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.

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.

This unwelcome gift—in addition to the seemingly inevitable yearly rate increase that everyone gets—comes in the form of a higher premium and marks your status in having moved to another age rate band.

You’re probably aware that older people pay more for their health insurance and younger people less, and you may have already experienced such an increase.

Nevertheless, in these lean times, its not something you want to come as a surprise. “Happy birthday! Blow out the candles! Your premium just went up $100 a month!” ProtectPlus uses a range of age bands that are common in health insurance plans:

• under 30
• 30–39
• 40–49
• 50–54
• 55–60
• 60–64
• 65 and older

If you’re with another insurer, you should check to see where the bands fall on your policy. You can’t avoid getting older, of course, but if a higher premium will create a financial burden, you can switch to a less expensive plan during open enrollment (November 2 to December 31). Otherwise, you will have to live with the higher rates for your newly attained age until the next year.

Keep in mind that the rates for your spouse and dependents are dependent on your age band, so their big birthdays don’t count in terms of premiums. You can celebrate as you see fit, and not have to worry about higher rates on their birthdays.

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Maintaining the longer open enrollment period adopted in 2007, the Group Insurance Trust has announced that open enrollment begins on November 2 and ends December 31.

CalCPA member firms that haven’t offered ProtectPlus plans to their employees can, of course, enroll in Group Insurance Trust plans at any time.

Firms can consider the full range of offerings for 2010 that include;

• 5 copay plans
• 3 HSA-eligible plans
• 2 Anthem Blue Cross HMO plans

This is also the time of year that the Trust announces plan changes and premium adjustments. As always, premium  increases are anticipated with concern, but the good news is:

The Trust has been able to maintain its single digit  premium increases for the seventh consecutive year.

This is a remarkable achievement when you consider that ProtectPlus also beat industry averages in each of these years.

Several benefit improvements will be implemented in 2010.

• All ProtectPlus copay plans will see a reduction in the copay amount for generic prescription drugs from $15 to $10.
• Improved coverage for mental health and substance abuse services on all copay, HSA-eligible, and Anthem Blue Cross HMO plans.
• Medical plans will now align all mental health and substance abuse member cost-sharing provisions with those offered for in-network and out-of-network medical services and remove any visit limitations (in accordance with the Mental Health Parity and Addiction Equity Act of 2008).

The Trust will also combine several copay plans for 2010.
Last year the Trust offered eight copay plans, including both regular and enhanced versions of:

• Protect 15
• Protect 25
• Protect 35

The enhanced versions of these plans—which waive the deductible for the first six in-network office visits—proved so popular that trustees were persuaded to include the enhanced benefits as standard features in the copay plans at these levels.

For 2010 the Protect 15, Protect 25 and Protect 35 plans will all feature the enhanced benefit of six office visits that are not subject to the plan’s deductible, while the Protect 10 and Protect 45 plans will retain their original structure.

Vision Service Plan and Delta Dental rates will be restructured for 2010.
Going forward, rates for both plans will be based on firm size in much the same way the medical plan rates are structured.

• Effective January 1, 2010, firms with two or more participants will see a reduction in VSP and Delta Dental rates while others will note a small increase.

Changes in Premiums
Some ProtectPlus members will see changes in their premiums next year that reflect altered geographical rate bands. Anthem Blue Cross has re-aligned several zip codes in rate areas one, two, and three, and the Trust has followed its lead in order stay consistent. For some, these changes will mean lower than average premium increases, while for others, unfortunately, it may mean an increase in excess of the average overall premium increase.

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You may choose to offer your employees almost any combination of the CalCPA ProtectPlus plans. This exclusive coverage is a great enticement for attracting and retaining top-level talent to your firm.

Here is a quick look at our plans.

To find the plan that be fits your needs, please use our Plan Selector Tool.

• Protect 10 $10 copay, 10% coinsurance, 
individual deductible $250/Family $500. More details

• Protect 15 $15 copay, 20% coinsurance, Individual deductible $250/Family $500, the first 6 in-network office visits per calendar year are exempt from annual deductible. More details

• Protect 25 $25 copay, 30% coinsurance, Individual deductible $500/Family $1,000,the first 6 in-network office visits per calendar year are exempt from annual deductible. More details

• Protect 35 $35 copay, 40% coinsurance, Individual deductible $500/Family $1,000, the first 6 in-network office visits per calendar year are exempt from annual deductible. More details

• Protect 45 $45 copay, 50% coinsurance, no in-network deductible. More details

• Protect HSA 1500 $1,500 Individual deductible $1,500/Family $3,000, 30% coinsurance, $4,500 Individual out-of-pocket maximum. More details

• Protect HSA 2500 $2,500 Individual deductible $2,500/Family $5,000, -0- coinsurance, $2,500 Individual out-of-pocket maximum. More details

• Protect HSA 2850 $2,850 Individual deductible $2850/Family $5,650, 30% coinsurance, $5,500 Individual/ out-of-pocket maximum. More details

• HMO Value 80 $15 copay, no deductible, 20% coinsurance for most covered expenses. More details

• HMO Advantage 100 $10 copay, no deductible, no additional charge for most covered expenses. More details