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Juliet Fitzgibbons

Juliet Fitzgibbons

Juliet joins Fall River as an Account Executive and brings over 15 years of prior broker and account management experience. Her experience brings extensive knowledge on employee benefit programs, account management and creative cost-saving strategies and compliance solutions for employers of various sizes.

She is responsible for new business proposals, client renewals including plan benchmarking, rate analysis and mid-year reviews. She helps clients navigate healthcare systems and educates employers and employees through open enrollment meetings and day-to-day service requests. Juliet joined Fall River in 2015.

Tuesday, 24 November 2015 13:38

2016 Connect For Health Assessment Fees

In 2013, the Legislature passed a law that allocated federal grants to support Connect for Health Colorado - Colorado’s state insurance exchange. Beginning in 2015, Colorado will be self-sustaining through a Special Assessment Fee which is applied to all health plans in Colorado, including group insurance and partially self-funded arrangements, for employers of all sizes. 

Here are a few details you need to know:

  • The 2015 assessment is currently $1.25 per member / per month
  • In 2016, it will be $1.80 per member / per month
  • Calendar year 2016 is the last year this assessment is available under current statute

How your health insurance company will collect this fee depends on which carrier you have.  In general, carriers will include the fee as an additional line item on the bill, rather than building it into your premium, unless noted otherwise.

  • Anthem – Line item for all groups
  • Aetna – Currently planning to charge only groups 100+; process to be determined
  • Cigna – Line item for all groups
  • Humana – Since they are in the process of being acquired by Aetna, they’ll follow Aetna’s process in 2016
  • Kaiser –  Will begin charging in 2016 but process to be determined
  • Rocky Mountain Health Plans – Line item for all groups
  • United Healthcare – Line item for all groups

For more information about this fee, please go to www.connectforhealthco.com.

Employers were warned in 2014 that the ACA came with a new medical billing and coding system. As of October 1st, the United States implemented the tenth revision to the ICD (International Classification for Diseases) codes in an effort to more thoroughly define diseases and injuries. 

This change will allow key industry stakeholders to better track and manage diseases and patterns, measure the quality of care, evaluate patient outcomes, ensure patient safety, manage population health, detect fraud / abuse and track detailed data on injuries and accidents to compare global pandemics—all of which support the shift toward value-based healthcare.

 However, the coding system comes with other changes that are not so exciting.  Doctors and other medical professionals will now have to learn the 140,000 new codes which have been added to describe treatments provided on billing statements as well as private insurance claims. This is a huge leap from the 17,000 codes that previously existed before October 1.

 This complex conversion could lead to disruptions across the medical field. Providers may see overall delays in claims processing, and some individuals may have insurance claims that are denied for services that were provided, but not properly coded. 

The Health Information and Management Systems Society (HIMSS) published an article earlier in the year stating coding errors can reach a staggering 19.7% out of total claims submitted. The Centers for Medicare and Medicaid Services (CMS) published a counter article in July 2015, indicating the ICD-10 testing results displayed a 98% success rate and they would not expect ICD-10 to impact patients unfavorably. Another hurdle facing a clinic or a provider is that medical billing and coding is a highly demanded profession and this transition of codes would make it more competitive and thus more costly than before.

If you or your employees are experiencing escalated claims issues, please reach out to your account manager at Fall River - This email address is being protected from spambots. You need JavaScript enabled to view it.

The Medicare Modernization Act (MMA) requires Employers with prescription drug coverage to complete two items each year regarding Medicare Part D.  The first deadline is October 15th annually, and the other is 60 days from the beginning of each new plan year.  These tasks are required regardless of whether your plan’s prescription drug coverage is considered to be creditable coverage, which means that the coverage is expected to pay, on average, as much as the standard Medicare prescription drug coverage.  

The MMA imposes a late enrollment penalty on individuals who meet two criteria:

  • NOT electing Medicare Part D during their initial enrollment period for the Medicare prescription drug benefit AND 
  • NOT maintaining creditable coverage from the time of the initial eligibility and when the individual ultimately elects Medicare Part D

To avoid this penalty, this creditability information is critical to a Medicare eligible individual’s decision on whether to enroll in a Medicare Part D prescription drug plan. Your job as an employer is simply to communicate the creditable status of your plan, both to participants and to the Centers for Medicare and Medicaid Services (CMS).

Here’s what you need to do:

1.  Send your plan’s creditability information to all Medicare-eligible individuals that are on the employer-sponsored health insurance plan.  

There are model notices (links below) that you can use to notify employees, one stating that a plan is creditable, and one stating that a plan is not creditable.  Although you do not have to send the notice to employees that are not on the employer health plan, we recommend that you send it to all employees who are on the healthcare plan, even if they are not Medicare-eligible.  Many employers have grown to the point where they don’t personally know all their plan participants, so it’s safest to send to all enrolled. This notice is due each year by October 15th.

2.  Certify on the CMS website whether your plan is considered creditable or not, within 60 days from the beginning of each plan year.  Employers can usually find out if their plan is creditable from the prescription drug carrier (or medical plan, if bundled).  Completion of this requirement involves filling out the disclosure form on the CMS website to certify the plan’s creditability (see the links below).

Please note that although the notice is an annual requirement in the fall, the employer also has an obligation to provide notification to a Medicare-eligible individual when they join the health plan, as well as when a Medicare-eligible individual goes onto COBRA coverage, and to any retirees from the plan.  Again, many employers simply choose to provide this to all new hires to avoid missing anyone.

Click here and scroll down to “Medicare Part D” for the CMS website instructions as well as the two model notices that you can use for your employees. This email address is being protected from spambots. You need JavaScript enabled to view it.

 

Partially self funded plans are benefit plans that look and feel like a traditional health insurance plan. If they are structured properly, there is little or no risk to the employer with a significant potential to gain in a given year.  These plans can often offer a better value and price than fully-insured plans because they are not subject to all of the rating requirements of the ACA.  There are also plans available that let employers “dip their toes” in the waters of self funding to get a feel for what their claims experience might look like. 

 

Not sure if partial self funding could benefit your organization?  You’re in luck.   Fall River’s 2015 Feasibility Study analyzes the advisability for groups of different sizes and locations to become partially self-funded or whether groups already self-funded should be moving up or down the spectrum when it comes to risk continuum. We do all the due diligence for you.

 

We utilize our self funding expertise and our in-house actuarial tools to evaluate each scenario and present you with an analysis specific to your organization, at no cost to you. In addition, the results will be summarized with no company names and presented at the CO-SHRM conference on Friday, October 2nd in Keystone.  

 

A short survey will determine if you are eligible. If so, we will contact you to schedule the review and provide a checklist of required documents.  If you would prefer to analyze these options next year, we would invite you to sign up in advance for our 2016 study beginning early next year. 

 

For more information on the Feasibility Study, please contact Juliet Fitzgibbons at This email address is being protected from spambots. You need JavaScript enabled to view it.

 

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