Melanie Epstein


Effective May 1, 2014,  UnitedHealthcare is implementing a new procedure known as the Mail Service Member Select program for members to obtain their maintenance medications.  Click here for the current list(subject to change) of maintenance medications.

After two fills at a retail pharmacy, the program requires the use of home delivery for medication that is taken on a regular basis. However, the member can choose to decline mail service and continue filling their maintenance medication at a retail pharmacy at their normal cost share amount. If a member does not take any action, all additional fills may be at the full out-of-network cost.     The mail order prescriptions are filled by OptumRx Mail Service Pharmacy.

Members will receive a letter explaining the program after the first time they fill a maintenance medication.    The letter will explain that they have the option to transfer their prescription to mail order OR decline the mail service.    Either choice requires a phone call to OptumRX at 1-866-236-1495.  A second contact either  by phone or mail is made after the second refill of the prescription offering the same options.    Again, if a member does not take any action, all additional fills may be at the full out-of-network cost.

Please share this information with your employees.  Click here for the flyer UnitedHealthcare has provided about this  program.

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Congratulations to our team for making it through the first open annual individual open enrollment for the new Affordable Care Act plans!  The enrollment period ended March 31, 2014.   The next open enrollment will begin November 15, 2014 and will run through February 15, 2015.

We are now in the Special Open Enrollment Period which started April 1, 2014.    A Special Open Enrollment period is an opportunity to purchase an individual policy outside of the annual open enrollment period as a result of specific events called qualifying events.   These policies can be purchased through the Exchange if you qualify for financial subsidies or directly to the insurance companies if a subsidy is not needed.  You have 60 days in most cases from your Qualifying Event (QE) to purchase the policy.  Here is a list of qualifying events:

*Marriage/Domestic Partnership


*Adoption or Guardianship of a child

*Loss of your health coverage due to:

  1.  Involuntary loss of employer sponsored coverage that meets minimum essential coverage – *(at the time of  this loss you could choose COBRA/State Continuation if available or an individual policy)
  2. Loss of affordable employer sponsored coverage – affordable is defined as your share of individual coverage costing you more than 9.5% of your income from your employer
  3. Divorce
  4. Reaching the maximum dependent age limit on your parent’s policy
  5. Expiration of your COBRA coverage
  6. Termination by the carrier of an existing individual plan-30 days to apply for this QE
  7. Loss of Medicaid or CHIP eligibility

*A permanent move that puts you outside of your current insurance company’s service area

*Becoming an American Citizen

*Leaving incarceration

IMPORTANT NOTES:  A Special Enrollment Period will not be given if you voluntarily terminate your coverage or your policy was terminated due to non-payment of premiums.

Medicare Supplemental and dental plans can be purchased at any time throughout the year.

Please call us to discuss your options if you have experienced a qualifying event.

Posted on by Melanie Epstein in Health Care Reform Leave a comment

CareFirst Early Renewals – DEDUCTIBLE TO BE RESET!

CareFirst has confirmed that their claims system did not reset the deductible for some of their contract year groups who renewed off-cycle with a December 1, 2013 effective date.   This means that claims processed for dates of services December 1, 2013 or after may have been inadvertently paid instead of applying to the deductible.   Deductibles must be reset to $0 in order to comply with CareFirst contracts as well as federal and state regulations.

CareFirst will be correcting their claims system during the month of March.  When this adjustment occurs, claims from members who appeared to have reached their deductible limit will be adjusted to comply with the contractual reset requirement.  Some members may also receive reprocessed Explanation of Benefits (EOBs) indicating an additional payment is due to their providers(s).

Please share this information with your employees.  Should you have any additional questions, please contact us.

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We have now been through two months of renewals under the new Affordable Care Act plans.   We have had the opportunity to compare the group rates to rates for individual plans available for purchase without any medical underwriting.   Overall, the individual plan premiums are up to 40% lower than the group plans.   While the group plans are more costly, they do provider a higher level of benefits.  One example pertains to the prescription benefit.  The group plans provide the benefit subject to flat copays for most tiers while the individual plans charge a percentage of the prescription cost ranging from 20% to 50%.  The individual plans also have higher out of pocket maximums.

The IRS released Notice 2013-54 which has been interpreted as prohibiting individual policy premiums from being paid either by the employer directly and taking the cost as a business expense or by the employee via pre-tax payroll deductions.  We believe the purpose of this prohibition is to prevent an employee from applying for a financial subsidy through an Exchange and at the same time getting the plan paid by the employer or paying the premiums pre-tax.

The conclusion is that while the individual policies are less expensive than the group plans, the loss of the tax deduction both to the employer and the employee may mitigate the rate differences between the group and individual plans.

One exception to the potential lack of tax deductibility for an individual policy may apply to shareholders who own 2% or more of an S-Corp.   We believe that an individual policy purchased for one of these shareholders can still be deducted on the personal tax return of the shareholder if the policy is paid for by the S-corp and included in the W-2 wages of the shareholder.

As always, please contact your accountant to discuss their position on this taxability issue.

Posted on by Melanie Epstein in Compliance Leave a comment



The Massachusetts Health Care Reform Act requires Massachusetts residents to have health insurance that meets minimum standards or be subject to tax penalties.  This is a state tax penalty in addition to the new federal Affordable Care Act tax penalties.    The requirement can be met by an employee if they have employer sponsored coverage as long as that coverage is considered “creditable.”    In order for a group health plan to be considered “creditable,” it must meet Minimum Creditable Coverage(MCC) Requirements. Employers are required to complete Form-MA 1099-HC and mail to their Massachusetts employees by January 31 each year.    Please contact us if you need assistance with determining the MCC status of your plan.

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Small Business Health Options Program

The SHOP marketplace for small businesses has delayed their opening for shopping for small business health insurance until April 1, 2014 for a June 1, 2014 effective date


MHIP PLUS  – the termination date of the Maryland Health Insurance Plan subsidized policies has been extended from January 1, 2014 until March 31, 2014.   The termination date for MHIP, Maryland Health Insurance Plan non-subsidized plans remains June 30, 2014.

Premium Bills for Marketplace Policies

Maryland Health Connection will not be processing payments at this time for purchased ACA policies.  All premium bills will come directly from the insurance company.

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ATTENTION DENTAQUEST POLICYHOLDERS – DENTAL CLEANING OR EXAM NEEDED TO QUALIFY FOR ROLLOVER DOLLARS! The countdown has begun – not only to the holidays – but to the end of the year deadline to qualify for the Dentaquest “rollover” benefit.  This great benefit allows you to “rollover” some of your unused annual maximum from one calendar year to the next when certain parameters are met.   Each member in your family is eligible for their own rollover benefit and qualifies independently.

The first parameter is that you have received at least one cleaning or oral exam during the calendar year.   We have seen many insureds lose their rollover benefits when they would have otherwise qualified because of the lack of a cleaning or oral exam during the year.   The second parameter is that the amount of claims paid by DentaQuest does not exceed the threshold they have established which varies based on your annual maximum in your plan per the following chart:


DentaQuest automatically calculates your rollover eligibility and you will receive a letter in February, 2014 advising the amount of the rollover that you have qualified for.  Please share this information with your employees and coworkers.  Click here for the brochure that explains the details.

And more good news from DentaQuest!  While the Affordable Care Act required medical plans to allow dependent children to remain on the family policies until age 26, this did not apply to dental policies.  DentaQuest has decided to extend the dependent eligibility to age 26 on all of their policies beginning with your first renewal date after November 1, 2013.

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Despite the government shutdown, the Affordable Care Act is moving full steam ahead.  Today is opening day for the individual purchasing exchanges.  In Maryland, the exchange is called Maryland Health Connection and is being run by the State.  The District of Columbia’s exchange is called DC Health Link and is being run by the District. Virginia’s exchange is being run by the federal government.  Melanie Epstein and Peter Vinton have completed the required trainings and are authorized to sell plans on the exchange and as always off of the exchange as well.    Individual plans outside of the exchange will be available for January 1, 2014 without medical underwriting.  If you are eligible for financial assistance, you must purchase your coverage through an exchange.    As you can imagine, there are still a lot of questions and confusion.  We will do our best to help you determine your options!

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One of the main provisions of the Affordable Care Act is the establishment of a health insurance marketplace called an exchange.  The exchange is a governmental agency set up in each state where individuals and small businesses (50 or less full/time equivalent employees for right now) can purchase health insurance from insurance companies regardless of any preexisting conditions.  Some individuals may qualify for financial assistance for the premiums via an Advanced Premium Tax Credit as well Cost Sharing Reductions.  Some businesses may qualify for a Small Business Tax Credit.  In order to take advantage of these subsidies, the health insurance must be obtained via the exchange.

The Affordable Care Act has put the responsibility on informing employees about the exchanges on employers subject to the Fair Labor Standards Act (FLSA) regardless of whether or not you currently have a group plan established.

Here is the link to the Department of Labor’s guidance regarding this required notice:

Pages 3 and 4 do a good job of explaining the requirements of the notice and links to the model notices are provided in Section E.  There are two separate notices, a Model Notice  for those employers currently sponsoring a plan and a Model Notice  for those that do not.

If you are currently sponsoring a plan, pages 1 and 2 should be completed with page 3 being optional.   You will notice on page 2 the question regarding whether or not your plan meets the “minimum value standard.”  This is a difficult and complicated actuarial calculation defined in the Affordable Care Act. There are no requirements for small businesses to offer minimum value coverage and a delay in penalties for large employers.    As a result, the answer to this question is for informational purposes only at this time to help the exchange qualify individuals that may be eligible for the subsidies.

At this point, CareFirst is the only carrier that has performed this calculation and has advised that all of their plans for groups up to 200 do meet the minimum value standard.  Therefore, if you are a CareFirst client, you can check this box confirming that your plan meets this standard.

All of the other carriers have been silent to date and we do not have indication that they will be providing this information.   In an effort to provide you with some direction, we contacted the Department of Labor/Employee Benefit Security Administration directly.  They indicated that the notice they provided was simply a “model” and employers could edit and answer that question as they see fit.     Here is an example of what you could use:  “we are unable to determine whether our current plan meets minimum value as our current insurance carrier has not provided us with this information.”

The notices are due to the employees by October 1, 2013.  Please call us if you have any questions.

Posted on by Melanie Epstein in Health Care Reform Leave a comment

New Maryland Health Insurance Exchange – 10 Facts

I attended the producer training this week for Maryland Health Connection, the state’s marketplace for individuals and small businesses (50 or fewer employees) to purchase health insurance beginning in 2014.    Here are the top 10 facts learned:

  1.  No more denials for preexisting conditions! – Beginning January 1, 2014, any individual with a pre-existing condition cannot be denied coverage when applying for health insurance.  This eliminates the entire medical underwriting process our individual clients have endured.  However, you must purchase the coverage during the annual open enrollment period or at the time of a loss of existing coverage.
  2. Premiums can only be based on your age, tobacco use, geographic location and family composition (that’s new!)  Health status of an individual or of employees of a small group cannot be used.
  3. Family composition rating:    Whether you are in a small group or an individual purchasing coverage and whether purchased from Maryland Health Connection or directly from an insurance company your rate will based on your age + age of your spouse + age of any of your covered dependents over age 21 + ages of your three oldest children.  This means that each employee in a small group will have their own rate.    Yes – those of you who have had your older dependents on your plan even though they are eligible for coverage through their own jobs as the rate was the same no matter how many children you had should reevaluate.  Give us a call to help you sort through this after October 1 when the new plans and rates will be available.
  4. Tobacco users can be charged 50% more.  This applies to individuals and well as members of groups.  It is unclear whether all insurance companies will be charging this tobacco surcharge.
  5. The rate categories have been narrowed – the buckets are individuals under age 21, those over age 64, and those between ages 21-64.   In this last category the ratio of the oldest to the youngest is 3:1.  This means that the highest rate cannot be greater than three times the lower rate.
  6. To take advantage of the small business tax credit or the advanced premium tax credit (APTC) which is financial assistance at certain income levels for individuals, coverage must be purchased through the exchange.
  7. If you are enrolled in an employer sponsored plan, regardless of the type of plan offered or cost of the plan to you, you are not eligible for the APTC.  On the contrary, if you have waived your employer’s group plan and you meet the other qualifications for the APTC, you will be eligible.
  8. Pediatric Dental must now be included in all plans that are offered outside of the exchange as an essential health benefit.  Within the exchange, the plans can exclude this benefit as it can be purchased separately.
  9. In-vitro fertilization and hair prosthesis benefits are additional essential health benefits that will be available on individual policies only.
  10. The Maryland Health Insurance Partnership premium subsidy plan for small businesses that has been available will be eliminated.  These businesses will need to apply for coverage through the exchange to see if they can qualify for the small business tax credit.  The Maryland Health Insurance Plan State Plus (MHIP+), MHIP Federal and MHIP Federal Plus will be eliminated as of December 31, 2013.  If you have any of these policies you will need to apply for coverage through the exchange.  We can help!

Please call our office if you have any questions on any of these facts and to review your individual situation.


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