CalCPA ProtectPlus

Many people in the Medicare program may find themselves lost in a maze of paperwork and unanswered questions. On occasion we post helpful information from Medicare’s website. The Medicare website provides a wealth of information to those that need help understanding the many facets of how Medicare works. Below you will find information about how Medicare works with other insurances. Over the next couple of weeks we will share additional information from the Medicare website regarding conditional payments. We hope you find this information beneficial. To find more useful tools from Medicare, click here to visit their site.

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If you have Medicare and other health insurance or coverage, each type of coverage is called a “payer.” When there’s more than one payer, “coordination of benefits” rules decide which one pays first. The “primary payer” pays what it owes on your bills first, and then sends the rest to the “secondary payer” to pay. In some cases, there may also be a third payer.

What it means to pay primary/secondary

• The insurance that pays first (primary payer) pays up to the limits of its coverage.
• The one that pays second (secondary payer) only pays if there are costs the primary insurer didn’t cover.
• The secondary payer (which may be Medicare) may not pay all the uncovered costs.
• If your employer insurance is the secondary payer, you may need to enroll in Medicare Part B before your insurance will pay.

Paying “first” means paying the whole bill up to the limits of the coverage. It doesn’t always mean the primary payer pays first in time. If the insurance company doesn’t pay the claim promptly (usually within 120 days), your doctor or other provider may bill Medicare. Medicare may make a conditional payment to pay the bill, and then later recover any payments the primary payer should’ve made.

If you have questions about who pays first, or if your insurance changes, call the Medicare Coordination of Benefits Contractor.

Note: Tell your doctor and other health care providers if you have coverage in addition to Medicare. This will help them send your bills to the correct payer to avoid delays.

[Information Source]

Losing a loved one is never easy, but for surviving family members, the loss can be even more overwhelming when faced with the loss of medical coverage. This is especially difficult for the surviving spouse and dependents of sole practitioners who are unlikely to qualify for COBRA or CalCOBRA. In order to provide some peace of mind to its members, ProtectPlus copay and HSA-eligible plans offer a unique benefit known as Rights of Survivorship to all ProtectPlus plan participants. Under Rights of Survivorship, the covered spouse and eligible dependents of a deceased plan member may retain their ProtectPlus medical coverage without going through underwriting. Survivor benefits begin after COBRA and CalCOBRA benefits have been exhausted, or if the surviving spouse does not qualify for COBRA or CalCOBRA, the extended coverage kicks in immediately.

Coverage continues until the earliest of the following events:

The date the individual(s) reaches age 65; b. The date the surviving spouse remarries; c. The date the individual(s) becomes covered under any other group health plan regardless of whether that coverage is less valuable; d. The date the individual(s) becomes entitled to Medicare; or e. The first of the month for which the surviving spouse or eligible child(ren) fails to make the required payment for the continuation coverage.

If you have any questions about the Rights of Survivorship benefit, or other questions about ProtectPlus copay and HSA plans, contact Banyan Administrators, managers for the CalCPA ProtectPlus programs, at (877) 480-7923.

Please note that Rights of Survivorship do not apply to Anthem Blue Cross HMO Participants.

We’ve been providing health and welfare benefits to California CPAs for over 50 years and we know how important it is for members to get fast, accurate answers to their health insurance questions. Now you can get answers even faster when you use the “Live Chat” feature on the www.cpaprotectplus.com website. CalCPA ProtectPlus strives to find new and better ways to make health insurance simple and understandable for CalCPA members. The addition of live chat is the perfect way to get help without picking up the phone!

Make sure to check it out! Look for this button on the top right of the website!

Here are some details about our new Live Chat feature:

• Chat is available M-F, 8:00 a.m. – 5:00 p.m. (PST)
• Chat online with the same Banyan representatives who have helped you in the past
• Fast response time
• Option to print transcript of chat
• No menu tree – you go straight to a representative that can help you

The Group Insurance Trust is proud to announce that once again it has renewed its B++ rating from A.M. Best Co., a global credit rating agency and the leading provider of information in the insurance industry. While affirming the performance of the Trust and its insurance offerings, the rating also offers subscribers the reassurance that an outside evaluator has recognized the program’s consistent financial stability. When determining a rating, Best examines every aspect of an insurer, including its operations, financial data, governance, plan design, claims, and many other factors. Moreover, the Group Insurance Trust maintains the distinction as the first Multiple Employer Welfare Arrangement in the nation to receive a Best rating.

Health Maintenance Organizations (HMOs) represent “pre-paid” or “capitated” insurance plans in which individuals or their employers pay a fixed monthly fee for services, instead of a separate charge for each visit or service. The monthly fees remain the same regardless of types or levels of services provided by physicians who are employed by, or under contract with the HMO.

Most people are used to reviewing their health insurance coverage and needs on an annual basis during their open enrollment period. After all, this is the one time during the year they are free to make changes in their health coverage to reflect changes in their lives. It may be they want to increase benefits or, conversely, opt for lower premiums. Or, not uncommonly in the current economic climate, they might want to add a dependent child to their plan who has moved back home after college. Under new health care regulations, some may even be adding an uninsured adult child under the age of 26.

Life Events

Beyond the options offered by the annual open enrollment period, health insurance subscribers may be unaware that a number of significant life events—a marriage or divorce, loss of eligibility under another plan, a child’s birth or adoption or placement for adoption—can also trigger a “special enrollment” opportunity outside their annual open enrollment period. This special enrollment window applies only to the individual(s) and event in question and can’t be used to make other plan changes.

Newly Acquired Dependents

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), coverage for a newborn child begins on the day of birth. You can also add coverage for a child while in the process of adoption once you have assumed full or partial financial responsibility for the child. In either case, you must notify the insurer within 30 days.

Coverage of a new spouse begins the first day of the month following the enrollment request. Covered individuals must notify insurers within 30 days to attain coverage for a new spouse. As with any new plan member, those individuals over age 19 who are eligible for a special enrollment period may be subject to preexisting condition exclusions, but prior creditable coverage can reduce or eliminate the exclusion period.

Loss of Other Coverage

Another sort of special enrollment opportunity arises when an employee who previously declined coverage through an employer’s group plan loses coverage from another source. This situation can arise because of a divorce or legal separation, the death of a spouse, or the loss of insurance through a spouse’s job loss. Under these circumstances employees can enroll in an offered plan under the same terms as any new employee. The employee can also apply for coverage of his or her spouse and dependents.

There are, however, some very important conditions to keep in mind. The employee must request enrollment within 30 days of loss of coverage and must have officially waived coverage at the time it was offered. Both employers and employees should keep the latter in mind because health plans have the right to require a copy of the waiver the employee signed when coverage was originally declined. An employee who hasn’t completed and signed a waiver of benefits may not qualify for a special enrollment opportunity later. Additionally, the California Health and Safety code requires employers to provide notice to employees of this requirement and the potential consequences of failing to complete the waiver.

Banyan Administrators have been providing us with beneficial information about different aspects of the Health Care Reform and how it affects us. Over the next months and years, employers will be faced with numerous changes, many of which require regulatory clarification. Banyan will continue to keep us up to date and on target with decisions that affect our plans. 

To view this article in PDF format, click here.

The following information is provided by Banyan Administrators:

Another component of the Health Care Reform Act signed into law on 3/23/2010 is that beginning with the 2011 tax year, employers must report the aggregate cost of applicable employer-sponsored health insurance coverage on employees W-2 forms.  General information about this requirement has been provided, however, the Department of Labor (DOL) has not yet issued Interim Final Rules on this provision of the Health Care Reform Act.

1. When does an employer have to be ready to be in compliance with this new reporting requirement?

Employers must be prepared to accurately report this information on an employee’s 2011 W-2 form as early as February, 2011.  Although employers will be sending most of the 2011 W-2 forms to the employees in January, 2012, if an employee terminates employment in 2011, they do have the right to request an early 2011 W-2 form.  Employers must be prepared for this possibility. (continue reading…)

The old idiom with the words, “two is company,” was reinforced at a recent CalCPA member event. A ProtectPlus staff member was chatting with an accountant who described himself as a sole practitioner while mentioning that he had an assistant. He subscribed to ProtectPlus as a sole practitioner, he said, because the person who helped him already had medical coverage through her spouse’s employer, and she wanted to keep that coverage.

Alerted to a possible misunderstanding, the ProtectPlus representative responded by pointing out that under ProtectPlus rules even if his employee waived coverage, the accountant qualified for the lower premiums of firms with 2 to 14 employees. In addition, if the firm ever moved to another carrier, it would not be subject to underwriting to qualify for coverage. Moreover, simply having that employee on staff is enough to qualify for the lower rates as long as the employee is working a minimum of 20 or 30 hours a week. Even if the employee waives the benefit—whether because he or she has other group insurance coverage or a Kaiser plan—the CPA still qualifies for coverage at the two-member firm rate.

ProtectPlus subscribers should keep in mind that the same rules apply to a CPA sole practitioner who employs his or her spouse. As long as the spouse works at least 20 hours per week and is compensated as an employee, the CPA firm is defined as a group of two. The CPA can purchase a ProtectPlus policy at the lower rate, forego underwriting, and choose whether to include the spouse as a dependent on his or her policy, or cover the spouse as an employee under their own policy. However, in firms where the only other employee is the spouse, the Trust requires documentation (W-2, payroll records, income tax returns, etc.).

For CalCPA members—especially sole practitioners and small firms—one of the greatest benefits of the Group Insurance Plans is access to high quality medical insurance at prices that are competitive to those usually offered to large firms. While true sole practitioners are subject to underwriting, the ProtectPlus policies available to them will for the most part be miles ahead of anything they can purchase on the individual market. And even those who don’t qualify for coverage due to their medical history may qualify for a ProtectPlus HIPAA option. For more information please contact Banyan Administrators (877) 480-7923.

The following information is from the IRS Web site, IRS.gov:

IR-2010-38, April 1, 2010

WASHINGTON ― Many small businesses and tax-exempt organizations that provide health insurance coverage to their employees now qualify for a special tax credit, according to the Internal Revenue Service.

Included in the health care reform legislation, the Patient Protection and Affordable Care Act, approved by Congress and signed by President Obama on March 23, the credit is designed to encourage small employers to offer health insurance coverage for the first time or maintain coverage they already have. In general, the credit is available to small employers that pay at least half the cost of single coverage for their employees.

“This credit provides a real boost to eligible small businesses by helping them afford health coverage for their employees,” said IRS Commissioner Doug Shulman. “We urge small businesses and tax-exempt employers to look closely at this important tax break — which is already effective — to see if they qualify.”

The maximum credit is 35 percent of premiums paid in 2010 by eligible small business employers and 25 percent of premiums paid by eligible employers that are tax-exempt organizations. In 2014, this maximum credit increases to 50 percent of premiums paid by eligible small business employers and 35 percent of premiums paid by eligible employers that are tax-exempt organizations. (continue reading…)

The Group Insurance Trust has always made a priority of providing CalCPA  members the first-class service that they deserve. This goal is expressed in the quality benefit plans offered by the Trust, the range of choices, and the customer service that supports the use of those plans on a daily basis. Aiming to enhance this experience even further, the Trust has recently contracted with Banyan Administrators, LLC, to handle the administrative services formerly provided by Seabury & Smith.

About this Change
Susan Young, executive director of the Group Insurance Trust commented,

In light of Seabury’s long service to the Trust, deciding to move our account wasn’t easy. However, in seeking the best possible service for our members, we wanted to take advantage of Banyan’s skills.

Starting November 1, 2009, Banyan will be responsible for the following:

• Customer service
• Billing
• Payment processing
• Record-keeping
• Marketing support
• Receiving and accounting for participant contributions
• Maintaining records of eligible participants
• Preparing financial reports for GIT staff and trustees
• Banyan will also process all enrollment and change applications
• Maintain an interface with Anthem Blue Cross
• Help new firms and new employees set up their accounts, and manage employee eligibility

For many ProtectPlus members, of course, the primary and often the only point of contact with the plan administrator is when they call or email with a question. Banyan brings to this customer service role a history of serving 220 organizations and group plans beginning in 1994, including other MEWAs (Multiple Employer Welfare Arrangements) in its home state of Pennsylvania that have similar needs and concerns as the Group Insurance Trust. Scott Fair, executive vice president of Banyan, is very clear about “how important customer service interactions are in presenting the face of an organization.”

Banyan Customer Service Center
The Banyan customer service center is staffed by Banyan representatives—all  are licensed brokers—who are there to answer your questions whether by phone or email. Moving all these services to a higher level, Banyan brings with it a high degree of technological sophistication, so that relevant information will be more quickly and easily accessible. For a benefits  administrator this can mean resolving an eligibility issue online, and for Trust staff, the ability to monitor plan performance more closely. (continue reading…)

Having recently completed what looked like a paperwork endurance contest,  GIT staff and trustees were rewarded in  May when the Trust received a financial strength rating of B++ from insurance  company rating agency A.M. Best. In a press release announcing its positive evaluation, Best stated that the rating reflected the Trust’s “synergy with CalCPA, favorable level of capitalization and positive operating performance.”

The release went on to say that the Trust’s risk-adjusted capital position “remains favorable,” and is built upon “its historically positive operating results.” This gives a tremendous boost to all the GIT plans, affirming that they are as reliable as they are valuable.

Extended Rate Guarantee
On the heels of this good news, the Trust has announced that it will guarantee current 2009 premium rates for any newly enrolling firms through December 31, 2010. In terms of cost, there will never be a better time to switch to ProtectPlus than now. As CalCPA members you have available a variety of high quality health insurance plans that are already  competitively priced. By acting now, you and your employees can maintain current 2009 rates throughout 2010. Add to this the fact that ProtectPlus rate actions have averaged 7 percent over the past six years, which is significantly below average annual rate increases industry-wide,  and you should have all the incentives you need to enroll now. (continue reading…)

This is Part 2, of a three part article.  For Part 1, an introduction, see Employers, What You Need to Know About the Federal Stimulus Package: Part 1.

This article was written by Connie Chuang and Gage C. Dungy, attorneys with the labor and employment law firm of Liebert Cassidy Whitmore.

Qualified Individuals on COBRA/Cal-COBRA Can Now Receive a 65% Federal  Subsidy for Health Insurance Premiums for up to Nine Months.

Employees who were involuntarily terminated between September 1, 2008, through December 31, 2009, will be eligible for a 65% federal subsidy of their COBRA/Cal-COBRA health insurance premium payments.

For example, an employee who normally pays $1000/month in health insurance premiums under COBRA/Cal-COBRA, would only be required to pay $350/month (35%) because the other $650 (65%) would be covered by this federal subsidy.

The federal subsidy ends after one of the following circumstances occurs (whichever comes first):

• Nine months after the first receipt of the subsidy;
• The employee becomes eligible for coverage on another employer’s plan (or Medicare); or
• The maximum period of COBRA/Cal-COBRA coverage ends.

The subsidy plan became effective on the day the federal stimulus package was signed into law.  However, for individuals whose health insurance premium payments are paid on a monthly basis, the plan becomes effective on March 1, 2009.  Although the time period for qualification dates back to September 1, 2008, the federal subsidy does not apply retroactively before the effective date of the law. (continue reading…)

Understanding the Medicare system that serves as the primary health insurer for almost everyone in this country who is 65 or older is vital in planning your health insurance needs. If you are approaching that age, you should start familiarizing yourself with the system before you retire.

You need to know how various parts of Medicare work, how they relate to the supplemental insurance policies (Medigap) and how they interact with your workplace group insurance plan.

In addition, understanding the relationship between Medicare and your group health policy becomes more important and more complicated if your spouse is covered under your plan at work. HIPAA, COBRA and CalCOBRA provisions may determine the availability of his or her coverage. (continue reading…)