by Admin. | Jul 16, 2012 | COBRA, Health Care Reform, individual health insurance, PPACA
The Con Ed lockout this Summer couldn’t come at a more heady time. I’m not referring to the obvious temperature swelter but more to the employee health benefits that are at the back bone of virtually every recent Labor dispute. With the Con Ed dispute, Management’s has acquiesced on the health insurance . “Con Ed did accede to “public pressure” on Sunday by reinstating health insurance for the 8,500 members of Local 1-2 of the Utility Workers Union of America, a company spokesman said. The workers have been collecting unemployment benefits for two weeks but had to pay for their own prescription medicine and doctor visits because the company cut off health coverage when the old contract expired, at midnight June 30.”
Interestingly, Unions are major stakeholders in Healthcare as their benefits have been traditionally rich incentives attracting to workers. However, with A.C.A. (Affordable Care Act) otherwise known as Obamacare their health programs are very much in danger of additional taxation or member withdrawal. Unions estimate these provisions will raise the cost of health coverage by an additional $1,000 a year. In fact, a Union members may fare better on the Individual Mandated Exchange with projected individual direct insurance dropping 70% things will open up. A lower/middle income member will likely qualify for an additional discount credit. A more affordable health plan just may be a possibility.
There are other reasons the Individual Health Plan may be better:
- Unions as other self insured group must now comply with added benefits for preventive care, maternity care, Age 26 dependent care, pre-existing condition waivers.
- No Annual Limits on essential benefits by 2014
- No Lifetime Limits
- No more mini-med plans – discount health plans are prohibited. The movie John Q , based on a true story, where a father is told his son’s transplant will not be covered based on th elicited mini-med plan covering him up to $20,000. Large companies such as McDonald’s have also sponsored mini meds.
- Cadillac Tax – By 2018 a 40% excise tax on health plans that exceed $10,200(single) and $27,500 (family).
The original Cadillac Tax was pushed back by the behest of Unions to 2018 from the original proposed 2014 date. Most Unions with generous health care packages would not be complaint within that time frame.
However, not all is grim for Unions. HHS has issued waivers to 1,625 plans covering 3,914,356 individuals were exempt from these mandates through 2014. According to Heartland “More than half of the approximately four million individuals receiving waivers are union members, including 82.9 percent of those covered in the most recently updated list of waivers.”
With current administration posts coming from Union there wouldn’t be much surprise if these allowances continue. Would it be that bold to predict for Union Members in 2014 will be allowed to use their Individual Exchange income tax credits for their Union benefits packages? Small businesses may not be as lucky.
by Admin. | Jun 28, 2012 | Health Care Reform, individual health insurance, Obamacare, PPACA, Tax
At 10 AM today the Supreme Court in a 5-4 decision upheld the Patient Protection and Affordable Health Care Act’s individual mandate as constitutional.
The text of the opinion, in National Federation of Business vs. Sebelius, Case Number 11-393, is available here.
Imposition of a tax “leaves an individual with a lawful choice to do or not do a certain act, so long as he is willing to pay a tax levied on that choice,” Roberts says. “The Affordable Care Act’s requirement that certain individuals pay a financial penalty for not obtaining health insurance may reasonably be characterized as a tax. Because the Constitution permits such a tax, it is not our role to forbid it, or to pass upon its wisdom or fairness.”
According to Footnote 11, which is on page 44 of the slip opinion: Those subject to the individual mandate may lawfully forgo health insurance and pay higher taxes, or buy health insurance and pay lower taxes. The only thing that they may not lawfully do is buy health insurance and not pay the resulting tax.With this decision finalized, New York State (and the rest of the country) can now move forward with implementing the law. We embrace the much-needed clarity and looking forward to working with our clients moving ahead.Millennium Medical Solutions Corp will be planning health care seminars to review the decision and overview to help understand the impact on employers, plan benefits, and providers. We welcome your suggestions on specific topics or questions you want us to focus on. Please join us!
Our office will continue to monitor events and inform our members of any other important news.
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Imndiv Mandatae requirement_flowchart_3
Individual Mandate Penalty Chart
by Admin. | Jun 25, 2012 | Health Care Reform, Obamacare, PPACA
The biggest Supreme Court Ruling in a decae is expected this Thursday before the Summer recess. Yet thats when the fun begins. Possible outcomes:
- Delay hearing the legal issues associated with case for several years due to the Tax Issue.
- Invalidate the Individual Mandate.
- Invalidate all or part of the Medicaid Expansion requirements.
- Uphold PPACA as is.
- Declare the entire Act unconstitutional due to the lack of a Severability Clause if any of the key provisions such as the Individual Mandate overturned.
If individual mandate is repealed but leave other PPACA provisions in place, this outcome could greatly limit the coverage goals underpinning the Affordable Care Act and cause significant problems in the health insurance markets. For example, MIT economist Jonathan Gruber said, “Without a mandate the law is a lot less effective. The market will not collapse, but it will be a ton more expensive and cover many fewer people.”
While States such as NY may follow Massachusetts and set up their own Individual Mandate this becomes challenging with less Federal funding. Funding for the individual market place subsidy with subsidies could collapse. See subsidy calculator here.
Eliminating the mandate would increase premiums and mean that far fewer of the uninsured would be covered. This is known as adverse selection where the sick population would be willing to pay higher premiums and forcing the healthy population to opt out of exchange. States such as NY in fact have seen the Individual Market spiral out of control as they are high risk adverse group in order to supplement the preferred guaranteed non-preexisting condition group marketplace. Furthermore, NYS requires guaranteed issue for pre-existing condition for individual members with prior coverage.
If the court invalidates the individual mandate and leave rest of Act in tact it may lead to a death spiral. Popular reforms such as overage 26 dependent coverage and expected pre-existing condition waiver in 2014 would possibly be dismantled.
The decision would punt health-care reform back to Congress, which “isn’t doing anything this year” and thus create major uncertainty going into the November elections. Taxes on pharma and medical devices would remain, while managed-care and hospital companies would suffer big losses. Insurers would be forced to take on sick patients without benefitting from the healthy ones who would have been enrolled under the mandate.
In this scenario, a lot of companies would simply cut their losses and leave the individual insurance market altogether; the law would essentially “run them out of business.
Either way the lack of uncertainty has delayed hospitals and insurers from new hires and taking decisive actions. Same time next week we hope to celebrate July 4th with certainty. |
by Admin. | Jun 25, 2012 | Health
Consider Supplements to Primary Medical Plans
Most are familiar with the AFLAC duck when it comes to supplemental benefits to primary medical plans. Today, primary medical plans are extremely valuable but in many cases the benefits paid cover only a fraction of the true cost of a major illness or injury. For instance, a person who suffers a severe heart attack can expect to experience a lengthy hospital stay, followed by a period of recuperation at home or in an extended care or rehabilitative facility. A primary medical plan will cover a significant portion of the hospital and physician costs, but the insured is likely to be responsible for some expenses. Depending on the terms of the plan, these expenses can be substantial.
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Most Popular Benefits
The most in-demand voluntary benefits continue to be those that supplement core medical, life, or disability insurance coverage, according to surveys. These include dental, critical illness, specific illness, hospital supplemental, medical supplemental, disability buy-up, and supplemental life coverage. However, demographic trends are also contributing to growing interest in long-term care and financial planning products.
As more people are faced with their parents’ elder care needs, they begin to appreciate the cost of extended care and anticipate what their needs may be in a few years. And, many mid-career employees face the double crunch of saving for retirement at the same time they are financing college education for their children.
Perhaps reflecting the many demands on the time and money of today’s employees, 28 percent of participants in one survey said they wanted employers to provide a wider array of voluntary benefits. In addition, 30 percent of respondents said they were interested in having employer-provided access to financial planners to assist them in making decisions. |
Furthermore, an individual experiencing a health crisis such as a heart attack can expect to be absent from work for some time. A disability plan usually replaces only 60 percent to 70 percent of wages, and not everyone has disability coverage. This disruption to an individual’s income stream, combined with the added medical expenses, can devastate a family’s financial well-being, and can even force tough decisions about treatment options.
The prospect of experiencing a severe health calamity is not as uncommon as one might think. According to a study by the National Heart Lung and Blood Institute, 1.1 million Americans have heart attacks each year. And the American Cancer Society predicts more than 1.4 million new occurrences of cancer annually in the U.S., with men accounting for a slightly higher percentage than women.
Fortunately, insurance products are available that supplement a primary medical plan. Usually available to employees on a voluntary basis and at group rates, these products can fill gaps in traditional health insurance coverage such as the indirect costs of an illness or injury. Surprisingly, the indirect costs can sometimes outweigh the direct cost of medical care.
The following provides an overview of the types and benefits of supplemental medical insurance products. Remember that different carriers may market similar products under various names, and that the specific benefits provided may vary.
Critical illness insurance usually pays a cash benefit upon diagnosis of a life-threatening disease or condition, such as cancer, heart attack, stroke, or the need for an organ transplant. The benefit can be used as the insured — or survivors — see fit. For instance, the benefit may be used to pay for health care from an out-of-network provider under the primary plan; experimental treatment not covered by the primary plan; indirect costs associated with medical treatment, such as transportation, lodging, and child care; as well as lost income.
Some carriers offer disease-specific insurance. The most well known among these products is cancer insurance. Depending on the way the policy works, specific disease insurance may pay a cash benefit upon diagnosis, and/or may provide coverage beyond the primary medical plan for treatments associated with the disease, such as radiation and chemotherapy in the case of cancer insurance. Some cancer insurance carriers provide disease management services through a health care professional with expertise in oncology.
Catastrophe medical insurance provides coverage that kicks in after the primary medical plan has run out. Although many primary medical plans have high lifetime limits, some do not. This is especially true of those purchased with economy of premium in mind. Catastrophe plans carry a high deductible, but typically all medical expenses paid both by the insured and the insured’s primary plan count toward the deductible. In light of the high cost of health care, a low-limit primary plan can be easily exhausted. Consider the medical costs associated with a premature baby or the trauma of a major automobile accident. Catastrophe insurance provides much needed benefits for all of these types of occurrences.
Hospital indemnity insurance supplements the primary medical plan if an illness or injury requires a hospital stay. Depending on the policy terms, benefits may be paid for specified hospital procedures or on a cash per diem basis.
With today’s skyrocketing costs of medical care prompting employers to study how health insurance is offered to employees, voluntary supplemental medical coverage may be an appropriate offering for your workplace. Adding supplemental medical coverage to an umbrella of voluntary benefit offerings can bring value as well as flexibility to your employee benefit package. Remember that coverages vary by carrier, and by state. Speak with your insurance agent to learn which supplemental insurance products provide the coverages that best suit your needs.
For more information on how a work-site supplemental package would help you and your company please contact us at (855)667-4621 info@medicalsolutionscorp.com today.
by Admin. | Jun 12, 2012 | Health Care Reform, Hospitals, PPACA
Accountable Care Organization
NYU Beth Israel Hospital Merger and ACO
Accountable Care Organization
As reported in NYT last week – New York Hospitals Look to Combine, Forming a Giant “The proposed merger would bring together NYU Langone Medical Center, a highly specialized academic medical center, and Continuum Health Partners, a network of several community-oriented hospitals, including Beth Israel and the two St. Luke’s-Roosevelt campuses.”
Anticipating changes in the way health care is paid for and delivered abound. WIth new Health Care Reform law the traditional fee-for-service model is being sacked in favor of patient care coordination. The consolidations by hospitals are needed in order to deliver the scales build on the ACO model of using independent providers/facilities.
Accountable Care Organization (ACO) – These organizations coordinate patient care and provide the full range of health care services for patients. The health reform law provides incentives for providers who join together to form such organizations and who agree to be accountable for the quality, cost, and overall care of Medicare beneficiaries who are enrolled in the traditional fee-for-service program who are assigned to the ACO.
The fee-for-service system has evidentially driven costs by incentivizing volumes of added procedures. The ACO model is built on par excellence hospitals such as Mayo Clinic where there is team of providers are financially incentivized for patient care coordination outcomes and high quality of care. The ACO’s payment would be tied to achieving goals that improve health care and save money. Members of the ACO would divvy up that payment. Today’s payment system, investments in providing better care are doubly penalized. If a hospital hires a nurse to follow up with patients after they are discharged in order to reduce readmissions — for example, to help patients with diabetes improve blood sugar control — it must pay for the nurse, which is typically not reimbursed by insurance companies or Medicare, and it loses revenue by preventing the readmission.
Congress included ACOs in the health care law as a way to rein in Medicare spending. That federal program pays for health care for people 65 and older and the disabled. The federal government estimates ACOs could save the Medicare program up to $940 million over four years. Medicare recently began testing this system with 32 pilot ACOs in 18 states, including one in the New York City area – Bronx Accountable Healthcare Network.
Some have pointed to ACO Model just as a pro-merger supporting argument with the FTC. These significant mergers create market dominance and therefore limit competition and drive up health care dollars. And yet Hospitals operate on thin profit margins and cannot afford to lose market share therein lies is the conundrum.
Addendum news: July 18, 2012 – Aetna and Hunterdon HealthCare Partners Forge New Accountable Care Relationship
by Admin. | May 30, 2012 | healthcare, Hospitals
Patients Waking Up To Major Colonoscopy Bill
The NYT article – Waking Up to Major Colonoscopy Bills illustartes what our clients are increasingly running into – increased out of pocket expenses.
“Patients who undergo colonoscopy usually receive anesthesia of some sort in order to “sleep” through the procedure. But as one Long Island couple discovered recently, it can be a very expensive nap. Both husband and wife selected gastroenterologists who participated in their insurance plan to perform their cancer screenings. … And in both cases, the Gastroenterologists were assisted in the procedure by anesthesiologists who were not covered by the couple’s insurance. They billed the couple’s insurance at rates far higher than any plan would reimburse — two to four times as high, experts say.”
Patients can go for Colonoscopies either in an outpatient medical office or in ambulatory hospital setting. Gastrointerologists cannot bill for the anesthesia unless there is an employed licensed Anesthesiologist on staff. The treating Physician cannot be the same person who administer/monitors the sedation. Generally speaking the Anesthesiologist in a hospital settings are separate entities and attempt to bill independently form the hospital charges. Now you can begin to see how patients are getting added billing.
Furthermore, we are seeing increasing out of network charges with Physicians dropping health plans in certain geographic areas as well as insurers shifting more of the costs burden.
The posting Out of Control Out of Network Charges points to examples such as – “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.
Our clients get 3 bills with any procedure needing general anesthesia
1) A bill from the hospital
2) A bill from the surgeon
3) A bill from anesthesia
Actually, the physician bill is typically the lowest cost of the bill . On a $5,000 total bill the GI may only get 10%. Sometimes the hospital and anesthesia charges are bundled into a single bill but many times they are not. On most plans patients can negotiate with the hospital depending on pre-authorization the anesthesia bill and resubmit charges. This is probably the most common appeal we perform on behalf of our clients.
Patient on a cost sharing plan with in-network deductibles may fair better with outpatient office colonoscopies. From an insurer costs perspective the charges in an office setting are typically $2,000-$2,500. So why do it in the hospital? The procedure may require general anesthesia and financial incentives. Also, at times the procedure may be a loss to the provider. For example, Pediatricians will not perform Gardasil vaccination because the vaccine costs more than what the pediatrician will get reimbursed to give it.
The vast majority of providers make sure that patients were in-network or arranged pre-payment plan prior to the procedure. As with most non-HMO plans, however, the responsibility rests with patient to make sure everything is pre-authorized and in network is possible.
by Admin. | May 14, 2012 | Hospitals, United Healthcare
Oxford /United Healthcare has announced last week their contract termination with the Valhalla teaching hospital, Westchester Medical Center effective May 1, 2012. The NYS “cooling off period” imposes both parties to renegotiate a contract until July 1st. The hospital will be considered in-network until that time.
This marks the second time a large health insurer has terminated their contracts with Westchester medical Center. Empire had terminated their contract on Nov 10, 2010 after a similar dispute and is still not under contract. While contractual posturing is all too common in the health industry with eleventh hour agreements, we are seeing this disturbing trend playing out in other instances now.
We will monitor the situation and keep members posted. Oxford member letters explaing this are going out. Please contact us with any questions.
by Admin. | May 1, 2012 | HSA, Tax
The IRS has released the 2013 Health Savings Account (HSA) inflation adjustments.
In 2013 HSA limits are as follows: 
HSA Annual Contribution Limit:
Single – $3,250 (up from $3,100 in 2012)
Family – $6,450 (up from $6,250 in 2012)
HDHP Minimum Annual Deductible (No change from calendar year 2011):
Single – $1250 (up from $1,200 in 2012)
Family – $2500 (up from $2,400 in 2012)
HDHP Out-of-Pocket Maximum:
Single – $6250 (up from $6,050 in 2012)
Family – $12,500 (up from $12,100 in 2012)
HSA Video
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.
Please contact us for more customized information and how to incorporate this into your employee benefits.
by Admin. | Mar 29, 2012 | Health Care Reform, individual health insurance, Obamacare
The same analogy would hold true with auto insurance where only the risky drivers would only participate making it impossible to afford coverage. Just imagine buying a health plan on the way to the hospital? Coining this as "ambulance-care" would be more fitting than "ObamaCare".
After 3 days of Health Care Reform Supreme Court Hearings, a central components debated is the constitutionality of forcing an individual to purchase health insurance. Certainly it would be costly if one could just opt out at any time and then come back in you would be left with a high risk pool.
The same analogy would hold true with auto insurance where only the risky drivers would only participate making it impossible to afford coverage. Just imagine buying a health plan on the way to the hospital? Coining this alternative as “ambulance-care” would be more fitting than “ObamaCare”.
Of course there are Individual Mandate penalties. So how does the penalty work?
In 2014, the penalty for being without health insurance is $95 per adult and $47.50 per child (up to $285 for a family) or 1.0% of family income, whichever is greater.
In 2015, the penalty for being without health insurance is $325 per adult and $162.50 per child (up to $975 for a family) or 2.0% of family income, whichever is greater.
In 2016, the penalty for being without health insurance is $695 per adult and $347.50 per child (up to $2,085 for a family) or 2.5% of family income, whichever is greater.
As of now, there are no known method to enforcing the penalty if you don’t buy insurance and you don’t pay the penalty. In fact, the law specifically states that no criminal action or liens can be imposed on you but I am certain that will change. I would also think that if a large numbers of people continue to choose not to enroll and the cost of premiums increase, the chance to revise the low penalties and increased enforcement are inevitable.
In conclusion, the Supreme Court ruling set for June is worth watching but only for legal wonks. With average health insurance single rates costing $600/month wouldnt you pay the penalty and just opt out?
by Admin. | Mar 26, 2012 | Long Term Care, MEDICARE
LTC MetLife Hiring Independent Caregiver
Click Above
LTC MetLife Hiring Independent Caregiver
As people age—or due to a life-changing event such as a stroke—the ability to live inde- pendently may change. Over 44 million Americans spend time caring for family members or friends who can no longer live on their own without assis- tance.1 Often a family member or friend steps in to help the person with the activities of daily living such as bathing and dressing, everyday chores, or preparing meals.
Over time, the need for assis- tance often increases, which in turn increases the time commitment from family
and friends. Individuals often desire to remain in their own home, even though they need more help to stay there. It is frequently at this point that caregivers must begin to look at sources beyond the family to assist with care.
More info
