The Federal Mandate works to level the playing field while providing care to everyone, including those with pre existing conditions, to avoid insurers "cherry-picking" healthy members. To accomplish this, a portion of the revenue from the companies with healthier members goes to the companies with less healthy members. However, defects in the small-group program have resulted in New York’s smaller, more-innovative insurers like CareConnect to subsidize larger competitors.

The Direct Effect to Northwell CareConnect
 CareConnect has to make a significant transfer of revenues as mandated by the Affordable Care Act.
 To illustrate: Care Connect has approximately 7% in fixed costs, 80% in medical expenses, along with state and federal taxes of 5%. This illustrates that CareConnect is doing well and would generally lead to a slight increase if any.
​
However,
 In 2016 with revenues of approximately $700,000,000, CareConnect’s Federal Risk Adjustment liability is $112,000,000
 92% of that revenue transfer is going to Oxford which maintains approximately 55% of the  total NYS market. In the downstate area (which most of us live in) they represent 70% of the market.

Right now, Northwell CareConnect has the most cost effective plans in each of the Metallic Levels. CareConnect with other organizations are trying to have this mandate repealed for the small group marketplace (2‐100 ee’s on the payroll). It is creating a burden on small businesses and their employees along Main Street. If the Federal Risk Adjustment mandate were to be repealed, executives at CareConnect stated they would apply for a minimal increase, if any.

So far the Mandate remains, causing Northwell CareConnect to request withdrawal from the health insurance marketplace. CareConnect operations will continue over the next year as the company works with its customers, businesses and others to help transfer policy holders to other health plans. Throughout the transition, CareConnect will continue to pay claims and serve members, patients and providers.  Optimistically, we are hoping for a change of heart from the ACA. This directly affects hard working New Yorkers trying to obtain quality affordable coverage.

• Insurers have been unsure whether the mandate requiring everyone to have insurance will be repealed.
• Insurers do not know whether the Administration will continue to make payments to compensate them for cost share reduction subsidies given to lower income individuals
• Ultimately insurers will factor in this uncertainty in their premium offerings.
• The ever increasing taxes being buried within the premiums are also creating havoc and in reality are being paid by employers and employees.
• The Federal Risk Adjustment Mandate: This one has really backfired and did not go according to the game plan. It appears it became one of those “OOPS situations. In reality, it is causing one of the major insurers in the NY Market with 18% of the business to exit the health insurance business. The irony is that they were doing very well. The astronomical amount (approx. $112 million) they have to pay because of the Federal Risk Adjustment mandate is not allowing then to be competitive and profitable. This action is causing the most competitive insurance company providing access to quality physicians and hospitals to leave. Northwell CareConnect offered the best price point in the entire marketplace. When comparing apples to apples, the next option is more costly to employees. Once again, small employers and employees get clobbered.​

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So much of life, work, family and entertainment now takes place online, so it’s no surprise healthcare delivery is increasingly happening online as well.

There were 1 million virtual doctor visits in 2015

Why?

• Cost reduction. For both preventative care and acute incidents, telemedicine has been shown to reduce the number of emergency room visits.
• Technology is a prime enabler of telehealth growth. Video conferencing applications have become so sophisticated the virtual has actually become close to physical. People are becoming comfortable using applications like Face Time and Skype.
• For millennials the desire for telemedicine will come naturally.
• Because it is so convenient people will gravitate toward it.

A 2016 survey reported by the national Institute of Health showed between 94-99% was very satisfied with telehealth.
Who can benefit?

• For those of you who have Northwell CareConnect or OSCAR have the opportunity of utilizing telemedicine.
• There is no charge for the telemedicine visit.

Most of us at some point in time have had to select a health insurance plan. There are many factors to consider in order to select the plan that is right for you. At Mainline insurance we conduct a full needs assessment before we even begin to look at plans. That way we show you plans that make sense and remove the plans that are not really an appropriate option. 

A simple needs assessment is conducted in a few minutes. We evaluate your health, income, age, eligibility and provider network preferences.

First is your overall health, how often do you see a doctor? once a year? once a month? Do you see any specialists or take any medications on a regular basis. If so are these medications generic or specialty drugs? Let's say for example you are healthy, a physical once a year and the occasional cold. It may make sense for you to lean towards a lower premium plan at the catastrophic, bronze or silver level. All ACA plans include free preventative care (physical, blood work, usually a free doctor visit) For a healthy individual this may be suitable for your needs and save you money with lower monthly premiums while still providing max out of pocket protection in the event of something catastrophic happening.

Alternatively, maybe you see a doctor often, perhaps you are diabetic. Typically, people in this situation require multiple specialist visits a year, monthly medication and durable medical equipment. For these individuals it makes sense to do a platinum level plan. Although premiums are much higher, the max out of pocket is lower and in the long run you will actually save money as you engage the healthcare system.

In the individual market, income is important. For an individual in New York earning between $16k and $46k/year you will likely qualify for subsidies in the form of Advanced Premium Tax Credits. These APTCs will reduce your monthly premiums by an amount dependent on you income. It is important to consult a professional so they can assess your income accurately and get you the appropriate tax credit amount. 

Age does make a difference, If you are younger than 30 you have plan options that are relatively inexpensive, so if you are healthy they may be the most economical option and provide only the coverage you need instead of paying for services you won't use. For older individuals you may think, "Well I'm healthy, I don't need a high level plan." This may be true, but keep in mind as you get older, things break, that's life unfortunately. In that case it may be worth it to have the security of a gold or platinum plan.

Eligibility is a big factor. During Open Enrollment, which is between November and February anyone can freely purchase or change health insurance plans without restriction. However, if you are outside of this time period in what's call Special Enrollment, you will need to have what is called a Qualifying Life Event. This is typically an involuntary loss of coverage (ex. lost a job, lost coverage). There are other's but we will save them for another day.

Finally, we look at provider network. If you are seeing a doctor or prefer certain doctors and hospitals its important we consider only plans that cover those physicians. At Mainline we have the resources to determine which doctors are in a plans network and which ones are not. Let us do the research for you.

If this all seems too complicated and too labor intensive don't worry, we have licensed brokers standing by ready to assess your needs and find the plan that's right for you.

The types of Voluntary Benefits are:
Dental, Vision, Short Term Disability, Long Term Disability, Life Insurance

Dental insurance is designed to pay a portion of the costs associated with dental care. Generally dental offices have a fee schedule, or a list of prices for the dental services or procedures they offer. Dental insurance companies have similar fee schedules which is generally based on Usual and Customary dental services, an average of fees in your area. The fee schedule is commonly used as the transactional instrument between the insurance company, dental office and/or dentist, and the consumer.

Vision insurance and vision plans can lower your cost of eye care and prescription eyewear. Vision insurance is an optional health policy that entitles you to specific eye care and eyewear benefits defined in the policy.

Short Term Disability Insurance can replace a portion of your income during the initial weeks of a disabling illness or accident. Policies can cover from the first 6 months up to a year of a disability, providing coverage during the waiting period of most Long Term Disability Insurance plans.

Once the short-term benefits expire (generally after three to six months), long-term disability insurance pays a percentage of your salary, usually 50 to 60 percent, depending on the policy. The benefits last until you can go back to work or for the number of years stated in the policy.

Life Insurance is a contract between an insurance policy holder and an insurer or assurer, where the insurer promises to pay a designated beneficiary a sum of money (the benefit) in exchange for a premium, upon the death of an insured person (often the policy holder). Depending on the contract, other events such as terminal illness or critical illness can also trigger payment. The policy holder typically pays a premium, either regularly or as one lump sum. Other expenses (such as funeral expenses) can also be included in the benefits.

How will the government know who has coverage through their job? Simple, sort of. Employers are required to complete the 1094C ACA Compliance draft form. It is called the transmittal of employer provided health insurance offer and coverage information returns. It will be used to identify employees on payroll that are receiving health coverage. It is also accompanied by a 1095C form to be filed by ALE members which is the Applicable Large group Employer(50+ employees on payroll). The Internal Revenue Service has issued draft versions of the reporting forms. Most employers will begin using the forms next year to show that their group health insurance plans comply with the health care reform law.

The long-awaited draft forms are the first practical application of employers' health care coverage and enrollment reporting obligations under the Patient Protection and Affordable Care Act since the regulations were finalized in March.

The forms are the primary mechanism through which the government intends to enforce the health care reform law's minimum essential coverage and shared responsibility requirements for employers.

Beginning in 2015, employers with at least 100 full-time employees will be required to certify that benefits-eligible employees and their dependents have been offered minimum essential coverage. Their employees' contributions to their premiums must comply with cost-sharing limits established under the reform law. Smaller employers with 50-99 full-time employees are required to begin reporting in 2016.

Additionally, self-insured employers will be required to submit documentation to ensure compliance with minimum essential coverage requirements under the reform law's individual coverage mandate. Download the 1094C ACA Compliance Form Draft below.

This form is a draft and not to be used for filing. The purpose is to give employers a better understanding of the program requirements and prepare them for compliance in 2015. As always Mainline Insurance is on your side and ready to assist in form preparation and enrollment.

Beginning January 1, 2014, all current Emblem plans (including the GHI Healthy NY EPO and HIP Healthy NY HMO) will end. At this time, new plans will be offered. For Clients that have Emblem through HealthPass or the LIA, existing plans will be mapped to a different plan being offered. All new Emblem plans will meet the 10 essentials benefits that are now required by the Affordable Care Act.

The benefits and rates for all the new Emblem HMO plans (including Healthy NY) are attached to this distribution. The Affordable Care Act, requires benefits such as physical therapy, mental health/substance abuse treatment, chiropractic, and durable medical equipment to be included in the Healthy NY Plan.

The network of doctors and hospitals on these plans have also changed. If continuing your current physician relationship is important to you, we suggest contacting your physician’s office to see if they participate in the new network. The name of the new network is Select Care.  If  your physician already participates in the Select Care Network or you are willing to change physicians, this plan is a viable cost effective option. It should be noted that this plan has a significantly smaller physician network.

If you wish to choose any of the new Emblem plans for January 1, 2014, you are required to fill out new applications to reapply.

The Emblem Healthy NY Plan, while competitively priced, has a smaller network than previous. We are here to help you, with this transition of benefits. Mainline Insurance will review all of the options available to you and synthesize the optimal individual solution. We are very sensitive to our client’s benefit needs and budgets.  If obtaining benefits on the New York State Health Benefit Exchange is the most viable option, Mainline Insurance is certified and authorized to help you with this at no additional cost.

For clients that have Emblem and are billed directly from Emblem, additional steps must be completed or no coverage will be effective for January 1, 2014.

It has been difficult due to technical malfunctions and insurance network changes to identify participating physicians. We hope to see these issues remediated over the next few months. However, for the present time please check directly with those providers that are vital to your well being about which networks they participate in.  This is very important as we previously mentioned, networks have changed significantly.



Click To Download 2014 Emblem HMO Plan Design And Rates

Click To Download 2014 Emblem Healthy NY Rates

Click To Download 2014 Emblem Healthy NY Plan Design

is a key component of the Affordable Care Act.

Purpose:
    To help covered individuals and families with the out of pocket expense when they access care.

How Does Someone Qualify?

• Household income must be between 100% - 250% of the Federal Poverty Level.(FPL)
  
• Covered individuals must be legally present in the USA.
  
• Covered individuals must not be eligible for Medicare or Medicaid.
  
• Covered individuals must not be eligible for employer sponsored affordable healthcare coverage. This appears to give incentive for small businesses with employees in lower income bracket to drop coverage and have employees go on their own. We have a strategy for this situation to help both the employer and employee.
  

For 2014 under the Affordable Care Act the maximum out of pocket limit is: $6,250 for a single and $12,500 for a family. this is where the Cost Sharing Reduction kicks in.The level of  reduction in the out of pocket limit is based on income level.                                   

Example:
    This example is an approximation.

• 100-200% of Federal Poverty Level                     the reduction in the out of pocket is by 66%
  
• 200-300% of FPL                                                the reduction in the out of pocket is by 50%
  
• 300-400% of FPL                                                the reduction in the out of pocket is by 33%
  

The maximum out of pocket limit is reduced by the percentages you see above.

If you fall into the 200-300 of FPL category you would qualify for a 50% reduction.
This would mean the maximum you would pay out of your pocket for co-pays and deductibles would be $3,125 for a single or $6,250 for a family.

The Cost Sharing Subsidy is a key component in the new Affordable Care Act to help making healthcare affordable.

Regards,
Vincent

This months marks the start of open enrollment. You will have the opportunity to change plans if you are unhappy with the one you are currently on. 

Medicare Open Enrollment Period: October 15th, 2013 through December 7th 2013

If you have a Medicare Supplement Plan here are some of your options.

1. Move to a Medicare Advantage PPO program
   
2. Move to a Medicare Advantage HMO program
   

Currently, you do not have a network of providers to deal with. You have access to any provider or hospital that accepts Medicare. With all of the Medicare Supplement plans we offer Part D for prescription drug coverage.

The Medicare Advantage PPO and HMO Programs have networks to access to receive the most cost effective care. The Medicare Advantage program allows you to go outside the network but with higher out of pocket costs

If you have a Medicare Advantage PPO here are some of your options.

1. Move to a Medicare Advantage HMO program, however you lose the ability to use out of network providers.
   
2. Move to a Medicare Supplement program with no restrictions on network providers. You have access to any provider or hospital that accepts Medicare.
   
   

If you have a Medicare Advantage HMO here are some of your options.

1. Move to a Medicare Advantage PPO program and have the option of going to doctors out of network.
   
2. Move to a Medicare Supplement program and have access to any provider or hospital that accepts Medicare.
   
   

Programs that Mainline Insurance Offers:

• United Healthcare Medicare Supplement offered through AARP
  
• Part D prescription drug coverage.
  
• United Healthcare Medicare Advantage HMO program
  
• Empire BCBS Medicare Advantage PPO program.
  
• Empire BCBS Medicare Advantage HMO program
  
• Emblem Medicare Advantage PPO program.
  
  

Programs Costs

• Medicare Supplement plans with Part D come in the  $200 to $300 range monthly. Most clients enjoy the comprehensive benefits of Plan F with the Part D prescription drug coverage.
  
• Medicare Advantage plans as an HMO or a PPO run between $0 to $200 monthly depending on which county you reside.

Best Regards,
Vincent Reda