Update – Medicare Advantage – No No

Medicare Advantage (MA) has received mixed reviews after 25 years of implementation. While it may benefit employers, unions, and states with retiree obligations, it has raised concerns for seniors, doctors, and the government. Seniors may receive worse care under MA compared to traditional Medicare, doctors face cumbersome prior authorizations, and the federal government spends more on MA per capita than traditional Medicare. Additionally, several major insurance companies offering MA plans are involved in lawsuits.

Medicare Advantage began life as a brilliant idea: a public-private partnership to keep older people healthier and reduce costs.

At the time in 1992, both President George H.W. Bush and his challenger, Bill Clinton, supported it. An editorial in The New York Times declared, “The debate over health care reform is over. Managed competition has won.” What finally emerged in 1997 — Medicare Choice, now known as Medicare Advantage — was hailed as a win-win-win for patients, providers, and payers.

Twenty-five years later, a different consensus is clear: Medicare Advantage (MA) is a failure for seniors, who receive worse care than they do under traditional Medicare; for doctors, who must negotiate costly and dangerous prior authorizations for their patients; and for the federal government, which spends more per capita on MA than on traditional Medicare. Further, eight of the ten largest insurance companies offering Medicare Advantage plans are currently defendants in False Claims Act lawsuits brought by whistleblowers or the Department of Justice.

But it’s been a winner for employers, unions, and states that have pension and health care obligations to their retirees. They push hard to get people off traditional Medicare and onto MA plans. That’s because retiree benefits often include supplemental or Medigap policies that former employers pay for, while Medicare Advantage plans are almost entirely paid for by the federal government. Medicare Advantage plans are also winners for the private insurance companies that offer and administer them. Their gross margins are typically two to three times greater than other insurance plans.


Evidence of Coverage (EOC) | Medicare

What is it?

If you’re in a Medicare Plan, your plan will send you an “Evidence of Coverage” (EOC) each year, usually in the fall. The EOC gives you details about what the plan covers, how much you pay, and more.

When should I get it?


Who sends it?

Your plan

What should I do if I get this notice?

  • Review any changes to decide whether the plan will continue to meet your needs in the next year. 
  • If you don’t get this important document, contact your plan.

Benefits Provided by Medicare Advantage

Medicare Advantage, also known as Part C, is offered by private insurance companies. It was introduced in the 1980s to provide competition and choice. Seniors may find that these private plans offer convenience, a wider range of benefits, and lower out-of-pocket costs than Original Medicare. More than 3,100 Medicare Advantage plans are available nationwide as of 2020, with the average beneficiary being able to choose from 28 different plans.

  • You are always responsible for copayments and coinsurances, and sometimes even for deductibles. Therefore, the cost could be quite high. There is an out-of-pocket limit – $8,300/year.
  • Your choice of doctors/hospitals is limited by the provider network within a specific geographic area. Members are required to pay an increased cost, sometimes up to the full price, for services outside the provider network.
  • Medicare providers may not always accept Medicare Advantage plans so your choices may be limited. Some doctors and hospitals do not participate in any Medicare Advantage plans and others only in a selected few.
  • Many plans require referrals for specialists and other services.
  • Medicare Advantage plans may change every year. Such changes may affect your premium, deductibles, copayments/coinsurances, and the scope of extra services.

Affordable Care Act’s Glitch

A new KFF analysis estimates 5.1 million people nationally fall into the Affordable Care Act’s “family glitch” that occurs when a worker receives an offer of affordable employer coverage for themselves but not for their dependents, making them ineligible for financial assistance for marketplace coverage.

The so-called glitch occurs because the ACA prohibits people with an offer of affordable employer coverage from purchasing subsidized coverage through the ACA marketplace. Under current rules, the affordability of employer coverage is based on what it would cost just to cover the worker and not their families.

Worker-only coverage with an out-of-pocket premium up to 9.83% of the worker’s household income is considered affordable, even if the additional cost of covering their dependents would push them above that threshold. President Biden hinted about a potential administrative fix to address the glitch in a recent executive order.

The analysis provides a demographic profile of those currently affected by the glitch:

• The vast majority (85%) are currently enrolled in employer-sponsored coverage and likely spending far more for their health insurance than people with similar incomes with subsidized coverage through the marketplace. Nearly a half million are uninsured.

• Most (54%) are children, and, among adults, most (59%) are women. • Texas (671,000), California (593,000), Florida (269,000), and Georgia (206,000) have the largest number of people affected by the glitch.

Understanding #Medicare Parts A, B, C & D

Do you really need to know the details of what Parts A, B, C, and D stand for? Doesn’t Medicare just pay its share of your bills and that’s it? Well, not entirely. Medicare’s architecture is more than a tad weird, but each of its building blocks determines the coverage you get and what you pay.

Besides that, however, is the simple fact that making sense of Medicare is difficult unless you understand what Parts A, B, C, and D actually mean.

Part A

Medicare Part A is usually described as hospital insurance — a term originally coined to distinguish it from medical insurance (Part B). But the phrase is misleading. “Hospital insurance” sounds as though Part A covers your entire bill if you’re admitted to a hospital, but it doesn’t work that way. The services you receive from doctors, surgeons, or anesthetists while you’re in the hospital are billed separately and are covered under Part B. And you don’t even have to be hospitalized to get services under Part A, because some are provided in settings outside the hospital or even in your own home.

A more accurate way to think of Part A is as coverage primarily for nursing care. It helps pay for the following:

  • The services of professional nurses when you’re admitted to a hospital or a skilled nursing facility (such as a nursing home or rehab center) for short-term stays or when you qualify for home health services or hospice care in your own home
  • A semiprivate room in the hospital or nursing facility
  • All meals provided directly by the hospital or nursing facility
  • Other services provided directly by the hospital or nursing facility, including lab tests, prescription drugs, medical appliances and supplies, and rehabilitation therapy
  • All services provided by a home health agency if you qualify for continuing care at home
  • All services provided by a hospice program if you choose to stop treatment for a terminal illness

The vast majority of people in Medicare are eligible for Part A services without paying any premiums for it. That’s because Part A is essentially paid for in advance by the Medicare payroll taxes that you or your spouse contributed from every paycheck while working.

But, of course, Part A services themselves aren’t free. You still pay deductibles and co-payments for specific services.

Part B

Many people in Medicare never need to go into the hospital, but almost everybody sees a doctor or needs diagnostic screenings and lab tests sooner or later. That’s where Part B — known as medical insurance — comes in. The wide range of services it covers includes the following:

  • Approved medical and surgical services from any doctor who accepts Medicare patients, whether those services are provided in a doctor’s office, in a hospital, in a long-term-care facility, or at home
  • Diagnostic and lab tests done outside hospitals and nursing facilities
  • Preventive services such as flu shots, mammograms, screenings for depression and diabetes, and so on, many of which are free
  • Some medical equipment and supplies (for example, wheelchairs, walkers, oxygen, diabetic supplies, and units of blood)
  • Some outpatient hospital treatment received in an emergency room, clinic, or ambulatory surgical unit
  • Some inpatient care in cases where patients are placed under observation in the hospital instead of being formally admitted
  • Inpatient prescription drugs given in a hospital or doctor’s office, usually by injection (such as chemotherapy drugs for cancer)
  • Some coverage for physical, occupational, and speech therapies
  • Outpatient mental health care
  • Second opinions for non-emergency surgery in some circumstances
  • Approved home health services not covered by Part A
  • Ambulance or air rescue service in circumstances where any other kind of transportation would endanger the patient’s health
  • Free counseling to help curb obesity, smoking, or alcohol abuse

You must pay a monthly premium to receive Part B services unless your income is low enough to qualify you for assistance from your state. Most people pay the standard Part B premium, which is determined each year by a formula set by law ($144.60 in 2020). If your income is over a certain level, however, you’re required to pay more.

You also pay a share of the cost of most Part B services. In traditional Medicare, this amount is almost always 20 percent of the Medicare-approved cost. Medicare Advantage health plans charge different amounts — usually flat dollar co-pays for each service.

Part C

The coverage provided by Part A and Part B together form what is known as traditional or original Medicare — so named because that was the extent of the program’s coverage when it began back in 1966. It’s also called fee-for-service Medicare because each provider — whether it’s a doctor, hospital, laboratory, medical equipment supplier, or whatever — is paid a fee for each service.

But these days Medicare also offers an alternative to the traditional program: a range of health plans that mainly provide managed care through health maintenance organizations (HMOs) or preferred provider organizations (PPOs). These plans are run by private insurance companies, which decide each year whether to stay in the program. Medicare pays each plan a fixed fee for everyone who joins that plan, regardless of how much or little health care a person actually uses. This health plan program is called Medicare Advantage or Medicare Part C.

Medicare Advantage plans must, by law, cover exactly the same services under Part A and Part B as traditional Medicare does. (So, if you need a knee replacement, for example, the procedure is covered — regardless of whether you’re enrolled in a Medicare Advantage plan or in the traditional program.) But the plans may also offer extra benefits that traditional Medicare doesn’t cover — such as routine vision, hearing, and dental care. Most plans include Part D prescription drug coverage as part of their benefits package.

Still, being enrolled in one of these plans is a very different experience from using the traditional Medicare program. Your out-of-pocket costs are different, and so are your choices of doctors and other providers.

Part D

Part D is insurance for outpatient prescription drugs — meaning medications you take yourself instead of having them administered in a hospital or doctor’s office. Medicare’s drug benefit was only added to the program in 2006, a full 40 years after Medicare began. Since then, it has saved huge amounts of money for millions of people and allowed many to get the meds they need for the first time.

Part D is a complicated benefit that takes a lot of getting used to. Here are just some of the peculiar ways it differs from other drug coverage you may have used in the past:

  • Coverage goes through four distinct phases during a calendar year, and in each phase the same drug can cost a different amount.
  • To get coverage, you must select just one private plan that provides Part D drugs out of many plans (at least 15) that are available to you.
  • Different plans cover different sets of drugs, and no plan covers all drugs.
  • Plans set their own co-pays for each drug, and these amounts can vary enormously, even for the same drug.
  • Plans may require you or your doctor to ask permission before they cover certain drugs or to try a less-expensive version before they cover the one you were prescribed.
  • Plans are allowed to change their costs and benefits or to withdraw from Medicare entirely each calendar year.

Source:  Patricia Barry

Black Doctors Work to Make Coronavirus Testing More Equitable

When the coronavirus arrived in Philadelphia in March, Dr. Ala Stanford hunkered down at home with her husband and kids. A pediatric surgeon with a private practice, she has staff privileges at a few suburban Philadelphia hospitals. For weeks, most of her usual procedures and patient visits were canceled. So she found herself, like a lot of people, spending the days in her pajamas, glued to the TV.

Read more…

What Changes May Occur With Trumps Healthcare Plan

Two years later, what has his administration done to change the ACA, and who’s been affected? Below are five of the biggest changes to the federal health law under President Trump.

1. Individual mandate eliminated

What is it? The individual mandate is the requirement that all U.S. residents either have health insurance or pay a penalty. The mandate was intended to help keep the premiums for ACA policies low by ensuring that more healthy people entered the health insurance market.

What changed? The 2017 Republican-backed tax overhaul legislation reduced the penalty for not having insurance to $0.

What does the administration say? “We eliminated Obamacare’s horrible, horrible, very expensive and very unfair, unpopular individual mandate. A total disaster. That was a big penalty. That was a big thing. Where you paid a lot of money for the privilege […] of having no healthcare.” — President Trump, The Villages, Florida, Oct. 3, 2019

What’s the impact? First of all, getting rid of the penalty for skipping insurance opened a new avenue of attack against the entire ACA in the courts, via the Texas v. Azar lawsuit. Back in 2012, the ACA had been upheld as constitutional by the U.S. Supreme Court, because the penalty was essentially a tax, and Congress is allowed to create a new tax. Last December, though, a federal judge in Texas ruled that now that the penalty is $0, it’s a command, not a tax, and is therefore unconstitutional. He also reasoned that it cannot be cut off from the rest of the law, so he judged the whole law to be unconstitutional. A decision from the appeals court is expected any day now.

Eliminating the penalty also caused insurance premiums to rise, says Sabrina Corlette, director of the Center on Health Insurance Reforms at Georgetown University. “Insurance companies were getting very strong signals from the Trump administration that even if the ACA wasn’t repealed, the Trump administration probably was not going to enforce the individual mandate,” she says. Insurance companies figured that without a financial penalty, healthy people would opt not to buy insurance, and the pool of those that remained would be smaller and sicker.

So, even though the $0 penalty didn’t actually go into effect until 2019, Corlette says, “insurance companies — in anticipation of the individual mandate going away and in anticipation that consumers would believe that the individual mandate was no longer going to be enforced — priced for that for 2018.” According to the Kaiser Family Foundation, premiums went up about 32%, on average, for ACA “silver plans” that went into effect in early 2018, although most people received subsidies to offset those premium hikes.

2. States allowed to add “work requirements” to Medicaid

What is it? Medicaid expansion was a key part of the ACA. The federal government helped pay for states (that chose to) to expand Medicaid eligibility beyond families to include all low-income adults, and to raise the income threshold, so that more people would be eligible. So far, 37 states and Washington have opted to expand Medicaid.

What changed? Under Trump, if they get approval from the federal government, states can now require Medicaid beneficiaries to prove with documentation that they either work or go to school.

What does the administration say? “When you consider that, less than five years ago, Medicaid was expanded to nearly 15 million new working-age adults, it’s fair that states want to add community engagement requirements for those with the ability to meet them. It’s easier to give someone a card; it’s much harder to build a ladder to help people climb their way out of poverty. But even though it is harder, it’s the right thing to do.” — Seema Verma, administrator of the Centers for Medicare and Medicaid Services, Washington, Sept. 27, 2018

What’s the impact? Even though HealthCare.gov and the state insurance exchanges get a lot of attention, the majority of people who gained health care coverage after the passage of the ACA — 12.7 million people — actually got their coverage by being newly able to enroll in Medicaid.

Medicaid expansion has proven to be quite popular. And in the 2018 election, three more red states — Idaho, Nebraska and Utah — voted to join in. Right now, 18 states have applied to the federal government to implement work requirements; but most such programs haven’t yet gone into effect.

“The one work requirement program that’s actually gone into effect is in Arkansas,” says Nicholas Bagley, professor of law at the University of Michigan and a close follower of the ACA. “We now have good data indicating that tens of thousands of people were kicked off of Medicaid, not because they were ineligible under the work requirement program, but because they had trouble actually following through on the reporting requirements — dealing with websites, trying to figure out how to report hours effectively, and all the rest.”

If more states are able to implement work requirements, Bagley says, that could lead “to the loss of coverage for tens of thousands — or even hundreds of thousands — of people.”

CMS administrator Verma has pushed back on the idea that these requirements are “some subversive attempt to just kick people off of Medicaid.” Instead, she says, “their aim is to put beneficiaries in control with the right incentives to live healthier, independent lives.”

3. Cost-sharing reduction subsidies to insurers have ended

What is it? Payments from the federal government to insurers to motivate them to stay in the ACA insurance exchanges and help keep premiums down.

What changed? The Trump administration suddenly stopped paying these subsidies in 2017.

What does the administration say? “I knocked out the hundreds of millions of dollars a month being paid back to the insurance companies by politicians. … This is money that goes to the insurance companies to line their pockets, to raise up their stock prices. And they’ve had a record run. They’ve had an incredible run, and it’s not appropriate.” — President Trump, the White House, Oct 17, 2017

What’s the impact? This change had a strange and unexpected impact on the new insurance markets set up by the ACA. Insurers were in a bind: They had to offer subsidies to low-income people applying for insurance, but the federal government was no longer reimbursing them.

“The first thinking [was], ‘Oh gosh, that’s going to cause premiums to go up, and it’s going to hurt the marketplace,’ ” says Christine Eibner, who tracks the ACA at the nonpartisan RAND corporation. “What ended up happening is, insurers, by and large, addressed this by increasing the price of the silver plan on the health insurance exchanges.”

This pricing strategy was nicknamed “silver loading.” Because the silver plan is the one used to calculate tax credits, the Trump administration still ended up paying to subsidize people’s premiums, but in a different way. In fact, “it has probably led to an increase in federal spending” to help people afford marketplace premiums, Eibner says.

“Where the real damage has been done is for folks who aren’t eligible for subsidies — who are making just a little bit too much for those subsidies,” Corlette adds. “They really are priced out of comprehensive ACA-compliant insurance.”

4. Access to short-term “skinny” plans has been expanded

What is it? The ACA initially established rules that health plans sold on HealthCare.gov and state exchanges had to cover people with preexisting conditions and had to provide certain “essential benefits.” President Obama limited any short-term insurance policies that did not provide those benefits to a maximum duration of three months. (The original idea of these policies is that they can serve as a helpful bridge for people between school and a job, for example.)

What changed? The Trump administration issued a rule last year that allowed these short-term plans to last 364 days and to be renewable for three years.

What does the administration say? “We took swift action to open short-term health plans and association health plans to millions and millions of Americans. Many of these options are already reducing the cost of health insurance premiums by up to 60% and, really, more than that.” — President Trump, The White House, June 14, 2019

What’s the impact? The new rule went into effect last October, though availability of these short-term or “skinny” plans varies depending on where you live — some states have passed their own laws that either limit or expand access to them. Some federal actuaries projected lots of people would leave ACA marketplaces to get these cheaper plans; they said that would likely increase the size of premiums paid by people who buy more comprehensive coverage on the ACA exchanges. But a recent analysis from the Kaiser Family Foundation finds that the ACA marketplaces have actually stayed pretty stable.

Still, there’s another consequence of expanding access to these less comprehensive plans: “People who get these “skinny” plans aren’t really fully protected in the event that they have a serious health condition and need to use their insurance,” Eibner says. “They may find that it doesn’t cover everything that they would have been covered for under an ACA-compliant plan.”

Medicare’s Uncapped Drug Costs Take A Big Bite From Already Tight Budgets

5. Funds to facilitate HealthCare.gov sign-ups slashed

What is it? The ACA created Navigator programs and an advertising budget to help people figure out specifics of the new federally run insurance exchanges and sign up for coverage.

What changed? In August 2017, the administration significantly cut federal funding for these programs.

What does the administration say? “It’s time for the Navigator program to evolve. … This decision reflects CMS’ commitment to put federal dollars for the federally facilitated Exchanges to their most cost effective use in order to better support consumers through the enrollment process.” — CMS Administrator Seema Verma, written statement, July 10, 2018

What’s the impact? It’s hard to document what the impact of this particular cut was on enrollment. The cuts were uneven, and some states and cities got creative to keep providing services. “We have seen erosion in overall health insurance coverage,” Corlette says. “But it’s hard to know whether that’s the effect of the individual mandate going away, the short-term plans or the reductions in marketing and outreach — it’s really hard to tease out the impact of those three changes.”

Source: NPR

Dems tee up new document fight with DOJ over Obamacare – POLITICO

Health care
Dems tee up new document fight with DOJ over Obamacare


05/14/2019 06:00 AM EDT

House Democrats are mounting yet another confrontation with the Justice Department that could lead to subpoenas, but this time it’s not about special counsel Robert Mueller’s report — it’s about health care.

Five committee chairman foreshadowed a possible subpoena as soon as May 24 if Attorney General William Barr declines to provide documents related to his decision to stop defending the constitutionality of the Affordable Care Act — the health care law signed by President Barack Obama in 2010.

In letters to Barr and White House Counsel Pat Cipollone, the chairmen say they’ve been asking since April 8 for documents connected to the decision, as well as testimony from four key officials involved in the effort. The request, they said, sought a response by April 22 but that the reply fell short. Now, they’ve giving the Justice Department two more weeks to meet the committees’ demands. They’re also asking the White House to make budget director Russ Vought available for an interview.

“If we do not receive a response by this date, we will have no choice but to consider alternative means of obtaining compliance,” the lawmakers wrote.

The letters are signed by Oversight Chairman Elijah Cummings (D-Md.) , Energy and Commerce Chairman Frank Pallone, Jr. (D-N.J.), Ways and Means Chairman Richard Neal (D-Mass.), Education and Labor Chairman Bobby Scott (D-Va.) and Judiciary Chairman Jerry Nadler (D-N.Y.).
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Nadler’s committee has already voted to hold Barr in contempt for refusing to provide an unredacted version of Mueller’s report to Congress as well as Mueller’s underlying evidence. But the full House has yet to consider the committee’s effort. Speaker Nancy Pelosi indicated last week that other committees may want to combine similar contempt proceedings into one overarching floor vote that could come in the next few weeks.

Democrats are also locked in confrontations with the Trump administration over accessing Trump’s tax returns — a request made by Neal’s Ways and Means Committee. The House Intelligence Committee has demanded access to Mueller’s report as well on national security grounds and issued a subpoena for his files last week.

The new effort on health care could become part of the broader strategy, if they continue to accuse the Justice Department of stonewalling by the time the new deadline arrives on May 24. But convincing other lawmakers to wait until June — following a weeklong Memorial Day recess — for a comprehensive contempt vote could be difficult. Rank-and-file Democrats have been clamoring for punitive measures against Barr for weeks for his handling of Mueller’s report.

Unlike the other demands, though, Democratic leaders, though, believe that picking a fight on health care is better politics — and it shows their efforts to confront the Trump administration has policy dimensions, not just Trump-focused investigations.

Democrats have attributed the Trump administration’s efforts to overturn the health care law, known familiarly as Obamacare, to “politically motivated forces” in the White House. The Obama White House took a similar step in 2011 when the Justice Department, at Obama’s urging, stopped defending the Defense of Marriage Act, which barred federal recognition of same-sex marriages — a move social conservatives denounced at the time.

The Department of Justice declined to comment.

via Dems tee up new document fight with DOJ over Obamacare – POLITICO

The Williamson Group, LLC

#HealthInsurance Premiums and Coverage

This year’s sprawling InsureTech Connect conference, held October 2-3 in Las Vegas, was bigger and better than ever. More than 6,000 insurance company and insuretech representatives, along with 50 insurance regulators, shared what’s happening in the insuretech space today and what industry impacts to expect in the near term. (No one predicted that the conference-ending performance by Salt-N-Pepa would be so great.) Here were some of the more interesting takeaways, soundbites and predictions, at least from our perspective:

  • The use of big data and algorithms represents the biggest shift in the insurance industry in over 200 years.
  • Data is already revealing secrets, letting insurers see subgroups within groups that previously appeared monolithic. Insurers are using data sets that were not traditionally available.
  • Insurers are gathering “tons of data” that they believe to be highly predictive. The way the industry evaluates risk 10 years from now will make today’s methods seem “medieval.”
  • Body implants in the next five years will capture and transmit health status in real time. As a result, life insurers could become health advisors, coaching insureds on what they should do to live longer.
  • The job of the regulator is to worry about everything. When it comes to insurers’ use of big data, regulators are most concerned about underwriting and rating.
  • Among other things, regulators worry that data problems and “witches’ brew” algorithms will result in unfair discrimination. They’re also concerned that some people won’t be able to get insurance because of more individualized risk analysis.
  • Even accurate data can be problematic if it contains proxies for unlawful factors. In addition, “unintended bias in data is a massive problem” that needs to be addressed.
  • Regulators expect senior management to have “accountability for and mastery of the algorithms” their companies are using.
  • Algorithms shouldn’t be black boxes. They should be designed to be explainable.
  • The sources of data used by insurers should be documented and auditable. Every factor should be predictive.
  • Digital ethics are a big issue. “Anything that can’t be automated will become more valuable in the future, including ethics.”
  • “Push it. Push it real good.”

AHCA or Trumpcare

eo-trump-1200As a business owner, you may have heard a lot of buzz about Obamacare’s “employer mandate.” Maybe you’re still wondering what it is and whether it applies to you. The short answer is that if you have fewer than 50 full-time-equivalent (FTE) employees, you don’t have to worry about the employer mandate. (For a definition of FTE, see the end of this article.) The mandate requires only larger companies to offer health coverage to employees.

That said, there are plenty of important things for owners of smaller businesses to know about Obamacare. Here’s a summary of key points for Connecticut business owners who have between one and 49 employees:

You aren’t legally required to offer health insurance to your employees. If you have fewer than 50 FTEs, whether or not to provide coverage is entirely up to you.

You may be legally required to notify your employees about Obamacare. Whether or not you choose to provide insurance, if your business is covered by the Fair Labor Standards Act, you must notify all your employees about Obamacare’s basic provisions before October 1, 2013 — and you must notify all new hires after that. The U.S. Department of Labor has published sample notices you can use. There’s no penalty under the law for failing to provide notice.

You can purchase health insurance for your employees using Connecticut’s small business marketplace. The small business marketplace is often called the SHOP, shorthand for the Small Business Health Options Program. You can find Connecticut’s SHOP at Access Health CT.

Beginning October 1, 2013, you can use the marketplace to compare health plan prices and features, find out whether your business qualifies for a cost-saving tax credit, and purchase a new plan. For now, the small business marketplace is available only to businesses with 50 or fewer employees. For coverage year 2016, however, the marketplace will be open to employers with up to 100 FTEs.

Your business may qualify for a tax credit. If you have fewer than 25 FTEs and purchase employee insurance through the marketplace, you may qualify for the “small business health care tax credit.” The credit is available to businesses with employees whose average annual wages are less than about $50,000. You must also pay at least 50% of your employee’s health insurance premiums. If your business qualifies, the credit could cover up to 50% of your contribution toward your employee’s insurance — 35% for nonprofits.

You have new rights under the law. No matter where you purchase your employee health plan, insurance providers can’t turn down your company based on your employees’ health status, including pre-existing conditions. Nor can they charge higher premiums for women or employees with high medical costs. (These protections don’t apply to grandfathered plans — those created before March 23, 2010 that meet certain additional requirements.)




For more information about your rights, contact the Connecticut Insurance Department.

If you use the small business marketplace, you must offer coverage to all of your full-time employees. That means people who work for you an average of 30 or more hours per week or 130 hours per month. This calculation does not include employees covered by another plan, such as Medicare, Medicaid, or the military — but it does include full-time workers with private plans.

To use a marketplace plan, at least 75% of the employees to whom you offer coverage must sign up for it. If your business doesn’t meet the minimum participation requirement, you may still be able to sign up for a plan during a special enrollment period at the end of this year. Ask a marketplace representative or your broker for more information.

What Does “Full-Time Equivalent” Mean?

Under Obamacare, a full-time employee is defined as one who works an average of 30 hours per week, or at least 130 hours per month. To figure out your business’s number of FTE’s, you need to add together the hours of full- and part-time employees. For instance, if you have two employees who work 15 hours per week, that equals one full-time worker.


That Was Then…

Businesses may be able to buy health insurance through what are called association health plans under a planned federal rule change. President Donald Trump signed an order directing his administration to write rules that would allow groups and associations of employers to sponsor coverage that can be marketed in multiple states.

Under current rules, insurance must be purchased in a state where a consumer lives or a company is located. Rules formulated under Trump’s order would be expected to protect association health plans from some state and federal requirements. However, they’re not likely to affect insurance policies until 2019 at the earliest because of the process for writing federal regulations.

Under the version that passed the House, states would be able to create their own list of “essential health benefits.” Those benefits — currently set by the Obama-era health care law — determine services on which large employer plans cannot impose annual or lifetime coverage caps. There also must be an annual out-of-pocket spending maximum for those covered.

Under the Republican bill, large employers would be able to use the essential health benefits definition from any state, that’s where the impact could come. For example if  Alabama opts to cut a cluster of health care protections,  employers could potentially  use Alabama as a benchmark,”

Where to Get Help

Visit Connecticut’s small business marketplace. As the Obamacare rollout continues, more information will be available from the SHOP at Access Health CT or 855-SMBIZCT (855-762-4928).

The Dark World of Healthcare Marketing – What You Should Know


Solicitation and  Marketing Requirements



The purpose of an advertising regulation is to give a complete and accurate description to the public, prevent unfair competition, and set a minimum standard of conduct. In most states, each insurer must provide the Department of Insurance a copy of any advertisement prior to its use.

Each insurer must maintain at its home or principal office, a complete file containing every printed, published or prepared advertisement of its individual, blanket, franchise and group policies.

Advertisements are printed or published material, audiovisual material and descriptive literature, to include newspapers, magazines, radio scripts, television scripts, billboards, sales talks, presentations, and personal testimonials. Additional requirements:

■    Insurance companies are responsible for the accuracy of its personal testimonials.

■    Insurers may include statistical information as long as it is accurate and the source is named.

■    The agent must include the full name of the insurer when advertising a certain type of policy.

■    When an agent misleads the public in an advertisement, both the insurer and agent are held accountable.

■    When insurers advertise that a group endorses a certain health product, the public must be made aware of any control the insurer may have over the group.

■    When insurers advertise by comparison of like products, the comparisons must be complete to include rates, policies, benefits, and dividends.

■    The history of a very high or unique claim settlement cannot be used in advertising by the agent or insurance company.

Prohibited Forms of  Advertising

■    No advertisement of a hospital or facility confinement benefit shall advertise that the amount of the benefit is payable on a weekly or monthly basis when, in fact, the amount of the benefit is based on a daily pro rata basis related to the total amount of days of confinement.

■    An advertisement cannot use the words: “only,” “just,” “merely,” “minimum,” or similar words to imply a minimal imposition of restrictions and reductions.

■    An advertisement cannot imply that claim settlements are generous or liberal or use similar words to imply the same thing.

■    Any advertisement that uses a policy title to misrepresent or that might misrepresent coverage is unlawful.

Do Not Call Registry – The Federal Trade Commission amended the Telephone Consumer

Protection Act (TCPA) to give consumers a choice about receiving unwanted telemarketing calls. It is illegal for most telemarketers or sellers to call a number listed on the National Do Not Call Registry. Companies must update their list at least once every 31 days. The TCPA also limits the hours that telemarketers may call noncustomers at home to between the hours of 8 am – 9 pm.

Sales Presentation – Agents are required to provide prospective health insurance buyers with all sales materials used when soliciting policies of insurance.

Outline of Coverage – An outline of coverage (also called a policy summary) must be provided to a prospective buyer of health insurance at the time of application or policy delivery. The outline of coverage includes benefits, premiums, and other relevant information regarding the sale of the policy.

Healthcare, Health Insurance, Marketing, Telemarketers, Phone Solicitors, Health Insurance Agents, Do Not Call Registry

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