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Update: Oxford/United and Mt Sinai Health Systems Split

Update: Oxford/United and Mt Sinai Health Systems Split

Recently, UHC/Oxford and Mt Sinai Health System had split effective January 1, 2024.  Since that time there have been a state-required cooling-off period and ongoing talks on resolution but that has not yielded a positive outcome yet.  The Mount Sinai Hospital, Mount Sinai Queens, and their related hospital outpatient locations will remain in-network for all patients until at least Friday, March 1.

According to UnitedHealthcare/Oxford: 

  • People enrolled in UnitedHealthcare fully insured commercial plans have continued network access to all of Mount Sinai’s hospitals through Feb. 29, 2024, due to New York cooling-off requirements.
  • Unless they obtain admitting privileges to another in-network hospital, the majority of Mount Sinai’s physicians will no longer participate in our network for employer-sponsored and individual plans, including the Oxford Health Plan, effective March 22, 2024.
  • This negotiation only impacts our relationship with Mount Sinai for employer-sponsored and individual commercial plans, including Oxford. All other active contracts, including Medicare Advantage and the Empire Plan, remain in place with no change.

The two organizations had a three-year agreement that took effect on Jan. 1, 2022, which was canceled before it was supposed to expire amid a dispute over payment rates. Both institutions are blaming one another for the standoff.

Mount Sinai claims UnitedHealthcare compensates it an average of 30% less for care than other health systems in New York. The insurer pays New York-Presbyterian $25,911 for a normal vaginal birth, and Mount Sinai $15,989, Mount Sinai said.

“Mount Sinai must be paid fairly,” spokeswoman Lucia Lee said in a statement. “As Mount Sinai costs substantially less than our peers, UHC/Oxford will actually end up paying more for patients to get care at other systems in New York. This cost — estimated to be at least $140 million more over the course of a year — will be passed on to employers and patients.”

UnitedHealthcare says Mount Sinai sought “outlandish price hikes” that would increase costs for services an average of 50% over three years or $600 million — an estimate disputed by Mount Sinai. For example, a regular, outpatient colonoscopy at South Nassau costs about $6,000 and would be about $8,700 in three years under Mount Sinai’s proposal, according to UnitedHealthcare.

    Mt Sinai Hospitals & Health System

    Facility NameCounty
    Mount Sinai Beth IsraelNYC
    The Mount Sinai HospitalNYC
    Mount Sinai MorningsideNYC
    The Mount Sinai WestNYC
    Mount Sinai-Union SquareNYC
    Mount Sinai Kravis Children’s HospitalNYC
    Mount Sinai-Behavioral Health Center (MSBHC)NYC
    Blavatnik Center, Medical CenterNYC
    New York Eye and Ear Infirmary of Mount Sinai NYC
    Mount Sinai BrooklynBrooklyn
    Mount Sinai QueensQueens
    Mount Sinai South NassauLong Island

     

    Neighboring Hospitals

    Bellevue Hospital Center

    NYC

    New York Presbyterian Queens

    Queens

    Elmhurst Hospital Center

    Queens

    New York Presbyterian Weill Cornell

    NYC

    Flushing Hospital Medical Center

    Queens

    North Shore University Hospital Manhasset

    Long Island

    Lenox Hill Hospital

    NYC

    NYU Langone Hospital Brooklyn

    Brooklyn

    Long Island Jewish Medical Center

    Brooklyn

    NYU Langone Hospital Long Island

    Long Island

    Maimonides Medical Center

    Brooklyn

    St. Francis Hospital

    Long Island

    Mercy Medical Center

    Long Island

    St. Johns Episcopal Hospital

    Queens

    New York Presbyterian Columbia

    NYC

    St. Joseph Hospital

    Queens

    New York Presbyterian Lower Manhattan Hospital

    NYC

    Wyckoff Heights Medical Center

    Brooklyn

     

    Both sides need each other as both are market leaders in their fields. It is our hope and most of our clients that they get this resolved soon. In the meantime, please bookmark our site for the latest updates.  And do reach out to us and learn the steps that you can take to smoothen this temporary roadblock.

    Resources:

    https://www.uhc.com/sinai

    https://keepmountsinai.org/

    For information about transparency providers and new tech tools contact us at info@medicalsolutionscorp.com or (855)667-4621.

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    Why We Love PEO This Valentine’s Day

    Why We Love PEO This Valentine’s Day

    Why We Love PEO This Valentine’s Day

    We already love Professional Employer Organizations (PEO)– our clients do too.  Today we’re counting down our top 5 reasons why we love PEO:   Top 5 Reasons Why We Love PEO

    1. National Capabilities: It ensures your compliance with local and federal laws, even if your business has locations in different states. Access to a national provider healthcare plan, not single state carriers

    2. Liability Protections:  Some liability moves to the PEO service instead of your company. 

    3. It saves you money on HR staff.  Being part of a PEO gives you a clear-cut idea of what your costs are going to be a year in and year out. The PEOs work tirelessly to keep their insurance renewals down, so their clients won’t leave. Every year they work with the insurance carriers to introduce new plans and ways to reduce the costs of insurance to their clients. This gives you the ability to forecast and know precisely what your costs will be.

    4.  Technologies:  Online HR resources for self-service issues  Ability for employees to make personal changes on their own, online. Ability to track PTO (paid-time off).

     5. One Vendor: It streamlines HR tasks like payroll, taxes, employee benefits, worker’s compensation, 401K, and HR administrative tasks. 

    Our PEO Quoting Tool ensures that we have first-hand insight as to what the small business owner needs to be successful. Click below for a quote.

    PEO: Co-Employment

     

    FDA Allows FL To Import Canadian Rx: Impact On Employer Plans

    FDA Allows FL To Import Canadian Rx: Impact On Employer Plans

    Recent headlines announced a new regulatory view from the federal government regarding the ability of US consumers to obtain drugs from other countries. In particular, the Federal Drug Administration (FDA) approved an application from the State of Florida to obtain some specified prescription pharmaceuticals directly from Canadian sources for some of its state-funded programs and expanding to its Medicaid population. The move was hailed by many as a necessary first step in controlling prescription drug prices. How it will be implemented and whether the option benefits employer plans are still not clear.

    Background

    The US is typically described, as it is in this Rand study, as having higher costs for brand-name prescription drugs than other countries. There are reasons for that, including price controls in other countries that artificially restrict prices for brand-name drugs in those countries. Ironically, the Rand study also notes that prices for generic drugs are typically lower in the US than in those other countries. Nevertheless, for decades, many observers have advocated the ability of US-based individuals and plans, including employer-sponsored health plans, to import brand-name drugs from those other countries with the hope of driving down the costs of prescription drugs that are used by US citizens.   

    Congress has investigated the effects. The potential impact has traditionally been seen as ambiguous, as it is not clear how the Canadian or other governments would react or whether the consumer can be adequately assured, in the absence of FDA approval, of actually obtaining the same or the equivalent of the FDA-approved pharmaceutical. Recent history has seen those pressures increase, and the FDA may be more inclined to permit more importation of drugs than in previous years. Ironically, perhaps, there has been a move in the market that should make generic drugs less expensive (as they have been increasingly costly in recent years as well).  

    With the approval of the Florida application to import brand name prescription drugs for some of the Florida-run plans, many employers will ask if that avenue will be available for employer plans as well.

    pharmacist giving a prescription

    Employer Plan Impacts

    There has traditionally been little enforcement of the prohibition of importing prescription drugs. Note that even bringing drugs to the US for personal use is technically illegal (unless it meets a couple of narrow exceptions), but it is just not an emphasis of the FDA for enforcement.  

    Employers are being contacted by various vendors who claim to help employer plans reduce prescription drug costs by importing the drugs from Canada. If there is no enforcement, the question is whether the employer plan should go ahead and pursue that option. There is no “right” answer, but there are various factors that employers should consider before they sign on.  

    Will importation result in real cost savings, and are these medications the major cost drivers for the employer’s group health plan? Will drug manufacturers react by increasing prices to US importers? There is certainly no reason to believe that the medications will be sold in the US at lower prices. Perhaps that will be true, but some news reports have noted that Canadian authorities are not keen on making limited drugs widely available to US patients.

    There is no specified pathway for employer plans to gain access to the prescription drugs and the savings, if any, that the states can negotiate. It is entirely possible, given the statements from the Canadian authorities, that limited volumes, if any, of the drugs will be available given the concern of the Canadian government for the health of their citizens.

    It is also unclear whether expanding the program to other countries will assist with the volume of drugs available for import to the US. The pharmaceutical industry (which has its own point of view, of course) has provided information for years that it is just not possible for the FDA to know that drugs imported from other countries are safe and effective. The FDA itself has noted that it cannot vouch for the safety of drugs from other countries. So, employers will need to take additional steps to ensure the safety of the drugs if they seek to use that route. 

    Conclusion

    Employers have been seeking importation as a silver bullet to lower prescription drug costs for their plans. Given the prescription drug inflation of the last few years and the unsustainable costs, employers are desperate for some relief. The final verdict on whether this approach will effectively address medical costs remains uncertain.

    Interested in learning more? World Payroll or our PEO Partners can assist with the E-Verify process. Please email info@medialsolutionscorp.com or call us at 855-667-4621. 

    Name
    Sending

    Please Note: While the information within this alert may concern certain employment laws and regulations to be aware of, it is provided solely as general guidance so that you maintain compliance. It is not the equivalent of legal advice, nor does it serve as a  substitute for the advice of an attorney, if applicable.
    FEDERAL JAN 2024  SMALL GROUP ANNUAL OPEN ENROLLMENT WAIVER

    FEDERAL JAN 2024 SMALL GROUP ANNUAL OPEN ENROLLMENT WAIVER

    Federal Open Enrollment (FOE)

    Great news, during FOE groups will not be subject to any enrollment participation requirements!

    FOE will run from 11/15 through 12/15. ​See below for submission timelines:

    • 12/1 effective date groups must be entered by 11/24
    • 1/1 effective date groups must be entered by 12/15​

    A little-known requirement but most important under the Affordable Care Act (ACA) is that Health Insurers must waive their minimum employer-contribution and employee-participation rules once a year. ACA requires a one-month Special Open Enrollment Window for January 1st coverage.

    The special open enrollment period occurs November 15th through December 15th of each year, allowing eligible small group employers to enroll for coverage effective January 1st of the following year.

    Background

    The ACA has a section in it called the “guaranteed issuance of coverage in the individual and group market.” It stipulates that “each health insurer that offers health insurance coverage in the individual or group market in the state must accept every employer and individual in the state that applies for such coverage.” The section also states that this guaranteed issuance of coverage can only be offered during (special) open enrollment periods and that plans can only be offered to applicants that live in, work in, or reside in the plan’s service area(s).

    Participation and Contribution Requirements

    In many states (including California and Nevada), carriers can decline to issue group health coverage if fewer than 70% of employees elect to enroll in coverage. Some carriers may have even tighter participation requirements.

    Generally speaking, employees with other coverage (Medicare, other group coverage, individual coverage through the Exchange, etc.) are removed from the participation requirement calculation – though it varies by insurance carrier.

    Furthermore, employer contribution rules require employers to contribute a certain percentage of premium costs for all employees in order to attain group health coverage. Some businesses struggle to meet these contribution requirements for a variety of financial reasons.

    Problem Solved: Special Open Enrollment Period

    Many employers want to offer coverage to their employees but are denied because they struggle to meet participation and/or contribution requirements. Employers cannot force employees to enroll in coverage unless the employer pays for 100% of the employees’ premiums, which many employers cannot afford. Even with moderate to generous employer contributions, many employers still find young and lower-income employees waiving coverage. 

    The U.S. Department of Health & Human Services provides final guidance on this in regulation 147.104(b)(1): “In the case of health insurance coverage offered in the small group market, a health insurance issuer may limit the availability of coverage to an annual enrollment period that begins November 15 and extends through December 15 of each year in the case of a plan sponsor that is unable to comply with a material plan provision relating to employer contribution or group participation rules.”

    If your employer groups are struggling with participation and/or contribution, the Special Open Enrollment Window is the time to enroll them in coverage.

    For more help with the Special Open Enrollment Window contact us at info@medicalsolutionscorp.com or (855)667-4621.

    Put You & Your Employees in Good Hands

    Get In Touch

    For more information on PEOs or a customized quote please submit your contact. We will be in touch ASAP.

    2024 Open Enrollment Checklist

    2024 Open Enrollment Checklist

    2024 Open Enrollment Checklist

    To download this entire document as a PDF, click here: Open Enrollment eBook

    This Compliance Overview is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice.  Readers should contact legal counsel for legal advice. 

    In preparation for open enrollment, Employers should review their plan documents in light of changes for the plan year beginning Jan 1, 2024. Below is an Employer 2024 Open Enrollment Checklist including some administrative items to prepare for in 2024.

    Change has been constant for employer plans in the last few years. Unfortunately, 2023 was no exception. As they prepare for 2024 open enrollment, employers must incorporate new requirements affecting the design and administration of their health plans for plan years beginning on or after Jan. 1, 2024. Those changes include items that are adjusted for cost of living changes each year, – e.g., the cost-sharing limits for high deductible health plans (HDHPs), contribution limits to health savings accounts (HSAs), as well as new requirements due to legislative and regulatory updates, such as the expiration of COVID-19 mandates, to name a few.

    Employers should ensure their health plan is updated and communicate benefit changes to participants through an updated summary plan description (SPD) or a summary of material modifications (SMM) for the 2024 plan year.

    As a general best practice, employers should confirm that their open enrollment materials contain certain required participant notices and consider including some periodic notices, such as the Medicare Part D creditable/non-creditable coverage notice, in their open enrollment materials.

    PLAN DESIGN CHANGES

    ACA Mandates 

    Affordability Requirements 

    Under the ACA’s employer shared responsibility rules (the “pay or play” rules), applicable large employers (ALEs) (those with 50 or more full-time employees or the equivalent) are required to offer affordable, minimum value health coverage to their full-time employees (and dependent children) or risk paying a penalty. 

    Under the ACA, an ALE’s health coverage is considered affordable if the employee’s required contribution to the plan does not exceed 9.5% of the employee’s household income for the taxable year (as adjusted each year). The adjusted percentage is 9.12% for 2023.

    The affordability percentage for plan years that begin on or after Jan. 1, 2024, will be 8.39%.  That is another reduction demonstrating the need for ALEs to monitor the affordability percentage each year so they can confirm that at least one of the health plans offered to full-time employees satisfies the ACA’s affordability standard (typically by the use of one of the optional safe harbors – federal poverty level, W-2 or rate of pay).

    Out-of-pocket Maximum

    Under the ACA, non-grandfathered health plans (which apply to almost all employer plans) are subject to limits on cost sharing for essential health benefits. Confirm that out-of-pocket maximum limits for your health plan comply with the ACA’s limits for the 2024 plan year. 

    Plan years beginning on or after Jan. 1, 2024:

    • $9,450 for self-only coverage
    • $18,900 for family coverage

    Note, the out-of-pocket maximum limits for HDHPs compatible with HSAs must be lower than the ACA’s limits. For the 2024 plan year, the out-of-pocket maximum limits for HDHPs are $8,050 for self-only coverage and $16,100 for family coverage. 

    Preventive Care Benefits