It’s open enrollment season again and the Group Insurance Trust has taken the opportunity to strengthen its offerings with two new medical plans that give members even more flexibility in fine tuning their coverage through different levels of deductibles, co-pays, and premiums. Protect 40, a new co-pay plan, features a higher deductible and a higher $40 co-pay than the popular Protect 35 plan but lower than the Protect 45 copay plan. Protect HSA 3,500, a new HSA-eligible plan, features higher deductibles and lower member-paid coinsurance than the Protect 1500, 2500 and 2850 HSA plans with premiums approximating those of the Protect 45 copay plan.

As in previous years, the annual open enrollment period—continuing this year from November 1 through December 16—allows CalCPA-member firms a variety of options. Firms can offer employees the Trust medical, dental, and vision plans as a new benefit, while employees who had previously declined coverage can also enroll at this time. Current subscribers can take advantage of this opportunity to review their insurance needs, consider the new plans, and/or make any changes they have contemplated during the year. Finally, keep in mind that while most employers offer a single plan, your firm may elect to offer a combination of ProtectPlus co-pay, ProtectPlus HSA and Anthem Blue Cross HMO plans.

Choosing the Right Plan

While reviewing all the available choices might seem a daunting task, a new set of video presentations featured on the ProtectPlus website has just made it easier—even a little entertaining. Using the Video Toolbox feature on the homepage, you can get a video summary for each plan. The videos are segmented into topics such as coinsurance and deductibles so you don’t need to watch the whole presentation to get the information you are looking for. New videos are being added weekly, so be sure to check back frequently. Of course, you can still access plan information in written form. The 2012 EZ Guide is available online as an easy-to-read Summary Plan Benefits Comparison Chart. Once you’ve selected the plan or plans you’re interested in, you can get quotes based on the demographics of your firm using the Get a Quote Tool. If you have questions click on Ask the Expert and submit your query to the Trust staff. While they promise to get back to you within two days, you often receive an answer within the hour.

New Pharmacy Benefit Manager

Beginning January 1, 2012 ProtectPlus co-pay and HSA plan pharmacy benefits will be serviced by Medco rather than Express Scripts. (Please note that this change does not affect HMO participants.) Current subscribers who aren’t making any changes in their coverage should receive a welcome packet in the mail from Medco in the middle of December. Included in the mailing will be a welcome letter describing Medco services as well as your new pharmacy benefits ID card, which you will need to obtain your prescription drugs.

Between now and January 1, 2012 you can access the Medco open enrollment website to look up the cost of your prescription drugs pre- and post-deductible under the Medco pharmacy plan. After January 1, use your new Medco ID number to register at Medco.com to access the Medco mail order pharmacy and your personal prescription drug records. Although copays and coinsurance levels are not changing, differences between the old and new prescription drug formularies may result in an increase or decrease in your out-of-pocket costs.

Members who currently use specialty prescription medications for complex conditions will receive a letter introducing them to Accredo, Medco’s provider of specialty drugs. The letter will include information on contacting Accredo’s specialty pharmacists and nurses toll-free, 24 hours per day, 7 days a week. There is also an explanation of procedures for transitioning your specialty prescriptions and for scheduling regular deliveries.

Whether offered as an employee benefit through a group plan or purchased as an individual policy to help create a family safety net, long-term disability (LTD) insurance provides income when a policyholder suffers an injury or illness and can’t work. While most of us don’t believe, and can’t imagine, that we will ever need it, the value of such coverage is self-evident. Knowing it’s there certainly provides reassurance to policyholders and their families.

Like most things that seem self-evident, however, real life circumstances are often less than simple. If you’re in a coma, no one would suggest that you should come in to work anyway, but if you’re in pain, who decides if you’re in too much pain to work? Should your insurer take your word for it? Does it serve an insurance company to believe you, and if it disagrees, who is the final arbiter?

On September 9, the California state legislature unanimously passed SB 621 with the intent to take the ultimate decision-making authority for disability claims out of the hands of insurance companies and turn it over to the courts. The legislation is now awaiting the governor’s signature, which is considered almost certain. Originally authored by California’s new insurance commissioner Davey Jones when he was a state assemblyman, the bill continues many years of efforts to do away with “discretionary clauses” by which insurers reserve the right to make the final ruling on the legitimacy of disability claims.

For instance, you claim a back injury and your insurer decides that it is not disabling. At that point you appeal to your carrier. If they deny you again, and a discretionary clause is part of their policy, your options are extremely limited. Few courts would support your right to pursue a claim further.

According to Jones, such clauses “give insurance companies the freedom to easily justify coverage denials when a policyholder takes a carrier to court over denied benefits and claims. This bill levels the playing field for consumers so they can have their day in court and get the benefits they paid for with their premiums.”

While the passage of SB 621 marks a step forward for policyholders, it won’t by itself put an end to discretionary clauses. Group LTD insurance is governed by federal ERISA rules, which specifically allow the inclusion of discretionary clauses in policies. Nevertheless, in practice their use is significantly diminishing, if a carrier wishes to have full discretionary powers, highly specific language will need to be in disability plan’s Summary Plan Description..

During his tenure as Insurance Commissioner, John Garamendi was successful in getting a number of group disability insurance carriers to remove such language from their policies. Also, in recent years courts have asserted the right to review disputed claims and substitute their judgments for that of insurance administrators.

On their part, many insurance companies have recognized the ill-will generated by putting their policyholders in a compromised position and are voluntarily making changes. These changes certainly signal the future direction of LTD insurance. Moreover, because the same or similar practices appear in life insurance and long-term care policies, consumers can expect to see parallel changes in plan design over time.

The CalCPA ProtectPlus group LTD plans with Lincoln Financial do not give the insurance carrier discretionary power to solely determine whether a claim should be paid or not. Instead, Lincoln’s contract provides a process where a claimant can request a review by the California Department of Insurance. For more information on the CalCPA group LTD plans, visit www.cpaprotectplus.com or call Hover Insurance Services, Inc. (800) 805-9480. Groups with 2-9 employees contact Banyan Administrators, LLC (877) 480-7923.

Doug Hessel is Program Director, CalCPA ProtectPlus Ancillary Products at Hover Insurance Services. You can contact him at dhessel@hoverinsurance.com

A popular feature in comprehensive benefits packages, long-term disability insurance provides replacement salaries for employees who suffer from an extended illness or injury. While many employers carry an inexpensive group LTD plan as a matter of course, only some take advantage of an IRS ruling that would allow disabled employees to receive their disability income tax free. This failure can prove costly for employees and represents a lost opportunity for savings by employers as well.

Maximizing Benefits

The IRS ruling in question (Revenue Ruling 2004-55) clarifies the distinction between before-tax and after-tax benefits as it applies to disability income, and it provides a mechanism for distinguishing between them. Simply stated, if an employer pays 100 percent of an employee’s premium, the salary replacement benefits to the employee are taxable. Conversely, if the employer increases an employee’s pay to cover the cost of LTD and then deducts the premium from the employee’s check, the benefits are tax free.

Of course, this change means that the employer and employee incur some extra expenses—an increased salary will mean increased FICA, SDI, and so forth—but these are relatively small expenses. Consider the difference in benefits. An employee who is earning $60,000 a year and is covered by an employer-paid LTD plan offering a two-thirds salary replacement, will receive $3,350 a month if disabled. Assuming he or she has a 16 percent effective tax rate, that net replacement salary is reduced to $2,814. That’s a cost of more than $500 a month as opposed to the few dollars a month that employer and employee would have paid in compensation-based taxes.

Moreover, employers who are looking for savings should note that a less expensive after-tax LTD plan—providing only 60 percent salary replacement rather than the two-thirds given in the example above—would net the employee $3,000 per month, an improvement of almost $200 a month. In other words, by offering the LTD as an after-tax benefit, employers can provide employees with larger benefits with less coverage and pay smaller premiums (as much as 20 percent with some carriers). The cliché of a win-win situation has rarely been so applicable.

Avoiding the Three-Year Look-Back Rule

If your firm is paying LTD premiums in pre-tax dollars and is ready to change, be sure to take advantage of a mechanism provided in IRS Ruling 2004-55 that allows benefits to be tax free from day one.

Ordinarily, the IRS applies a three-year look-back rule that considers benefits taxable in the proportion that they were paid for by before-tax premiums over the last three years. However, the IRS has provided a method that allows employees to qualify for tax-free benefits immediately after the change is made to paying with after-tax dollars. The workaround requires specific amendments to the plan description and a modified enrollment form that allows employees to elect for after-tax payment of the LTD insurance. (See below for information on obtaining sample forms.)

Employees can decide on an individual basis whether they want to have their LTD paid for in pre- or after-tax dollars, so firms can implement the program for employees who want to take advantage of this opportunity without forcing others to make any change in the way they have traditionally received benefits.

Doug Hessel is Program Director, CalCPA ProtectPlus Ancillary Products at Hover Insurance Services. For further information and sample forms email dhessel@hoverinsurance.com

The following information is from Banyan Administrators, LLC:

Despite Potential PPACA Problems on the Horizon…HSA Enrollment Continues to Rise

Since health savings accounts (HSAs) were first authorized in January of 2004 as a tax-advantaged portal for medical savings, America’s Health Insurance Plans (AHIP), which is a trade association representing the health insurance industry, has conducted an annual survey of the HSA market. According the 2011 AHIP survey, HSA plan enrollment in the United States has almost doubled over the last three years, going from 6.1 million participants in 2008 to 11.4 million participants in 2011. From 2010 to 2011, the number of Americans covered by HSAs linked to high-deductible plans (HDHPs) increased by 14%.

Other key findings from the AHIP survey are:

• Large-group coverage was the fastest growing market for HSA plans between 2010 and 2011, with a growth of 26%.

• Individual market coverage was the second fastest growing market for HSA plans, with a growth of 15%.

• Over 6.3 million individuals were enrolled in HSA plans in the large-group market.

• Around 2.8 million individuals were enrolled in HSA plans in the small-group market.

• Approximately 2.4 million individuals were enrolled in HSA plans in the individual market.

The Impact Of The Patient Protection and Affordable Care Act On HSAs

As it relates to HSA plans, AHIP has noted that some of the provisions in the Patient Protection and Affordable Care Act (PPACA) could create some potential unintended consequences that might disrupt, if not limit, the availability of HSA plan coverage. Three of the main problems noted by AHIP include:

1. Medical loss ratio regulation.

This requires an insurer to spend 80% or more of a consumer’s premiums on direct, non-administrative patient care and improvements to such care’s quality. AHIP asserts that medical loss ratio regulations will be especially problematic for HSA-eligible HDHPs. Participating in a qualified HDHP is a requirement to participate in an HSA. HDHPs provide individuals with a low-premium, high-deductible alternative to traditional health plans. These plans might have lower benefit costs, but they certainly aren’t always cheaper to administer from a per-enrollee standpoint. As a result, they may naturally have lower medical loss ratios.

2. Over-the-counter (OTC) medication restrictions.

After 2011, funds from HSAs can’t be used to purchase OTC medications unless the individual has a prescription in hand. By limiting consumer access to many common OTC drugs, such as those used for allergies and colds, consumers will be left in default to use more expensive prescription drugs.

3. Minimum actuarial value requirement.

Each level of insurance coverage (platinum, gold, silver, and bronze) sold in either the small or individual market will be required to meet a level-specific minimum actuarial value starting in 2014. The actuarial value is a dollar value based on the average benefits expected to be paid out by a particular plan. Bronze, which is the lowest level, will be required to have at least a 60% actuarial value. Under the Patient Protection and Affordable Care Act, the Secretary of Health and Human Services is to institute a process that will determine actuarial values. The health care reform law specifically instructs that the HHS Secretary may include annual employer HSA contribution amounts within the actuarial value calculation. Of course, this wording means annual employer HSA contribution amounts may not be calculated. AHIP recognizes that including this in the calculation will help to ensure continued consumer access to affordable, high-quality coverage since inclusion will considerably increase the probability that HSAs will meet the minimum requirements.

In closing, AHIP’s survey clearly reflects that HSA enrollment is steadily growing. Policymakers should recognize that HSA plans are more important than ever when it comes to U.S. consumers having access to affordable, quality coverage.

[Information Source]

Fortunately for consumers, the cost of prescription drugs still accounts for only 10 percent of healthcare spending nationwide. This is only good news because increases in the cost of hospital care and physician services have grown even faster, exceeding 5 percent annually.

Generic Counterparts

Nevertheless, several important factors have helped keep prescription costs in check. First and foremost, has been the introduction of generic alternatives when brand-name pharmaceuticals lose patent protection.

A report by the Kaiser Family Foundation points out that, “almost 80 percent of FDA-approved drugs have generic counterparts,” and explains that when there are two generic alternatives on the market, the generic price is usually about half the original price of the brand name drug. Moreover, when several competing generics are available, prices often plummet to 20 percent or less of the original brand cost.

The Value of a Formulary

In conjunction with cost-sharing techniques such as deductibles, copayments and co-insurance, another tool used by health insurers to keep prescription expenses down is the use of a formulary. Comprising a list of approved prescription drugs, formularies encourage the use of generics and lower-priced alternatives among their subscribers by creating a differentiated copayment schedule. Under such an arrangement, if you elect a brand-name drug when a generic equivalent is available, you will be responsible for a greater share of the cost.

Formulary lists are typically assembled by teams of doctors and pharmacists who evaluate drugs on the basis of safety and effectiveness in the treatment of diseases. Lists are updated regularly and will usually contain both brand name and generic drugs. When a generic is available for a brand-name product, the brand-name product is generally considered non-formulary. Typically only the generic equivalent will be on the formulary list, a practice endorsed by the FDA. In this way a formulary decreases the total prescription costs for a medical plan by steering subscribers to lower cost alternatives that fully meet their needs.

Other “utilization management strategies,” as they are known in the healthcare industry, include the requirement for prior authorization in the case of certain drugs and/or greater patient cost-sharing for new, bio-tech, and specialty pharmaceuticals. Such measures aid in controlling the cost of premiums for all plan participants.

ProtectPlus Formulary

Beginning January 1, 2011, ProtectPlus adopted use of the same formulary utilized by the Anthem Blue Cross HMO plans. The formulary is updated quarterly and can be found online at the ProtectPlus website under “Anthem Blue Cross Formulary List.”

 The copayment structure for ProtectPlus copay plans and Anthem Blue Cross HMO plans is the same for a 30-day supply bought through an in-network retail pharmacy and a 60-day supply when ordered through Anthem’s Express Scripts mail order pharmacy.

• generics = $10 copayment              

• brand-name = $150 annual deductible per member

• brand-name/formulary = $25 copayment

• brand-name/non-formulary = $45 copayment

• self-injectables (excluding insulin) = 30 percent of prescription drug maximum amount

One way to keep your prescription drug costs down is to provide a copy of the Anthem formulary list to your doctor. He or she can then use it to help select the best medication for you while still being mindful of your out-of-pocket costs. Another good strategy is to let your pharmacist know that you prefer to use generics when possible. Many pharmacies will substitute a generic when available unless the prescribing physician specifies a brand-name with the phrase “dispense as written,” but you can’t assume it. Ultimately, what matters is taking the appropriate medication for your condition. However, if an equivalent drug is available that will safely and effectively treat the condition and save you money, where is the downside?

On May 1, 2011, The ACS|BNY Mellon HSA Solution “The HSA Solution” will offer a way for account holders to create and send one-time or recurring payments from their HSA ─ on demand ─ in five easy steps. 

Below we have put together a few of the Frequently Asked Questions (FAQs) regarding our Direct Pay HSA service:

How will account holders access the new Direct Pay HSA functionality?  

Account holders will be able to click on a “Direct Pay HSA” tab along the top navigation bar from their ACS|BNY Mellon HSA Solution Account Summary page; then click on “Access Direct Pay HSA”.

What are the necessary steps to create a payment request?

There are five basic steps to creating a payment online using Direct Pay HSA:

• Step #1: Click on the “Direct Pay HSA” tab from the Account Summary page
• Step #2: Click on “Access Direct Pay HSA”
• Step #3: Select “New Transaction” on the Direct Pay HSA home page
• Step #4: Click on “Send a Payment” and complete the payment information
• Step #5: Review and “Submit” the payment request for processing

What information will account holders need to know in order to create a payment using Direct Pay HSA?

• Payment amount
• Issue date
• Payee’s name
• Payee’s address including street address, city, state and ZIP code

Is there a charge to the account holder for creating a payment online using Direct Pay HSA?

Account holders do not incur transaction or postage fees with any payments they create using Direct Pay HSA.

What if I have additional questions?

The following training materials will be located on the “Direct Pay HSA” tab:

• Direct Pay HSA Frequently Asked Questions (FAQs)
• Direct Pay HSA flyer
• Direct Pay HSA online educational video

We thank you for your business and the opportunity to serve you!

The ACS|BNY Mellon HSA Solution

[Information Source] [Email Blast to Health Plans]

Combined tax forms 1099-SA and 5498-SA were mailed to The ACS|BNY Mellon HSA Solution account holders on January 29, 2011. The information on these forms will be submitted to the IRS. Account holders receive these combined tax forms for their records only. Account holders use the information on these forms to complete IRS Form 8889.  The 1099-SA and 5498-SA forms do not need to be attached to the account holder’s tax return.

Tax form 5498-SA: This form reports contributions made to an account holder’s Health Savings Account (HSA) by the account holder or by an eligible individual on the account holder’s behalf, as well as contributions made by their employer, if applicable. The IRS requires The ACS|BNY Mellon HSA Solution to issue form 5498-SA to every account holder who had any contribution activity in their HSA during the previous tax year (2010). Account holders can access this form by logging into their HSA account; click on the “Account Holders Services” tab then “View Tax Forms”.

Note: If an account holder makes a prior year (2010) contribution by April 18, 2011 they will receive an amended 5498-SA in May.

Tax form 1099-SA: This form reports distributions made from an account holder’s HSA. The IRS requires The ACS|BNY Mellon HSA Solution to issue Form 1099-SA if account holders took a distribution from their HSA during the previous tax year (2010). Account holders can also access this form by logging into their HSA account; click on “Account Holders Services” then “View Tax Forms”.

IRS form 8889: Account holders must obtain, complete and file IRS Form 8889 as part of the federal tax filing by April 18, 2011. It is downloadable from www.irs.gov or account holders can log into their HSA account and click on the “Account Holder Services” tab; then click “Useful Links”; then “Form 8889″. If both spouses have an HSA, then two forms are required (one for each account).

Additional HSA tax resources are available!

• Two online tax educational programs are now available. You may either click on the “watch video” links below or access the tax programs on our Web site at hsamember.com; click on the “Tools” section in the middle of the home page or by clicking on the “Resources” tab in the upper right corner of the home page.
   
  It’s Tax Time:
  Need tax filing information for HSAs?

Tax Guidelines for HSAs  Watch video
Information on HSA tax forms  Watch video

• Employers can log on to the hsamember.com Web site using their employer ID and view additional tax information in a presentation specifically designed for employers. To access this presentation, click on the “Reports” tab; then click on the PDF labeled “Tax Information for Employers”.

Do you have additional HSA tax questions?

For additional HSA tax questions, call the Employer Support Team at 866-712-4551, Monday through Friday, 8:00 a.m. to 8:00 p.m., Eastern time.
  

[Information Source, Image Source] 

Not only are most children getting fluoride in their drinking water, but they are also getting it from toothpaste, mouthwash and some kids are even getting regular fluoride treatments when they have their teeth cleaned by their dentist.

In the report released last Friday by the Department of Health and Human Services, it was recommended to change the level of fluoride per liter of water to 0.7 milligrams which would replace the standard range since 1962 of 0.7 to 1.2 milligrams per liter.

Many parents may become concerned by this report, since we have all been told over the past years to let our children drink our tap water because of the health benefits of the fluoride. Now we will need to wait and see what further information the HHS comes back to us with by spring 2011 when they are expected to publish their final community water fluoridation report.

To read the full report from the HHS, click here. Also, for more information about fluorosis and young children’s intake of fluoride, check out this link from Delta Dental.

[Information Source]

Following is an outline of the most important plan modifications subscribers will see this year. Some are in response to health care reform but not all.

Health Care Reform Mandates

Beginning January 1, every health plan must comply with the following provisions:

• All dependents up to age 26 are eligible for coverage
• No cost-sharing for in-network preventive services
• No pre-existing limitations for children under 19
• Prior authorization or higher cost-sharing disallowed for out-of-network emergency services
• New rules for appeals process
• Removal of lifetime maximum limits (copay and HSA plans)
• Removal of lifetime limits for hospice care (copay and HSA plans)
• Removal of annual limits on durable medical equipment (HMO plans)

Premium Rates

Naturally, all these mandated changes come at a price. Over the past seven years, the Group Insurance Trust has delivered single digit increases that were well below national and regional trends. However, a thorough analysis of the costs associated with these mandated benefits, plus unusually high claims experience in 2009, resulted in an increase to CalCPA ProtectPlus medical plan rates that is significantly higher than that of previous years.

Because each firm’s rates are based on a combination of factors, each firm’s increase is unique. Renewal packets, including rate information specific to each firm, were mailed to participating firms on November 1. If you did not receive your renewal package please contact Banyan Administrators, LLC at (877) 480-7923 immediately.

Plan Design Changes

In addition to the mandated changes described above, for the 2011 calendar year the Trust is implementing changes specific to the ProtectPlus program. There are also changes specific to Anthem HMO plans.

Prescription Drug Formulary

A significant change to be implemented in the ProtectPlus copay and Anthem Blue Cross HMO plans in the coming year is the introduction of the Anthem Blue Cross formulary (preferred list of drugs). This list is updated quarterly by a committee of doctors and pharmacists who evaluate drugs on the basis of safety and effectiveness in the treatment of diseases. To view the list on www.cpaprotectplus.com, click on Forms/Prescription and select Anthem Blue Cross Formulary List.

The formulary list contains both brand name and generic drugs. In many cases when a generic is available for a brand name product, the brand name product will be considered non-formulary and only the generic equivalent will be on the formulary list, a practice endorsed by the FDA.

Beginning January 1, the copayment structure for ProtectPlus copay plans and Anthem Blue Cross HMO plans will be the same for a 30-day supply bought through an in-network retail pharmacy and a 60-day supply when ordered through Anthem’s Express Scripts mail order pharmacy.

• generics = $10 co-payment
• brand-name = $150 deductible per member
• brand-name/formulary = $25 co-payment
• brand-name/non-formulary = $45 co-payment
• self-injectables (excluding insulin) = 30 percent of prescription drug maximum amount

Administrative Updates

In addition to these rather significant changes in Trust plans, there are a couple of administrative issues that are important to note.

Anthem will be issuing new ID cards for all subscribers, regardless of whether they make an open enrollment change. This change is required by the National Blue Cross and Blue Shield Association, which is trying to standardize ID cards across all Blue plans. Please alert your employees to watch for an envelope from Anthem.

The Anthem Blue Cross HMO customer service phone number is now (888) 209-7847. This is the same customer service number that PPO and HSA subscribers currently use.