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Monday, 15 February 2016 17:00

Three Steps to More Accurate Carrier Invoices

Have you ever experienced billing or invoice issues? Frustrated with people you already terminated still showing up on your bill? Look no further as your Fall River team is here to help! 

When processing eligibility changes such as enrollments, changes or terminations, you can follow these three simple steps to improve the accuracy of your carrier bills. 

Step 1 – Process On Time

  • If you have an impending enrollment, change or termination, it is best to get these submitted to the carrier as soon as possible to prevent any processing delay. The cutoff for the next bill is often 2-3 weeks before the end of the month, which is why people you’ve already terminated can still be showing up if you didn’t terminate them soon enough.  If you want a person who’s terminating on 3/31, for example, to NOT be on your April bill, you may need to get that done as soon as 3/10, depending on your carrier and the billing cycle dates you’ve selected.
  • If terminations are not submitted prior to the actual termination date, carriers do have the right to bill you for the following month of coverage. It’s the most common billing issue and unfortunately, there’s not much that can be done about it. In the Colorado fully insured market for groups with 2-99 employees, carriers will not allow terminations after the effective date unless proof of other coverage is provided.  So, that 3/31 term MUST be done on or before 3/31, otherwise you may be tracking down a copy of the employee’s next ID card before the term can be done.

Step 2 – Process Online

  • Most carriers offer an Online Employer Portal for managing eligibility and paying premium invoices. The fastest way by far to process any eligibility enrollment, change or termination is to complete them online, as most carriers will update their systems in real-time or within 24 hours of the transaction. If you need help obtaining a login and password for an Employer Portal or would like additional training for your carrier-specific portal, please contact your Fall River Account Executive.
  • Billing and invoicing cycles vary from carrier to carrier. The invoice should show your due dates, remittance details (including overnight payment or wire transfer options) and/or other carrier-specific instructions. 
  • If you have signed up to receive electronic invoices, carriers will typically email you in advance when the invoice is ready to view. But watch out…sometimes these emails will appear in your junk folder and could go unnoticed unless you check that folder regularly. 

Step 3 – Audit Your Bill 

  • As soon as you receive your premium invoice, whether paper or electronic, try to reconcile it with your records as soon as possible - the sooner the better while it is still fresh in your mind. If you notice any concerns, reach out to your Fall River Account Executive and we can help you get it resolved. Clients have called us after finally noticing errors that have been on the bill for many months – it is very difficult to help you get your money back if too much time has passed.
  • Most carriers do not allow self-adjusting and require that you pay your invoice as billed.  There can be serious consequences to short-paying your bill, up to and including termination.  If there are folks on your invoice you’ve already terminated, the invoice will auto-adjust next month to credit the premiums back.
  • If payments aren’t received within the 31 day grace period, carriers may terminate coverage and it can be difficult to reinstate. To prevent a lapse in coverage, make payments by the due date or call the carrier to discuss financial arrangements, and don’t self-adjust (ie short-pay) your bill. 

We hope these tips are helpful – please feel free to call us at any time at 303.369.3200 with any billing challenges you may be having.

Published in Best Practices
Tuesday, 15 December 2015 23:00

Is the Cadillac Tax Dead?

On Friday, December 18th, Congress passed and the President signed a very significant Omnibus spending bill.  This bill includes several tax relief measures related to the ACA:

  • A two year delay (from 2018 to 2020) on the Excise Tax, commonly known as the Cadillac Tax
  • A two year moratorium (2017-18) on the medical device tax that is currently in effect
  • A one year moratorium (2017) on the ACA insurer tax which has been built into all fully insured premiums since 2014

Each of these changes is a temporary rather than permanent elimination of these taxes. The moratorium on the latter two taxes, since they are already in effect, may result in a slight easing of your 2017 renewal increase if you have a fully insured medical plan (self funded plans are not subject to the health insurer tax, which is by far the larger of the two).  In the absence of new legislation to make the changes permanent, the restoring of the insurer tax two years later could then bump up the 2019 fully insured renewal increases, much as employers experienced in 2014 when this tax first went into effect.

The great debate that will continue is whether these bills increase the likelihood of eliminating the taxes altogether.  While many employers are in favor of permanent elimination, the costs of even the temporary elimination could result in a significant addition to the national deficit, since there were no corresponding “pay for’s” in the legislation to replace the lost revenue. Permanent elimination could add quite a bit more to the deficit, which affects us all as taxpayers.

The spending bill also included some notable features unrelated to the Affordable Care Act, such as the extension of healthcare benefits for 9/11 first responders, the removal of the ban on U.S. exports of crude oil, and an extension of a business tax credit for research and solar/wind credits, as well as other popular tax deductions. Notably for employers with Section 132 pre-tax parking and transit benefits, the bill awarded equal status between transit and parking, allowing a monthly income exclusion of up to $250 for both transit passes/vanpools as well as parking.

If you have any questions about the impacts of this bill on your ACA planning or compliance, please This email address is being protected from spambots. You need JavaScript enabled to view it.

Published in Healthcare Legislation
Sunday, 06 December 2015 17:00

2016 Ballot Issue: “State Health Care System”

Colorado voters will soon decide whether we should be the first state to implement a “single-payer” system, or universal health care for residents.  Keep an eye out for Initiative 20, the “State Health Care System”, which was certified recently as having obtained enough signatures to reach the 2016 ballot.

What this would mean to Colorado citizens:

  • Single-payer system through ColoradoCare; bills paid by them and not private insurance companies
  • Coverage would extend to anyone who earns income and lives in Colorado
  • People who qualify for existing federal health programs such as Medicaid and Worker’s Compensation would continue, but the administration would fall under ColoradoCare
  • Colorado residents would choose their own medical providers
  • 10% payroll tax–employers would pay 6.67% and employees would pay 3.33%.  Self-employed people would pay 10% of their net income.

The idea of a single-payer system for health care has been a hot topic for several years, and continues to be a heated debate.  Proponents, such as Ivan Miller, the Director of ColoradoCare and head of the Colorado Foundation for Universal Health Care, contend that this type of system would extend coverage for $5 billion less than they pay now, by reducing administrative costs associated with private insurance and the pharmaceutical industry.  Opponents of the bill, such as Byron McCurdy, Board President of the Colorado State Association of Health Underwriters, goes so far as to say that “A single-payer system would destroy our industry.”  Nearly one-fifth of Colorado jobs are in the health care industry, and the belief is that physicians and hospitals would be very difficult to recruit, and the idea of a better health care system would be shattered from the start.  Critics of this bill also warn that it is a massive expansion of government that would double the size of the Colorado budget, and it’s possible even that won’t be sufficient to fund the care we’ve come to expect.

If the ColoradoCare bill is passed by voters in 2016, Colorado would become the first state in the country to implement a universal health care system.  However, Colorado is not the first state to have attempted this measure.  In 2011, the Vermont state government passed a law that established Green Mountain Care, the first single-payer system where residents would have received universal health care coverage, with the expectation that overall health care spending would be reduced.  Through 2014, Green Mountain was working on laying out the provisions and responsibilities of the bill, and trying to reconcile the $2 billion in extra spending that would have been necessary to fund the single-payer system.  Ultimately in December 2014, the universal health care plan in Vermont was abandoned, citing tax requirements on citizens and small businesses.

Stay tuned to see if the same situation occurs in the 2016 Colorado vote.

Published in Healthcare Legislation
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.

Published in Healthcare Legislation

The definition of a “Small Group” in Colorado for insurance purposes has long been considered to be a group employing 50 or less individuals.  The Affordable Care Act originally redefined a Small Group as a group with 100 or less individuals, and also proposed implementing a new rating mechanism for all small groups in 2016.  

The new age-banded rating structure requires that rates be determined upon each member’s exact age.  This has many companies, primarily those in the 51-100 space, struggling to prepare for new administrative complexities that they are not used to since they have always been composite-rated.  

On October 7, 2015, the federal Protecting Affordable Coverage for Employees (PACE) Act was enacted into law after much debate and lobbying in Congress. This bill re-set the definition of a small group under the ACA back to 2-50, and allows the states to extend the small employer definition up to 100 employees if they choose. 

Colorado and a few other states (CA, MD, NY, VA and VT) have already passed legislation to expand the small employer definition up to 100 employees for 2016. The PACE Act may have some of these states re-evaluating the guidance and whether it is worth the time and money to change the small group definition.  As it stands today, we do not expect the state of Colorado to change their current position, which defines Colorado Small Group as a group of under 100 employees.  Much work has already been done at the carrier level to accommodate the new definition, and it may be too late in the year for them to change their stance.

As having a different rate for every employee can be very challenging, we have two key suggestions.  First, if you are becoming subject to age-banded rates for the first time, we highly recommend using an online enrollment tool if you don’t already.  This enables you to load all the rates in advance once, so that each new employee comes on and the system has already priced out what the rates will be depending on their exact situation.

Secondly, small groups subject to the new rating structure can still create composite rates for their employees if they so choose.  The benefit is to be able to communicate the same rate to all employees regardless of age, based on their tier of coverage.  We can help you estimate what adequate composite rates would be for your group.  

These estimated composite rates are used only for establishing your employer/employee contributions and will not affect what you see on your insurance company bill.  Thus, it’s important that groups choosing this route be aware that they are taking a risk of not collecting enough premium to balance out at the end of the year should enrollment fluctuate from what was anticipated when the composite rate estimates were established.   Companies using composite rates would want to revisit them each year with the changes in enrollment over the last 12 months. Groups with high employee turnover or contract employees may not want to use composite rates because of this uncertainty.

Finally, consider a partially self funded plan, which enables you to keep your composite rates indefinitely.  Read more here.

This continues to be a hot topic and we’ll monitor the news for additional guidance in Colorado!This email address is being protected from spambots. You need JavaScript enabled to view it. or give us a call with any questions.

Published in Healthcare Legislation
Monday, 19 October 2015 18:00

ICD-10 Implementation May Increase Claims Issues

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.

Published in Healthcare Legislation
Monday, 28 September 2015 13:56

A Potential Snag with Opt-Out Credits

Large employers who offer an opt-out provision, where the employee “opts out” of the company’s benefits plan in exchange for cash or an increase in the employee’s salary, need to be aware of the impact this could potentially have when determining “affordability” under the employer mandate. 

In 2015, the employer mandate is in effect for large employers (defined as those with 100 or more full-time or full-time equivalent (FTE) employees), who must provide “minimum essential coverage (MEC)” to at least 70% of their full-time employees or potentially pay an assessment if they do not offer coverage, or if they offer coverage that isn’t “affordable”. 

Starting January 1, 2016, employers with 50 to 99 full-time employees or FTEs will be required to comply with the mandate as well.  

Although no guidance has been released with regard to an opt-out provision under the employer mandate, it has been suggested that it will most likely mimic the individual mandate’s calculation of affordability.


What are the IRS Guidelines for the Individual Mandate? 

An employee can be eligible for a tax credit on the individual exchange if their employer coverage is unaffordable, which is defined as the employee’s contribution towards coverage exceeding 9.5% of their income.  The amount they have to contribute to employer coverage also impacts whether they are subject to the individual mandate.  

An employee’s contribution is reduced by the amount the employer contributes, as long as the employee cannot elect to receive the employer contribution as a taxable benefit (such as cash). Therefore, employer opt-out contributions that can be taken as cash must be counted as employee contributions for affordability purposes under the individual mandate.


Potential impact of the affordability requirements under the Employer Mandate

An example:

  • An employer requires a $90 per month per employee contribution towards the cost of the plan.
  • This amount would almost certainly meet the affordability test for all employees. 
  • In addition, the employer offers all employees a $100 per month opt-out credit.
  • Based on how they interpret opt-out credits for the individual mandate, it appears the IRS may interpret the employee contribution to be $190 ($90 plus the $100 that the employee must forego to elect the coverage). 

Now, many of the employer’s lowest wage employees could fail the 9.5% affordability test, potentially subjecting the employer to a $3,000 affordability penalty for any of those employees who choose subsidized coverage on the exchange rather than the employer’s plan. Whether or not the coverage is affordable is communicated on each employee’s 1095 form starting in 2016.

Employers offering an opt-out provision should carefully review their benefits plan, and potentially check with legal counsel, to determine if the current arrangement violates the affordability requirements under the employer mandate. We also recommend outsourcing the preparation of your 1095 forms, to alleviate the time and compliance hassles associated with them. 

If you’d like to discuss the potential impact of your opt-out provision, just give us a call or This email address is being protected from spambots. You need JavaScript enabled to view it..  


Published in Healthcare Legislation
Friday, 29 May 2015 07:25

Staying out of Jail and the Poor House

Mile High SHRM PDG featuring Kristen Russell and Dean Heizer
Thursday, June 25th, 3-5 pm
CSU Downtown, 475 17th Street Suite 300, Denver, CO 80203

There are so many laws driving your practices regarding HR and Benefits, that it's getting tougher and tougher to keep track of them all. Yet with the threat of significant fines and even jail time for violations, you’ve got to stay on top of the most important ones.

Join us for a high energy and entertaining pick-me-up to the end of your day as we review the most common mistakes that land an HR person in trouble, especially regarding your employee benefits.  We'll cover what you thought you knew, but might be surprised about, on the following topics:

  • ERISA – it’s not just for retirement plans, as the DOL is auditing more and more health plans.  We’ll cover some classic retirement plan blunders, but also what you need to do on your health plan – and why so many employers are out of compliance!
  • HIPAA Discrimination Rules and how to keep your wellness program legal based on all the latest guidance (click here for more topics and to register)
  • The ADA as it impacts wellness and workers comp and wellness programs;
  • COBRA goofs you might just have made at one time or another; and 
  • Tricky situations under disability leave and the FMLA.

Towards the end we'll have time for sharing best practices among peers, and networking, accompanied by some adult refreshments. Who knew Happy Hour could be so fun AND educational??  This program is free for Mile High SHRM members, and very affordable for others.  Register here.


Published in Best Practices

We often talk to small and mid-sized employers about the advantages of a Partially Self Funded plan, which most large employers already use.  These include the avoidance of most premium tax, more control over plan design, and access to data that you can use to lower future renewals.

But two forces are coming together to bring more focus on partial self funding.  First, for groups under 50 employees, the end of transition relief that had allowed some smaller plans to avoid the new community rating rules means the four impacts below are hitting those groups this fall. Second, for groups with 51-99 employees, all four of these factors go into effect with your first renewal in 2016:

  • Limited Age Rating: Rates for younger groups may go up once they switch to the new rating. Insurance companies today typically charge 5 to 7 times as much for the oldest enrollees compared to the youngest. Under the ACA, they’re limited to 3 times as much.  This is good news for groups with an older population, but if most of your employees are younger than age 40, this may result in higher rates at the point you switch to a community-rated plan (this Fall for many groups under 50)
  • No Industry Rating: Employers who are in industries generally considered to be healthy get lower rates today to reflect this. Since January of 2014, the ACA no longer allows industry rating for groups under 50, and it’s disallowed in 2016 for groups 51-99, so many smaller plans who may see a bump at their next renewal when they move to an ACA-compliant plan
  • No Rating for Health Status: Groups under 50 employees in Colorado haven’t been rated by health status in a number of years, but small groups in most other states were. Discounts for healthy groups went away in all states for groups under 50 in 2014, and they disappear for all groups up to 100 employees in 2016
  • Age-Rating:  Most employers with 10 or more employees are accustomed to composite rates, where there is a single set of 4 tier rates for all employees.  This structure changes on ACA-compliant small group plans to having a different rate for every single age, as well as separate rates for each dependent.  This requires much more administration work, especially if you don’t have an online enrollment system, which we would highly recommend

Small groups under 50 employees who had used transition relief to put off joining an ACA-compliant plan will have some planning to do to avoid potential unpleasant surprises at their next renewal.  Similarly, groups between 50 and 100 employees will face a major rating change, and partially self funding can be a great way to avoid those changes permanently.  There is some talk of a delay of this rating change for groups of 51-99, but until we see something more concrete we’re encouraging groups to prepare as if it were going into effect on schedule in 2016.

If you are an employer with a relatively healthy population, you may wish to strongly consider a partially self funded plan with your next renewal.  We are helping some of our clients evaluate this strategy now so they can plan ahead of their anniversary date. Kristen will also be giving a number of seminars on partial self funding this year at the Mountain States Benefit Update Conference and also the CO-SHRM conference in Keystone. 

Please This email address is being protected from spambots. You need JavaScript enabled to view it. or give us a call at (303) 369-3200 if you would like some tips on how to approach this important decision.

Published in Best Practices
Thursday, 23 April 2015 18:00

Impact of the ACA on Businesses

Since the implementation of the Affordable Care Act, experts have attempted to analyze the cost effects on American employers.  While broad generalizations cannot be made since results can vary by state and industry type, the largest differentiator seems to be group size.   Larger employers may tell you that the cost impacts have not hurt their businesses, however small employers report a drastically different perspective.  In summary:

  • Small employers (50 employees or less) are already feeling the cost impact of the ACA
  • Mid-size employers (50-99 employees) will most likely not see the impact until 2016, when the mandate begins requiring employers to provide coverage or pay a tax penalty for each uninsured employee beyond the first 30.   Many of these employers are already complying with many provisions of the mandate and may not see much of a cost impact.
  • Large employers (99 employees or more) have seen very little effects since most are already in compliance.  The cost impact associated with the ACA is a small fraction of what they pay overall for employer-sponsored health insurance.

Although those large groups may not have yet seen a large cost impact, provisions such as the Cadillac tax in 2018 on the most generous health plans may cause some employers to re-evaluate their plans. If they haven’t felt the cost impact like smaller groups have, they most likely did experience some transitional headaches accompanying the need to change their benefit structure to be in compliance with the ACA.

To read more about why large groups are not feeling the pain associated with the costs of the Affordable Care Act, click on the following link: 


Small employers are exempt from the mandate, and could potentially drop group coverage without a financial penalty.  However, they also know that having a benefit package helps to attract and retain good employees.  They may find themselves weighing the need to attract a good workforce with the increasing costs of health insurance and the impact on their budget.

According to a 2014 survey conducted by Morgan Stanley, small groups in many states reported that their premiums increased substantially.  In Colorado, renewal premiums spiked by an average of 29% and many employers opted to “grandmother” their plans in order to delay the financial impact of the transition to ACA-compliant plans.

What makes this transition especially difficult for small employers that already have a tighter budget than larger companies, is that they could be faced with the difficult choice of dropping group coverage altogether or passing some of the cost increases to employees in the form of higher out-of-pocket costs or higher employee premium responsibility.   A subset of small employers, particularly in certain industries, is going as far as  reducing employee hours to limit their eligibility on the group plans.  A survey by the Society of Human Resources Management found that 1 in 5 small businesses are reducing workers’ hours to less than 30 hours per week, making them ineligible to participate in the group plan, but possibly eligible for subsidized coverage through the individual Exchanges. 

To read more about the effects of the ACA on small businesses, click on the following link:


As the effects of the ACA continue to evolve in the coming years, Fall River is positioned to help our clients navigate each step of the way.  If you have any questions about the impact of the ACA on your business, This email address is being protected from spambots. You need JavaScript enabled to view it.!

Published in Healthcare Legislation
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