Archive for Health Care Reform & You

31 million will still be uninsured

// September 9th, 2013 // Comments Off on 31 million will still be uninsured // Health Care Reform & You

After 2700 pages of legislation that no one read, and over 19,000 pages of regulations, todays Washington Post article points out the glaring reality that it didnt fix anything of the 41 million that were supposed to get insurance, 31 million will still be uninsured.  Call you Congressmen/women, to delay the full implementation. Surely they can work on some amendments to make this law less cumbersome, less laden with fees and taxes, more accessible to everyone.  Costs for insurance in the majority of the states will increase.  The only saving grace will be the premium tax credits given to thos folks who fal within 100-400 percent of the Federal Poverty level.


We can do better.  Reach out before it is too late.


ACA Projected To Leave 31 Million Americans Without Coverage.

On its front page the Washington Post Share to FacebookShare to Twitter (9/9, A1, Kliff, Sun) profiles a handful of those who will be “left behind” when the Affordable Care Act goes into effect, and the free clinics from which they must continue to seek care. The piece estimates that despite the law’s coverage expansion, 31 million people will still be without insurance by 2023.

Individual Mandate Penalties

// July 1st, 2013 // Comments Off on Individual Mandate Penalties // Health Care Reform & You

The individual mandate starts October 1, 2013 when the Healthcare Marketplace is scheduled to be opened. Individual Mandate if you do not enroll and get insurance before 3/31/2014 you will be penzlised $95 or 1% of your income up to the threshold set by the Federal Government.

Confused, contact us for assistance/

Draft Applications for Subsidies under Healthcare Reform

// April 30th, 2013 // Comments Off on Draft Applications for Subsidies under Healthcare Reform // Health Care Reform & You

After much criticism, the applications for individual and family pre-certification for government subsidies have been modified and shortened.  These forms will verify you and your family’s eligibility for a subsidy when the Insurance Exchanges are up and running.  The exchanges are targeted to be ready in October 2013 with insurance plans being effective January 1. 2014.

These forms will verify your citizenship, employment and income status by sending the form to the various government agencies.

If you have any questions, please feel free to contact us.

Individual Healthcare Pre-app

Exchange Pre-app Family

Seven Important Facts about Insurance Exchanges for Employers

// April 15th, 2013 // Comments Off on Seven Important Facts about Insurance Exchanges for Employers // Health Care Reform & You

The following article is being reprinted from the Aflac website.  It gives a succinct look at seven important facts that will impact employers with the release of the upcoming insurance exchanges.

Exchange Facts

For more information, please contact us at:



Updates to Womens Healthcare

// May 21st, 2012 // Comments Off on Updates to Womens Healthcare // Health Care Reform & You

As of August 1, 2012, the following women’s health services are considered preventive and therefore, generally covered at no cost share, when provided in-network.

These benefits apply to new business effective August 1, 2012..
Women’s preventive health benefits
• Well-woman visits (annual routine physical, annual routine GYN exam and prenatal visits)
• Screening for gestational diabetes
• Human Papillomavirus (HPV) DNA testing
• Counseling for sexually transmitted infections
• Counseling and screening for human immunodeficiency virus (HIV)
• Screening and counseling for interpersonal and domestic violence
• Breastfeeding support, supplies and counseling
• Contraceptive methods and counseling
The federal health care reform legislation, known as the Patient Protection and Affordable Care Act (PPACA), was signed into law on March 23, 2010.

Some of the PPACA provisions will impact health care this year but many other provisions will not take effect until 2014 and beyond.

For more information, you may visit or contact us for further information.

Update on Grandfather Provisions under Healthcare Reform

// January 1st, 2011 // 2 Comments » // Health Care Reform & You

As a byproduct of The Patient Protection and Affordable Care Act (PPACA), one of the chief issues has been the “Grandfather” regulations that were originally issued in June and updated in mid-November by the federal government. On November 17, an amendment to the original “Grandfather Regulations” was released concerning how employers can maintain grandfathered health plan status. Here is a recap of both regulations in a “question” and “answer” (QA) format.What is a grandfathered plan?

“Grandfathered health plan coverage means the coverage provided by a group health plan, or a health insurance insurer, in which an individual was enrolled on March 23, 2010” and “as long as (the plan) maintains the status under the rules.”1 It allows a plan to keep most of the design elements and benefit structures that were in place prior to PPACA’s enactment. Some exceptions apply as discussed below. 

What is the intent behind the grandfather regulations?

Federal regulators note that PPACA “balances the objective of preserving the ability of individuals to maintain their existing coverage with the goals of ensuring access to affordable essential coverage and improving the quality of coverage.”2 Federal regulators elaborate further, “Decisions about the value of retaining or relinquishing status as a grandfathered health plan are complex, and the wide array of factors affecting insurers, plan sponsors, and enrollees poses difficult challenges…”3

How does a health plan become grandfathered?

Plan sponsors must decide if they wish to continue to offer the plan or coverage they had in effect on March 23, 2010 with only limited changes as described in this update. They also must meet various requirements to maintain grandfathered status pursuant to the federal regulations. In addition, the plan sponsor must provide its covered members with notice of grandfathered status and maintain key plan documents to verify that status.

What are grandfathered plans NOT exempt from?

A plan that maintains grandfather status is still required to comply with a number of the federal regulatory provisions that were issued on June 17 and updated in November. As of September 23, 2010, grandfathered plans must:

  • Prohibit pre-existing condition exclusions for individuals under age 19 (and all individuals for plan years beginning on or after January 1, 2014)
  • Prohibit lifetime limits on essential health benefits
  • Restrict annual limits before plan years beginning on or after January 1, 2014, and prohibit all annual limits for plan years beginning on or after
    January 1, 2014
  • Prohibit rescissions other than for fraud or intentional misrepresentation of material fact
  • Extend dependent child coverage to age 26, unless the dependent has other eligible employer-sponsored health coverage available
  • Provide uniform explanation of coverage documents.

What are grandfathered plans EXEMPT from?

A plan that maintains grandfather status is exempt from several provisions of the health care reform legislation. Grandfathered plans do not have to:

  • Eliminate cost-sharing for certain preventive services 
  • Prohibit discrimination based on salary for coverage or premiums
  • Provide choice/direct access requirements allowing members to designate any participating primary care physician or pediatrician they choose
  • Eliminate certain prior authorization or additional cost-sharing requirements that were reduced or eliminated under PPACA including a prohibition against pre-authorization requirements for OB/GYN and emergency services
  • Implement the new internal appeals/external reviews process in place for coverage determinations and claims decisions
  • Comply with certain HHS reporting requirements.

What changes CAN grandfathered plans make?

Grandfathered plans are still able to make routine changes while maintaining continued grandfather status. Some of the routine changes include the ability to:

  • Raise premiums to reasonably keep pace with health care costs provided the change does not cause the plan to exceed other applicable limits
  • Increase deductibles and other out-of-pocket costs “within limits”
  • Continue to enroll new employees and new family members, subject to an anti-abuse rule
  • Make changes to comply with new federal and state regulations provided such changes do not cause the plan to exceed applicable limits
  • Increase benefits or voluntarily comply with provisions of PPACA, provided such change does not cause the plan to exceed applicable limits
  • Make changes to a plan’s provider network and prescription drug formulary
  • Make changes to accommodate mergers and acquisitions
  • Changing a third-party administrator or a broker/agent/navigator.

Note:  Many of these examples are not part of the official regulations, so additional regulatory guidance may be required. 

Can plans switch insurance companies and maintain grandfather status?

The November 17 amendment “allows all group health plans to switch insurance companies and shop for the same coverage at a lower cost while maintaining their grandfathered status, so long as the structure of the coverage doesn’t violate one of the other rules for maintaining grandfathered plan status.”4 

The HHS website states further:

“The purpose of the grandfather regulation is to help people keep existing health plans that are working for them. This amendment furthers that goal by allowing employers to offer the same level of coverage through a new issuer and remain grandfathered, as long as the change in issuer does not result in significant cost increases, a reduction in benefits, or other changes described in the original grandfather rule.”

HHS notes that “the original regulation only allowed self-funded plans to change third-party administrators without necessarily losing their grandfathered plan status.” The revised regulation impacts “insured group health plans” but not the “individual market.” HHS elaborates that “(u)nder this amendment, all employers have the flexibility to keep their grandfathered plan but change insurance company or third-party administrator.” The regulation was motivated in part to allow employers to shop for better-priced insurance.

Can plans offer incentives for wellness programs?

Group health plans may continue to provide incentives for wellness programs by providing premium discounts or additional benefits to encourage healthy behaviors by rewarding high-quality providers and incorporating evidence-based treatments into benefit plans as permitted under other applicable laws. However, penalties such as cost-sharing surcharges may violate the limits applicable to grandfathered plans, and should be carefully considered prior to implementation.

What notifications must grandfathered plans provide to your clients?

To maintain grandfathered status, a plan must include a statement in any plan materials provided to beneficiaries describing the benefits provided under the plan.  The statement must indicate that the plan believes it is a grandfathered health plan within the meaning of PPACA and provide contact information for clients to ask questions or make comments. Although the grandfather regulation does not state when this notice must be provided, issuers are presuming that it must be provided in plan materials upon renewal for plan years beginning on or after
September 23, 2010. A grandfathered plan also must maintain records documenting the terms of the plan or coverage in effect on March 23, 2010, and any other documents necessary to verify, explain or clarify its status as a grandfathered plan.5 

What changes cause loss of grandfather status?

Compared to the coverage in effect on March 23, 2010, grandfathered plans cannot:

  • Eliminate all or substantially all benefits to diagnosis or treat a particular condition
  • Increase the cost-sharing requirement (such as co-insurance) 
  • Substantially increase deductibles or out-of-pocket limits (i.e.; more than the sum of medical inflation plus 15 points)
  • Decrease its contribution by more than five percentage points below the average contribution rate by the employer who sponsors the plan.6   
  • Impose a lifetime limit on the dollar value of the benefits for the first time.7

Can employers offering coverage with multiple plan designs change one and stay grandfathered?

If an employer offers several plan options or benefit packages and only makes changes to one or a subset of the offerings, the packages that have not been amended (or are amended within limits allowed under the grandfather regulations) can retain their grandfathered status. The grandfathering determination is made separately with respect to each plan offering or benefit package available under group health plan or health coverage or to each plan.8

Can employers offering coverage eliminate one of several plans and stay grandfathered?

An employer could lose grandfathered status by eliminating one of several plan offerings or benefit packages. Although employees may voluntarily switch plans or benefit packages as permitted, an anti-abuse rule under the grandfather regulation applies to situations where an employer eliminates a plan option or benefit package.

Under the anti-abuse rule, the remaining plan offering/benefit package will lose grandfather status if:

  • Employees are transferred into the remaining plan offering/benefit package; and

 more information becomes available, BenefitMall is committed to keeping you
up-to-date in a timely manner. Visit to view past Legislative Alerts in the “Newsroom” section. Or, you may visit for blog posts, polls, surveys and numerous resources. If you have any questions, please contact your local BenefitMall Sales Team and they will be happy to assist you. Thank you for taking the time to read through this important notification.

1 Federal Register vol. 75, no. 116, June 17, 2010, pg. 34562.

2 Idbid. pg. 34540.

3 Idbid. pg. 34549. 

4 The updated announcement is posted at the U.S. Department of Health and Human Services website at See also Federal Register vol. 75, no. 221, Nov. 17, 2010, pgs. 70114-70122.

5 Idbid. pg. 34554.

6 As noted in the regulations:  “if the contribution rate is based on the cost of coverage, a group health plan or group health insurance coverage ceases to be a grandfathered health plan if the employer or employee organization decreases its contribution rate towards the cost of any tier of coverage for any class of similarly situated individuals by more than 5 percentage points below the contribution rate on March 23, 2010” Idbid.  34543.

7 Idbid. pgs. 34547 & 34560.

8 Idbid. pgs. 34541 and 34558.

9 Idbid. pgs. 34558-34559.

10 Idbid. pg. 34559.







Top Trends in Voluntary Benefits for 2009

// November 9th, 2010 // Comments Off on Top Trends in Voluntary Benefits for 2009 // General Benefits Information, Health Care Reform & You, Trends in Disability Insurance

In addition to the legislative efforts currently taking place in Washington D.C. to nationalize the health care industry. The industry itself has shifted in several different ways in the past several years.

  • Health care costs are continuing to increase forcing more cost shifting to the employees
  • Benefits managers are moving more towards allowing the employees to be decision makers rather than acting as a parental unit
  • Employers are looking for technology to assist with enrollment and benefits management
  • More and more employers are moving to voluntary benefits as a supplement.

Voluntary benefits complement an employers core benefits program by offering employees choices to help fill coverage gaps in major medical, disability or life insurance.

An employer may be able to reduce major medical premiums by increasing the deductible and adding a voluntary supplemental health prgram like Aflac that helps employees cover the higher out of pocket costs. As a voluntary supplemental plan, the employee who feels they need additional coverage, or who want to fill in some of the gaps can elect additional coverage and those that are secure in their base medical plan can opt out. The plans offer the employees a way to manage major medical costs and to fill gaps if necessary.

Selling voluntary benefits to the employer and employee requires a consultative approach where the broker understands the major medical benefits being offered, the gaps that may exist, the make up of the employee base. Voluntary benefits are best sold in a one on one environment where a broker can work with each individual to custom fit a program to fit not only their pocketbook but correctly assess the gaps in coverage.

Voluntary benefits fit with high deductible plans, with Health Savings accounts and can even supplement the Flexible Spending Accounts.

Voluntary benefits are typically sold to employees on a pre-tax basis thus saving both the employee and employer some Federal and FICA tax monies.

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