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Appeals information updated

Although the appeals provision of the health care reform law was effective in 2010, the U.S. Department of Labor provided an enforcement grace period until July 2011 for some requirements until additional guidance is issued. We are anticipating further guidance, which we believe may address some requirements that we and other carriers have expressed concern about, including:

· Diagnosis codes and treatment codes ( and their descriptions) on explanation of benefit forms, which raises privacy concerns

· Group-specific language requirements, which put additional responsibilities on customers 

For details on our current implementation efforts, please review the fact sheet that outlines our implementation efforts for both parts of the appeals provision: (1) adverse benefit determinations and (2) appeals process.

New fact sheets outline market reforms in 2014

In 2014, some of the most significant requirements of the health care reform law will take effect. In addition to the availability of exchanges, 2014 will bring changes to health insurance markets, product designs and employer responsibilities. 

We’ve developed a new fact sheet that outline key changes coming in 2014, including:

· Exchanges

· Health plan product framework

· Additional product requirements

· Free choice vouchers

· Rating requirements (small group only)

· Combined risk pool (small group only)

The information in the fact sheet is based on the provisions in the health care reform law. Many of the details about 2014 market reforms will need to be clarified by regulations.

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Healthcare Reform updates

In a recent sit down in Washington, regulators and policymakers from several key agencies and associations sat down to discuss several issues.  Amongst those issues discussed were:

Several common themes emerged during the meetings:

  • Timelines
    • Both the public and private sector policy experts appear to be genuinely concerned about addressing PPACA’s quick timelines for implementation. Beyond the politics, there appears to be an apolitical sentiment that we need to move more slowly. However, the regulators would need additional legislative or regulatory guidance to change the major timelines that were established through PPACA statutory requirements.  
  • Exchanges1
    • Most states are busy sorting out the governance structure of the public exchanges and beginning to identify some of the key exchange operational elements in 2011.
    • PPACA authorizes a variety of options related to how the exchange models can be configured ranging from the Massachusetts’ “active purchaser” model to Utah’s “all comers” approach.  
    • The Small Business Health Options Program (SHOP) exchange concept appears to be a legislative after-thought and more details need to be sorted out.
    • The same rating rules should be implemented both inside and outside each public exchange to help avoid adverse selection.
    • Tracking eligibility for individuals and families overtime is going to be a challenge and might generate privacy concerns.
    • Policymakers were very interested in learning more about how private exchanges, such as BenefitMall, have been successful.
  • Benefits
    • The definition of the essential benefit package(s) offered through the exchanges will have a profound impact on PPACA’s ultimate success.
    • Existing and future federal/state m andated benefits will likely be unaffordable.
    • After the BenefitMall meetings, regulators appear to have a greater underst anding of the wide range of current benefit offerings (which supports the premise that one size does not fit all.)
  • Funding
    • Many of PPACA’s original cost estimates were not accurate.
    • Significant cost and implementation challenges lie ahead – both at the state and federal levels.
    • The threat of de-funding PPACA and the ongoing budget battles are having a chilling effect on some regulatory activities.
  • Underst anding the Market
    • There appears to be a greater appreciation of how PPACA could help and hurt the private sector.
    • More attention needs to be devoted to the impact of PPACA’s insurance market reforms.  
    • Regulators are interested in learning more about local market purchasing trends from experts like BenefitMall.
  • Supporting the Consumer2
    • Meeting participants appear to recognize that inexperienced Navigators (a concept embedded in PPACA) should not replace the role of a licensed broker.

o A greater awareness of the backend support services is more apparent, including the need for a broker’s services to help consumers answer health questions.

Current PPACA activities in the pipeline include:

  • On Thursday, Representatives Mike Rogers and John Barrow introduced legislation to exempt broker compensation from the medical loss ratio calculations.
  • A myriad of funding and defunding measures continue to wind their way through the halls of Congress.
  • Health care providers continue to wait for the Centers for Medicare and Medicaid Services (CMS) to publish regulations governing accountable care organizations (ACOs).
  • The Institute of Medicine is currently studying how PPACA’s Essential Benefit packages should be designed.3
  • State activity continues to heat up with almost 500 bills recently introduced in the majority states which reference PPACA’s state-based exchanges.4
  • The five court cases challenging PPACA’s individual m andate will likely be appealed to the U.S. Supreme Court.5
  • With Republicans beginning to announce their intention to run for President, the 2012 campaign season will begin shortly – which will provide an opportunity to re-evaluate PPACA’s insurance market pre-suppositions and legislative policy goals.
  • Congress is still addressing the repeal of the 1099 reporting requirements.6
  • With 42 out of 100 Senators firmly opposed to the nomination of Don Berwick as CMS Administrator, President Obama will likely need to consider new c andidates since 60 senators must vote for the nomination.

Interestingly, this week HHS Chief Sibelius again signaled more flexibility in how the states can implement PPACA. However, Republicans continue to complain that they are not seeing enough follow-up to these promises.7

1. BenefitMall’s Issue Brief on Exchanges at https://www.benefitmall.com/PORTAL/Portals/0/BenefitMall Brief.pdf

2. Unfortunately, many policy experts still believe that offering an online web portal will be enough to empower employers and individuals to make a health insurance purchasing decision.  This is just not the case.

3. http://www.iom.edu/Activities/HealthServices/EssentialHealthBenefits.aspx

4. Based upon Westlaw search run on March 17, 2011 (Search Terms “Patient Protection and Affordable Care Act” and “Exchanges” used in the same bill).

5. http://www.healthcareexchange.com/blog/michael-gomes/eleventh-circuit-court-appeals-hear-vinson-case-declared-ppaca-unconstitutional

6. https://www.benefitmall.com/PORTAL/Portals/0/Legislative Alert/20101029LegislativeAlert.pdf

http://www.politico.com/news/stories/0311/51269.html

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A Short Course in Budgeting for College Students

One “extracurricular” activity that every student should master while in college is personal money management. Typically, a student’s day-to-day spending is done on an improvised basis, meaning that overspending is often the norm rather than the exception.

It is estimated that during a school year the average college or university student will spend approximately $4,000 for books, supplies, transportation, and personal expenses (Trends in College Pricing—2009, The College Board). However, there is often room for economizing. The first place to look is at food and telephone calls. Difficulty may occur in controlling these expenses, especially if pizza is ordered regularly at 2 am and long-distance friends are simply a phone call away.

While many students may assume it costs less to live off campus than in a dorm, they may be in for a surprise. In college towns with a high dem and for off-campus housing, accommodations within walking distance of the campus may tend to be expensive. Some l andlords require a one-year lease—a period longer than the school year—thus, subleasing privileges should be included as part of an “economical” lease. However, off-campus students can save money by sharing housing and doing their own cooking.

Money Smarts 101

The following may serve as important steps toward helping your student underst and college finances:

1. Before your student leaves for college, sit down and have an open discussion of expectations—both your child’s and yours.

2. Consider providing a lump sum each semester, making it clear how long the money must last.

3. Explain when checks or money transfers can be expected, the amounts that will be received, and any rules concerning the use of funds.

Since most students rely on savings and checking accounts—regardless of whether they include parental funds, their own, or a combination of both—it is important for them to underst and how these accounts work. The ability to balance an account accurately and make needed corrections is especially critical.

Many undergraduates may keep most of their funds in hometown financial institutions. However, managing financial affairs long-distance can be difficult. Verifying an account balance quickly with an out-of-state bank can be both costly and time-consuming. So, it may be a good idea to keep a smaller account on campus.

While some parents may fear a credit card can give a student who has difficulty managing his or her affairs too much of a cushion, others find a credit card can provide a useful backup, especially in an emergency or for certain expenses. For instance, it can help with car rentals, plane fares, and railroad tickets. In addition, trying to get money to college students in different locations can be frustrating, and it is often impossible for anyone to cash personal checks away from home.

Making the Grade

Ideally, college students should take full charge of a semester’s spending. Life becomes much easier for parents when college-age children can manage their own finances, and the students will learn valuable life skills in the process.

This article appears courtesy of Karl Susman.  Karl Susman is a representative of the New Engl and Life Insurance Company. He focuses on meeting the individual insurance and financial services needs of people on the West Coast.  You can reach Karl at the office at (424) 785-4337. New Engl and Life Insurance Company, 501 Boylston Street, Boston, MA 02116

 

Copyright © 2011 Liberty Publishing, Inc. All Rights Reserved.

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Surveying the Economic Horizon

When weather forecasts turn out wrong, we usually can make alternate plans that have little consequence in the larger scheme of life’s events. In contrast, when economic forecasts disappoint, the consequences may be more significant. Nevertheless, making decisions about your financial future involves some guesswork, and an educated guess—even with elements of uncertainty—may be a better alternative than traveling into the future with no forecast at all.

Unfortunately, economic forecasting, like forecasting the weather, is far from an exact science. Even professional economists may strongly disagree on the direction of the economy at any given point in time, based on differing interpretations of conflicting economic indicators. Although many factors are important in assessing the economy, this discussion will focus on two key points that can help you get a better feeling for where our economy currently st ands and in what direction it may be headed in the near future.

How Much Longer?

Economic forecasters are always searching for storm clouds that might signal an economic downturn. Since consumer spending has historically accounted for about two-thirds of the economy, many observers have looked to “pocketbook” issues in search of primary clues as to which way the economy may be heading.

While consumers don’t usually cut back first and cause a recession, buying more on credit translates into greater monthly payments, and at some point, consumers can do only what their incomes will allow. With personal debt historically on the increase, keeping an eye on consumer debt levels is particularly important because of the sheer weight of total consumer spending in our economy. However, it may be wise to eventually concentrate your attention on current federal decisions that set the foundation for our overall economic climate.

The Role of the Federal Reserve Bank (The Fed)

Even the casual observer of business news knows that “Fed watching” is a serious activity in the financial and business sectors. You may be wondering, however, why the Fed is so important.

While consumers can affect the economy by acting according to their own perceptions and pocketbook pressures, federal policy decisions, such as fiscal and monetary measures, can also move the economy. Fiscal policy, enacted by Congress in the form of tax and/or spending legislation, is the by-product of the political process and the prevailing political climate. In contrast, monetary policy is the purview of the Fed, whose role is to evaluate all of the forces acting on the economy (individual, market, and governmental) and to take the action it believes will keep the economy on an even keel.

The Fed can manipulate the money supply in hopes of obtaining a desired effect over time. However, the Fed’s most effective short-range policy decisions with which to manipulate the economy involve short-term interest rates. Consequently, the Fed can realistically have only one target—inflation. If the Fed perceives that prevailing forces will increase inflation, it will attempt to slow the economy by raising short-term interest rates (the assumption being that increases in the cost of borrowing money are likely to dampen both personal and business spending behavior). Conversely, if the Fed perceives the economy has slowed too much, it will attempt to stimulate growth by lowering short-term interest rates (the assumption being that lowering the cost of borrowing will stimulate personal and business spending).

In carrying out this balancing act, a very cautious Fed walks a fine line. If it doesn’t tighten the reins soon enough (by raising interest rates), it runs the risk of inflation getting out of control. If it fails to loosen soon enough (by lowering interest rates), it can plunge the economy into recession. Indeed, one might argue that the primary goal of the Fed is to keep inflation low enough so that it is not a factor in business decisions.

Up, Down, or Sideways?

By looking at your own spending outlook and debt burden ( and that of your friends, relatives, and business associates), you may gain some insight into the short-term future of the economy. While by no means the complete story, it does represent a large chapter since it is the one over which individuals can exercise the greatest control. When combined with a little judicious Fed watching (e.g., several interest rate moves in the same direction may be an indication that the Fed is on a mission), you may have a fairly good basis for making sound decisions with regard to your own financial future.

 

This article appears courtesy of Karl Susman.  Karl Susman is a representative of the New Engl and Life Insurance Company. He focuses on meeting the individual insurance and financial services needs of people on the West Coast.  You can reach Karl at the office at (424) 785-4337. New Engl and Life Insurance Company, 501 Boylston Street, Boston, MA 02116

MetLife does not provide legal or tax advice. Before implementing any strategy discussed herein, you should consult with your own financial, tax, and/or legal advisors to determine its applicability in light of your own situation.

Copyright © 2011 Liberty Publishing, Inc. All Rights Reserved.

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Small Group and Large Group Definitions and Differences

The Patient Protection and Affordable Care Act (or health care reform law) established several new st andards for private health insurance coverage. As part of these st andards, the law established federal definitions of “small employer” and “large employer” for health insurance markets. Previously, states defined these markets.
From now until 2016, states can define the size of small groups:

Small employer can be either 50 and fewer or 100 and fewer.  Beginning in 2016, the definitions in the federal health care reform law will apply:

Small employers are those who had, on average, 1-100 employees in the preceding calendar year and at least one employee on the first day of the plan year. (Note that this means sole proprietors could be considered part of the small group market.)

Large employers are those who had, on average, 101 or more employees in the preceding calendar year and at least one employee on the first day of the plan year.

These definitions are based on full-time equivalent calculation that accounts for both full-time and part-time employees. Full-time seasonal employees who work fewer than 120 days during the year are excluded.  On the surface, the inclusion of group size definitions in the federal health care reform law appears to bring more uniformity to health insurance markets. However, the definitions aren’t applied consistently throughout the law. For example, the medical loss ratio provision of the health care reform law amended the Public Health Service Act – but it didn’t change the existing, conflicting group size definitions in the Public Health Service Act.  In addition, some provisions that set different thresholds consider only full-time employees in the calculation rather than full-time equivalents.

Thanks to our friends at Anthem Blue Cross for this helpful information!

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Changes in health insurance

An interesting thing happened the other day. The Department of Health and Human Services (HHS) made an amendment to current gr andfathering regulations. Previously, an employer group health plan could lose its gr andfather status if the employer, among other actions, changed health insurers. Thanks to this recent amendment, employers have more flexibility to shop their coverage and change insurance insurers and not lose their gr andfathered status, so long as the structure of the coverage doesn’t violate one of the other rules for maintaining gr andfathered plan status.

HHS was concerned that the original gr andfathered language would yield the unintended consequence of forcing employers to offer the same level of benefits to all of their employees thus causing premiums to rise substantially. Ultimately, HHS realized that allowing employers some flexibility in this regard would help some Americans retain their current coverage and, perhaps, their jobs.

This is huge, but not because of what it does for employers or their employees. My guess is that the amendment will affect maybe 1% of consumers. What is significant, what we can’t lose sight of, is that this is clear evidence that HHS and the Administration are willing to listen to and act on employers’, consumers’, insurers’ and other stakeholders’ concerns and ideas on how to make healthcare reform more workable and successful for Americans.

The Patient Protection and Affordable Care Act (PPACA) consists of over 2,700 pages. When all is said and done, between additional legislation and lots of regulations, the bill page volume could easily grow to over 200,000 over the next 10 years. We have all known for some time that many of the details in this massive legislation would have to be filled in as time passes. Early indicators like the one above as well as regulations postponing the W-2 requirement for one year, giving carriers a little more flexibility on children-only policies and granting waivers to some employers enabling them to continue using mini-med plans should give us renewed hope that our healthcare system can be reformed in a positive way. The result of the November 2nd elections reinforce my belief in this regard.

I heard from one industry leader that PPACA is very likely to cause wild gyrations in the healthcare delivery system over the next decade. There are likely to be lots of “ups” and “downs” in our journey. For me, I choose to believe that these recent “ups” are positive signs that once we’ve reached our destination, we’ll discover that Americans are benefiting from a vastly improved system and that the agent remains at their side just as they have been so every step of the way.

Thanks for this article from our friends at Warner Pacific!

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Personal Protection From Crime

According to the U.S. Department of Justice Bureau of Statistics, property crime makes up slightly more than three-quarters of all crime in the United States. Not only that, in about 84% of all burglaries, the offender gained entry into the victims residence or other building on the property. And today, crime extends far beyond the doors of your home. The U.S. Postal Service recently reported ten million incidents of identity theft in the United States.

In this issue of the "Insurance Reporter," we focus on protecting yourself and your loved ones from burglary and crime. How can you feel empowered instead of frightened? How do you improve security at your home? Are guns in your household really the way to go? Read these stories and more to get some of the facts you need to make safety improvements in your life.

We appreciate your continued business and look forward to serving you.
Regards,
Karl D. Susman

Personal Protection From Crime

Safety Expert Shares Tips To Feel Empowered Instead Of Frightened
At some point in your life, you may run the risk of being a victim of crime.
Instead of feeling frightened, however, safety expert Tom Patire says you can feel empowered if you know how to protect yourself.
Patire’s newest book, "Personal Protection H andbook," is full of tips for protecting yourself and your family. When he wrote this book, he went right to the source, talking to people who were serving time. They all told him, "We didn’t choose the victims, they chose themselves."
Patire tells The Early Show co-anchor Rene Syler, "The bad guy is st anding in the wings looking around and sees the person on the cell phone looking at the ground or the air and they become an easy mark. Most people will park their car real quick and rush to the store and forget where they parked their car and w ander loosely around out there and who comes? The bad guy."

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How to Protect Your Home From Burglars

Get Tips on Making Your House Safer When Thieves Come to Call
Ridgewood, N.J., schoolteacher Noreen Clark was sure her home was safe from an intruder invasion. The daughter of a retired police officer thought a security system she had installed when she purchased her home last December would prevent burglary.
She also changed all the locks, and if that didn’t work, there was always her golden retriever Jack.
"I feel very secure here. I feel that, on a scale of one to 10, I’m close to a nine or a 10," Clark said.
She was so confident that she agreed to let "Good Morning America’s" safety and security expert Bill Stanton come out and audit her home.

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Nowadays, Crime Prevention and Technology Are Often Interwoven
It didn’t take long for video images of the crash of the US Airways plane in the Hudson River to be available everywhere. The crash was recorded by a security camera, one of the most prevalent uses of technology in crime prevention. Moreover, a recent article in Parade magazine stated that Las Vegas was the best place in the country to have a heart attack, with a 67 percent survival rate. The remarkable rate was attributed to the vast amount of human and electronic security present in Las Vegas casinos and on Las Vegas streets. The Parade article also stated that the survival rate in Chicago, where there are no casinos, is just 2 percent. Technology has changed our world.

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Identity Theft
According to the U.S. Postal Service, there were almost ten million incidents of identity theft in the United States in 2004 at a cost of $5 billion to consumers.
Victims report spending 30 hours, on average, cleaning up after an identity crime at an average cost of $500.
It’s in the newspapers every day and on the news every night. People worry that someone will run up charges on their credit card or fleece their bank account while their back is turned. There is reason to worry. All a thief needs is your Social Security number to commit identity theft. This crime is relatively easy to commit, but investigating and prosecuting it is complex and time-consuming. But once you know the facts and some preventive measures you can take, you can win the fight against identity theft!

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Lethal Weapons In The Home


Picture this. It’s late at night and you hear a noise at the back door or a window inside your home. You get up to investigate and find an intruder breaking into your home. What would you do?
The first answer is to call the police, but in the time it takes for them to arrive, a criminal may harm you or your family. Chances are the home invader will be armed with a knife or a gun, so the job of defender may be left entirely up to you.
Owning A Gun

While it’s always wise to do everything you can to safeguard your home from a break in, if a criminal is intent on getting into your house, chances are they will. This frightening concept causes home owners all over the country to purchase firearms and keep them easily accessible. Simply having the gun can make people feel safer, but if you own one it is vital to learn how to properly h andle, maintain and fire the weapon.
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Karl Susman interviews Tairy Rich

Did you know Susman Insurance is licensed in California, Oregon, Washington, Arizona and Nevada?  Susman Insurance Agency owner Karl Susman interviews Susman client Tairy Rich about what it is like to live in Nevada with an insurance agent in California.

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CSE Insurance Company helps after a car accident

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Have an iPhone?  iPad?  iPod Touch?  Chances are you just may, and if you do you should check out the new FREE application from CSE Insurance. 

When involved in a car accident, only about a million things go through your mind.   Who was at fault, who was driving the other car, damage to yourself or your car, the other people, the other car, where you are, what time it is and on and on.  CSE knows this and is offering this great little application to help you out.   With just a few clicks you are prompted for information you should be getting including the names of driver’s involved, witnesses, photos of the cars, the location of the accident, details and observations and the like.  You can even call the Police or a tow truck right from within the application.  Some additional functions include finding a local CSE Insurance Company independent insurance agent, like Susman Insurance Agency and requesting insurance quotes and proposals.  Nice job, CSE!