Archive for the ‘US Health Insurance’ Category

« Older Entries

Health Net Group – new underwriting guidelines for 2012

Wednesday, May 9th, 2012

Good Neighbor Insurance provides group health insurance to our clients.  One of the best group insurance companies in Arizona is the Health Net Group plans.  You may view request more information on this option for your organization by going to our Arizona web site at www.gnazhealth.com or call us at 480.633.9500. 

Effective in 2012, Health Net is coming out with some new underwriting guidelines for their Small Group Products.  Some of the new guidelines are:

  • Case Completion Deadline:  Groups not completed by the 25th CALENDAR day of the month will be moved to the next available effective date.  If the 25th falls on a weekend or holiday, the deadline will be the following business day.
  • Copies of ID Cards:  Groups with MORE THAN 50% of the total eligible population waiving for valid reasons is required to submit copies of ID cards.
  • Carve-Outs:  The following documentation is required for all carve-outs:
    • Require letter from group or broker on Company letterhead, describing basis for the carve-out and include names, titles and SSN’s of those eligible.
    • Must have a minimum of 5 ENROLLED employees.
    • Require individual medical underwriting, regardless of group size.
  • Former PEO Groups:  Groups contracted with a PEO will not be considered for coverage as the employer-employee relationship is between the PEO and the employees.  However, HN will consider groups leaving a PEO.  The following documentation will be required:
    • Copy of document severing the contract between PEO and Employer (from the PEO).
    • 2 weeks of payroll from the employer or professional payroll company.
    • Proof of prior coverage through the PEO in the form of group contract, prior carrier bill, or copies of medical ID cards for the majority of those enrolling.

NOTE:  Groups that did not have medical coverage through the PEO will be treated as newly established groups.

  • Newly Established Group:  A minimum of 4 weeks of payroll prior to the requested effective date must be supplied. 

Doug Gulleson loves to scuba dive overseas and makes sure he has his U.S. health care and overseas health care, www.gnazhealth.com , information with him at all times when he travels Keep our blog close by you, www.gntravelinsurance.com, for continual updates on the changes with the U.S. health care system.

Bookmark and Share

Tags: ,
Posted in Health Net |

COBRA – notice requirements

Wednesday, May 2nd, 2012

Good Neighbor Insurance at www.gnazhealth.com continues to update our clients on the new health insurance laws.  There are six major coverage options for those in the US and even though some of the rules and regulations are similar for all many differences are there and it all depends on how old you are and for whom you work.  Many critical details of this new insurance law will be clarified in the months and years to come. 

These six major coverage options are:

(1) Individual or family coverage (private health care plans)

(2) Employee/employer group option for small businesses (typically under 50 employees)

(3) Employee/employer group option for large businesses (typically larger than 50 employees)

(4) Exchange options through the state you are residing in (fully integrated 1-1-2014 and are quasi-government and private insurance coverage combined)

(5) Medicare (which include Parts A, B, C, and D) for those 65 years onwards

(6) Full government health plans like Medicaid, CHIP, TRICARE, VA and other coverage plans as may be designated by the Department of Health and Human Services based mostly on financial criteria and/or military service.

Notice requirements

  Who sends notice? Content required Sent when? DOL Model notice available? Alternate notice available?
General or initial notice Plan administrator to covered employee and spouse Minimum requirements Within 90 days of commencement of coverage Yes SPD
Qualifying event notice-employer Employer to plan administrator Info about plan, qualifying events, and dates of events 30 days after qualifying event Yes None
Qualifying even notice – employee Covered employee to plan administrator Plan must provide a reasonable written procedure 60 days after qualifying events No Depends on plan procedure
Election notice Plan administrator to qualified beneficiary Minimum requirements as listed in final regulations 14 days after notice of QE, or 44 days if employer is plan administrator Yes None
Notice of COBRA unavailability Plan administrator to individuals who provided QE notice Why individual is not entitled to COBRA Same as election notice timeframe No None
Early termination notice Plan administrator to qualified beneficiaries Reason for, date of termination, conversion rights, if any “As soon as practicable” after decision is made to terminate No None

Election period

The Qualified Beneficiary has 60 days from the later of a) the date coverage would be lost as a result of the Qualifying Event, or b) the date the notice was provided to the Qualified Beneficiary. There have been, however, a number of court cases in which the date the  Qualifying Event Notice was actually received marked the beginning of the 60-day election period.

Before rejecting an election form that may be received a few days after the 60-day election period ends, the Plan Administrator should determine whether the Qualified Beneficiary actually made the election within 60 days of the receipt of the Qualifying Event Notice. The maximum COBRA continuation period is generally measured from the date of the Qualifying Event , not the date of election.  As a result, a Qualified Beneficiary who waits until the last day of the election period before choosing to elect will have his/her coverage reinstated retroactively back to the original benefits termination date.

Election without a premium payment

A Qualified Beneficiary has 45 days from the date of the election in order to make the initial premium payment. The Plan Administrator may not make the election of coverage contingent on the Qualified Beneficiary making the first premium payment at the time of election. If the Qualified Beneficiary fails to make the initial premium payment within the 45-day grace period, all COBRA continuation coverage will be terminated.

For a group health plan that provides health services such as an HMO or a walk-in clinic, a Qualified Beneficiary who has not yet elected or paid for coverage may be required to either elect and pay for continuation coverage, or pay a reasonable charge for services (but only if the Qualified Beneficiary will be reimbursed within 30 days of election and payment of continuation coverage).

Doug Gulleson loves to scuba dive overseas and makes sure he has his US health care and overseas health care, http://onlineglobalhealthinsurance.com/my-travel-guard.asp , information with him at all times when he travels   Keep our blog close by you, www.gntravelinsurance.com, for continual updates on the changes with the U.S. health care system.

Bookmark and Share

Tags:
Posted in Understanding COBRA |

COBRA – length of coverage for qualifying events

Tuesday, April 3rd, 2012

Good Neighbor Insurance at www.gnazhealth.com continues to update our clients on the new health insurance laws.  There are six major coverage options for those in the US and even though some of the rules and regulations are similar for all many differences are there and it all depends on how old you are and for whom you work.  Many critical details of this new insurance law will be clarified in the months and years to come. 

These six major coverage options are:

(1) Individual or family coverage (private health care plans)

(2) Employee/employer group option for small businesses (typically under 50 employees)

(3) Employee/employer group option for large businesses (typically larger than 50 employees)

(4) Exchange options through the state you are residing in (fully integrated 1-1-2014 and are quasi-government and private insurance coverage combined)

(5) Medicare (which include Parts A, B, C, and D) for those 65 years onwards

(6) Full government health plans like Medicaid, CHIP, TRICARE, VA, and other coverage plans as may be designated by the Department of Health and Human Services based mostly on financial criteria and/or military service.

COBRA Background

Congress passed The Consolidated Omnibus Budget Reconciliation Act (COBRA) in 1986. One of the provisions of COBRA is to provide certain individuals with the right to temporarily continue their health coverage at group rates. The law generally applies to employers who sponsor a group health plan and have 20 or more full or part time employees during 50 percent or more of the business days in the preceding calendar year.  A “group health plan” is defined as a plan that provides medical benefits for the employer’s own employees and dependents through insurance, HMO, or self funded arrangement. Medical benefits may include:

1. Hospital Care

2. Physician Care

3. Prescription Drugs

4. Other types of medical care, such as dental and vision.

Life insurance is not covered under COBRA.

Qualifying Events

Qualifying Events are events that would cause a covered employee to lose group health coverage.  The Plan Administrator will send a Qualifying Event Notice to a Qualified Beneficiary who has a Qualifying Event as listed below.

1. Termination of employment (for reasons other than gross misconduct)

2. Reduction of hours worked by the covered employee.

3. Death of the covered employee.

4. Divorce or legal separation.

5. Dependent child no longer meets the plan’s eligibility requirements.

6. Dependent loses coverage due to the employee becoming entitled to Medicare.

7. Company files for Bankruptcy under Chapter 11 of the U.S Bankruptcy Code.

Length of Coverage for Qualifying Events

The length of COBRA continuation coverage that must be offered depends on the type of Qualifying Event. When a Qualifying Event causes a loss of coverage, the employer must allow COBRA continuation coverage under the group health plan for up to 18 months for Qualifying Events that are the termination of employment or reduction of hours.  This period may be extended to 29 months if the Qualified Beneficiary is or becomes disabled at any time during the first 60 days of continuation coverage. A second Qualifying Event for a dependent occurring during the 18-month continuation coverage period of the first Qualifying event extends the original period to 36 months.

It is important to note, however, that COBRA continuation coverage may terminate prior to the end of the maximum coverage period for any of the following reasons:

1. Non-payment of premiums. Continuation coverage for a Qualified Beneficiary may be terminated if the premiums are not paid in a “timely” manner. A payment is considered “timely” if it is made on the due date, or within the 30-day grace period (45 days for the initial premium payment).

2. Termination of all Group Health Plans.  Continuation coverage for a Qualified Beneficiary may be terminated if the employer ceases to sponsor any group health plan.

3. Other Coverage. Continuation coverage may be terminated if the Qualified Beneficiary first becomes covered under another group health plan, which does not contain any pre-existing exclusion limitation, after the Qualified Beneficiary elects COBRA continuation coverage.

4. Entitlement to Medicare. Continuation coverage may also be terminated if the Qualified Beneficiary first becomes entitled to Medicare after the Qualified Beneficiary elects COBRA continuation coverage.

5. Loss of Social Security Disability Status. Continuation coverage may be terminated if the

Qualified Beneficiary is determined to be no longer disabled by the Social Security Administration.  Coverage can, however, be terminated only during the 11-month disability extension period.

6. Termination for Cause. Continuation coverage may be terminated, for cause, if the Plan would otherwise terminate coverage on that basis for similarly situated covered employees.

18 Months for Qualifying Events:

1. Termination of employment for reasons other than gross misconduct.

2. Reduction in the number of hours of employment. For these Qualifying Events, the maximum continuation coverage period will be 18 months, measured from the date of the Qualifying Event. This maximum coverage period may be extended to 29 months if a Qualified Beneficiary who is, under Title 11 or XVI of the Social Security Act, determined to have been disabled at the time of a Qualifying Event, or, within the first 60 days of COBRA continuation coverage for all Qualified Beneficiaries. COBRA continuation coverage may be expanded to 36 months for a spouse or dependent of an employee who has experienced one of the above listed Qualifying Events if a second Qualifying Event occurs, (such as divorce, legal separation, death of the employee, Medicare entitlement, or loss of dependent child status) during the original 18 month COBRA continuation coverage period. Notification by the Qualified Beneficiary should be made to the Plan Administrator within 60 days of the second Qualifying Event, and within the original 18 month COBRA continuation coverage period.

36 Months for Qualifying Events:

1. Death of the covered employee.

2. Divorce or legal separation.

3. Dependent child ceases to meet the plan’s eligibility requirements

4. When dependents would lose coverage due to covered employee becoming entitled to Medicare (see next section).  For these Qualifying Events, the maximum coverage period will be 36 months, measured from the date of the Qualifying Event, or, up to 36 months measured from the date of the covered employee’s Medicare entitlement, if the covered employee becomes entitled to Medicare and, within 18 months thereafter, has a Qualifying Event that is either termination of employment, or reduction of hours.

29 Months for Qualifying Events:

A Qualified Beneficiary who is determined under Title II or XVI of the Social Security Act, to have been disabled at the time of a Qualifying Event, or, within the first 60 days of COBRA continuation coverage for all Qualified Beneficiaries, may be eligible to continue coverage for a total of 29 months (11 additional months). The Qualified Beneficiary must provide, to the Plan Administrator, a determination of disability from the Social Security Administration

within 60 days of the date of the determination, and prior to the end of the original 18-month COBRA continuation coverage period. The employer is permitted to charge up to 150% of the applicable premium during the 11 month disability extension. The Qualified Beneficiary is also required to notify the Plan Administrator, in writing, if the Social Security Administration has determined that the Qualified Beneficiary is no longer disabled under Title II or XVI of the Social Security Act. Bankruptcy of the Employer When a retiree, spouse or child of a retiree loses coverage within one year before or after the commencement of proceedings under Chapter 11 of the U.S. Bankruptcy Code

The maximum period of COBRA continuation coverage is as follows:

1. Coverage will continue, until the date of death, for covered employees, who retired on or before the date of the loss of coverage. Lifetime coverage is also available to widows or widowers of retirees.

2. Continuation coverage will be made available for the spouse and dependent children of a retiree for 36 months from the date of death of the retiree.

Other Coverage

The employer may not deny to the Qualified Beneficiary the option of COBRA continuation coverage based on the fact that the Qualified Beneficiary has other health coverage prior to the date COBRA continuation coverage is elected.

Gross Misconduct

The employer, however, is not required to offer COBRA continuation coverage to individuals who have been terminated from employment because of “gross misconduct” (IRC section 4908B (f)(3)(B). Unfortunately, “gross misconduct” is not defined in COBRA law. In the absence of any clear guidance from the IRS or Department of Labor on what constitutes gross misconduct, the employer should consider denying continuation coverage only in cases where the employer has a clear, well-documented case of gross misconduct. There have been numerous court cases in which ex- employees have sued challenging their former employers’ failure to offer continuation coverage. Because of the nature of the alleged behavior, what might be considered gross misconduct in one job or industry may not be considered as such in another, and as a result, there has been no clear standard to follow. It is recommended that before a Plan Administrator denies continuation coverage to a  Qualified Beneficiary because of termination due to gross misconduct, they make certain that they are able to produce sufficient documentation to back the claim. Also, if the employee accused of gross misconduct is allowed to resign, this may be seen as intent on the employer part to waive COBRA.

Doug Gulleson loves to scuba dive overseas and makes sure he has his U.S. health care and travel medical insurance, http://onlineglobalhealthinsurance.com/my-travel-guard.asp , information with him at all times when he travels   Keep our blog close by you, www.gntravelinsurance.com, for continual updates on the changes with the U.S. health care system.

Bookmark and Share

Tags: , ,
Posted in Understanding COBRA |

Team up with one of our past GNI Arizona vendors on tackling brain tumor disease

Friday, March 16th, 2012

To our Arizona Clients and Neighbors:

Good Neighbor Insurance (GNI), www.gnazhealth.com and www.gninsurance.com, believes in being a servant to our clients.  We have the privilege of helping you, our Arizona neighbors and clients, with providing the best Arizona medical insurance coverage on the market.

Jeff, my dad, and I are the owners of Good Neighbor Insurance (GNI).  We can only be this great for our clients because of our GNI Team.  Who is the GNI Team?  They are our associates as well as our vendors.  One may not think of vendors as part of the company team. They are, in fact, a vital part. 

One of our vendors has been with us for many years.  They are a husband and wife CPA team, Perkins Accounting, here in Gilbert, Arizona.   This article is dedicated specifically to our past CPA team, Sandy and her husband Richard.  Last year tragedy struck the Perkins family due to their son, Sam, passing away suddenly with brain cancer at the young age of 20, in late 2011.  Our prayers and hearts go out to Sandy and Richard during this time.  It was with great sadness to hear that Sandy and Richard have decided to leave their CPA business.  We will miss their business friendship!

Good Neighbor Insurance has asked Sandy and Richard what we can do to help in their time of need.  They have asked us to share with you, our Arizona clients and neighbors, information about brain tumor research and organizations that are involved in curbing this fatal disease.

Here is the information, in Sandy’s own words, on organizations her and Richard are working closely with.

1.  Students Supporting Brain Tumor Research (SSBTR) - their web page is http://www.ssbtr.org/.

This is taken from their webpage:  “Students in leadership positions learn about brain tumors and gain real world experience in running a non-profit business while raising funds for brain tumor research. Beneficiaries of the money we raise are Barrow Neurological Institute, National Brain Tumor Society, Phoenix Children’s Hospital, Steele Children’s Research Center in Tucson, and Translational Genomics Research Institute (TGen). With your help we can make a difference.

The intent of our website is to further our objectives of disseminating information about this disease process, stimulating more widespread involvement within our community through donating, volunteering and participating in one or more of our events, and publicizing and promoting this exceptional student-run organization.

The things I like about this organization are that the money raised is given to local institutions and that it is a great way to get high school and college students involved.  They are our future!

2.  National Brain Tumor Society (NBTS) their web page is http://www.braintumor.org/.

This is from their website:

“National Brain Tumor Society believes that potentially-transformative research must be supported by informed private funders. Public research funding is essential for basic and early translational research, but there are systemic challenges to scientists who have the potential to make progress in leaps and bounds, rather than incremental steps.

Academic institutions and individual researchers contribute essential findings to the brain tumor field. National Brain Tumor Society is committed to moving this critical knowledge beyond the bench by connecting it to industry partners. Biotechnology and pharmaceutical companies have the motivation, expertise and resources to drive promising science into clinical trials – and beyond, to the brain tumor patients who need more effective therapies to improve quality of life.

National Brain Tumor Society has always funded investigations for both adult and pediatric tumor types. Across the field, there remains a substantial difference in scientific knowledge between adult and pediatric tumors. Now, our Pediatric Research Initiative prioritizes the areas of research that we believe will close this knowledge gap and lead to swifter progress in future pediatric research.”

I like this organization because it is a national organization with various fundraisers such as walks and runs etc throughout the country.  They focus on brain tumor research for both adult and children.  Research on pediatric cancer in general and brain tumors especially is very underfunded.

3.   I forgot to mention that the NBTS is having a walk this weekend March 18th at Steele Indian School Park. We have a team (Team Sam – The Lion) of about 25 people to walk for Sam.

The following is the link to the team page for Sam:  http://www.braintumorcommunity.org/site/TR/Events/BTW-AZ?team_id=49952&pg=team&fr_id=1781

Thank you for allowing us to share with you, our Arizona clients and neighbors, part of our past GNI Team member’s story.  Do call on any of us here at Good Neighbor Insurance for your Arizona health insurance needs.  You may also reach us at our web site at www.gnazhealth.com and get live quotes here at www.gnhealthplan.com. 

Warm regards,

Doug Gulleson, MBA

Good Neighbor Insurance

doug@gninsurance.com

p. 480.813.9100 | f. 480.813.9930  |  866.636.9100

Get to know us even better on:  YouTube  |  Twitter  |  Facebook  |  Blog

Bookmark and Share

Tags: , ,
Posted in Good Neighbor Insurance |

COBRA – 2012 news

Wednesday, March 7th, 2012

COBRA refers to the Consolidated Budget Reconciliation Act of 1985, and specifically to the Title X of the Act.  This benefit allows the member of a group policy, who has lost their coverage due to a “qualifying event” to continue coverage the former employee’s expense for a period of time.  This is the same group policy with the primarily difference of having the former employee paying the total premium.  The COBRA option may be elected after leaving work and if elected the former employee may have this continuation of group coverage for up to 18 months and longer if divorced or if spouse has passed on.

Here are a few answers to commonly asked questions on COBRA for the 2012 year.

Q:        Since the Patient Protection and Affordable Care Act (the PPACA signed into law 2010) is phasing in, are employers still required to administer COBRA?

A:        Yes, in fact, there was no mention of COBRA in the PPACA legislation.  Continuation coverage will likely become more cumbersome for employers and carriers under health reform.  As individual choices increase so too will the requirement to explain cover options and choices to participants.

Q:        When PPACA goes into effect, will terminating employees have to be offered COBRA?  Won’t they have access to guaranteed issue at the exchanges?

A:        While no clear direction has been published, here’s what we know.  The intent of the exchanges is to offer more choices and drive down costs.  The current requirement in most states for groups subject to mini-COBRA with fewer than 20 employees, and for those subject to federal COBRA with more than 20 employees is as follows:

  • Those who experience a qualifying event (including termination of employment) are entitled to be offered continuation coverage (the ability to continue on the group coverage at the same rate under the same plan).
  • They should also be afforded the opportunity to keep the coverage for a period of time.
  • At the time of the qualifying event, the person might be in the middle of a deductible or in the midst of treatment supported by the current plan.  So if the continuant is in the midst of services or treatment, a continuation option greatly eases the transition.

With these facts in mind, employers should plan to offer COBRA even after PPACA goes into effect.  Employers will likely have to present any/all options to terminating employees.

Q:        What are the most common COBRA mistakes that employers make?

A:        We all know COBRA is complicated, especially during and after open enrollment.  Below are a few of the most common oversights:

  • Failing to give appropriate notices – especially to qualifying beneficiaries.
  • Failing to offer open enrollment to COBRA participants.
  • Providing more coverage than what is required, or for longer than required.
  • Failing to document when notices were sent
  • Forgetting to collect COBRA premiums from participants.
  • Overpaying insurance invoices and/or continuing to pay for participants who have dropped off the plan.

Doug Gulleson loves to scuba dive overseas and makes sure he has his US health care and overseas health care, www.gnazhealth.com, information with him at all times when he travels Keep our blog close by you, www.gntravelinsurance.com, for continual updates on the changes with the US health care system.

Bookmark and Share

Tags: ,
Posted in COBRA, Updates 2012 - 2014 |

PCIP federal high risk pool insurance news – 2012

Friday, March 2nd, 2012

Good Neighbor Insurance, www.gnazhealth.com, is continuing to update our clients on the new health insurance laws.  There are six major coverage options for those in the US and even though some of the rules and regulations are similar for all many differences are there and it all depends on how old you are and for whom you work.  Many critical details of this new insurance law will be clarified in the months and years to come. 

These six major coverage options are:

(1) Individual or family coverage (private health care plans)

(2) Employee/employer group option for small businesses (typically under 50 employees)

(3) Employee/employer group option for large businesses (typically larger than 50 employees)

(4) Exchange options through the state you are residing in (fully integrated 1-1-2014 and are quasi-government and private insurance coverage combined)

(5) Medicare (which include Parts A, B, C, and D) for those 65 years onwards

(6) Full government health plans like Medicaid, CHIP, TRICARE, VA and other coverage plans as may be designated by the Department of Health and Human Services based mostly on financial criteria and/or military.

PCIP = Pre-existing Condition Insurance Plan also called the federal high risk (pool) insurance plan

The new government pre-existing condition insurance plan (PCIP or also called the federal high risk pool) is the new health plan through the federal government that President Obama signed into law back in March of 2010.

Here are some 2011 year highlights since this federal high risk health pool insurance option has started:

1.  48,879 enrollees to date (December 2011)

   *  Enrollment is running far below expectations, the PCIP designers have   stated. 

2.  Enrollees are averaging $29,000 in claims per year in the federal PCIP plan. 

  *  Twice the average of traditional state high risk pools.  

3.  State high risk plan comparison over the federal PCIP high risk plan:

  *  In Colorado, as an example, the average state high risk pool has 137 hospital admissions /1,000 enrollees per year. 

  *  The hospital rate for the PCIP plan in Colorado is 562 admissions per 1,000 per year. 

4.  Another example of state high risk plan over the federal PCIP high risk plan is in Kansas.

  *  Kansas state risk plan average $1,376 per month of claim expenditures per enrollee. 

  *  PCIP federal high risk plan average $3,449 per member of claim expenditures per month. 

5.  PCIP federal high risk program does not charge higher premiums because of the policyholder’s medical condition.   Premiums do vary only on the basis of:

  *   Age

  *  Geographic area

  *  Tobacco use  

6.  The PCIP federal high risk program, even though it is in the ‘red’ financially, is able to stay in the ‘black’ by being bailed out through the federal taxes paid by U.S. citizens/residents. 

7.  About half of the states are administering their own PCIP program instead of allowing the federal government to run their PCIP high risk plan.  

  *  The states with the highest PCIP federal high risk plan enrollment are:

    • California
    • Pennsylvania
    • Texas

8.  To keep the PCIP federal high risk plan from overcrowding other private and public health coverage, Congress requires that all PCIP enrollees be individuals who have gone without health insurance, including state risk pool plans, for at least six months.

9.  There is no waiting periods for pre-existing conditions to be covered on the PCIP federal high risk pool.  Once accepted all medical conditions are covered.  

10.  To learn more about the federal PCIP high risk plan please go to  http://www.pciplan.com/.  

Keep our blog close by you, www.gntravelinsurance.com, for continual updates on the changes with the U.S. health care system.  Doug Gulleson loves to scuba dive at Lembeh Dive Resort in Indonesia.  He makes sure he has his U.S. health care and overseas travel adventure sports insurance, www.gninsurance.com/extreme-sports, with him at all times.

Bookmark and Share

Tags: ,
Posted in Updates 2012 - 2014 |

Medical Loss Ratios (MLR) insurance news

Wednesday, February 22nd, 2012

Good Neighbor Insurance, www.gnazhealth.com, is continuing to update our clients on the new health insurance laws.   There are six major coverage options for those in the US and even though some of the rules and regulations are similar for all many differences are there and it all depends on how old you are and for whom you work.  Many critical details of this new insurance law will be clarified in the months and years to come. 

These six major coverage options are:

(1) Individual or family coverage (private health care plans)

(2) Employee/employer group option for small businesses (typically under 50 employees)

(3) Employee/employer group option for large businesses (typically larger than 50 employees)

(4) Exchange options through the state you are residing in (fully integrated 1-1-2014 and are quasi-government and private insurance coverage combined)

(5) Medicare (which include Parts A, B, C, and D) for those 65 years onwards

(6) Full government health plans like Medicaid, CHIP, TRICARE, VA and other coverage plans as may be designated by the Department of Health and Human Services based mostly on financial criteria and/or military.

Medical Loss Ratio (MLR) information

Is it true?  Health plan profits are the cause of higher health care spending?

Reality check:  The latest Yahoo! Finance quarterly corporate financial reports –

  1. The health care plan industry’s average profit margin is 4.40%.  This ranks the health care plan industry 143 out of 215 different industries.
  2. Within the health care sector, the health care plan industry ranks 12th out of 16.

Is it true?  Medical Loss Ratios implementation will make insurance prices more competitive?

Reality check:  Insurance markets vary considerably from one state to another.  In rural states, for example, some carriers that currently provide coverage in remote areas will be unable to meet the MLR requirements and will exit the market, leaving consumers with fewer choices.  Furthermore, the administrative costs of marketing a new plan in a state will be prohibitive given the MLR requirement, so companies will have no incentive to enter a new state and offer consumers new health plan choices.

Is it true?  It’s the cost of health insurance that’s the problem and agent and broker commissions only contribute to high insurance premiums.

Reality check:  Actually, agent and broker commissions have nothing to do with how health insurance premium rates are determined.  Insurance companies have to hire employees to sell and help administer these plans or insurance companies can “hire this out” in the form of agents and brokers.  It is cheaper for insurance companies to have agents and brokers do the work since if they do not sell and administer they do not get paid.  However, if insurance companies have to hire employees to provide this vital service the insurance company would still have to pay the employee even though they may not sell the product. 

When using agents and brokers the commission is never part of the insurance revenue stream but is a pass-through expense. It is billed that way both as a consumer convenience and as a means of complying with state premium tax and consumer protection laws.

Is it true?  Buying insurance is a lot like buying an airline ticket and health reform will make shopping for coverage even easier.  Why should anyone pay an agent or broker to help them?

Reality check:  Purchasing health insurance as an individual or as a business owner as an employee benefit is one of the most important financial decisions you can make.  It is nothing at all like buying a plane ticket.  An airline ticket is a one-time purchase that takes you to a known destination.  The variables for how to get thee may cost you time and frustration, but that is all.  Health insurance is a complex financial product and price alone does not determine the best coverage choice. What may be best for one family member is not the best for another. 

Moreover, unlike airline tickets, the purchase of health insurance typically includes considerable assistance after the sale.  Insurance brokers assist consumers with plan selection, insurance billing, claim filing, and contract interpretation.  Brokers often intercede on behalf of clients to obtain payment for services that may not be typically or otherwise covered under the plan.  For employers, brokers often serve as an extension of the human resources department and design comprehensive benefit programs, provide employees with information about the selected plans, process enrollees, and handle compliance matter, as well as servicing employee claims concerns.

Is it true?  Insurance brokers are big business and they make too much money? 

Reality check:  There are approximately 500,000 health insurance brokers nationwide, and they work in every community.  For the most part, they operate Main Street small businesses rather than Wall Street-type firms.  Their mean annual wage in 2010, according to the Bureau of Labor Statistics, was $62,520.

Doug Gulleson loves to scuba dive overseas and makes sure he has his US health care and overseas health care, www.gnazhealth.com , information with him at all times when he travels Keep our blog close by you, www.gntravelinsurance.com, for continual updates on the changes with the US health care system.

Bookmark and Share

Tags:
Posted in Medical loss ratio (MLR) |

Supreme Court schedules PPACA healthcare law briefs for March 2012

Wednesday, February 15th, 2012

Good Neighbor Insurance (www.gnazhealth.com and www.gninsurance.com) is continuing to update our clients on the new health insurance laws.   There are six major coverage options for those in the US and even though some of the rules and regulations are similar for all many differences are there and it all depends on how old you are and for whom you work.  Many critical details of this new insurance law will be clarified in the months and years to come. 

These six major coverage options are:

(1) Individual or family coverage (private health care plans)

(2) Employee/employer group option for small businesses (typically under 50 employees)

(3) Employee/employer group option for large businesses (typically larger than 50 employees)

(4) Exchange options through the state you are residing in (fully integrated 1-1-2014 and are quasi-government and private insurance coverage combined)

(5) Medicare (which include Parts A, B, C, and D) for those 65 years onwards

(6) Full government health plans like Medicaid, CHIP, TRICARE, VA and other coverage plans as may be designated by the Department of Health and Human Services based mostly on financial criteria and/or military

The Supreme Court on Thursday set the schedule for briefs to be filed ahead of hearing arguments in late March over President Barack Obama’s sweeping healthcare overhaul law.  The high court agreed to a proposal by the three main parties in the legal battle and by two attorneys who have been appointed to argue certain positions.   In a brief order, the court for the most part required that the first set of briefs will be due starting in early January, the other side will file their briefs in February and final reply briefs will be submitted in early March.

The court on November 14 agreed to hear an Obama administration appeal defending the law and urging it be upheld as well as two separate appeals by 26 states and an independent business group challenging the law and urging it be struck down.

The court agreed to consider the following four separate questions:

  1. Whether the U.S. Congress overstepped its powers by requiring all Americans to buy health insurance by 2014 or pay a penalty, a provision known as the individual mandate.
  2. Whether the rest of the law can survive if the mandate is struck down.
  3. Whether challenges to the mandate must wait until after it takes effect in 2014.
  4. Whether Congress improperly coerced the states to expand the Medicaid program that provides healthcare to the poor and the disabled.

The Supreme Court cases are National Federation of Independent Business v. Sebelius, No. 11-393; U.S. Department of Health and Human Services v. Florida, No. 11-398; and Florida v. Department of Health and Human Services, No. 11-400.

Doug Gulleson loves to scuba dive overseas and makes sure he has his U.S. health care and overseas health care, www.gnazhealth.com , information with him at all times when he travels Keep our blog close by you, www.gntravelinsurance.com, for continual updates on the changes with the U.S. health care system.

Bookmark and Share

Tags:
Posted in 2010 - 2012 |

Health care updates – February 2012

Wednesday, February 1st, 2012

Good Neighbor Insurance, www.gnazhealth.com and www.gninsurance.com , is a leading health insurance broker for those in Arizona and those living and traveling outside the U.S.  Here is some notable health news to keep in mind:

HHS (Health and Human Services) loosens electronic health records standards.  This relaxation of healthcare regulations is a push to create jobs without waiting for Congress.  The U.S. Government believes the best use of health information technology will help doctors and hospitals in delivering the right care to the right patient at the right time.  Northeast Ohio is home to one of the strongest networks of electronic medical records in the nation.  

Healthcare reform is said to be benefitting West Virginia Medicare Members.  More than 25,000 West Virginia Medicare members have saved more than $13 million in Rx drugs in 2011 as a result of the Affordable Care Act.  The infamous “doughnut hole” in the Medicare Part D Rx drug benefit is being eliminated over the next few years which is helping save Rx drug cost.

This is not just happening in West Virginia but also throughout the country as stated by many officials in each state.  They are echoing that “Medicare’s prescription coverage gap is getting noticeably smaller and easier to manage this year for millions of older and disabled people with high drug costs.”  The “doughnut hole,” an anxiety-inducing catch in an otherwise popular benefit, will shrink about 40 percent for those unlucky enough to land in it, according to new Medicare figures provided in response to a request from The Associated Press.

Group medical benefit rates still are on a rise but the increases have moderated.  Eighteen months after passage of the Patient Protection and Affordable Care Act (PPACA) group medical benefits costs rose one again according to a recent survey.  The survey finds that the largest accounts – groups with more than 500 employees, benefitted most from the new law.  Most of the group increases ranged from one percent to ten percent. 

Many employers state that the rate increase was lower but that was due to many employers moving to higher deductibles and copays to offset rate increases, which means passing the cost to the employee when using medical insurance.  However, one big emerging development since the passage of the PPACA in 2010 is that carriers and employers are offering fewer options compared to pre PPACA.  As health care costs continue to rise, employers are looking for new ways to promote and maintain a healthy workforce. Demand for wellness tools among employees is also increasing.

California is trying to make its Pre-Existing Condition Insurance Plan (PCIP) go in the black.   The PCIP will morph into California’s exchange program in 2014.  The number of enrollees is still much lower than expected and the average amount of claims per enrollees much higher than expected. PCIP is supposed to provide comprehensive health coverage for people with health problems for a price similar to the price of ordinary individual commercial health coverage.  Eligibility is not base on income and the risk pools cannot charge higher rates for people with more sever health problems.  Congress let states choose between running PCIP risk pools themselves or letting HHS provide PCIP risk pool services for their residents.  To avoid crowding out existing commercial health coverage and government-provided coverage, including existing state-funded risk pools, PPACA drafters required that PCIP enrollees have gone without any form of health coverage, including state risk pool coverage, for at least 6 months.  

Currently only 23,000 people have enrolled into the PCIP program.  The enrollees have been averaging claim cost of $3,100 per member per month, officials say.  The high cost means that, unless more funding surfaces, the program can afford to serve only about 6,800 enrollees at a time, not 23,000, officials say.  The state has found that 19% of the enrollees are ages 29 or under, 41% are ages 30 to 49, and 39% are ages 50 to 64.  The plan administrator is processing 91.5% of clean clams within 10 business days, compared with a goal of 90%.

Seniors go to social sites in droves to share their feeling and opinions on Medicare. They are the fastest growing group of users on sites like Facebook, LinkedIn, and Twitter. They have expanded their share of the social networking areas by more than 150 percent over the past two years.  One of the things seniors want is education.  They often go online to see advice about a program that is constantly changing, like Medicare.  A senior mentioned on one of the post “Who can explain and make all these rules and restrictions easy to read.”  Next to education seniors also want to make sure that the information is trustworthy and not just a sales pitch for a special Medicare benefit.

Seniors spend a lot of time talking about Medicare plans types and supplements.  Medicare Part D comes first as the hot topic then a close second is about Medicare supplements.  Seniors are constantly confused by changes to private plans and so vent their frustrations on the insurance companies handling the Medicare advantage or supplement plans.  However, as the insurance companies explain, a majority of the new rules and changes have come down the U.S. government and they must comply with all these added rules.   The new PPACA health rules signed into law in March 2010 is why most of the changes and new rules have come from. 

A new trend is happening in the U.S., “doctors do not do old.” A looming shortage of geriatricians adds another wrinkle to dealing with long-term medical care issues.  Older people tend to need more medical care than younger people, and the average age of a U.S. resident is going up.  But because the U.S. government reimburses doctors less money through Medicare than what the going rate is for private practice less and less doctors want to venture into this profession.  It comes down to dollars and cents says many doctors.  “We have to follow extra government laws handed down by the PPACA, Congress, and the department of Health and Human Services.  And to top it off we get paid less on the dollar for Medicare patients, since the government reimburses us most of the time we see those who are 65 and over, than through private insurance.”  Medicare primarily covers those who are age 65 and over in the U.S.  So more work for Medicare clients and getting paid less by the government is causing a shortage of geriatricians in the U.S.   

One of the ways to counter this trend is for the government to improve the state of geriatric education by requiring hat every medical school it helps have an affiliation with a nursing home as well as with a teaching hospital.  Currently there is only around 3% of medical schools that have required classes in geriatrics.  Some say that that must increase because “out of sight out of mind” sets in.   Having geriatrics more front-and-center in medical school will help bring more doctors into this field.  However, again, many if not most decisions are based on income potential.  As an official at a local medical teaching hospital stated “as long as Medicare reimbursement to doctors is less than the open market there will always be a shortage of geriatric doctors.”  Many things change but math calculations never change. 

Doug Gulleson loves to scuba dive overseas and makes sure he has his US health care and overseas health care, www.gnazhealth.com , information with him at all times when he travels   Keep our blog close by you, www.gntravelinsurance.com, for continual updates on US and international health care.

Bookmark and Share

Tags: , ,
Posted in 2010 - 2012 |

Long term care information – 2012

Wednesday, January 11th, 2012

Long term care (LTC) is coverage that provides home health care, adult day care, and nursing home coverage for individuals 65 onwards or someone who has a chronic or disabling condition that needs constant supervision.  This benefit package helps provide for the cost of long term care beyond a predetermined period.   

LTC is not health insurance or medical care.  Individuals who require LTC are usually not sick in the traditional sense but instead are unable to perform the daily activities.  Activities of Daily living (ADL) is what health professionals call the routine ability of feeding, bathing, dressing, grooming, work, homemaking, and leisure.   There are several evaluation tools that the medical profession uses such as the Katz ADL scale, the Lawton IADL scale, the Roper-Logan Tierney model of nursing, and the program of all-inclusive care for the elderly (PACE).  

Good Neighbor Insurance, www.gnazhealth.com, provides different LTC options for our clients.  Good Neighbor Insurance (GNI) also provides individual and family health insurance, Medicare Supplement plans, dental plans, personal property and casualty cover, and other benefits such as short term travel insurance.  You may reach any of GNI’s agents by calling their toll free number at 866-636-9100 or Phoenix Arizona number at 480-633-9500 or email them at info@gninsurance.com.

Why do U.S. citizens purchase LTC cover?

  • Protect assets
  • Avoid becoming a burden to their family
  • Ensure they receive care in a quality facility
  • Ensure they have options for care
  • Be able to maintain personal dignity and independence
  • Have peace of mind.

Why U.S. citizens do not purchase LTC cover?

  • Is it affordable?
  • Is it the best way to protect my assets?
  • How do I make sense of this complicated product?
  • What is in the fine print?
  • When is the best time to buy?
  • Will the benefit level be enough when the time comes?
  • Am I not covered already?
  • What if I never need it?
  • Why has no one approached me about it?

What do our clients expect from one of our LTC agents?

  • Life experience – an older agent because of a greater life experience
  • Low pressure, easygoing manner – no hard sale
  • The ability to explain the benefits in easy terms
  • Specific knowledge of the senior market
  • Agent should have a LTC policy too

Who typically desires to purchase a Long Term Care policy?

  • Female, Caucasian, age 55-64
  • Married with adult children
  • Working in a white-collar profession; not yet retired
  • College educated
  • Living in a metropolitan area with a population of at least 250,000
  • A homeowner with 11 or more years in a the current resident
  • Affluent; upper middle class with a household income of $100,000 or more
  • A “planner” who is interested in financial issues; owns life insurance and other conservative investment products
  • Family oriented
  • Exposed to LTC issues; knows someone (a family member or friend) who has needed LTC services
  • Research oriented; an online user; self-educated about LTC
  • Generally skeptical and mistrusting of financial advisors and insurance companies

Doug Gulleson loves to scuba dive overseas and makes sure he has his US health care and overseas health care, www.gnazhealth.com , information with him at all times when he travels   Keep our blog close by you, www.gntravelinsurance.com, for continual updates on US and international health care.

Bookmark and Share

Tags: ,
Posted in General information |

« Older Entries