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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 

    doctor examining a baby being held by mother

    The ACA requires non-grandfathered health plans to cover certain preventive health services without imposing cost-sharing requirements (e.g., deductibles, copayments, or coinsurance) when in-network healthcare providers supply the services. The preventive care services covered by the requirements are based on the following:

    • Evidence-based items or services that have a rating of A or B in the current recommendations of the United States Preventive Services Task Force (USPSTF).
    • Immunizations for routine use in children, adolescents, and adults that are currently recommended by the Centers for Disease Control and Prevention.
    • Evidence-informed preventive care and screenings are included in the Health Resources and Services Administration (HRSA) guidelines for infants, children, and adolescents.
    • Evidence-informed preventive care and screenings are included in HRSA-supported guidelines for women.

    There needs to be some clarity. An ongoing court case has raised some uncertainty about using the USPSTF recommendations. However, guidance from federal agencies will permit employers to use those factors without the risk of penalties for the time being. Therefore, employers should monitor future developments regarding the ACA’s preventive care mandate, which is expected by the end of 2023.

    Coverage For COVID-19 Vaccines, Testing And Treatment

    Because the COVID-19 public health emergency has ended (see Alert here), health plans are no longer required to cover COVID-19 diagnostic tests and related services without cost sharing or other medical management requirements. Health plans are still required to cover recommended preventive services (under the ACA requirements), including COVID-19 immunizations, without cost sharing, but this coverage requirement can now be limited to in-network providers.

     

    patient getting temperature taken by doctor

    For plan years ending after Dec. 31, 2024, an HSA-compatible HDHP is no longer permitted to provide COVID-19 testing and treatment benefits without a deductible (or with a deductible below the minimum deductible for an HDHP). Therefore, employers should

    • Determine whether health plans will impose cost-sharing requirements, prior authorization, or other medical management requirements on COVID-19 testing for the upcoming plan year.
    • Determine whether health plans will continue covering COVID-19 immunizations without cost sharing from all healthcare providers or whether this first-dollar coverage will be limited to in-network providers.
    • Confirm that HDHPs that do not have a calendar year as the plan year will not pay benefits for COVID-19 testing and treatment before the annual minimum deductible has been met for plan years ending after Dec. 31, 2024.
    • Notify plan participants of any changes for the 2024 plan year regarding COVID-19 testing and vaccines through an updated SPD or SMM.

    Health FSA Contributions

    The IRS issued a memorandum on claims substantiation (see Article here) for health FSAs. The memorandum clarifies that health FSA expenses are not considered properly substantiated if employees self-certify expenses, if the plan uses sampling, if only amounts over a certain level are substantiated, or if charges from favored providers are not substantiated. Employers should, therefore, review the health FSA substantiation procedures to make sure they comply with IRS rules. 

    HDHP and HSA Limits for 2024

    2024 Health Savings Account Limits announced

    If you offer an HDHP to your employees that is compatible with an HSA, you should confirm that the HDHP’s minimum deductible and out-of-pocket maximum comply with the 2020 limits. The IRS limits for HSA contributions and HDHP cost-sharing increase for 2024. The HSA contribution limits will increase effective Jan. 1, 2024, while the HDHP limits will increase effective for plan years beginning on or after Jan. 1, 2024.

    • Check whether your HDHP’s cost-sharing limits need to be adjusted for the 2024 limits.
    • If you communicate the HSA contribution limits to employees as part of the enrollment process, these enrollment materials should be updated to reflect the increased limits that apply for 2024.

    The following table contains the HDHP and HSA limits for 2024 as compared to 2023. It also includes the catch-up contribution limit that applies to HSA-eligible individuals who are age 55 or older, which is not adjusted for inflation and stays the same from year to year.

    Type of Limit20242023Change
    HSA Contribution LimitSelf-only$4,150$3,850Up $300
    Family$8,300$7,750Up $550
    HSA Catch-up Contributions (not subject to adjustment for inflation)Age 55 or older$1,000$1,000No change
    HDHP Minimum DeductibleSelf-only$1,600$1,500Up $100
    Family$3,200$3,000Up $200
    HDHP Maximum Out-of-pocket Expense Limit (deductibles, copayments and other amounts, but not premiums)Self-only$8,050$7,500Up $550
    Family$16,100$15,000Up $1,100

    HDHP Design Option – Telehealth  

    At the beginning of the COVID-19 pandemic, Congress temporarily relaxed the rules for HDHPs to allow them to provide benefits for telehealth or other remote care services before plan deductibles were met without jeopardizing HSA eligibility.  That relaxed rule currently applies for plan years beginning before Jan. 1, 2025. 

    • Determine whether HDHPs will waive the deductible for telehealth services for the plan year beginning in 2024
    • Communicate plan changes for the upcoming year to participants through an updated SPD or SMM

    Mental Health Parity – Required Comparative Analysis For NQTLs  

    The Mental Health Parity and Addiction Equity Act (MHPAEA) requires parity between a group health plan’s medical/surgical benefits and its mental health or substance use disorder (MH/SUD) benefits. These parity requirements apply to financial requirements and treatment limits for MH/SUD benefits. In addition, any nonquantitative treatment limitations (NQTLs) placed on MH/SUD benefits must comply with MHPAEA’s parity requirements. For example, NQTLs include prior authorization, step therapy protocols, network adequacy, and medical necessity criteria. 

    MHPAEA requires health plans and issuers to conduct comparative analyses of the NQTLs used for medical/surgical benefits compared to MH/SUD benefits. This analysis must contain a detailed, written, and reasoned explanation of the specific plan terms and practices and include the basis for the plan or issuer’s conclusion that the NQTLs comply with MHPAEA. Plans and issuers must make their comparative analyses available to specific federal agencies or applicable state authorities upon request. 

    • Employers should request that health plan issuers (or third-party administrators) confirm that comparative analyses of NQTLs will be updated, if necessary, for the plan year beginning in 2024 and make the analysis available to the employee.

    Open Enrollment Notices

    Employers who sponsor group health plans should provide certain benefits notices in connection with their open enrollment periods. Some of these notices must be provided at open enrollment time, such as the Summary of Benefit and Coverage (SBC). Other notices, such as the WHCRA notice, must be distributed annually. Although these annual notices may be provided at different times throughout the year, employers often include them in their open enrollment materials for administrative convenience. 

    In addition, employers should review their open enrollment materials to confirm that they accurately reflect the terms and cost of coverage. In general, any plan design changes for 2024 should be communicated to plan participants through an updated SPD or an SMM. 

    Summary Of Benefits And Coverage


    The ACA requires health plans and health insurance issuers to provide an SBC to applicants and enrollees each year at open enrollment or renewal. Federal agencies have provided a template for the SBC, which health plans must use. 

    • Note that for self-funded plans, the plan administrator is responsible for providing the SBC. For insured plans, the issuer usually prepares the SBC. If the issuer prepares the SBC, an employer is not required to also prepare an SBC for the health plan, although the employer may need to distribute the SBC prepared by the issuer. 

    Medicare Part D Notices

    Group health plan sponsors must provide a notice of creditable or non-creditable prescription drug coverage to Medicare Part D-eligible individuals covered by, or who apply for, prescription drug coverage under the health plan. The notice alerts the individuals about whether their prescription drug coverage is at least as good as Medicare Part D coverage. The notice generally must be provided at various times that cannot always be anticipated, including when an individual enrolls in the plan and each year before Oct. 15 (when the Medicare annual open enrollment period begins). Therefore, the best practice is to provide it annually at open enrollment, as that will ensure timely compliance. Model notices are available on the Centers for Medicare and Medicaid Services’ website

    Annual CHIP Notices 

    Group health plans covering residents in a state that provides a premium subsidy to low-income children and their families to help pay for employer-sponsored coverage must send an annual Children’s Health Insurance Program (CHIP) notice about the available assistance to all employees in that state. The U.S. Department of Labor (DOL) has provided a model notice.

    Initial COBRA Notices 

     COBRA applies to employers with 20 or more employees who sponsor group health plans. Group health plan administrators must provide an initial COBRA notice to new participants and certain dependents within 90 days after plan coverage begins. The initial COBRA notice may be incorporated into the plan’s SPD. Because the COBRA election-period will not start until this notice is provided, it is helpful to many employers to include a copy in the open enrollment materials as a backup. 

    woman holding a small cartoon heart over her chest

    Notices Of Patient Protections 

    Under the ACA, group health plans and issuers that require the designation of a participating primary care provider must permit each participant, beneficiary, and enrollee to designate any available participating primary care provider (including a pediatrician for children). Additionally, plans and issuers that provide obstetrical/gynecological care and require a designation of a participating primary care provider may not require preauthorization or referral for such care. If a health plan requires participants to designate a participating primary care provider, the plan or issuer must provide a notice of these patient protections whenever the SPD or similar description of benefits is provided to a participant. If an employer’s plan is subject to this notice requirement, they should confirm that it is included in the plan’s open enrollment materials. This notice may be included in the plan’s SPD. Model language is available from the DOL. 

    Grandfathered Plan Notices 

    If an employer has a grandfathered plan, they should include information about its grandfathered status in plan materials describing the coverage under the plan, such as SPDs and open enrollment materials. Model language is available from the DOL. 

    Notices Of HIPAA Special Enrollment Rights 

    At or before enrollment, an employer’s group health plan must provide each eligible employee with a notice of their special enrollment rights under HIPAA. This notice may be included in the plan’s SPD.

    HIPAA Privacy Notices  

    The HIPAA Privacy Rule requires covered entities (including group health plans and issuers) to provide a Notice of Privacy Practices (or Privacy Notice) to everyone who is the subject of protected health information (PHI). Health plans are required to send the Privacy Notice at certain times, including to new enrollees at the time of enrollment. Also, at least once every three years, health plans must either redistribute the Privacy Notice or notify participants that the Privacy Notice is available and explain how to obtain a copy. Self-insured health plans are required to maintain and provide their own Privacy Notices. However, special rules apply for fully insured plans, where the health insurance issuer, not the plan itself, is primarily responsible for the Privacy Notice.

    woman holding a piece of paper with "HIPPA" on it

    Special Rules for Fully Insured Plans 

    The plan sponsor of a fully insured health plan has limited responsibilities with respect to the Privacy Notice, including the following:

    • If the sponsor of a fully insured plan has access to PHI for plan administrative functions, they are required to maintain a Privacy Notice and to provide the notice upon request.
    • If the sponsor of a fully insured plan does not have access to PHI for plan administrative functions, they are not required to maintain or provide a Privacy Notice.
    • A plan sponsor’s access to enrollment information, summary health information, and PHI that is released pursuant to a HIPAA authorization does not qualify as having access to PHI for plan administration purposes.

    Model Privacy Notices are available through the Department of Health and Human Services.

    WHCRA Notices 

    Plans and issuers must provide notice of participants’ rights to mastectomy-related benefits under the WHCRA at the time of enrollment and annually. The DOL’s compliance assistance guide includes model language for this disclosure.

    SARs 

    Plan administrators required to file  Form 5500 must provide participants with a narrative summary of the information in Form 5500, called a summary annual report (SAR). A model notice is available from the DOL. 

    Group health plans that are unfunded (that is, benefits are payable from the employer’s general assets and not through an insurance policy or trust) are not subject to the SAR requirement. The plan administrator generally must provide the SAR within nine months of the close of the plan year. If an extension of time to file Form 5500 is obtained, the plan administrator must furnish the SAR within two months after the close of the extension period. 

    Wellness Program Notices 

    Group health plans that include wellness programs may be required to provide certain notices regarding the program’s design. As a general rule, these notices should be provided when the wellness program is communicated to employees and before employees provide any health-related information or undergo medical examinations. These notices are required in the following situations:

    • HIPAA Wellness Program Notice—HIPAA imposes a notice requirement on health-contingent wellness programs offered under group health plans. Health-contingent wellness plans require individuals to satisfy standards related to health factors (e.g., not smoking) to obtain rewards. The notice must disclose the availability of a reasonable alternative standard to qualify for the reward (and, if applicable, the possibility of waiver of the otherwise applicable standard) in all plan materials describing the terms of a health-contingent wellness program. The DOL’s compliance assistance guide includes a model notice that can be used to satisfy this requirement.
    • ADA Wellness Program Notice—Employers with 15 or more employees are subject to the Americans with Disabilities Act (ADA). Wellness programs that include health-related questions or medical exams must comply with the ADA’s requirements, including an employee notice requirement. Employers must give participating employees a notice that tells them what information will be collected as part of the wellness program, with whom it will be shared, and for what purpose, as well as the limits on disclosure and the way information will be kept confidential. The U.S. Equal Employment Opportunity Commission (EEOC) has provided a sample notice to help employers comply with this ADA requirement.

    ICHRA Notices 

    Employers may use individual coverage HRAs (ICHRAs) to reimburse their eligible employees for insurance policies purchased in the individual market or Medicare premiums. Employers with ICHRAs must notify eligible participants about the ICHRA and its interaction with the ACA’s premium tax credit. In general, this notice must be provided at least 90 days before the start of each plan year. Employers may provide this notice at open enrollment time if it is at least 90 days before the beginning of the plan year. A model notice is available for employers to use to satisfy this notice requirement.

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    Enhance Your Employee Benefits Package.  A competitive benefits package is key to keeping and attracting top talent.  Assess your current benefits package and consider making necessary adjustments to include options, such as expanded mental health support, for example. 

    GENERAL HR  

    Review Employee Records.  The fourth quarter is a good time to review your employee records and check record retention guidelines. Don’t forget to dispose of outdated termination and outdated job applications properly. With W2s around the corner, make sure all addresses and information are updated.

    Develop and Distribute Your 2024 Calendar.  Create and distribute a calendar outlining important dates, vacation time, pay dates, and company-observed holidays for 2024. 

    Review and Update Employee Handbook. Review your employee handbook to make sure it is up-to-date and addresses areas, such as employment law mandates, new COVID-related policies, guidelines for remote working, privacy policies, compensation and performance reviews, social media policies, attendance, and time-off, break periods, benefits, and procedures for termination, discipline, workplace safety, and emergency procedures.

    PLEASE NOTE: This Checklist 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. This information is for general reference purposes only. Because laws, regulations, and filing deadlines are likely to change, please check with the appropriate organizations or government agencies for the latest information and consult your employment attorney and/or benefits advisor regarding your responsibilities. In addition, your business may be exempt from certain requirements and/or be subject to different requirements under the laws of your state. (Updated Sept 3, 2023)

    Contact us at (855) 667-4621 or email us at info@medicalsolutionscorp.com

     

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    NYS DFS 2024 Rates Approved

    NYS DFS 2024 Rates Approved

    Earlier today, the long-awaited NYS Dept of Financial Services approved 2024 health insurance rate requests. And it was worth it with small groups stabilized.  Small group rates increased by 7.4% and  12.4% for individuals.

    As per NY State Law, Health Insurers are required to send out early notices of rate request filings to groups and subscribers. Despite only 3 months of mature claims data experience for 2023  health insurers’ original requests were noticeably above the average of 22%/individuals and 15.3% for small groups.

    State Department of Financial Services officials asserted the rising cost of medical care — including in-patient hospital stays and rapid increases in drug prices — continued to be the main driver of health insurance premium increases. The final approved rates for 2024 would keep health insurers’ profit provisions at 1%, state officials added, noting they sought to limit those returns in light of ongoing inflationary pressures harming consumers. That said, in anticipation of spikes in claims submissions + overall inflation, a larger-than-average increase is needed. This is in addition to increases in pricing by hospitals, consolidated IPA groups, and pharmaceuticals.

    Rate Factors

    The state noted that the premiums increase main drivers are medications.  “Rising medical costs and inflation continue to put upward pressure on premiums,” said Superintendent Harris. “With our rate actions announced today, we continue to prioritize the financial well-being of consumers while ensuring that New Yorkers have access to a robust, stable health insurance market.”  Also, DFS, recognizing the continued uncertainty of the pandemic’s effect on consumers’ healthcare costs and the economy, held insurers’ profit provisions to a low 1%. 

    Health Insurers

    Oxford/Unitedhealthcare, notably, got only a 4.7% rate increase approval for next year. This is a sharp reduction from the original 15.5% request in part to disagreed anticipated costs, held reserves, overall market pricing, and reinsurance gained from ACA’s Risk Corridor.  See more info here, https://medicalsolutionscorp.com/risk-adjustment-reinsurance-and-risk-corridors/.

    Small Group Market   

    Almost 800,000 New Yorkers are enrolled in small group plans, which cover employers with up to 100 employees. Insurers requested an average rate increase of 15.3% in the small group market, which DFS cut by 52% to 7.4% for 2024, saving small businesses $607 million. A number of small businesses also will be eligible for tax credits that may lower those premium costs even further, such as the Small Business Health Care Tax Credit.

    DFS SMALL GROUP MARKET RATE ACTIONS