Permission Given by HHS to Renew Policies

 Last week (Nov. 14, 2013) the White House announced that insurers will not be required to meet most of the provisions of the Patient Protection and Affordable Care Act (PPACA) if they renew individual or small group policies that were in effect on Oct. 1, 2013. The Department of Health and Human Services (HHS) concurrently sent a Letter to all Insurance Commissioners that provides additional details on the waiver. Essentially, coverage that does not meet the “insurance market reforms” that are scheduled to take effect in 2014 may still be provided for renewals with policy years beginning between Jan. 1, 2014, and Oct. 1, 2014. All newly issued policies must meet the PPACA requirements.

Because states have jurisdiction over insurance, state insurance commissioners must approve any extension. While most are still reviewing the situation, several states have said they will not permit extensions. In addition, insurers are encouraged but not required to retract previously sent cancellations and provide coverage that does not meet the 2014 requirements, and at this time it is unclear which insurers (if any) will choose to offer current coverage into 2014.

If an insurer chooses to reinstate previously cancelled policies and renew others that are not PPACA-compliant, it appears that the renewed policies will largely follow the current rules.

However, according to the HHS letter, these renewed policies will still need to meet a few of the new requirements:

  • Limit eligibility waiting periods to 90 days (as of the start of the 2014 plan year)
  • Remove pre-existing condition limitations for adults in the group market
  • Satisfy the health non-discrimination rules (which includes the wellness program rules)

Newly issued policies will need to meet all of the PPACA requirements starting in 2014.

The HHS letter only addresses individual and small group policies, so it appears that insured plans in the large group market and self-funded plans will still be required to meet all of the PPACA requirements, including the out-of-pocket limit, maximum waiting period, pre-existing condition limitation prohibition and dollar limit prohibition, as of the start of the 2014 plan year.

There are many unanswered questions, including whether an insurer may provide the option to renew current coverage only to certain policyholders, whether new rate filings will be required (or allowed), whether state laws that now include PPACA requirements would be violated with the extension, and how feasible reversal is so late in the year.

Leave a Comment (0) →

Innovative ways through the ACA provisions for employers

Employers are continuing looking for solutions that help manage there businesses more efficiently and also navigate the provisions of the Affordable Care Act (ACA).  If it make sense, employers should consider looking at alternative funding options – like Self Funding or Level Premium programs.

For those of you looking at these options, below are the provisions that do and don’t apply.

ACA Provisions That Do Apply:

  • Minimum Value Plans
  • Unlimited lifetime maximums
  • Out of pocket & deductible limits
  • Kids to age 26
  • Summary of Benefits and Coverages (SBC’s)
  • 60-Day Notice of Material Modification
  • 90-Day waiting period (exempt from California’s 60 Day)
  • W-2 reporting & plan transparency reporting to HHS
  • PCORI Fees & Transitional Reinsurance Fee
  • Discrimination based on health status

ACA Provisions That Do Not Apply:

  • Minimum Loss Ratio (MLR)
  • Comply with 3:1 pricing guidelines
  • Geographical rating areas
  • State or Federal review of premium adjustments
  • Annual Health Insurance Tax (HIT)
  • Provide Essential Health benefits “EHB”
    • Minimum Value is required so no loss of benefit
    • Self-funded plans typically provide richer benefits than fully insured plans

Interested in learning more?  Please contact us at 916-932-2864 – as we are happy to help.

Leave a Comment (0) →

Three Strategic Steps to Getting Your Business Ready for 2014



Health Care Reform (ACA) has so many provisions to be aware of that it can be downright overwhelming.  Here are the top three, often overlooked, strategies to help your company get ready for the changes to come.


  •   Determine who is eligible for the marketplace subsidy.  Unless you pay for 100 percent of your employees’ premium, you have the possibility of a backlash from your staff.  Here’s how it works: If their income is 400 percent or less of federal poverty levels, they are eligible for a federal subsidy to offset their premium and sometimes co-pay expenses (this could make the marketplace plan less expensive than your employers’ group health plan).  If you are providing affordable coverage for your employees this means they end up missing out on their subsidy.  This step may take additional footwork as you will need to find out what their household income is.  You can accomplish this through a simple survey, though you’ll want to make sure it is HIPAA compliant to protect their information.
  • Review all your options.  Purchasing health insurance is a completely different process now.  Self-funding options are now available for smaller groups. New products and financing options are surfacing that mimic group insurance but are individual products,   taking the perceived risk of self-funding out of the picture.
  • Evaluate your compliance.  Certain mandates will automatically be dealt with or are already put in place, such as essential benefits, dependent coverage and lifetime limits.  Others are set at the company policy level and many will need to be updated to stay in compliance.  In particular, note what your waiting period is (must be less than 90 calendar days from the date of eligibility) and how many hours worked are needed to be eligible for coverage (30 hours will be the new federal full-time standard on Jan. 1, 2015).  If you have seasonal or part-time employees, you’ll want to spend extra effort managing the hours they work so eligibility doesn’t catch you unaware.  Payroll services are adapting their products to assist business owners with tracking the hours of part-time and seasonal employees.

Certainly there is a lot more to consider and know regarding the compliance, management, administration and strategy of health care reform.  Unless you’re a large company with dedicated benefit professionals, you probably don’t have the staff or the time to dedicate to these new regulations.  Lean on Innovative Broker Services by calling at 916-932-2864 for guidance on other strategies you can use as you prepare for 2014 and beyond.

Leave a Comment (0) →

Why do we still have COBRA?

Application for Health Benefits Pic

With the advent of the health marketplaces, why do we still have COBRA?

The framers of PPACA decided that COBRA should be available even after the health marketplaces become available primarily to avoid possible disruptions in care.  They felt that COBRA beneficiaries, many of whom have significant health conditions, should be allowed to stay with their current health care providers if they chose to.  With reports of narrow networks in some of the marketplaces, this concern has some basis.

The marketplaces will not offer ancillary benefits, so some individuals will elect COBRA to have access to continued dental or vision coverage.  Individuals anticipating a short period before new group coverage becomes effective also may choose to elect COBRA as a simpler bridge than moving into and out of the marketplace.

However, most experts believe that most COBRA-eligible individuals will decline COBRA and elect coverage through the marketplace instead.  Due to the premium subsidies, marketplace coverage may be less expensive than COBRA; it also does not have a maximum coverage period like COBRA does.  As COBRA beneficiaries tend to have claims that exceed premiums, employers will benefit from a migration of this population to marketplace coverage.

It appears that the marketplaces will basically follow the HIPAA special enrolment rules.  This means that if a person elects COBRA they will need to complete the maximum COBRA period in order to enroll in the marketplace outside of open enrollment.

Employers will need to provide the general COBRA notice to newly eligible individuals even after January 1, 2014.  The Department of Labor has provided an updated model COBRA election notice (at COBRA Continuation Coverage) that mentions the marketplace that will need to be given following a qualifying event.  It is unclear when employers must switch to the new notice; since the marketplace coverage will not begin until January 2014 to avoid confusion waiting to move to the new notice until this December may be the best option.

Leave a Comment (0) →

PPACA penalty deadline could move

By ,


The Obama administration might consider adjusting at least one Patient Protection and Affordable Care Act exchange application deadline.

Jay Carney, the White House press secretary, said today during a press briefing aired live on C-SPAN that the U.S. Department of Health and Human Services might be working on a fix for the conflict between the PPACA individual health insurance mandate penalty and the end of the open enrollment period..

Under current PPACA public exchange program rules, to get 2014 exchange health coverage in place by Jan. 1, consumers must sign up for coverage by Dec. 15.

But PPACA lets consumers buy exchange coverage on a true guaranteed-issue basis until March 31. After March 31, consumers with health problems might have to wait until the next open enrollment period to buy coverage.

PPACA also requires many consumers to have a minimum level of health coverage in place by March 31.

The law includes many “individual responsibility” mandate exceptions. But consumers who are subject to the mandate and fail to have a minimum amount of health coverage after March 31 may have to pay a $95 penalty or 1 percent of income, whichever is greater.

Some tax experts have said consumers would actually have to apply for coverage by mid-February to have the kind of coverage required by the mandate rules in place by March 31.

Carney said HHS officials want to do something about the conflict between the open enrollment deadline and the tax mandate deadline.

“They are working to align the policies — the disconnect — between the open-enrollment period and the individual responsibility timeframe,” Carney said.

In response to questions about problems with the federal exchange enrollment system, Carney said the administration is focusing on helping consumers get coverage rather than on determining who’s to blame for the problems.

When reporters asked about whether the administration would postpone general exchange application deadlines because of the problems, Carney said the country is just three weeks into a six-month enrollment period.

“We’re still early in the process,” and about 500,000 people already have submitted coverage applications through state and federal enrollment systems, Carney said.

“I’m not going to speculate about where we’re going to be in a few months,” Carney said. “We’re focusing on fixing problems now.”

Leave a Comment (0) →

Brass Tacks = Employers and Health Care Reform (ACA)

Medical Provider Pic

We’ve had a lot of employers request a simple, at-a-glance way to see all the PPACA requirements that apply to their business. This is no easy task given group size, SHOP exchanges and self-funding variables! Let’s just look at a few provisions that are effective for the plan year beginning on or after 1/1/2014:


Here’s what (non-grandfathered) large group insured plans (more than 50 employees) should be focused on:

  •  Eligibility waiting period maximum of 90 days
  • Pre-ex not permitted on anyone
  • Annual dollar limits prohibited on essential health benefits
  • Protections for those in clinical trials
  • Out of pocket may not exceed $6,350/$12,700
  • Guarantee issue and renewal apply
  • Revised wellness program rules

If you are a (non-grandfathered) small group (50 or fewer employees) insured plan, keep a watch on the following requirements that apply BOTH inside and outside the SHOP exchange:

  • Modified community rating applies
  • Essential health benefits (EHBs) must be offered
  • Deductible generally may not exceed $2,000/$4,000
  • Out of pocket may not exceed $6,350/$12,700
  • Must meet metal levels (60%, 70%, 80%, 90%)
  • Guarantee issue and renewal apply (subject to participation)
  • Single risk pool
  • Revised wellness program rules
  • Eligibility waiting period maximum of 90 days
  • Pre-ex not permitted on anyone
  • Annual dollar limits prohibited on essential health benefits
  • Protections for those in clinical trials

If you are a small OR large self-funded plan, the following requirements should be on your radar:

  • Eligibility waiting period maximum of 90 days
  • Pre-ex not permitted on anyone
  • Annual dollar limits prohibited on essential health benefits
  • Protections for those in clinical trials
  • Out of pocket may not exceed $6,350/$12,700
  • Revised wellness program rules
  • Transitional reinsurance fee, including reporting

If you need any additional clarification, do not hesitate calling us at 916-932-2864 as we’re here to help!


Leave a Comment (0) →

CA Maximum eligibility waiting period is 60 days


California AB 1083,(Chaptered Sept. 30, 2013)  enacts various provisions of the federal Affordable Care Act (ACA) into California state law and applies these provisions to insured health plans and HMO contracts in California, effective for plan years beginning on or after January 1, 2014. Most of the provisions in AB 1083 mirror those in the ACA, but one very important difference is that California’s maximum eligibility waiting period is 60 days after date of hire rather than 90 days.

Maximum 60-day Waiting Period Applies to both Small and Large Insured Plans

Initially it was widely believed that California’s maximum 60-day waiting period applied only to “small group” health insurance coverage, because AB 1083 primarily amends only the “small group” provisions in the California Insurance Code and the Health & Safety (H&S) Code. In recent months, however, California regulators (the California Department of Insurance and the Department of Managed Health Care) have confirmed that the maximum 60-day waiting period applies to large insured plans as well as to small insured plans. The AB 1083 provisions that limit the waiting period to 60 days are included not only in sections of the bill that amend California small group law, but also in sections that amend and replace California law that applies to all size health insurance and managed health care products (Health & Safety Code section 1357.51(c) and Insurance Code section 10198.7(c)).

Note that the requirements apply to insurers and HMOs, rather than to employers, so insurance contracts issued for 2014 should include the 60-day waiting period limit.

What Plans are Not Subject to the 60-day Waiting Period Limit?

California’s 60-day waiting period limit does not apply to self-insured plans nor to insured plans issued, renewed or delivered in other states. Such plans must comply with the ACA’s 90-day maximum waiting period, and insured plans in other states must comply with any state law limits in the applicable states. California’s 60-day limit also does not apply to insured dental or vision plans issued in California, although employers may elect to use the same waiting period for dental and vision as for medical plans.

Can a Plan Use “First of the Month after 60 days” rather than just 60 Days?

No, under both the California and federal waiting period limitations, the waiting period maximum requires coverage to be available as of the specified day (60th or 90th), not as of the first of the month following that day. Additionally, both the California and federal rules take all calendar days into account, not only business days. Since carriers generally allow enrollment only as of the first of the month, California employers may be required to offer coverage as of the first of the month following 30 days of employment, in order to meet the 60-day limit. At least one carrier has said informally that it is working on changing its enrollment systems to allow enrollment as of the 60th day after date of hire, but it remains to be seen whether this will be implemented and whether most carriers will take this approach.

The waiting period limitation does not include periods during which an individual could have been enrolled, but was not due to the individual’s failure to take the appropriate actions. For example, a plan or policy will be compliant if it allows an individual to enroll by the 60th day following date of hire if the individual submits a completed enrollment form, but an individual does not actually enroll until a later date because the individual fails to submit the completed enrollment form.

When in 2014 does the New 60-Day Limit Apply?

The new 60-day waiting period limit (and the federal 90-day waiting period limit) apply as of the first day of the “plan year” beginning on or after January 1, 2014. Thus, a calendar-year plan must comply as of January 1, 2014, and a July 1 plan year must comply as of July 1, 2014.

Small employers who are not required to file Form 5500s often do not specify their plan year. An issue may arise as to whether the plan year is the calendar year or the contract/policy year, especially if a small employer renews early (most carriers are offering “early renewal” as of December 1, 2013 to delay the effective date of certain ACA provisions). California AB 1083 refers to the federal definition at 45 CFR 144.103, which says “plan year” is:

  • The plan year specified in the plan document, or
  • If no plan year is specified in documents or there is no plan document, the plan year is the deductible or limit year used under the plan ( which is likely to be the calendar year for many health insurance contracts), or
  • If the plan does not impose deductibles on a yearly basis, the plan year is the policy year, or
  • In any other case, the plan year is the calendar year.

We conducted an informal poll of five health insurers that cover most of the small group market in California. They all said that any group renewing early will not be subject to the shorter waiting period limit until their 2014 renewal. So, a group that renews early December 1, 2013 will not have to comply with the 60-day waiting period limit until December 1, 2014. As of the date of this article, we have not heard otherwise from the California regulators. A word of caution: it appears—from the definition above—that if no plan year is specified and the deductible year is the calendar year, the regulators might be able to require compliance with the new 60-day limit as of January 1, 2014, even if the contract renewal date was December 1, 2013. We will keep you informed if we get additional information on this.

What is the Penalty for Non-Compliance? 

The penalties can be steep for carriers and others engaged in the business of insurance.  These penalties do not apply to employers.  Per Insurance Code section 10753.18, a  carrier who fails to comply with the 60-day limit on waiting periods could be subject to a fine of $2,500 for the first violation and $5,000 for each subsequent violation.  The penalty increases to $15,000 -$100,000 per violation, if the carrier repeatedly violates these requirements “with a frequency that indicates a general business practice or commits a knowing violation.”  Additionally, individuals or entities who are not carriers but who are  “engaged in the business of insurance” may be fined not more than $250 for the first violation, and $1,000-$2,000 for each subsequent violation or for a knowing violation.

Leave a Comment (0) →

IMPORTANT HCR UPDATE: Employer Mandate Delayed until 2015

Have you heard the news? The ACA has been postponed!

Let’s talk details:

1. What’s Been Delayed

The play or pay provision requires employers with 50 or more employees to do the following to avoid penalties:

  1. Offer minimum essential coverage to 95 percent of full-time employees
  2. Offer minimum value (60 percent) coverage to full-time employees
  3. Offer affordable (less than 9.5 percent of income) coverage to full-time employees
  4. Consider employees who average 30 or more hours per week full-time for purposes of their health plan
  5. Count employees’ hours to determine whether they average 30 or more hours work per week
  6. Because of the delay, employers will not need to meet these requirements for 2014.

2. What’s Still Required

The delay in the play or pay requirement does not affect the insurance market reforms.  This means that these requirements are still scheduled to go into effect as of the start of the 2014 plan year (with penalties of up to $100 per person per day for non-compliance).  These requirements apply to all plans except as noted:

  1. Waiting periods cannot be more than 90 days from the date the employee becomes eligible
  2. All pre-existing condition limitations must be removed
  3. The out-of-pocket maximum cannot exceed $6,350 for individual and $12,700 for family coverage
  4. Essential health benefits may not have annual dollar limits
  5. Grandfathered plans must cover dependent children to age 26 even if the child has access to his/her own employer-provided coverage
  6. The new wellness program requirements
  7. For small insured plans, whether in or outside the exchange/marketplace, coverage must include the essential health benefits, at the bronze, silver, gold or platinum level, with a deductible of not more than $2,000 for individual and $4,000 for family coverage
  8. For small insured plans, whether in or outside the exchange/marketplace, modified community rating (rating classes are limited to age, tobacco use, family size and geographic area), guaranteed issue and guaranteed renewal (with some limitations) will apply

3. What other PPACA requirements must employers also meet:

  1. Reporting and payment of the PCORI fee by July 31, 2013 for plans that ended Oct. 1, 2012 through Dec. 31, 2012
  2. Timely distribution of any MLR rebates the plan may receive
  3. Providing a Summary of Benefits and Coverage (SBC) as part of open enrollment
  4. Distributing the DOL notice regarding the exchange by Oct. 1, 2013
  5. Reporting health care costs on the employee’s W-2 (the exemption for employers that issued fewer than 250 W-2s in the prior year or that contribute to a multiple employer plan will continue for the 2013 W-2)
  6. Paying the transitional reinsurance fee, due in January 2015

4. What’s Next?

The government stated in the delay announcements that the exchanges are still expected to begin open enrollment on Oct. 1, 2013.  It is unclear at this point how the delay of the play or pay requirement will affect determination of employee eligibility for subsidies.  Presumably the official guidance that Treasury has promised to provide next week will address this issue.

If you have questions about how this will impact you, never hesitate to contact us.

Leave a Comment (0) →
Page 3 of 5 12345