We do more than just health insurance…

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Group Medical


  • Private
  • SHOP


Individual Medical


  • Marketplace
  • Private
  • Short-Term




  • Supplements
  • Advantage (MA)
  • Prescription (PDP)





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Life Insurance


  • Universal Life
  • Whole Life
  • Term Life
  • Final Expense Plans




  • Annuities
  • Disability




  • Call a Doctor Plus
  • Hospital Indemnity
  • Cancer Plans
  • Accident
  • Critical Illness
  • Long Term Care (LTC)
  • Short Term Care


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We do more than just provide health insurance…


PCORI Fee Due July 31st

2014 PCORI Fee is Due July 31st…

Riddled throughout the Affordable Care Act (ACA) / Obamacare were fees for this, and fees for that.  Some significant – some not so significant.  But all of which could be significant if you fail to pay them and pay them timely.  

One of the not-so-significant in size or dollar amount is the Patient Centered Outcomes Research Institute Fee that most group accident and health, or major medical plans are required to pay.

What is the PCORI Fee?

The PCORI fee was established and included in ACA to help fund the research efforts of the Patient Centered Outcomes Research Institute ultimately intended to assist patients, clinicians, purchasers and policy-makers, in making informed health decisions by advancing the quality and relevance of evidence-based medicine. The institute will compile and distribute comparative clinical effectiveness research findings  What exactly that means for most of us will likely never be known.

Who has to pay the PCORI Fee?

Generally speaking, any group health plan that is considered a “specified health plan” is subject to the fee.  For the most part, fully-insured carriers are paying the fee on behalf of their insured contracts.  Self-funded plans, however, must ensure that they include the annual PCORI fee in their 2nd Quarter Excise Tax Filing (due July 31st) – and use Form 720 accordingly.

How much is the PCORI Fee?

For 2014, the fee increased to $2 times the average number of participants in the plan.  There are a few different ways self-insured plans may calculate the number of participants, and they include:  the actual count method, the snapshot method, or the Form 5500 method.  Final regulations explain the calculation methods in greater detail.  Click here for more information.

What are some examples of specified health plans?

The IRS has published a chart here to outline plans that would be subject to the PCORI fee.  The most frequently overlooked plan is a self-funded Health Reimbursement Arrangement (HRA) that many employers administer in-house.  Excepted benefits are those not generally considered health coverage – or limited scope benefits (i.e. AFLAC Accident plan).  For further info on excepted benefits, refer to the Federal Register here.

You Can Keep What You Have…

        … and a few of our carriers are going to let you!

You may have heard about grandfathering and how it relates to your group health insurance plan, but have you heard that your plan may now be grandmothered?

Many businesses contracted under fully-insured group health plans seized the opportunity renew their contract(s) in December 2013 to avoid the sharp premium increase that Healthcare Reform was expected to impose as a result of the community rate reforms mandated for the small group market and under the Affordable Care Act (ACA).  For most, opting for the early renewal simply meant postponing the inevitable.

Recently, current Administration announced that once again insurers were going to be allowed to extend the delay of community rate reforms – and into 2015.  Although the decision was left to the States and insurance carriers to make, a couple of the more popular fully-insured carriers in NE Indiana have announced they will be doing just that.  Both Anthem BC/BS and PHP have opted to release “grandmothered” renewals for their existing groups currently active under 2013 contracts.  (Both chose not to extend the opportunity to Individual policyholders.)  There is a little hitch in the wagon, however.

Employers with 2013 contracts scheduled to renew beginning as early as May 1, 2013, can expect to receive a grandmothered renewal offer.  The offer, however, will be limited to current benefit plan(s) only.  In other words, no putting a band-aid on the increase by raising deductibles.  If you want to change the benefit plan – you must transition to the ACA side of the business.  And this equates to community rates for your group.

Here at Health Insurance Shop, we visited with each and every one of our small group clients last Fall to discuss the pros and cons of moving into an ACA compatible plan, and/or opting to accept the December renewal offer.  This year, we expect that the majority of our small group plans will agree that grandmothering will be the most affordable option – but do expect a handful could find that transitioning to the ACA side might make more sense.  Depending upon what their renewal offer/increase is.  Either way, we will be prepared to make recommendations for you to consider.

What Are Community Rates?

Did you know?  Rates are the rates, are the rates, are the rates.  That is basically what community rates mean.  The Affordable Care Act states that small group health plan rates can no longer discriminate based upon factors like health risk, SIC, etc.  Instead, rates may only be based upon a few factors:

  • where an employer is located (zip code);
  • the age of the individual covered
    • employee
    • spouse
    • dependent children under age 21
    • dependent children 21 and over
  • whether or not the covered individual uses tobacco products
  • how an individual is enrolled
    • single
    • family

SHOP Exchange Expected to be Open for 2015

The Patient Protection and Affordable Care Act (aka Healthcare Reform) included provisions for small employers to buy health insurance through an Exchange or Marketplace referred to as the Small Business Health Options Program (SHOP).  The implementation of SHOP in states with Federally Facilitated Marketplaces (FFM) was delayed for operation in 2014 to allow developers the time needed to ensure that the enrollment process would be as smooth as possible.  Now that most of the kinks have been worked out on the Individual enrollment side, confidence is high that small employers will have SHOP as an option later this year.

How Does SHOP Work? 

SHOP Exchange is expected to allow employers to choose a “metal tier” of benefit options (i.e. Bronze, Silver, Gold, or Platinum) from which their employees can select a benefit plan that meets their needs, wants, and pricing desires.  Employees would have the ability to choose between participating insurers, and any of the benefit plans they offer on that specified metal tier.  Unlike the historical “defined benefit plan” arrangements where the employer chooses the benefit plan(s), the employee will be in the plan selection driver’s seat in SHOP.

Since employers will be limited to specifying the metal tier of benefits for their employees, SHOP will transition small group plans into a “defined contribution” arrangement.  Meaning:  the employer will establish the dollar amount (or allowance) that they will contribute toward the cost of coverage for their employees by averaging the actual cost of plans selected.  Employers would then deduct the balance from employees payroll to be remitted to the SHOP.

Pro’s and Con’s of SHOP

As with any new program introduced to the market, SHOP will have good and bad attributes.  Recent releases from various industry publications would indicate that carrier participation in the SHOP program will be greater than what was anticipated for 2014.  As of today, it would appear that Anthem BC/BS and Physicians Health Plan (PHP) are definitely going to participating, with a few others seriously contemplating their position in the Indiana SHOP exchange.  The Pro in this case would be more carriers to choose from.

The number of plans offered, however, appear to be quite limited.  This could very well be due to the fact that mandates in the ACA require insurers to price products on and off the Marketplace the same.  When calculating in the guaranteed issue requirement, influx of adverse selection, and the likelihood that employees would choose a “richer” benefit plan if they have high healthcare utilization – insurers will align themselves in such a way to limit the exposure.  Reducing the number of plans available is certainly one way of accomplishing that goal, but isn’t necessarily the best option for a small group plan.  The Con in this case would be fewer plan designs to choose from.

Participation requirements will be monitored closely by carriers participating in the SHOP exchange.  In most states, 70% of your full-time eligible employees will be required to enroll in SHOP – regardless whether they may be enrolled through spouses employer plans, Medicare, or other coverage.  Some small groups plans may struggle to meet this requirement.

Who can enroll in SHOP?

Although a small group was redefined in ACA to include employers with fewer than 100 full-time equivalent employees (FTE), the initial implementation for SHOP will only be available to employers with fewer than 50 FTE’s.  It is expected that beginning 2016, eligibility for SHOP will expand to employers with few than 100 FTE’s.  With the numerous delays already experienced in Healthcare Reform – only time will tell.

Should you use an agent or broker instead of a Navigator to enroll in Obamacare?

The Affordable Care Act (ACA) – otherwise known as Obamacare – specifically included parameters under which properly certified individuals could assist the general public with the enrollment process into the Marketplace/Exchange.  These individuals were referred to as Navigators.

While Navigators are required to successfully complete the Centers for Medicare & Medicaid Services (CMS) certification process, these individuals were not required to be licensed agents or even be covered by Professional Liability or Errors & Omissions (E&O) insurance.  When I read this portion of the new law, I became deeply concerned over the misconceptions that were likely to happen due to the lack of insurance knowledge these Navigators would possess.

Having been employed in the health insurance industry for nearly 25 years, I knew all too well how complex benefit plans can be.  (I thought this was the reason I was required to be licensed and also required to maintain continuing education to renew my license.)  I was certain that the lack of knowledge of available health insurance plans; the narrowing of provider networks; and overall ignorance of benefit structure within plans was sure to prove to be a detriment as time goes on for those who enrolled into the Marketplace with a Navigator.  Some of these confused buyers have already contacted us to see if we could “fix” it for them or explain to them just exactly what they bought.

When choosing a professional to help with you with some task or process that you are not comfortable tackling yourself, it is best to try to get help from someone that has experience and knowledge in the subject at hand.  Choosing an agent or broker to assist you in enrolling in the Marketplace provides you with the ability to work with someone who lives and breathes health insurance.  Generally speaking, agents and brokers invest the time to study the differences between carriers, networks, and plan designs, in order to make effective recommendations based upon your needs.  When working with a Navigator, the experience is likely to be reduced to just picking a plan that has the lowest premium – and seeing what happens from there.

Choosing an agent or broker to assist you with enrollment in the Marketplace doesn’t cost you anything.  But what you gain from the experience and future relationship you will be sure to have with that agent or broker, could be priceless!