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Federal Open Enrollment Exclusion Deadline

Federal Open Enrollment Exclusion Deadline

A little-known exception for small businesses but most important under Affordable Care Act (ACA) is for 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 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 plans’ 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. This was even more evident in 2019 with the ACA’s federal Individual Mandate non-compliance penalty reduced to $0.00.

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.”


The annual Federal Employees Health Benefits (FEHB) Open Season is taking place from November 14, 2022 – December 12, 2022 this year. The annual open season provides federal employees, annuitants, and other eligible individuals the opportunity to review their plan options, make changes, and enroll for the upcoming benefit year that begins January 1, 2023.

Employers, if your group struggling with participation and/or contribution, the Special Open Enrollment Window is the time to enroll them in coverage.

Contact us today.


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

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Inflation Reduction Act to be Signed into Law, Includes Multiple Medicare Drug Pricing Reforms

Inflation Reduction Act to be Signed into Law, Includes Multiple Medicare Drug Pricing Reforms

Inflation Reduction Act to be Signed into Law, Includes Multiple Medicare Drug Pricing Reforms

On Aug. 12, the Inflation Reduction Act of 2022 (IRA) passed the U.S. House by a vote of 220-207, and President Biden is expected to sign it into law today. First passed by the U.S. Senate on Aug. 7, the $740 billion budget reconciliation package includes policies on Medicare drug pricing, Affordable Care Act (ACA) subsidies, energy, climate, and taxes. This update provides high-level details on the notable health care-related provisions in the IRA.

Allowing Medicare to Negotiate Drug Prices

With the goal of improving affordability for high-priced drugs in Medicare Parts B and D, the IRA directs the Department of Health and Human Services (HHS) to establish a drug price negotiation program for certain high-priced, single-source drugs and biological products. Under this program, the HHS Secretary will publish a list of selected drugs that meet certain criteria, then negotiate (and renegotiate as needed) maximum fair prices with manufacturers of those drugs. Drugs eligible for negotiation include the 50 Part B and 50 Part D single-source drugs with the highest total expenditures during the most recent 12-month period; however, negotiation is limited to Part D drugs for 2026 and 2027. Negotiated prices must take effect for 10 eligible drugs in 2026, increasing to 20 drugs in 2029. For 2026, the expenditure period to be reviewed is June 1, 2022 through May 31, 2023, and the selected drug list publication date will be Sept. 1, 2023.

Redesigning the Medicare Part D Program, Including Capping Annual Out-of-Pocket Costs for Beneficiaries

The IRA significantly reforms the Medicare Part D benefit design, including capping maximum out-of-pocket (OOP) costs at $2,000 annually, with a copay smoothing component; capping annual premium growth at 6%; and expanding eligibility in the Low-Income Subsidy (LIS) program.

Beneficiary Cost-Sharing Changes:

Beginning in 2024, beneficiaries will be responsible for $0 in the catastrophic benefit phase. There are no changes to the initial coverage phase or coverage gap phase.
Beginning in 2025, the coverage gap phase will be eliminated, and a new $2,000 OOP cap will be applicable with the option to spread OOP payments out over the course of the year. The initial coverage phase remains unchanged.

Part D Benefit Design: The bill restructures plan, manufacturer, and federal government liabilities for the different benefit phases beginning in 2025:

Initial PhaseCatastrophic Phase
Beneficiary: 25%
Plan: 65% for brands, 75% for generics
Manufacturer: 10% for brands, 0% for generics
Beneficiary: 0%
Plan: 60%
Manufacturer: 20% for brands, 0% for generics
Federal Government: 20% for brands, 40% for generics
Premium Stabilization: For 2024 through 2029, any increase in the Part D base beneficiary premium is limited to the lesser of a 6% increase from the previous year or the premium that would have been applied if the stabilization program was not established. In 2030 and subsequent years, the HHS Secretary is authorized to make adjustments necessary to the base Part D premium to ensure that premium is increased by the lesser of 6% or what the premium would have been if the stabilization program was not established.
Expanded LIS Eligibility: The bill expands eligibility for the Part D LIS program from 135% of the federal poverty level to 150% beginning in 2024.

Capping Insulin Cost-Sharing in Medicare

For 2023 through 2025, the bill caps beneficiary cost-sharing at $35 a month for Medicare Part D or Medicare Advantage Prescription Drug Plan (MA-PD) covered insulin products. In 2026 and beyond, it caps cost-sharing at the lesser of $35 or 25% of the maximum fair price or 25% of the plan’s negotiated price. The cost-sharing is capped regardless of where the beneficiary is in the benefit phase, and Part D and MA-PD plans are eligible for a retroactive subsidy in 2023 equal to the aggregate reduction in cost-sharing and deductible due to implementing this provision.

Implementing Drug Manufacturer Inflationary Rebates in Medicare

The legislation requires drug manufacturers to pay rebates to the government if drug prices in Medicare Part B and Part D rise faster than inflation, with rebates equaling the rate at which the price of the drug exceeds inflation. This rebate provision goes into effect Jan. 1, 2023 for Part B rebatable drugs and Oct. 1, 2022 for Part D rebatable drugs. Drugs with an average cost of less than $100 are excluded. Additionally, HHS is instructed to reduce or waive the rebate amount for a Part D rebatable drug if it is on the drug shortage list, per the Federal Food, Drug, and Cosmetic Act.

Requiring Vaccine Coverage in Medicare Part D

Beginning in 2023, Part D plans are required to cover all adult vaccines recommended by the Advisory Committee on Immunization Practices, without cost-sharing or the application of a deductible (other than vaccines covered under Part B). Part D and MA-PD plans are eligible for a retroactive subsidy in 2023 equal to the aggregate reduction in cost-sharing and deductible due to implementing this provision.

Extended Delay of the Medicare Part D Rebate Rule

The legislation includes an additional five-year delay of the implementation of a rule that would prohibit manufacturer rebates in Part D, to Jan. 1, 2032.

Extending Enhanced ACA Subsidies Through 2025

Originally set to expire at the end of this year, the IRA extends the enhanced American Rescue Plan Act (ARPA) ACA premium tax credit subsidies through 2025.

Article credited to CIGNA.
 Learn more about how we are successfully helping navigate SMB for 25+ years. If you have any questions or would like additional information, please contact us at 855-667-4621 or

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Supreme Court Upholds ACA Again

Supreme Court Upholds ACA Again

Obamacare Supreme Court Ruling

Supreme Court Upholds ACA Again

The U.S. Supreme Court ruled this morning that the Affordable Care Act may provide nationwide tax subsidies for people who purchase health insurance through an exchange.  The Court considered a challenge to a provision of the ACA concerning whether subsidies were available only to those who purchased health insurance on an exchange “established by the state.”  The Court, in King v. Burwell, ruled 6 to 3 in favor of upholding the eligibility for people to receive subsidies through either a state or federal health insurance exchange.

The opposite ruling would have had serious implications for the country due to the number of states relying on a federally-run exchange (37 states) and the number of customers who qualify for subsidies based on their income (about 85% of customers nationwide).   The Government’s argument prevailing:  defending the subsidies, the Government argued that if you look at the entire ACA and its history, it is clear that the subsidies are available to everyone who purchases insurance on an exchange, no matter who created it.

Please join us for upcoming Webinar on How to Prepare for Current and Future ACA Requirements.


Are you able to identify and address all of the ACA requirements? Have you developed a plan of action to help stay in compliance? This webinar will walk you through a three year case study and provide you with current and future solutions to help your group prepare for ACA challenges including the Cadillac Tax.

Some of the key webinar highlights include:

  • Will Federal subsidies stop in some states making residents unable to access subsidized Exchange coverage?
  • 3 year case study providing a practical view
  •  Will IRS information reporting still be required?
  • Could Congress step in and propose changes to the existing ACA law?
  • 2015 – Section 125 changes including eligibility, PRAs, excepted benefits and FSA plans for higher OOP exposure
  • 2016 – Renewal focus on HSA’s with a dollar for dollar matching contribution
  • 2017 – Further conversation of reducing benefit costs utilizing post deductible HRA’s and consideration of Defined Contributions

Practical information you can use – a webinar you will not want to miss!

New Election New Obamacare?

New Election New Obamacare?

New Election New Obamacare?Political Disillusionment Cartoon

The people have spoken at least for now and they are saying they are unhappy. The storm clouds over Obmacare has ushered in GOP victories:  +7 Senate  + 13  House.  47% of those who cast ballots in the midterms said the 2010 health care law, which opened for enrollment a year ago, went too far. On the other hand, 26 percent said the law didn’t go far enough, CNN exit polls reported. Only 22 percent said Obamacare was just about right.

How will GOP use these powerful election gains on Obamacare?

GOP still will not have the needed 60 Senate Seats to repeal the Affordable Care Act. That said, they will now be able to pass budget rules on the legislation since the Courts ruled  individual mandate penalty as a “tax”. Reinsurance funds such as Risk corridors could also be on the chopping block.  Other examples would be the definition of “full-time” employee taxes on employer penalties (bipartisan support), medical devices & tanning salons etc.

According to Huffington Post article GOP-Controlled Congress Expected To Try To Repeal, Weaken ACA while Republicans have been “chomping at the bit to repeal Obamacare” since it was signed into law in 2010, even a GOP-controlled Congress is unlikely to undo the law. However, that won’t stop Republicans from forcing at least one vote on repeal. President Obama “would then swiftly veto it, but not before Democratic senators were forced to cast a vote very directly in support of Obamacare, which remains generally unpopular.” Additionally, the GOP might take aim at several provisions of the ACA, such as the individual mandate, the employer mandate, the Independent Payment Advisory Board, and the medical device tax. Some Senate Democrats would likely join them in eliminating or amending some of these measures.

A Democrat President governing with both Houses going GOP may not be so bad after all.  The successful Clinton Presidency had to contend with the same balancing act.  Two decades later, the key question is can both branches find a  common ground and a productive working relationship?


For specific details on all available health plans in 2015, contact our team at Millennium Medical Solutions Corp  (855)667-4621.  We work in coordination with Navigators to assist with medicaid, CHIP Child Health Plus, Family Health Plus and Medicare Dual Eligibles.   We have Spanish, Russian, and Hebrew speakers available.  Quotes can also be viewed on our site.

See Health Reform Resource


Qualifying Events for Marketplace Special Enrollment Period

Qualifying Events for Marketplace Special Enrollment Period

health care reform faq

Qualifying Events for Marketplace Special Enrollment Period

After March 31, 2014, what are considered qualifying events for individuals to buy coverage from the Exchange Marketplace outside of the annual enrollment period?

Please note that the open enrollment for Marketplace coverage ends March 31, 2014.  See more at:  Obamacare 2014 Deadline Nearing. The next proposed open enrollment period is November 15, 2014 – January 15, 2015. According to the site, most special enrollment periods last 60 days from the date of the qualifying life event.

Whats is a Qualifying Event?

A Special Enrollment Period (SEP) is the time outside of Open Enrollment that allows individuals and families facing special circumstances (Qualifying Life Events) to enroll in a Qualified Health Plan. Eligible individuals have 60 days to enroll after their Qualifying Life Event. 

  •  Individual or dependent loses minimum essential coverage due to: job loss; employer no longer offers coverage; divorce; death of a spouse; becoming ineligible for Medicaid or Child Health Plus; expiration of COBRA; or health plan is decertified.
  •  Marriage, birth, adoption, or placement for adoption
  •  Gaining status as a citizen, national, or lawfully present individual
  •  Consumer is newly eligible or ineligible for tax credits and/or cost sharing reductions
  •  Permanent move to an area that has different health plan options
  •  Marketplace staff or contractor enrollment error
  •  Qualified Health Plan violated a provision of its contract
  •  American Indians can enroll or change plans one time per month throughout the year
  •  Other exceptional circumstances, as defined by HHS

Approximately 50% of all enrollments occur outside of Open Enrollment due to Qualifying Life Events.  If you are uninsured do not miss your chance to enroll before March 31!

When do I need to complete my application to avoid a federal tax penalty?

You need to complete your application by 11:59pm on Monday, March 31, 2014 to avoid a federal tax penalty. However, if you give us your word that you tried to apply for health insurance and were not able to enroll through no fault of your own, you will have until 11:59pm on Tuesday, April 15, 2014 to complete your enrollment.

I forgot about the enrollment deadline. Can I still buy health insurance through the Marketplace this year?

No. Unless you are Medicaid eligible or you are buying insurance for a child, you must have a major life-changing event called a qualifying life event to be eligible to buy insurance through the Marketplace this year after the deadline. If you don’t have a qualifying life event, you must wait for the next open enrollment period that begins on November 15, 2014 for coverage that starts on January 1, 2015.

When is my next chance to buy insurance through the Marketplace if I am not eligible for Medicaid?

The next open enrollment period for individuals and families begins on November 15, 2014 for coverage that starts on January 1, 2015.

Are there any exceptions to the open enrollment period?

Enrollment in Medicaid, Child Health Plus and the Small Business Marketplace continues all year.

Have a Qualifying Event?


Enroll Now using our online shopping tool
where you can compare plans and prices and enroll

Find us on the Health Insurance Marketplace where you may qualify for help to pay for your health insurance.  Qualifying Events for Exchange Marketplace. 76 percent of the uninsured are unaware of the looming March 31 sign-up deadline. Contact us at (855)667-4621.


PEO: Co-Employment