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CMS warning Hospitals on price transparency failure

(Read EBA’s Health Care Transparency December 8, 2020 blog for background.)

Centers for Medicare & Medicaid Services has started issuing warning letters to hospitals not in compliance with the hospital price disclosure rule.

The purpose of the rule, effective Jan 1., is to make hospital pricing information readily available to patients to compare costs and make more informed healthcare decisions. Hospitals are required to post machine-readable file with the negotiated rates for all items and services and display the prices of 300 shoppable services in a consumer-friendly format.

Hospitals have 90 days to respond. If still not in compliance, it may receive a second warning letter or it may be sent a request for a corrective action plan, CMS said.

What happens if a hospital is noncompliant? CMS may request a corrective action plan, or assess a penalty of up to $300 per day, and possibly publicize the penalty on a CMS website.

 

Employee Benefit Advisors provides, employee benefits, Healthcare Consumption Audits, tax-advantaged healthcare, compliance guidance for ACA and Health & Welfare DOL Audits, and PEO Advisory & Consulting Services. We can customize a wellness plan for your budget and culture.

COBRA and The American Rescue Plan Act

The American Rescue Plan Act of 2021 (“ARPA”) includes major changes to COBRA administration in 2021.image of a cobra snake

The Act creates an opportunity for free COBRA coverage during a six-month period from April through September 2021 for employees (and their family members) who experience a loss of group health coverage due to involuntary termination or reduced hours of employment.

The following will begin effective on 4/1/2021. – Employee Benefit Advisors would like to thank Diversified Administration in Hollywood Florida for providing the outline of the ARPA.

100% subsidies for COBRA Qualified Beneficiaries where the qualifying event was an involuntary termination of employment or reduction in hours, beginning 4/1/2021 (if signed this month) through September 2021 (6 months)
• The 100% subsidy is based on a COBRA premium that includes the 2% administrative fee that health plans are permitted to charge for COBRA. The assistance eligible individual does not pay the COBRA premium, but rather the premium initially is “advanced” by the employer, plan, or insurer and then reimbursed by the government through a refundable tax credit (against Medicare hospital insurance (HI) taxes).
• The subsidy will begin for coverage periods beginning on April 1, 2021 and ending on September 30, 2021. The subsidy would end sooner if the qualified beneficiary’s maximum COBRA coverage period ends or if the individual is eligible for another group health plan or Medicare.

Anyone in the COBRA-Election-Window, extending all the way back to last March (3/1/2020), or anyone who terminated COBRA early will have a special enrollment period for 60 days from the date that they receive a new required COBRA notice to make a new election for COBRA. Their COBRA will begin 4/1 and will be free for up to 6 months
• The COBRA Participant can have a GAP in coverage from their event date through 4/1 (This is entirely new to COBRA)
• If someone’s 18 months of COBRA expires before September, they do not get extra time on COBRA, their COBRA expiration date(s) are not extended in any way.

Anyone on COBRA, in the Election-Window or terminated COBRA early who is still within their COBRA Maximum Coverage Period (usually 18 months) can change plans (to a lower plan) 4/1/2021 in the special enrollment window.
• This is Optional and an employer can choose whether or not to offer this option to COBRA Qualified Beneficiaries.

Employers will have to review and audit all terminated employees back to March 1 of last year and determine if any former employees’ terminations were voluntary or involuntary.
• We have this reporting ability already, so some employers are already sending this info. However, many employers use the generic “Termination of Employment” option, all those will need to be reviewed by HR
• If your company uses file feeds, those must be updated accordingly to send the specifics on each termination of employment event.
• If your company uses our online COBRA event tools, the options to select Voluntary/Involuntary Terminations has always been an option, we will remove the option to submit Termination of Employment from the web-portals before 3/31/2021.

Employers are required to send notices to everyone terminated since last March
• The Act tasks the Department of Labor (DOL) and Internal Revenue Service (IRS) with issuing regulations and guidance regarding the application and administration of the COBRA subsidy provisions of the Act.
• In addition, the Act requires the DOL to produce model COBRA election notices within 30 days of enactment and a model COBRA premium subsidy expiration notice within 45 days of enactment.
• Employers will have to wait for these model notices to send, to ensure compliant notices are sent.
• Diversified Administration (my go to COBRA Administrator) will handle the generation and distribution of the notices for all COBRA clients once model notices are released.

Employers also have a second notice requirement at the end of the person’s subsidy period, to advise them of such.
• Diversified Administration will handle the generation and distribution of the notices for all COBRA clients.

Employers will have to pay up front for COBRA participants coverages and then get the money back through payroll tax credits/refunds
• Premium initially is “advanced” by the employer, plan, or insurer and then reimbursed by the government through a refundable tax credit (against Medicare hospital insurance (HI) taxes).
• For self-insured plans, the COBRA premium is covered by the employer and reimbursed through a payroll tax credit.
• For fully insured plans, the tax credit is claimable by the insurer and/or employer.
• This mechanism as described in the legislation is complex, and we’re awaiting the DOL/IRS guidance on the specifics of the credits.

Employee Benefit Advisors provides employee benefits, tax-advantaged healthcare, compliance guidance for ACA and Health & Welfare DOL Audits, and PEO Advisory & Consulting Services. We can customize a wellness plan for your budget and culture.

No More Surprises

Shock by your hospital bill?The No Surprises Act, a ban on surprise medical bills, will take effect beginning in 2022.

Surprise Medical Bills

Surprise medical bills occur when patients unexpectedly receive care from out-of-network health care providers. – A patient goes to an in-network hospital for surgery or emergency care, and an out-of-network doctor is involved in the patient’s care. Patients are not able to determine the network status of providers, such as emergency room doctors or anesthesiologists. The patient is simply not involved in the choice of provider.

No Surprises Act

The Act applies to surprise bills from doctors, hospitals, and air ambulances. It prohibits these providers from billing patients who have health coverage for unpaid balances. Providers will have to work with the health insurance issuer carrier to determine the appropriate amount to be paid by the plan.

(The No Surprise Act was included in the stimulus bill signed by President Trump on Dec 27, 2020.)

EBA will continue to keep you updated as information becomes available on the details of the law.

Employee Benefit Advisors provides employee benefits, tax-advantaged healthcare, compliance guidance for ACA and Health & Welfare DOL Audits, and PEO Advisory & Consulting Services. We can customize a wellness plan for your budget and culture.

Can employers require employees to have the COVID-19 vaccine before returning to work?

Yes, employers can require mandatory vaccinations, as a matter of prior health crises and common law. There will be some industries where it is going to be a mandate, like healthcare.

There are however possible exceptions; medical conditions, bona fide religious objection.

Two important questions.

  1. How can employers enforce this rule?
  2. What are alternatives to an employer mandate to get employees on board?

EBA has the answers to these questions and more.

Employers will need to have an administration process in place including privacy issues will play. Where can employers turn for guidance to formulating and implementing a plan? Contact Employee Benefit Advisors, we work with top HR Consultants like Ivelices Thomas, HR & Beyond.

 

Employee Benefit Advisors provides employee benefits, tax-advantaged healthcare, compliance guidance for ACA and Health & Welfare DOL Audits, and PEO Advisory & Consulting Services. We can customize a wellness plan for your budget and culture.

IRS Guidelines – Indexed for 2021

FICA
Social Security Tax is 6.2% on income up to $142,800
Medicare Tax unlimited 1.45% to Unlimited

High Deductible Health Plans
Minimum Annual Deductible (Individual/Family) $1,400 / $2,800
Maximum Out-of-Pocket Limit (Individual/Family) $7,000 / $14,000

Health Savings Accounts
Individual / Family $3,600 / $7,200
Catch-up Contribution $1,000

ACA Plan Limits
Out-of-Pocket Limits Individual / Family $8,550 / $17,100

Flexible Spending Accounts
Health Care Flexible Spending Account Maximums $2,750 Maximum carryover $550
Dependent Care Spending Account Maximum $5,000
The dependent care FSA maximum is set by statute and is not subject to inflation-related adjustments.

Mileage & Transportation 
Standard Mileage Rates
56 cents per mile for business miles driven
16 cents per mile for medical or moving purposes
14 cents per mile driven in service of charitable organizations

Parking (monthly) $270
Mass Transit Passes (monthly) $270

Compensation
Compensation Limit $290,000
Highly Compensated Employee Salary Amount $130,000
Annual Compensation for Key Employee $185,000
Defined Benefit Plan Limit $230,000
Defined Contribution Plan Limit $58,000

Retirement Plans
401(k) $19,500
401(k) Catch-up $6,500
403(b) $19,500
457(b)(2) and 124(c)(1) $19,500
457(b) Catch-up $6,500

IRA Limit $6,000/$7,000 for age 50+
Simple IRA Limit $13,500/$3,000 Catch-Up

 

Employee Benefit Advisors provides employee benefits, tax-advantaged healthcare, compliance guidance for ACA and Health & Welfare DOL Audits, and PEO Advisory & Consulting Services.

Health Care Transparency

New transparency requirements on group health plans and health insurers in the individual and group markets were issued by the Departments of Labor (DOL), Health and Human Services (HHS) and the Treasury (Departments).

The final rule requires plans and issuers to disclose:

  • Price and cost-sharing information for a list of 500 services must be available via the internet for plan years beginning Jan. 1, 2023. All items and services are required to be available for plan years beginning Jan. 1, 2024.
  • In-network provider-negotiated rates and historical out-of-network allowed amounts on their website for plan years beginning Jan. 1, 2022.

The final rule also allows insurers that share savings with consumers—resulting from consumers shopping for lower-cost, higher-value services—to take credit for those “shared savings” payments in their medical loss ratio calculations.

 

Employee Benefit Advisors provides employee benefits, tax-advantaged healthcare, compliance guidance for ACA and Health & Welfare DOL Audits, and PEO Advisory & Consulting Services. We can customize a wellness plan for your budget and culture.

Lifestyle Choices – Creating a Wellness Culture

BenefitsPro ran an article saying… Changing lifestyle choices could cut $730B in annual health care spending and that more than a quarter of all health care spending is due to conditions such as smoking, diabetes and poor diet.

“Nearly three-quarters of a trillion dollars in health care spending can be linked to modifiable health risks, such as obesity, high blood pressure, and smoking…”

There are three key strategies that would prove to be very effective towards changing lifestyle choices.

(1) Preventative – Individuals have a responsibility to be examined at least periodically (every two years, yearly as we get older – I will let the AMA set the standard) and get their immunizations. Those that do receive a premium credit.

(2) Wellness / Biometrics – Smokers should be charged more (no need to argue why, everyone should be aware of the added health risks and costs). Premium credits for those actively managing and meeting standards for blood pressure, BMI, cholesterol, and blood sugar level. People with obesity appear to have triple the risk of hospitalization with COVID-19, compared to people without obesity, the CDC reports. Being severely obese may increase the risk by 4.5 times. – All these biometrics are key indicators of health. Control these factors and receive a premium credit, those that do not should pay more. They are costing everyone else.

(3) Genetics & DNA – Technology is a great tool. Let us use it to help predetermine the medical conditions which we are predisposed. Not to punish people with higher costs, but to be proactive. A lifestyle change at an early age could help prevent certain illnesses. Information can be kept confidential with case managers and not shared or used with underwriting. – i.e. If you knew you had a family history of cancer, breast or colon, you could be proactive and monitor the signs. Same principle for other genetic diseases.

An important part of any health care discussions is preexisting conditions.  No one should be denied coverage due to preexisting conditions. However, no one should be allowed to burden the system who carries no insurance, goes to the doctor, learns they need medical care and now applies for insurance. They should be required to apply for insurance, bear a heavy portion of the medical expenses for a year or two (contracted rate), and have the carrier assign a case manager.

How do we pay for preexisting conditions? – Every transaction, buying aspirin, medical procedures, hospital stays – anything medical related – should be charged a ‘PreX’ fee of 1 penny (maybe 2 depending on the accounting). The money would go towards funding preexisting conditions, nothing else. If it raises more than is needed the surplus can be used for cancer or other medical research.

 

 

Employee Benefit Advisors provides employee benefits, tax-advantaged healthcare, compliance guidance for ACA and Health & Welfare DOL Audits, and PEO Advisory & Consulting Services. We can customize a wellness plan for your budget and culture.

What is Creditable Medicare Part D Coverage?

Medicare Part D notices are due before October 15,2020. But what does that mean and how do you know if your coverage is creditable?

If you have any type of group health plan the notice is sent to advise plan participants as to whether their prescription drug coverage is “creditable.”

What is Medicare D Creditable Coverage? – The Medicare Modernization Act made it a requirement that entities that offered plans which included prescription drug coverage had to disclose to all Medicare-eligible individuals whether that prescription drug coverage was “creditable.”

Defining Creditable – For the purposes of this requirement, “creditable” means that the coverage is expected to pay as much as the standard Medicare prescription drug coverage. Among the 2020 parameters for what is considered “standard” under Medicare D are:

  • Deductible: $435.00
  • Initial coverage limit: $4,020
  • Out-of-pocket threshold: $6,350

Determination of Creditable Coverage
The prescription drug plan is deemed to be creditable if it:

  • Provides coverage for brand and generic prescriptions
  • Provides reasonable access to retail providers and mail order coverage
  • Is designed to pay on average at least 60% of participants’ prescription drug expenses

The plan must also satisfy one of the following criteria:

  1. The prescription drug coverage has no annual benefit maximum benefit or a maximum annual benefit payable by the plan of at least $25,000
  2. The prescription drug coverage has an actuarial expectation that the amount payable by the plan will be at least $2,000 annually per Medicare-eligible individual
  3. For entities that have integrated health coverage, the integrated health plan has no more than a $250 deductible per year, has no annual benefit maximum, or a maximum annual benefit payable by the plan of at least $25,000 and has no less than a $1,000,000 lifetime combined benefit maximum.

Notification
The creditable or non-creditable coverage notice must be provided to Medicare Part D eligible individuals who are covered or who apply for the plan’s prescription drug coverage. This includes active, retired, disabled, and COBRA beneficiaries and dependents. The notice must be furnished no later than October 14. The Part D Annual Election Period runs from October 15 through December 7 of 2020.

It is often difficult to determine which participants are Medicare D eligible, so the prudent solution is to send the notification to ALL plan participants prior to October 14. Click here for a guide that  provides a calculator methodology for determining creditable coverage.

There is also a necessary notification requirement for entities to complete the Online Disclosure to CMS Form to report the creditable coverage status of their prescription drug plan. The disclosure should be completed annually no later than 60 days from the beginning of a plan year, within 30 days after the termination of a prescription drug plan, or within 30 days after any change in creditable coverage status.

Penalties
While there are no formal penalties attached to non-conformance of the requirement, the Medicare-eligible individual may incur a late enrollment penalty if notification as to non-creditable coverage exists and that individual then attempts to enroll in a Medicare Part D plan.

 

Employee Benefit Advisors provides employee benefits, tax-advantaged healthcare, compliance guidance for ACA and Health & Welfare DOL Audits, and PEO Advisory & Consulting Services.

Let the dogs out!

Surprise medical bill? – Surprise medical billing applies to fully-insured commercial insurance plans.   No federal laws exist to prevent surprise medical bills and of the states that do less than half provide comprehensive legislation.   Employees are confused when they receive a surprise medical bill and it generally reflects poorly on the company plan when it occurs.

Bill Dog was made for the moment a confusing medical bill arrives. Members can be confident before paying any medical bill. Bill Dog researches and explains every situation to our members.

  • What is the bill for?
  • What are the codes?
  • Are the charges too high?
  • I have insurance, why do I have this bill?
  • I am confused.

Bill Dog works directly with members, providers, and insurance companies to resolve issues, support appeals, and assist with price negotiations. Bill Dog provides an easy way to verify any medical bill so it can be negotiated and paid with confidence. It is easy to use. You can reach them by phone, chat, email or direct message. Codes and charges are verified. Billing errors are identified and corrected. Appeals and price negotiations are supported. It is results driven. Errors are identified and corrected — claims denials and out of network charges are verified.

 

Employee Benefit Advisors provides employee benefits, tax-advantaged healthcare, compliance guidance for ACA and Health & Welfare DOL Audits, and PEO Advisory & Consulting Services.

COVID-19 Disability Claims

Several clients have asked questions related to COVID-19 and their group disability insurance. Here’s a compilation of how carriers are administering claims.

Question: Is someone automatically disabled if he/she is placed under a quarantine related to the Coronavirus?

Answer: No. Standard policy language requires that an insured be disabled from his/her own occupation. Therefore, an insured is not automatically considered disabled if under a quarantine for any reason. However, some policies may contain quarantine provisions. It is important that you check your policy or (if self-insured) plan document, as this will dictate how claims are administered.

Question: Will a disability claim for an insured who is under a quarantine related to the Coronavirus be approved?

Answer: Possibly. Every claim is reviewed based on the disability policy language and the unique facts of the insured’s situation, including factors such as the diagnosis and medical certification; the progress of the virus/condition; the specific quarantine that the insured is subject to; and the insured’s ability to work remotely, among others.

Claims submitted listing a diagnosis of Coronavirus will be processed in compliance with all applicable contract provisions. In general, to be eligible to receive benefits, an insured must provide proof that he/she is:

  • Under the care of a Health Care Provider who is certifying the insured’s disability; AND
  • Unable to perform his/her occupation in the workplace or at home via remote access.

If the employee is symptomatic, then he/she may have a qualifying condition under FMLA (or even the ADA) which would require him/her to take leave. An important consideration is that the employee must be quarantined and not able to return to work. To the extent the quarantine is optional and the employee is symptomatic, the employee may also qualify for FMLA.

Situations involving furloughs or layoffs may be more complex. This may include eligibility for coverage for those who were actively at work prior to a furlough or layoff on a prior carrier’s policy. How will pre-existing conditions be administered? What about employees whose hours are reduced below the minimum hours required in the policy definition for eligibility? – There are many scenarios that may need to be reviewed by a broker with in-depth knowledge of contract language and claims experience.

 

Employee Benefit Advisors provides employee benefits, tax-advantaged healthcare, compliance guidance for ACA and Health & Welfare DOL Audits, and PEO Advisory & Consulting Services.

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