary leave.
Jan 1 Deadline is Today. Attention last minute health insurance shoppers you have until midnight to purchase a policy on the Health Exchange.
NYS Health Exchange is down again. Not surprisingly a large volume of late comers trying to beat t0morrows deadline for Jan 1, 2014. Last week a 34% enrollment spike in 1 week alone. Despite the 1 week extension the enrollments are still falling short of the original 600,000 projection. A significant percentage have instead been qualified under expanded Medicaid in NYS. At the same time many New Yorkers have had sole prop and husband/wife groups shut out of the small group market place. In addition, popular programs such as Healthy NY have been increased by 25-35% and new $600/single or $1200/family deductibles.
Facts:
Some people mistakenly believe they have until Dec. 31 to enroll in a plan that takes effect on Jan. 1. Others don’t realize they could pay a federal tax penalty if they don’t have health insurance in place by March 31.
Under the Affordable Care Act, most adults will pay a $95 penalty — or 1 percent of income — in 2014 if they don’t have health insurance coverage. The penalty rises to $695 — or 2 percent of income — by 2016.
To avoid the penalty, people must enroll in a plan by Feb. 15 or qualify for an exemption from the penalty.
Consumers who sign up by Dec. 23 and pay the first month’s premium by Jan. 10 will have coverage on Jan. 1, the industry group America’s Health Insurance Plans announced Wednesday.
If you make under $45,960 or your family makes under $94,200, you could get a real break on health insurance costs More low-income people will also be eligible for free coverage under Medicaid For those eligible, the subsidies will cap the amount you pay for your exchange policy at between 2% and 9.5% of your income (on a sliding scale, based on your income). To find out how much you would pay, estimate your income for this year and plug it into any health subsidy calculator. You can also see estimate subsidies with these ”health subsidy charts”.
Important: If the web site is down we can sign up via paper application to avoid the penalty. A surge of 34% enrollments in one week caused some technical delays last week.
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.
NYS Health Exchange 100,000 Enrolled. According to a USA Today article More than 100,000 enroll in N.Y. health exchange, up a third in less than two weeks according to the state Health Department .
According to the NYS Exchange site www.nystateofhealth.ny.gov– As of today, 100,881 state residents had enrolled in a health insurance plan through the state’s exchange. Additionally, 314,146 people had “completed applications” for coverage. The state did not break down the latest data based on the number of people enrolling in private insurance versus Medicaid. The state’s already “vast” Medicaid system “has been credited with having an easier transition to the health exchange.” New York state plans to enroll a total of 1.1 million people by the end of 2016
New York already has a vast Medicaid program, at an annual cost of $50 billion, it has been credited with having an easier transition to the health exchange. Reuters reported Dec. 4 that about 29,000 people signed up for health insurance through the federal HealthCare.gov website on Dec. 1 and Dec. 2 – eclipsing the 26,000 for all of October.
According to sources and our experience half of the Exchange applicants were to determined not be Medicaid eligible. The article Federal exchange sends unqualified people to Medicaid points out that some qualified Medicaid may not in fact be eligible. “The federal health care exchange is incorrectly determining that some people are eligible for Medicaid when they clearly are not, leaving them with little chance to get the subsidized insurance they are entitled to as the Dec. 23 deadline for enrollment approaches.”
New York State, unlike 36 states, runs its own exchange. The NYS website has had less issues than the troubled Federal health Exchange www.healthcare.gov. Our blog NYS Approves Health Insurance Exchange Rates describes how the new rates lower individual insurance market by 50%.
New York has various tiers of health insurers, and customers can pick from 16 insurers and 10 dental insurers. Quotes can also be viewed on our site. The program also has a small-business marketplace that offers health insurance to businesses with 50 or fewer employees. Large businesses that do not offer employees health insurance could be hit with a fine in 2015.
The exchange also offers tax credits to those who earn less than $45,960 as an individual or $94,200 as a family of four.People without health insurance would be hit with a fine on their income taxes for 2014, starting at about $95 or 1 percent of gross income. The fine can grow to as much as $695 a year , then double in 2015 and grow over time.
For more information regarding both Exchanges – Individual Exchanges or SHOP please contact our team at Millennium Medical Solutions Corp. We have Spanish, Russian, and Hebrew speakers available. Quotes can also be viewed on our site.
The following companies had health insurance plan rates for the health benefits exchange approved today by DFS. The rates approved today are subject to final certification of the insurers’ participation in the exchange.
Affinity Health Plan, Inc.
American Progressive Life & Health Insurance Company of New York
SHOP Exchange Delayed One Year. The White House just announced that the online Small Business Health Marketplace also known as SHOP Exchange has been delayed until 2015. Small businesses will still have the option to purchase coverage through the new marketplace but will not be able to do so online. Instead, until next fall, employers with fewer than 50 workers will need to work through a broker or agent to buy health plans for their employees.
The Small Business Health Options Program, or SHOP Exchange, has already had a troubled launch with multiple delays as the Obama administration has focused much of its efforts on launching the individual insurance marketplace where Americans can shop for subsidized health insurance coverage.
Small businesses buying coverage will still be eligible for small business tax credits to bring down the cost, according an administration memo. Also, businesses can still purchase the same plans and same rates available on Off-Exchange. Medical Insurance premiums through the business is an ordinary tax deductible expense.
According to NY Times Article, Online Health Law Sign-Up Is Delayed for Small Business – “The announcement of the delay, just before Thanksgiving, is reminiscent of the way the White House announced, just before the Independence Day weekend, a one-year delay in the requirement for larger employers to offer health insurance to employees.”
The recent setback is the latest in a stream of missed deadlines, including a postponement for a Spanish language sign-up tool announced this week. The administration also recently pushed back the enrollment deadline for individuals: People who sign up by Dec. 23 can get coverage that starts on Jan. 1. In an earlier delay, businesses with more than 50 workers were given until 2015 to meet the requirement to provide health insurance without paying a penalty. And the deadline date for individuals to avoid penalties for failing to get coverage was pushed back six weeks.
If you should have any further questions regarding the SHOP program or comments about the above or the attached, please let us know. We will continue to monitor this issue and all ACA implementation in an effort to keep you informed of new developments. In the meantime, please visit our https://medicalsolutionscorp.com/about-us/blog to view past blogs and Legislative Alerts.
Breaking News President Announces Cancelled Policies Fix
Yesterday, the President announced that people with health care coverage that is not Affordable Care Act (ACA)-compliant may be able to keep their plans in 2014. Effectively “Grandfathering” of plans purchased after the original law has passed in 2010 There has been a great deal of concern being reported in the national media around the prospect of millions of people losing their health insurance coverage effective January 1, 2014 because of the Patient Protection and Affordable Care Act (“PPACA” aka “ObamaCare”).
We are awaiting how specifically your State’s Insurance Commissioner will react to this. Questions remain about how this new policy will work, including how insurance commissioners will react, whether insurance companies will choose to continue these policies, what the rates for the policies will be, and whether this grandfathering will extend past 2014.
To be clear, what’s being reported principally has to do with the individual health insurance market in the US which insures approximately 15 million people, or about 5% of the country’s population. Within that segment of the privately insured market, a large percentage, certainly more than half, of individual policies are not considered to be “grandfathered” under the law’s requirements for such status. As a result, to be in compliance with the law’s new mandates and coverage requirements, virtually all “non-grandfathered” policies are scheduled to be terminated January 1st, and it will be up to individuals to replace their existing coverage with new compliant policies after this date.
These recent developments have resulted in
1) President Obama issuing an apology to affected individuals on November 7th.
2) the President’s announcement earlier yesterday during a hastily called press conference at the White House that pursuant to an Executive Order, Americans may keep individual health insurance policies they were told will be canceled because these policies failed to meet requirements established by the new law.
President Obama has left it up to the states to independently determine how they will go about implementing this change which is being characterized as an “administrative fix”. However, since the insurance business is state-regulated, each state will need to determine whether or not they will implement this change, and if they choose to implement it, they will have control over defining some of the specific parameters. Insurance companies will also need to quickly make decisions on how to accommodate this new provision if the change is adapted in a state in which they operate.
In closing, if you should have any further questions or comments about the above or the attached, please let us know.We will continue to monitor this issue and all ACA implementation in an effort to keep you informed of new developments. In the meantime, please visit our https://medicalsolutionscorp.com/about-us/blog to view past blogs and Legislative Alerts.
Why are my rates going up? The recent 2014 health insurance rates ranging in 15-20% increase is having a profound impact especially on small businesses. Benefits are furthermore deteriorating with new deductibles adding a 10% to the out of pocket costs for a net total 25-30% rate increase.
No pre-existing condition. Several new cost contributors aside from Essential Health Benefits Mandate are assigned. Recent articles such as Kaiser’s Popular Provision Of Obamacare Is Fueling Sticker Shock For Some Consumers attributes new Pre-Existing condition waiver as a factor. Starting Jan 1, 2014 anyone with or without prior health insurance can get immediate treatment without a 12 month waiting period. “But the provision also adds costs. To a larger degree than other requirements of the law, it is fueling the “sticker shock” now being voiced by some consumers about premiums for new policies, say industry experts.” With the guaranteed issue there are unknown costs that cannot be accounted for just yet. Example: An uninsured individual we know is delaying needed surgeries until January for this reason. The member will pay a $250/month premium and get a $40,000 surgery paid for immediately. How many young healthy members are needed to offset this cost?
Transitional reinsurance fee. This is paid by fully insured and self-funded plans. The goal of the fee is to stabilize the individual markets by reimbursing companies who insure a disproportionately large number of individuals who are high utilizers of health care services. Fees will be collected between 2014, 2015, and 2016.
Health insurance providers’ fee, also referred to as a health insurance tax, annual fee, and insurer fee. This will be assessed annually beginning in 2014 on health insurance carriers. The total amount to be collected in 2014 is $8 billion. The tax is based on premiums and by some estimates is expected to have a cost impact of 2 to 2.5 percent in 2014, and higher in subsequent years.
Exchange fee. For 2014, our state’s online exchange marketplace is funded through federal start-up grants. But states that run their own exchange, such as Washington, have been tasked with implementing a funding mechanism after 2014. In the session that ended in June, the Washington State Legislature approved a funding plan for our exchange that authorizes the use of a current insurance premium tax for the qualified health plans (QHPs) sold in the exchange and, if necessary, an additional assessment on carriers who sell QHPs through the exchange.
Patient-Centered Outcome Research Institute (PCORI) fee (also known as comparative-effectiveness fee). Health insurance issuers and sponsors of self-funded group health plans will be assessed this annual fee beginning in 2012 and ending in 2019. It funds patient-centered outcomes research. PCORI is a nonprofit corporation whose mission is to help people make informed health care decisions, and improve health care delivery and outcomes. The Group Health Research Institute has received two research awards from PCORI to study ways to improve care for back pain, and connect patients with community resources.
Essential Health benefits. The quintessential question asked is why are my rates going up so much this year has multiple answers with new Essential Health Benefits leading the way. The Essential Health Benefits Not Delayedarticle explains that The Affordable Care Act mandates that the plans include ten essential benefits, from care for pregnant mothers to substance abuse treatment. Popular local plans such as Healthy NY and Brooklyn Healthworks have afforded coverage for over a decade are are missing Mental Health, Chiropractic, and have a $3,000 Rx limit. All Individual Healthy NY and Sole Proprietors are terminating this year . Existing small businesses must buy the full version with Essential Health Benefits.
CASE: A Healthy Ny client just had an increase for singles from $412 to $519. She is a successful generous Caterer who is covering majority of a staff of 10 employees which is unusual for that industry. Her staff had an affordable benefits as well. They loved paying only $20, her Rx copay was only $10/generic and $20/brand for providers she did not have any deductibles. Hospitalization had full coverage with a modest copay. Statistically nearly 90% do not use more than $3,000 Rx. her new plan rolls automatically into the GOLD PLAN increasing her premium 25% along with a new $600 deductible on all benefits and a $40 copay for Specialist. She asked me I thought the new tax was only .9% medicare tax but evidently this IS HER NEW TAX.
So much for if you like your plan you can keep it promise. Even supporters such as Former President ClintonWeighs in on Obamacare. “Obama should honor his health-care promise: Pres. Clinton”, He personally believes President Barack Obama should honor his promise that people who have and like their insurance can keep it.
Do not under estimate the power of the Bill. The President is reviewing ways to allow some to keep their health plan but this would only apply to policyholders losing coverage. Stay tuned.
You can download the complete Essential Health Benefits NYS. Also, for a downloadable guide on self-insuring and secondary market reinsurance for your group please send contact form below. In the meantime, please visit to view past blogs and Legislative Alerts at https://medicalsolutionscorp.com/feed.
