Human Resources

Fat People Have Issues!

Medical issues

Before offending anyone – I posted the politically incorrect title in hopes of getting more people to read. I like fat people, many of my friends are fat. So please take it in good humor. I don’t need hate mail. I also recognize some people have genetic challenges.

The following was posted by one of my fellow CEBS (Certified Employee Benefit Specialist) colleagues. Employee Benefit Advisors has seen, time after time with my own clients, that weight loss is the number one factor to controlling health care costs.

“One of the most effective ways to ensure quality healthcare services is to not need it in the first place… All those overweight, please raise your hand. All those currently being treated for a preventable healthcare issue raise your hand.

My husband is 68 years old and was on high blood pressure, diabetes and cholesterol meds–pretty typical at this age. Oh, yes, and frequently had terrible heart burn. Lost 38 pounds and just had his annual physical. Doc took him off all his prescription meds and he no longer ever has heart burn. Go figure… How’d he do it? Cut way back on consumption of carbs/sugar. That’s it. Pretty simple. Nothing else…not even exercise. Now that he feels so good he has started to exercise on a regular basis.

Those of us paying taxes to support Medicare say, Thank you! “

Supreme Court to Hear Subsidies Case

Employee Benefit Advisors blogged Oct 9, 2013 and July 7, 2014 about court cases that had been falling under the radar. EBA said “These cases could dismantle health care reform as we know it.”

Friday, Nov 7, 2014, the Supreme Court announced that they will take up the challenges to whether subsidies should be available to consumers in federally facilitated marketplace (FFM) states. The case argument is that the statute, which states that subsidies are only to be made available in exchanges “established by states,” prohibits consumers in FFM and partnership states from being able to access subsidies, as the federal government is overseeing any non-state-based exchange.

With the basis of both the employer and individual mandates on the line, and therefore, the primary enforcement mechanisms of the healthcare reform law, this case has significant potential to destabilize healthcare reform. A ruling by the Supreme Court striking down subsidies in federal exchanges could have far-reaching effects to the entire health reform structure. If consumers are unable to purchase affordable coverage without subsidies they would not be compelled by or subject to the individual mandate to purchase coverage, and if employees are unable to obtain subsidized coverage through the marketplace then employers would not be subjected to the employer mandate, as the employer mandate is only triggered when a large employer does not offer affordable coverage and an employee receives subsidized coverage, and therefore may drop coverage altogether in states using the federal exchange.

HiRes

Humpty Dumpty sat on a wall,
Humpty Dumpty had a great fall;
All the King’s horses, and all the King’s men
Cannot put Humpty Dumpty together again.

…so apropos

 

 

 

 

 

 

Thanks to the National Association of Health Underwriters for providing the substance of the blog.

1 Month Orientation & 90 Day Waiting Periods

For plan years beginning in 2015, employers may require an employee to satisfy a one-month orientation/evaluation period in addition to a 90 day waiting period before he or she becomes eligible for benefits. The orientation period must be a reasonable and bonafide employment-based condition of eligibility in a position that is otherwise eligible for coverage and not a deliberate attempt to avoid the 90-day maximum waiting period. This period must be used for the employee and the employer to evaluate each other and to engage in orientation and training. This applies to grandfathered and non-grandfathered plans alike, as well as to self-insured and insured plans. 

The orientation period starts on the employee’s start date, and all calendar days count, including weekends and holidays.  One month is determined by adding one calendar month to the employee’s start date and subtracting one day. For example, if an employee starts working on May 3, the last permitted day of the orientation period is June 2.  Special rules apply if there is not a corresponding date in the next calendar month.

While an employee could conceivably be on the payroll for 120 days before becoming eligible for benefits, the maximum waiting period is still considered to be 90 days, because it does not begin until the day following completion of the orientation period.

Large employers should be aware that utilizing a one-month orientation period and a 90-day waiting period could cause them to be in violation of the employer play-or-pay mandate. The play-or pay mandate requires an employee to be covered by the first day of the fourth full calendar month of employment. For example, an employee who starts work on January 6 must be covered by May 1. If the employer starts coverage on May 6–one month plus 90 days after the date of hire–it would be in compliance with the 90 day requirement, but in violation of the play-or-pay mandate.

Information provided by ErisaPros.

Voting? – Average Health Premiums “Skyrocketed” After ACA

The Washington Times is reporting  that a new study of insurance policies before and after the implementation of the Affordable Care Act “shows that average premiums have skyrocketed, for some groups by as much as 78 percent.” Average premiums for the 23-year-old demographic rose “dramatically,” with men in that age group seeing a 78.2 percent price increase before government subsidies, and women seeing premiums rise 44.9 percent, according to a report by HealthPocket to be released Wednesday. The study, shared Tuesday with the Times, also found that premium increases for 30-year-olds increased 73.4 percent for men and 35.1 percent for women.

The article says that reasons for the premium increases include the ACA’s “prohibition on rejecting applicants with pre-existing conditions” and the heightened benefit mandate under the law.

Thanks to the NAHU Newswire for forwarding the information from the Washington Times.

Useful App: Medfax (Listed as One of the Best New Apps)

Need an independent, unbiased source of medical information about doctors, drugs, medical devices and hospitals?

MedFax can be used to verify doctors, prescription drugs, medical devices and hospitals. It provides reports that allow consumers to make well-informed decisions regarding their healthcare. One of the largest information sources of its kind, MedFax has combined and cross-referenced information from hundreds of sources, including state and federal agencies, the FDA, state health departments, county and federal courts and more. The result is over 1.5 million reports that present vital information right at the consumer’s fingertips.

  • Doctor Search – How well do you know your doctor? Check licensing, disciplinary record, malpractice history, etc…
  • Drug Search – Get complete information about your medications and their side effects.
  • Device Search – Complete information about the use and safety of medical devices.
  • Hospital Search – Find out how your hospital rates for patient satisfaction and safety.

Medfax brings unbiased, independent data source, Current information, continuous updates, Millions of records at your fingertips.

Section 125 Plans Allow Additional Mid-Year Changes

The IRS announced two new situations in which a participant may revoke his or her cafeteria plan election in order to purchase coverage through a marketplace (Exchange) established under the ACA.  These provisions do not apply to FSAs.  Change is permitted provided:

Employee Enrolls in Marketplace Coverage

  1. The employee is eligible for a special enrollment period during the Marketplace’s annual open enrollment period; and
  2. The employee enrolls in Marketplace coverage, effective immediately following the last day of the employer’s coverage.

Reduction in Hours of Service

  1. The employee changes from full-time status to part-time status (i.e., reasonably expected to average less than 30 hours per week), even if the reduction in hours does not result in the employee ceasing to be eligible under the group health plan; and
  2. The employee enrolls in another plan that provides MEC, effective no later than the first day of the second month following the month the original coverage is terminated.

Cafeteria plans must be amended to provide for the new permitted election changes in accordance with the guidance under Notice 2014-55.

New Preventive Care Services Schedule Now Available

Interim Final Rules related to the coverage of preventive services under the Patient Protection and Affordable Care Act (PPACA) were recently published. A complete list of required preventive services is available from the U.S. Department of Health and Human Services. The following is a partial listing of preventive services required to be covered under Health Care Reform.

For Adults
Blood pressure screening
Cholesterol screening for adults of certain ages or at higher risk
Colon cancer screening for adults over 50
Immunization vaccines (doses, recommended ages, and recommended populations vary)
Obesity and tobacco use screening
Type 2 diabetes screening for adults with high blood pressure

For Children
Autism screening for children at certain ages
Blood pressure screening
Alcohol and drug use assessment for adolescents
Developmental screening for children under age 3
Immunization vaccines from birth to age 18 (doses, recommended ages, and recommended populations vary)
Lead screening for children at risk of exposure
Obesity screening and counseling

Note:
The requirements to cover recommended preventive services without cost-sharing do not apply to grandfathered plans.
Coverage of preventive services does not disqualify High Deductible Health Plans HSA qualifying status.

COBRA – Good News for Employers trying to Manage Loss Ratios

Employee’s eligible for Cobra can opt for “Marketplace coverage” instead of COBRA.

Employees and their families eligible for, but not enrolled in, COBRA continuation insurance are able to enroll in Marketplace coverage outside of the normal open enrollment period, in most cases. It’s very possible employees eligible for COBRA continuation coverage could save on their monthly health insurance premiums by purchasing health insurance through the Marketplace. (Most employers offer a two or three plan choices with one carrier while the Marketplace makes all options, insurance carriers and plan designs, available that are offered in the Exchange.)

Updates to model notices informing employees of their eligibility to continue health-care coverage through the Consolidated Omnibus Budget Reconciliation Act are now available. The updates make it clear to workers that if they are eligible for COBRA continuation coverage when leaving a job, they may choose to instead purchase coverage through the Health Insurance Marketplace.

Employees and their families who are eligible for employer-sponsored coverage generally must be informed of their right to COBRA continuation coverage at the start of employment. They must also be informed of their right to purchase COBRA coverage when separating from a job. The proposed changes to the model notices would offer information on more affordable options available through the Marketplace, where workers and families may be eligible for financial assistance that would not otherwise be available for COBRA continuation coverage.

Fraud? – HDHP 50% Prompt-Pay Discount

Scenario: Employee has a HDHP and goes to Hospital. Hospital offer to discount the employee’s deductible by 50%. (i.e. Employee owes only half of the deductible, $3,000 debt is now $1,500.) The plan pays the full amount due above the deductible.

Has fraud been committed (knowingly or not)?

It is fraud because there’s a 3rd party involved – the insurance carrier or self-funded medical program. are providing an HDHP contract which pays “after the deductible has been met” – pursuant to the IRS rules to establish HSAs, etc. The representation is to them – that the deductible has been met – when it has not been met – a lie to gain profit (in this case the payment of the balance from their coverage). 

If a participant pays their “50%” out of their HSA / HRA account – then the insurance may end up getting a feed that illustrated the participants hadn’t met their deductible – even if the hospital is billing as if they had.  It is not uncommon for an HSA administrator to process first and pass along their EOBs to the insurance to match up with the provider bills.  In those cases, it would be a problem – because the insurance isn’t going to pay the hospital anything without knowing the full deductible had been satisfied.

The DOJ has not prosecuted this type of fraud in many years, but it seems rife for a state DOI to get involved.

Thanks to my CEBS’ colleagues. The above example and discussion came from our online link discussion.

W2 vs 1099 Worker – ACA Regulations make it Important to Get It Right

July 16th we blogged IRC 60566/6056 “will prove to be the most cumbersome and costly part of Obamacare.” We wrote: “Employers with part-time, seasonal and variable hour workers (someone working for a company with different job functions/classifications, thus hours under two different pay codes) will particularly have difficulties and will need a managed solution. This makes it more important than ever to properly class workers under either W2 or 1099.

Answer YES to the following and it indicates the worker is an Employee (W2).

  1. Does the business provide instructions to the worker about when, where and how too\ perform the work?
  2. Does the business provide training to the worker?
  3. Are the services provided by the worker integrated into the business’ operations?
  4. Must the services be rendered personally by the worker?
  5. Does the business hire, supervise and pay assistants to the worker?
  6. Is there a continuing relationship between the business and the worker?
  7. Does the business set the work hours and schedule?
  8. Does the worker devote substantially full time to the work of the business?
  9. Is the work performed on the business’ premises?
  10. Is the worker required to perform the services in an order or sequence set by the business?
  11. Is the worker required to submit oral or written reports to the business?
  12. Is the worker paid by the hour, week or month?
  13. Does the business have the right to discharge the worker at will?
  14. Can the worker terminate the relationship with the business at any they wish without incurring liability to the business?
  15. Does the business pay the traveling expenses of the worker?

If the answer is YES for the following questions, it indicates the worker is an independent contractor (1099)>

  1. Does the worker furnish significant tools, materials and equipment?
  2. Does the worker have a significant investment in the facilities?
  3. Can the worker realize a profit or loss as a result of his or her services?
  4. Does the worker provide services for more than one firm at a time?
  5. Does the worker make their services available to the general public?
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