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On April 18, 2017, the Department of Health and Human Services’ (HHS) Centers for Medicare & Medicaid Services (CMS) published its final rule regarding Patient Protection and Affordable Care Act (ACA) market stabilization.

The rule amends standards relating to special enrollment periods, guaranteed availability, and the timing of the annual open enrollment period in the individual market for the 2018 plan year, standards related to network adequacy and essential community providers for qualified health plans, and the rules around actuarial value requirements.

The proposed changes primarily affect the individual market. However, to the extent that employers have fully-insured plans, some of the proposed changes will affect those employers’ plans because the changes affect standards that apply to issuers.

The regulations are effective on June 17, 2017.

Among other things impacting group plans, the rule provided clarifications to the scope of the guaranteed availability policy regarding unpaid premiums. The guaranteed availability provisions require health insurance issuers offering non-grandfathered coverage in the individual or group market to offer coverage to and accept every individual and employer that applies for such coverage unless an exception applies. Individuals and employers must usually pay the first month’s premium to activate coverage.

CMS previously interpreted the guaranteed availability provisions so that a consumer would be allowed to purchase coverage under a different product without having to pay past due premiums. Further, if an individual tried to renew coverage in the same product with the same issuer, then the issuer could apply the enrollee’s upcoming premium payments to prior non-payments.

Under the final rule and as permitted by state law, an issuer may apply the initial premium payment to any past-due premium amounts owed to that issuer. If the issuer is part of a controlled group, the issuer may apply the initial premium payment to any past-due premium amounts owed to any other issuer that is a member of that controlled group, for coverage in the 12-month period preceding the effective date of the new coverage.

Practically speaking, when an individual or employer makes payment in the amount required to trigger coverage and the issuer lawfully credits all or part of that amount to past-due premiums, the issuer will determine that the consumer made insufficient initial payment for new coverage.

This policy applies both inside and outside of the Exchanges in the individual, small group, and large group markets, and during applicable open enrollment or special enrollment periods.

This policy does not permit a different issuer (other than one in the same controlled group as the issuer to which past-due premiums are owed) to condition new coverage on payment of past-due premiums or permit any issuer to condition new coverage on payment of past-due premiums by any individual other than the person contractually responsible for the payment of premiums.

Issuers adopting this premium payment policy, as well as any issuers that do not adopt the policy but are within an adopting issuer’s controlled group, must clearly describe the consequences of non-payment on future enrollment in all paper and electronic forms of their enrollment application materials and any notice that is provided regarding premium non-payment.

By Daniella Capilla
Originally Posted By

Medicare Costs Explained | Ohio Employee Benefits Broker

Categories: Medicare
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By Kathy Binkley, RHU, ChHC, Benefit Advisor at The Wilson Agency
A UBA Partner Firm

I’m sure you’ve heard the phrase “Nothing in life is free,” and nothing is – not even Medicare. In most cases, you won’t have to pay a premium to get Medicare, at least for Part A (here’s a refresher on the different parts of Medicare), but that doesn’t mean it’s free. You’ve just pre-paid in the form of taxes. So you don’t have to worry HealthCareCostabout a premium for Part A, which covers in-patient hospital expenses, assuming you or your spouse paid Social Security for at least 10 years. However, there are other costs associated with Medicare, which vary depending on the specific insurance. Here are the costs for 2015.

Part A (Hospital Insurance):
$1,260 deductible (each benefit period)
$315 copay (per day) days 61 through 90 at the hospital
$630 copay (per day) days 91 through 150 at the hospital

Part B (Medical Insurance):
Monthly premium: $104.90
Deductible: $147
Cost Sharing: $20, varies

Part D (Prescription Drug Coverage):
Part D is also subject to a premium, which varies by plan and income. Additionally, prescriptions are subject to copayment or coinsurance and a deductible (if the plan has one).

There is a seven-month initial enrollment period for signing up for Part A and B. If you do not enroll during this time period and do not have creditable health coverage (such as an employer group health plan), you could be responsible for a paying a penalty.

Take another look at the prices for Part A. Can you imagine what you could end up paying for a long-term hospital stay? Medigap plans are additional insurance to help cover costs that Medicare doesn’t cover, such as copayments, coinsurance and deductibles. However, Medigap insurance requires an additional premium be paid.

Needless to say, even with Medicare the costs can be catastrophic. This is why we can’t emphasize enough how important it is that you save enough money for retirement. However, we understand that in many situations people are unable or unaware of the exorbitant health care costs they will face in retirement, so here is an article that discusses additional ways that retirees can tame those health care costs.


UBA resource

Under federal regulations, Medicare is a secondary payer for many individuals who have an employer group health plan available to them, either as an employee or the dependent spouse or child of the employee. Read the answers to thirteen key questions about Medicare Secondary Payer rules including who is affected, what coverage must be offered to Medicare-eligible employees, whether Medicare premiums can be reimbursed, and more.

Top 5 Questions about Medicare Secondary Payer Rules | Ohio Employee Benefits Advisor

Categories: Medicare
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By Danielle Capilla, Chief Compliance Officer at United Benefit Advisors

Under federal regulations, Medicare is a secondary payer for many individuals who have an employer group health plan available to them, either as an employee or the dependent spouse or child of the employee. Generally the Medicare Secondary Payer rules prohibit employers with more than 20 employees from in any way incentivizing an steth1active employee age 65 or older to elect Medicare instead of the group health plan, which includes offering a financial incentive. Although premium payment arrangement rules under the Patient Protection and Affordable Care Act (PPACA) provide a limited circumstance for reimbursing Medicare premiums, this option is not feasible for employers with more than 20 employees due to Medicare Secondary Payer rules.

Q1. Who is affected by Medicare Secondary Payer rules?

A1. Medicare-eligible individuals age 65 or over whose employer group health plan is based on the current employment of the individual or spouse, by an employer that employs 20 or more employees, are protected by the Medicare Secondary Payer rules unless the active employee elects Medicare. Health insurance plans for retirees, or spouses of retirees, are not affected because retirement is not “current employment.” Individuals who are eligible for Medicare based on disability or end-stage renal disease (ESRD) are also affected.

Q2. What are employers with 20 or more employees required to offer their Medicare-eligible older employees?

A2. Employers are required to offer employees age 65 or over the same group health plan coverage offered to younger workers. Workers with Medicare-eligible spouses must be offered the same spousal benefits as employees with spouses that are not Medicare-eligible.

Q3. Are employees who are Medicare eligible required to elect their group health coverage or Medicare?

A3. Employees can elect, at their discretion, Medicare or the group health plan as their primary health insurer. Employees that elect their group health plan will then have secondary Medicare coverage if they enroll in Medicare. Their employer cannot induce them or provide incentives to select Medicare as their primary coverage.

Q4. If an employee elects Medicare as his or her primary insurer, may the employee enroll in a group health plan for secondary coverage?

A4. No, this is prohibited.

Q5. How does Medicare know if an individual has the option of enrolling in a group health plan through their employer?

A5. The Centers for Medicare and Medicaid (CMS) mails questionnaires to individuals before they become entitled to benefits under Medicare Part A or enroll in Medicare Part B to determine if they are eligible for primary coverage under another plan.


For more of the top questions and answers about reporting requirements, determining if you have 20 employees for Medicare Secondary Payer purposes, whether you can reimburse Medicare premiums, and penalties for rule violations, view UBA’s PPACA Advisor, “What You Need To Know About Medicare Secondary Payer Rules”.

Topics: PPACA Affordable Care Act, Group health plans, Medicare, Medicare secondary payer

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