PCORI Fees on Medical Mutual Bills

Healthcare Reform: PCORI Fees Appearing on Invoices in Early 2013

The federal government began assessing health plan sponsors a Patient Centered Outcomes Research Institute fee, or PCORI fee, this fall based on federal regulations in the Affordable Care Act. To cover this fee we will begin to include it on most fully insured group (all market segments) and most individual account invoices in 2013.

Beginning with the earliest possible invoice in 2013,* Medical Mutual will assess a $0.16 per member per month fee. The assessment will capture every contract holder and dependent in the calculation. Applicable group and individual invoices will include a line item for this fee that reflects the per-member-per-month charge. Areas of business not impacted by PCORI at this time include:

• High Risk Pool
• Medicare Supplement
• Individual Short Term
• Dental, Vision and Life

We are sending a letter to impacted 1-99 fully insured groups and to impacted individual policy holders, as well as our 100+ and self-funded groups.

 *As a courtesy to our customers, we are not assessing any fees to our fully insured group customers or individual customers for the first three months the PCORI fee was in place (October, November and December 2012). We will absorb this initial amount, which is about $150,000

Update from Medical Mutual of Ohio 12/3/2012

Find more information about PCORI here

Summary of Benefits and Coverage

The Summary of Benefits and Coverage (SBC) is a new plan document required by the Affordable Care Act.  The purpose of the SBC is to give members information about health insurance benefits in an easy to understand format.  All employers and insurance companies are required to use the same document format outlined by the final regulations.

The new SBC has required outlines which include:

• Basic benefits and coverage
• Cost sharing requirements
• Exclusion and limitations of the plan
• Examples of how the plan would cover:
• Normal delivery of a baby
• Type 2 Diabetes
• Information on how to access a uniform glossary that provides definitions of health coverage & medical terminology used in the SBC.  

You do not need a SBC for:

• Stand alone dental
• Stand alone vision
• The bank account of a Health Savings Account Health
• FSAs if funded solely with employee pre‐tax salary reductions

To whom must the SBCs be provided?

• Covered EEs
• Their covered dependents
• Anyone who is eligible to enroll

Timelines and Triggers for Distributing the Summary of Benefits and Coverage

Employer Sponsored Plans

• Renewal – No later than 30 calendar days before policy’s effective date
• New business – within 7 days of receipt of application
• Active enrollment periods  – SBC must be provided with enrollment materials
• Automatic enrollments – in which members do not have to take any action to sign up, the SBC must be provided no later than 30 days before the effective date.
• Open Enrollment –No later than first day of the open enrollment period
• New hires – SBC needs to be provided with enrollment or application materials.  If enrollment materials are not distributed, then no later than the first day of enrollment.
• Special enrollee – any member that gets married, has a child, or loses other coverage and enrolls outside of open enrollment - 90 calendar days from enrollment.
• Upon request – within 7 days
• Material Modification* – No later than 60 days before the effective date of the coverage change.  Send a notice of the Material Modification or a revised SBC.

*A material modification, as defined by ERISA is generally described as any modification to the benefits that either enhances or decreases the benefits to subscribers or that changes the content of the SBC.  

Individual plans:

• Renewal– No later than 30 days before the first day the new policy’s effective date.
• New Application – within 7 days.
• Upon Request – within 7 days.

Distribution of the Summary of Benefits and Coverage

The SBC may be delivered either in paper form or electronically.  If you choose to send the SBC electronically there are certain guidelines that need to be followed to avoid a penalty. 

Employees that are already enrolled and have access to the company’s computer system is an integral part of their job.

• The email must protect any private information.  
• Include the significance of the SBC
• Notify employee that a free paper copy is also available upon request.
• Maintain the style, content and format requirements of the SBC.

Employees that are already enrolled whose jobs do NOT have access to the company’s computer system as an integral part of their job.  Prior consent must be obtained from the employee to receive the SBC electronically. 

• The consent can be a paper notification or email and must include the following:
• Types of documents being sent
• How to access the SBC electronically
• Rights to withdraw from consent at any time
• Procedure for withdrawing consent

For anyone who is eligible for coverage but not yet enrolled:

• Paper notification or an email on how to access the electronic SBC. 
• Ensure the SBC is readily accessible.

The SBC will also be available in several different languages.   Depending on your individual situation, you may receive the SBC from your insurance provider, your employer or your current insurance agent. 

The employer is responsible for the distribution of the SBC to employees.  The insurance companies will not be distributing the SBCs directly to your employees. This is important to note since there is a financial penalty attached to these new requirements.

Penalty Information

Included in the new SBC requirements are financial penalties for noncompliance.  Employers offering group health insurance coverage that willfully fail to provide the SBC will be subject to a maximum fine of $1,000 daily for each employee plus a daily $100 penalty per employee in excise taxes.

For example if you have 50 employees and fail their SBC for 30 days:

                

Daily penalty 50 x $1000 = $50,000

30 days x $5000 = $1,500,000

Excise tax 50 x $ 100 = $5000

30 days x $500 = $150,000

TOTAL PENALTY:  $1,650,000

                               

However, during the first year of implementation the penalties will not be enforced as long as employers and insurance companies are working diligently and a good faith effort is being made to communicate the SBC to all parties.

If you are a current client of Creekstone Benefits and have any questions regarding the Summary Benefits and Coverage please contact us 740.967.0210.

For more detailed information and examples of the Summary of Benefits and Coverage please click on the links below:

Healthcare.govGeneral SBC Information 

Department of labor FAQ

Sample SBC

Uniform Glossary

Republican Platform for Medicare Changes

Amidst the fiery speeches and political pageantry, Republicans at the party’s national convention in Tampa last week adopted a party platform that attracted much media attention for its shifts on issues such as Medicare. The platform calls for significant changes to Medicare and Medicaid largely in keeping with proposals outlined by U.S. Rep. Paul Ryan (R-WI), the party’s nominee for vice president. The platform calls for partially privatizing Medicare by allowing seniors to choose between existing Medicare coverage and a subsidy to help buy private insurance. The platform also calls for converting Medicaid into a state block-grant program, giving states the power to control the number of people eligible for Medicaid and the benefits they receive. The proposals represent a change from previous Republican platforms but have the endorsement of both Ryan and the Republican presidential nominee, Mitt Romney. The Republicans also continue to call for repeal of the Affordable Care Act (ACA).

From Aetna, "Health Care Reform updates for the week of September 3"

Women's Preventive Healthcare Benefits – Effective 8/1/2012

As you may know, the federal health care reform legislation, known as the Patient Protection & Affordable Care Act (PPACA), includes changes that are being phased in over a number of years. The latest set of changes now includes coverage for Women’s Preventive Health Benefits.

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

• 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

To have these benefits you must be on a Non-Grandfathered plan, or one that has most likely changed since the PPACA was signed into law.   If you are unsure if you have these benefits and Creekstone Benefits is you broker please don't hesitate to contact us 740-924-0210.  If we are not your broker please contact your HR department or your current insurance broker.

2013 HSA Limits Announced

HSA Contribution Limit:
     Indvidual coverage: $3,250
     Family coverage:  $6,450

HDHP Minimum deductible:
     $1,250 Individual coverage
     $2,500 Family coverage

Out-of-Pocket Maximum Expense:
     $6,250 Individual coverage
     $12,500 Family coverage

Remember as of 2011 over-the-counter drugs may only be reimbursed if they have a prescription.

If a policyholder uses an HSA to pay for items or services that aren't qualified medical expenses, the tax penalty is 20% of the HSA distribution.

What to ask your doctor

Here are some important questions you should ask your doctor when you go for a visit:

•  Do I need to come back for another visit?
•  Can I call for any test results?
•  What else do I need to know or do?
•  Is this a preventive or a diagnostic care visit?
•  What should I do to prevent or delay health problems?
•  Are there any changes I should make to improve my health?
•  Are there any tests or screenings I should have, based on my age or other risk factors?
•  Am I due for any shots?

After you’ve talked with your doctor, there are three questions you should be able to answer for yourself:

   1. What is my main problem?
   2. What do I need to do?
   3. Why is it important that I do this?
If you can answer those three questions, you’ll know you got the information you need to get or stay healthy.

National Patient Safety Foundation, Ask Me 3.(Accessed January 2011): npsf.org
Anthem publication MANSH3911ABS Rev. 1/11 F007545

What’s preventive care and diagnostic care?

Did you know that there are tests that can help you stay healthy, catch any problems early on and could save your life? These tests are called preventive care because they can help prevent some health problems. They’re different from diagnostic tests, which help diagnose a health problem. Diagnostic tests are given when someone has symptoms of a health problem and the doctor wants to find out why.


It’s important to know the difference between preventive tests and diagnostic tests. For example, if your doctor wants you to get a colonoscopy (a test that checks your colon) because of your age or because your family has a history of colon problems, that’s called preventive care. But, if your doctor wants you to get a colonoscopy because you’re having symptoms of a problem, like pain, that’s called diagnostic care.

Preventive care is paid for by most medical benefit plans, but you’ll have to pay part of the cost of diagnostic care, depending on your specific plan.

Not all preventive care is recommended for everyone, so talk to your doctor about what you need.

Anthem: MANSH3911ABS Rev. 1/11 F007545