An update regarding Individual and Family plan [IFP] Reimbursement rates.

Question: When I contact a doctor to see if they take our insurance and tell them we have Blue Shield PPO, they say yes. Once I give them my subscriber number they say, “Oh, we don’t take Covered California plans.” Since my understanding is that all plans on exchange mirror those off exchange, I have asked the insurance company why certain doctors refuse. They said they can’t force doctors to take the plan. But, if the exchange plan pays exactly the same as the off exchange one, why would there be so many refusals (and trust me, there are a lot!). It has begun to feel like a plan purchased on exchange (without subsidy at this point) is like a welfare plan that no one wants to touch. Any ideas? Since we cannot switch to another plan at this point (no special circumstance) it has become quite irritating to be shoved off like we have the plague! Thanks!2015-ACA update

Answer: Unfortunately, the joke in the health Individual & Family [IFP] insurance marketplace these days is:  “Now we all (should) have insurance, but very few doctors who will take it.”  [Unfortunately, with every joke there’s a bit of truth  So “getting to keep your doctor,” wasn’t quite as realistic as it sounded” when our government officials mentioned this to Americans.]

The reality is many people on IFP plans have not been able to keep, or choose, the doctors they want to see.  When your doctor says they take Blue Shield PPO, that means they are included in the Blue Shield PPO networks for employer-based health plans, for the most part. Given the mandated restructuring of plans by the ACA, IFP plan reimbursement rates to doctors were reduced.

Thus, for example:  Covered California fosters competition between authorized carriers to yield the lowest premium rates possible in the current IFP marketplace. In order to compete, the carriers lean on their providers (doctors and hospitals) to accept ever lower reimbursement rates. Many providers refuse to participate in Covered California carrier networks resulting in “narrow networks” with fewer provider choices. Because 90% of patients are covered either by employer-based health plans or Medicare, doctors can opt of out Covered California with minimal downside to their practice.  Bottom line, Employer plans currently reimburse at higher rates.

What’s annoying employers most about the ACA now? by Christian Schappel

Recently, employers were asked which part of the ACA they most want to see changed. And in what’s likely to be a surprise to many, the No. 1 answer wasn’t the employer mandate.
EmployeesAlthough 70% of the 644 employers surveyed said they’d like to see the employer mandate repealed, it still wasn’t the highest vote-getter.

What was? Repealing the excise or “Cadillac” tax. All told, 86% of employers said eliminating the tax on high-cost health plans was atop their “Wish List” of the things they’d like to see done to the ACA.

The survey was conducted by the consulting firm Mercer.

So the top five changes employers would like to see to the ACA looked like this (employers could place multiple votes):

  1. Eliminate the excise or “Cadillac” tax — 86%.
  2. Repeal the employer mandate — 70%.
  3. Change the definition of a full-time equivalent employee to one who works 40 hours per week — 66%.
  4. Repeal and replace the ACA entirely — 54%.
  5. Repeal the individual mandate –51%.

Just missing the top five was: Allowing the use of stand-alone HRAs to purchase individual coverage — 51% (it received fewer “strongly favor” votes than did repeal the individual mandate).

The biggest impact?

When asked about the impact of the ACA on their organizations, employers said it:

  • created a significant administrative burden — 84% (with 51% saying the burden was “very significant”)
  • resulted in making unwanted plan design changes to avoid the excise tax — 29%, and
  • generated higher costs — 20%.

Has enrollment changed?

Employers were also asked if their health plan enrollment had changed as a result of the employer mandate, and the results closely mirror reports from the Congressional Budget Office (CBO):

  • “No” — 74%
  • “Yes,” an increase — 22%, and
  • “Yes,” a decrease — 4%.

The CBO has reported there’s been virtually no change in the number of employees enrolling in company-sponsored health coverage as a result of the ACA.

posted from:

Children Enrolled in Covered CA Medi-CAL Program MUST “Re-ENROLL”:

Children Enrolled in Covered CA Medi-CAL Program MUST “Re-ENROLL”:

Hispanic Family

During the week of February 15, DHCS sent a notice to existing Covered California consumers who have been deemed eligible for CCHIP.

Consumers should contact CCHIP to confirm their wish to either participate in the program or to opt for a Covered California plan without premium assistance.

The non-eligible (consumers over 19 years of age) CCHIP Covered California consumers will remain enrolled in their Covered California plan with their current premium assistance amount.

For more information Children Enrolled in Covered CA Medi-CAL Program MUST “Re-ENROLL”:


HHS Launches HIPAA Audit Program — Emery Benefit Solutions

OVERVIEW The Department of Health and Human Services (HHS) announced that it has launched the second phase of its HIPAA audit program, which focuses on compliance with HIPAA’s Privacy, Security and Breach Notification Rules. This second phase of the HIPAA audit program covers both covered entities and business associates. HHS’ Office for Civil Rights (OCR) […]

via HHS Launches HIPAA Audit Program — Emery Benefit Solutions

What Individuals with ACA Health plans Need To Know:

Now that you have enrolled in an ACA Compliant Health plan
Your Responsibility is not over:
Please make sure that you follow the below steps “regularly” to insure you are not terminated:
        1.  Check your accounts online frequently to insure the carriers have not made mistakes on your account, and that all payments are being applied before the due date.  [We have found that many Individual/Family plan (IFP) members are either being terminated for non payment, even though they state their payments were sent on time; or are receiving delinquency letters past the 30 day grace period allowed by the ACA.]
        2.  We “Highly Recommend” that you enroll in Auto Pay.  Below are the links to various carrier sites.  [You will need to check your online accounts regularly to make sure payments are being drawn monthly and on time, to avoid delinquency letters or worse Termination.]
  • Click on the name of your carrier to get information about setting up an auto pay:
Kaiser Permanente
Blue Shield of CA Health Net

        3.  Due to new ACA regulations it is extremely difficult to re-instate accounts and you will open yourself up to potential penalties under the ACA. [Remember Grace Periods are only 30 days for IFP accounts that are direct with the carrier, and 90 days for accounts enrolled via Covered Ca. The Grace Period is accumulative and starts from the day you did not  make a payment].
        4.  Please Do NOT wait until the last minute to pay on your accounts. Carriers are showing little to no compassion for late or missed payments.  *Check with your Carrier to confirm the due date of your bill.
We Highly Suggest:
  1. Paying your bill several days prior to the due date listed on your bill.
  2. Calling your carrier to confirm and memorize your billing due date.
  3. Try and send your payment in at least 10 days prior to the due date, to insure it is processed and applied to your account in time.
  4.   If possible,  have 1 months pre-payment paid on your account, incase a payment is not received in time.  
  5. Never let your account go beyond the 30 day grace period.
  6. Don’t Wait to receive a delinquency letter. Grace period letters seldom arrive in time to make your payment,within the 30 grace period allowed under the ACA.
       5.  If you are enrolled in a Covered CA account, Please Do NOT Forget:
    • Submit your income & tax information on time, before the April 15th deadline.  [You must contact  1-800-300-1506 to Fax or upload your taxes to your personal portal.  Covered CA will assist you with setting up your online account and give you the access code you need to do so.  Once logged in they will walk you through the upload process.]
    • Remember: ANY CHANGE IN INCOME (of + or – 10%) MUST BE REPORTED online via the Covered CA site.
        6.  Most of you will receive Obamacare-related tax forms [1095A’s] this year, if you haven’t already. Unfortunately, some Medi-Cal and Covered California enrollees are discovering errors on their forms – but corrections won’t come quickly.  The below link explains who will receive the forms, called 1095A’s, and what to do if they contain inaccuracies. To read the update, please click here.

NFIB Updates Senate on Obamacare: Data Validate the Doubters | NFIB

NFIB Updates Senate on Obamacare: Data Validate the Doubters | NFIB.


NFIB Updates Senate on Obamacare: Data Validates the Doubters


Most disappointing is that a large majority of small business owners report higher premiums despite the fact that the law was billed as a way for them to reduce their expenses.

—NFIB’s Holly Wade

Another Day, Another CBO Score

Another Day, Another CBO Score
CBO-HealthReformOn March 9, the Congressional Budget Office released a revised “score” of the healthcare reform law, projecting what it will cost the federal government over the next 10 years, among other things. The new score, or cost, of the bill was revised down to $1.207 trillion, or approximately $142 billion less than the CBO projection released back in January. That earlier forecast also lowered the projected cost of the legislation, as the CBO has consistently done since the passage of the law.  CBO logo-

The reason CBO cites for its repeated lowering of the cost of the law is lower-than-anticipated growth in health spending. However, since much of the slowdown in healthcare spending is directly attributed to national economic performance, the CBO noted the recent slowdown in costs may reverse, but “such a bounce back seems less likely in light of the further slowing of spending growth observed in the most recent data.”

While the Obama Administration has heralded the new budget forecast as good news for consumers and the law, the report isn’t completely rosy. The CBO predicts that the average premium for the second-lowest-cost silver plans offered via exchanges (which is the standard on which subsidy amounts are based) will go up by 8.5% annually between 2016 and 2018. CBO believes costs will rise during this time period due to the phasing out of the law’s market-stabilizing “Three R” risk-adjustment, risk corridor and reinsurance provisions, as well as the pressure to limit narrow network plans. However, the CBO projects that exchange coverage premiums will stabilize by 2018 and that premium costs will climb by just 5.6% annually beginning in 2019.

In addition to predicting higher premiums than expected for the next two years, the forecast also reduced the projected number of individuals who will obtain coverage due to the health reform law in the year ahead to 11 million. The projection stood at 12 million in January and 13 million this time last year. They have also reduced the number of people who will drop employer-sponsored coverage for exchange-based subsidized coverage by 1 million to 2 million and, overall, the CBO expects the number of individuals who will gain coverage due to the health reform law to be 24-25 million over the next decade, which is also lower than its prediction of 27 million earlier this year. It is very important to note that none of these predictions take into account the potential impact of a ruling for the plaintiffs in the King. V. Burwell case, which could overturn the flow of subsidies to eligible individuals covered via the federally facilitated marketplace.

While the new CBO score seemed to many (including your Washington Update authors) to come a bit out of the blue given that we just got the annual 2015 estimate in January, apparently the CBO decided it needed to review and revise quite a few of its initial budget estimates from January for big-ticket items.

The CBO also reserved the right to change its forecast at any time, based on future economic and market occurrences. “Projections of spending by private health insurers are highly uncertain, especially because the causes of the pronounced slowdown in spending in the past several years are not well understood,” the agency said. “Projections of growth in premiums for private health insurance offered through the exchanges are even more uncertain because the exchanges are so new.”

Majority of ObamaCare customers paying back subsidy


Need Assistance with the ACA Call (408) 615-1280 or Visit: .

A majority of ObamaCare customers, 52 percent, are being forced to pay back some of their subsidies during this year’s tax season, according to new data from H&R Block.  Customers are paying back an average of $530, which has caused a 17 percent drop in the average return so far this spring, according to the analysis by the tax services giant.

The Obama administration had warned that people could end up paying back some of their subsidies because many were relying on previous years’ income when applying for the tax breaks.

H&R Block has predicted that “most filers” would owe some of their subsidies back to the federal government because they were relying on 2012 income.

The new data, which was released Tuesday, only represents about six weeks of tax filings. Still, it could pose a significant challenge for the administration as it faces an already tough tax season.

“It’s costing taxpayers a large percentage of their refund – a refund many of them count on to pay household expenses,” Mark Ciaramitaro, vice president of H&R Block health care and tax services, wrote in a statement.

Last week, the Department of Health and Human Services asked 800,000 people to delay their tax filings because the agency sent out the wrong forms. The average refund so far this year is about $3,000, according to H&R Block.

Officials said last week that less than 10 percent of people had filed their taxes.

Source: The Hill, February 2015