Great article defining the 90 day wait and other statutes regarding the use of the wait period on Orientation Periods. Click on the Health Net Pic to read the entire article. 

Because Small Business Group Members may only be enrolled on the first of the given month, the longest probationary period a Small Business Group Employer may impose is the First Of the Month Following (FOMF) 60 days...

Blue Shield's new Treatment Cost Estimator video shows you just how powerful it is!  

Covered California
Open Enrollment Begins November 15
Open enrollment for 2015 health insurance plans through Covered California begins Nov. 15, 2014, and ends Feb. 15, 2015.

Covered California is a part of the state of California and was created to help you get health coverage to protect yourself and your loved ones. Having insurance can ensure your access to medical care if you get sick or are injured, so that you can keep your body healthy, but it also protects your peace of mind, because you can rest assured that you will have help when you need it most.

Make sure you don't miss the deadline! Obamacare closes up on March 31st.  Choose a plan by March 31st. Pay by April 25th! 

Give us a call at 888-587-9370. 

Proposed rules have been issued by the Internal Revenue Service for two types of reporting under the Affordable Care Act (ACA or health care reform law). A proposed rule means that parts of it could still change. Comments are being accepted through November 8, and hearings are scheduled in mid-November. The two types of reporting are: 

1. Employer mandate reporting (section 6056), and
2. Minimum essential coverage reporting for insurers and employers (section 6055)
 

The proposed rules are very technical. To see who is responsible for reporting and what data is expected to be reported, please view this fact sheet and FAQ. 

This article applies to:

• California
• Large Group

Under the health reform law, non-grandfathered health plans are required to cover certain preventive care services without cost-sharing as long as these services are provided by network doctors and health care professionals. Based on recent guidance from the federal government.

The Departments of Labor, Health and Human Services, and the Treasury issued a series of FAQs on Feb. 20, 2013, related to preventive care under the Affordable Care Act. The FAQs clarified: 

• The Departments’ stance on covering over-the-counter (OTC) medications and contraceptives when prescribed.
• Routine breast cancer susceptibility gene (BRCA) testing without cost-share.
• That health plans may cover the costs of purchasing instead of renting breast-feeding equipment  without cost-share.  

OTC medications and contraceptives covered without cost-share at point-of-sale starting Nov. 1, 2013
The FAQs state that aspirin and other OTC  items that have an A or B recommendation from the U.S. Preventive Services Task Force (USPSTF) must be covered without cost-sharing only when prescribed by a health care professional. The FAQs also clarify that contraceptive methods that are generally available OTC are only covered without cost-share if the method is both FDA-approved and prescribed for a woman by her health care provider. The Health Resources and Services Administration Guidelines do not include contraception for men.

The OTC drugs include aspirin, folic acid supplements for women, fluoride and iron supplements for children, and vitamin D supplements for older adults. OTC contraceptives for women include female condoms, emergency contraceptives (Next Choice™, Next Choice One-Dose™, Plan B One-Step®), and contraceptive film, foam and gel. The drugs on our revised Preventive Care Medications lists are covered at 100 percent when age- and gender-appropriate, prescribed by a health care professional and filled at a network pharmacy.

Because of these recommendations, customers with our carve-in pharmacy benefit  through OptumRx will cover select OTC contraceptives for women and select OTC drugs without cost-share when prescribed and filled at a network pharmacy. We are implementing a pharmacy point-of-sale solution for these OTC drugs as of Nov. 1, 2013. Mail-order pharmacy prescriptions for plans with a mail-order benefit begins Jan. 1, 2014. 

BRCA testing without cost-share effective Oct, 1, 2013
The Department of Health and Human Services (HHS) requires  both genetic counseling and BRCA testing, if appropriate, for a woman should be covered as a preventive service and without cost-share. 

A woman’s risk of breast or ovarian cancer is greatly increased if she inherits a BRCA gene mutation. The USPSTF issued a draft recommendation in April 2013 that would give a “B” rating to screening women who have family members with breast or ovarian cancer.  The screening identifies a family history that may be associated with an increased risk for potentially harmful mutations in breast cancer susceptibility genes (BRCA1 orBRCA2).  The rating provides coverage at no cost-share for  genetic counseling to women with a family history, and if appropriate following counseling, BRCA testing. 

UnitedHealthcare’s Preventive Care Services Coverage Determination Guideline  (CDG) currently covers screening and counseling at no cost-share and will cover the BRCA test without cost-share for some women starting Oct. 1, 2013.  The BRCA test as well as screening and counseling will be covered without cost-share for women age 18 years of age and older with a family history of ovarian and/or breast cancer and who do not have a personal history or current diagnosis of ovarian and/or breast cancer. Prior authorization requirements continue to apply.

UnitedHealthcare covers the BRCA genetic counseling and evaluation for BRCA testing today without cost-share as recommended by the current USPSTF recommendation and listed in our CDG.

Breast Pump Rental No Longer Covered as of Jan. 1, 2014
The federal government clarified in the FAQs that health plans may cover the costs of purchasing instead of renting breast-feeding equipment without cost-share. While UnitedHealthcare covers the rental of hospital-grade breast pumps today under the preventive care services benefit, effective Jan. 1, 2014, UnitedHealthcare will only cover the purchase of personal, double-electric breast pumps. 

In addition to the FAQs, studies show that due to the variability in breast pumps, high-quality, personal use double-electric breast pumps are as effective as, or potentially even more effective than, hospital-grade pumps in outpatient settings. Because a double-electric breast pump is portable and more convenient to use, we believe it provides a better experience for the mother and helps encourage breast-feeding. 

Timing of These Updates
The timing of these updates follows our standard approach when agencies recognized by the federal government recommend new preventive care guidelines or guidance. We update our Preventive Care Services Coverage Determination Guidelines as needed throughout the year and not upon a plan’s renewal. This supports the vital role that preventive care plays in helping our members live healthier lives. 

Also, remember that some grandfathered or exempt plans may not cover preventive services at 100 percent, so some plans may cover the preventive services described here with cost-sharing. 

The revised Preventive Care Medications lists are posted on myuhc.com, and the United for Reform Resource Center, and our Preventive Care Services Coverage Determination Guideline will be updated to reflect these changes.

During FMLA leave, an employer must maintain the employee’s coverage under any group health plan with the same coverage conditions as if the employee had been continuously employed during the FMLA leave period.  If the employer requires active employees to pay premium payments, then the same requirement applies to the employee on FMLA leave.  Employees on FMLA leave must have a minimum 30-day grace period in which to make premium payments.  If the employee does not make timely payments after this grace period, then the group health insurance may be suspended provided the employer notifies the employee in writing at least 15 days before the date the health coverage will lapse.  Employers may also choose to pay an employee’s share of the premiums during FMLA leave and recover those payments when the employee returns to work.  When the employee returns to work, the health coverage may be reinstated.

This "fee" is one placed on health plan carriers (for fully insured plans) and plan sponsors (for self-insured plans, including HRAs) that is intended to fund the Patient-Centered Outcomes Research Institute, a private nonprofit corporation created by PPACA to conduct research in evidence-based medicine.

For each policy/plan year, this “PCORI fee” is determined by multiplying $2 ($1 for policy/plan years ending during fiscal year 2013) by the average number of lives covered under the insurance policy or self-insured plan for that year. The fee may be increased for policy/plan years beginning after September 30, 2014 by the expected percentage increase in per capita national health expenditures. The fee is first applicable to policy/plan years ending after September 30, 2012 and is scheduled to sunset for policy/plan years ending after September 30, 2019.

Under section 4376, a “plan sponsor” of an applicable self-insured health plan includes the employer if the plan is established or maintained by that single employer. Health reimbursement arrangements (“HRAs”) and health flexible spending arrangements (“health FSAs”) are self-insured health plans under section 4376. However, the proposed regulations clarify that health FSAs that provide “excepted benefits” (e.g., limited scope dental or vision FSAs) will not be subject to the fee.

The regulations provide that employers that maintain HRAs and health FSAs will be subject to the fee when these plans are integrated, or otherwise provided in connection with, an insured group health plan. Importantly, multiple self-insured arrangements (e.g., an HRA and a health FSA) established and maintained by the same employer and with the same plan year are subject to a single fee. The proposed regulations provide a special rule that permits the employer, when determining the average number of lives covered under the plan, to assume that only one person is covered by an HRA or health FSA, even though an employee may have a spouse or dependents who are also eligible to received amounts under the HRA or health FSA.

Employers/plan sponsors required to pay the fee under section 4376 use Form 720, “Quarterly Federal Excise Tax Return.” However, employers filing Form 720 based only on their liability for the fee will be required to do so only once per year by July 31st. Full payment of the fee will also be due by July 31st of each year.

For the full text of the regulations, visit: http://www.gpo.gov/fdsys/pkg/FR-2012-12-06/pdf/2012-29325.pdf.

Full-time or part-time classification in 2013 will drive the play-or-pay requirements for 2014.  Employers who plan to use a 12-month look-back period going forward may use a transition rule that allows a six-month look-back period during 2013 to determine which employees will be considered full-time for all of 2014. Employers with a plan year beginning on January 1, 2014, should begin counting employee hours in April of this year if they would like the maximum permitted time to make these full-time employee determinations. Employee hours can be counted during the six-month period between April and September 2013, and the employer can use a 90-day administrative period between October and December to notify employees, handle enrollment, and have all eligible full-time employees enrolled and receiving coverage on January 1, 2014. Employers with a plan year beginning later in 2014 will have a little more time to start counting hours, but all employers should begin planning now so as to be able to use all the time allowed if needed.

Identifying whether employees qualify as full-time for purposes of the ACA can be complicated for employers with employees who work variable hours or seasonally, or for those with frequent turnover. The length of the look-back period chosen impacts the length of time the employer must offer such employees health coverage before their full-time status can be re-evaluated. Employers should consult with their legal and benefits advisors if they need assistance in making these determinations.