Thursday, October 13, 2016

Individual Health Insurance Rates Skyrocket for Health Exchange Market ( for Illinois

I just got back from a professional association meeting where a person from the department of insurance was presenting. What he presented is grim at best (slides are from that presentation). Below is a preliminary cut. I don't have the actual rates available to quote (they are coming any day), but by the look of the items below, it will be worse than bad. See my analysis at the end.

1. Selection of insurance companies available is less. Seven counties have one company available.

2. Rates for the LOWEST Bronze Level plan are going up 10% - 60%.

3. Rates for the second lowest silver plan (for which subsidies are based upon) are going up 25% - 60%

4. Rates for the lowest Gold are going up 40% - 70% with several counties not offering any gold plans at all.

What does this mean?

1. If you receive a subsidy, you will be protected for a majority of the increase due to your subsidy being dramatically increased. You may still pay more money.

2. Your choices are dramatically curtailed. Your best option will most likely be an HMO plan. Most carriers are driving towards that eventuality as it is the only way that they feel they can break even. Pretty much BCBS of Illinois (in my opinion) will be the only game in town as a quality carrier with decent rates. Cigna is joining the market in a few areas, but I don't have specifics.

3. If you need multiple specialists from multiple medical groups or the teaching hospitals (e.g. Northwestern Memorial, or a Northshore Hospital). You may not be able to access them via the exchange and would have to consider either a direct policy or if you have your own business, you may qualify for coverage (you no longer need two employees on the plan, but you do either need to have a husband/wife partnership that filed that way last year or at least one W2 employee - whether full or part time) that will give you access to the larger PPO networks. Contact me for specific details.

4. If you don't receive a subsidy, going outside of the exchange may give you more choices. Harken is leaving the Exchange market, but is still around if you go directly to them.

5. Some of you reading this won't be able to afford ANYTHING. If you fall into this category, I have several non-insurance programs that will avoid the penalty and typically cost significantly less (1/2 to 1/5 the cost of insurance). They do cover your bills, but you need to agree to their principals. Some have holes in the plan that need to be filled with another product, but overall, something is better than nothing.

Use this link to schedule a 15 minute call to discuss your situation.

Robert Slayton

Tuesday, August 23, 2016

Options Limited for Health Insurance in 2017

If you buy individual health insurance (especially via, your options WILL be limited this upcoming year.

Right now DuPage County (IL) has 4 options. Aetna, BCBS of IL, Coventry, and United Healthcare. BCBS and Coventry have PPO networks. In 2017, you will have BCBS and Cigna only as Aetna, Coventry, and United Healthcare pull out. Cigna will be an HMO. This means the ONLY PPO network available will be the Blue Choice PPO network via BCBS of IL (assuming they continue this plan, which I think they will). If you need a variety of specialists who are not in the same medical group, you will either have to pay out of pocket or change doctors.

Cook County won't be much better. You have 7 options, but 3 will be going away (see above). Harken Health (who currently has the best PPO network) will be changing the network to either a smaller PPO network or HMO (they haven't told me yet). In 2017, you will probably have Ambetter, BCBS of IL, Harken Health, Humana, and newcomer Cigna. The only two that would possibly have a PPO is BCBS of IL and Harken Health (see above).

Downstate will at least have Health Alliance (as of my writing this article) who offers a POS plan (less restrictive than an HMO, but not quite as flexible as a PPO) in addition to BCBS of IL.

BTW, I didn’t mention the premiums. Go to if you want to see how bad it is going to be.

To help people who can’t afford the cost, I have a new plan that is NOT insurance but is a cost sharing ministry that will be available to those who just can’t afford the new premiums. It avoids the penalty and has some holes, but something is better than going with nothing. If you want more information on this, contact me. The good news is that you can sign up at any time, but it does NOT cover any pre-existing conditions or medications other than generics. View this as a “last resort” plan.

Thursday, August 4, 2016

IRS Issues Draft Instructions for Forms 1094-C and 1095-C for 2016

IRS Issues Draft Instructions for Forms 1094-C and 1095-C for 2016   

August 4, 2016

By Larry Grudzien,, 708-717-9683

On August 1, 2016, IRS released draft instructions for Forms 1094-C and 1095-C for 2016. The following is an overview of important changes to the forms:

Form 1094-C

On line 22, box B is designated "Reserved." The Qualifying Offer Method Transition Relief is not applicable for 2016.

In Part III, column (b), "Section 4980H" was inserted before "Full-Time Employee Count for ALE Member" to remind filers that the Code Section 4980H definition of "full-time employee" applies for purposes of this column, not any other definition that an ALE Member may use for other purposes.

Form 1095-C:

The language "Do not attach to your tax return. Keep for your records." was inserted under the title of the form to inform the recipient that Form 1095-C should not be submitted with the return.
Changes to codes. Code 1I for line 14, and Code 2I for line 16, are no longer applicable and have been reserved.

New codes 1J and 1K have been added for line 14. These codes are used to reflect conditional offers of coverage to an employee's spouse. A conditional offer is an offer of coverage that is subject to one or more reasonable, objective conditions (for example, an offer to cover an employee's spouse only if the spouse is not eligible for coverage under a group health plan sponsored by another employer.

Multiemployer Plan  Interim Rule Relief:  The use Code 2E for line 14 has been extended to 2016.

Form 1094-C and Form 1095-C:

Transition relief. Several forms of transition relief were available to employers for 2015 under Code Sections 4980H and 6056, but only limited transition relief continues to apply in 2016. References to transition relief that applied only in calendar year 2015 have been removed. Descriptions of the remaining forms of transition relief have been amended to clarify for which months in 2016 the transition relief applies.

New Definition: The term "Employee Required Contribution" has been added.  This  term refers to the employee's share of the monthly cost for the lowest cost self-only minimum essential coverage providing minimum value that is offered to the employee by the ALE Member.

For a copy of the instructions, please click on the link below:

Tuesday, July 5, 2016

Employer Notices From the Marketplace - What to do

Many employers received notices last week about employees who are receiving subsidies on the individual exchange. This matters if you are classified as an ALE "Applicable Large Employer" as penalties may be assessed.

  1. If the employee is receiving a subsidy because you did not offer them coverage, then there is nothing you need to do.
  2. If the employee is receiving a subsidy because you did not offer a plan that met minimum essential coverage or affordability, then there is nothing you need to do.
  3. If you did offer coverage that was affordable and met minimum essential coverage, then you have 90 days within which to appeal.

Here is a link to that form:

If you are an ALE and don't know what I am talking about in the above 3 points, then you ABSOLUTELY need to talk to me, your current broker, or your Employment Attorney.

Below is a newsletter about this from a very good Employment Attorney (if you need one). Larry Grudzien (, 708-717-9638).

From the Desk of Larry Grudzien

What's up with the Notice from the Marketplace?        

July 3, 2016
Last week, many employers received notice from the Marketplace indicating one of their employees was qualified for advance premium tax credits. Many are asking what  is this notice and how should deal with it. The following explains what the notice is and what steps an employer should take.

What is this Notice?

Under Section 1411(e)(4) of the Affordable Care Act, a Marketplace must notify an employer if any of its employees is determined to be eligible for a premium assistance credit (or the cost-sharing subsidy) because the employer does not provide minimal essential coverage through an employer-sponsored plan, or the employer does offer such coverage but it is not affordable.

Under 45 CFR Section 155.310(h), the notice must:

  • identify the employee, providing the minimum necessary personally identifiable information;
  • state that the employee has been determined eligible for advance payments of the premium tax credit, listing the potential reasons for the determination (instead of the actual reason) and without providing tax return information;
  • indicate that, if the employer has 50 or more full-time employees, the employer may be liable under the employer responsibility rules of Code Section 4980H; and
  • notify the employer of its right to appeal the determination.

Under Section 1411(e)(4)(B)(iii) of the Affordable Care Act, a Marketplace must provide this notice regardless of the size of the employer even though the employer mandate penalties only apply to applicable large employers (ALEs).

In addition to the above notice, a Marketplace may also contact the employer to determine whether its employees are enrolled in or are eligible for affordable, minimum value coverage under an eligible employer-sponsored plan, as provided in 45 CFR Section 155.320(d)(3)(iii)(D).

What should an employer do after it receives this notice?

The employer may appeal a determination that an employee is eligible for advance payments of the premium tax credit based in part on a finding that the employer did not offer qualifying coverage to the employee, as provided in 45 CFR Section 155.310(h). While a Marketplace's determination does not itself trigger the employer mandate penalties (those penalties are assessed by the IRS), employers offering coverage that should not result in the receipt of advance payment of premium tax credits may wish to use the appeals process to ensure, as much as possible, that their employees are not mistakenly receiving such payments.

The appeal may be conducted by either a Marketplace or by HHS if a Marketplace has not established an appeals process.

A Marketplace must allow employers to request an appeal within 90 days from the date of the notice from the Marketplace and permit employers to submit relevant evidence to support the appeal, as provided in 45 CFR Section 155.555(c). An employer may request an appeal by completing an appeal request form. Click on link below to obtain a copy of the request form:

An employer may mail or fax an appeal request.

Under 45 CFR Section 155.555, this appeals process must give employers the opportunity to:
  • present information to a Marketplace for review of the determination, including evidence of the employer-sponsored plan and employer contributions to the plan; and
  • have access to the data used to make the determination to the extent allowable by law.

Under 45 CFR Section 155.555(d), once a Marketplace receives a valid appeal request, it must:
  • timely acknowledge the receipt of the request,
  • provide an explanation of the appeals process,
  • inform the employee of the appeal, and
  • provide the employee with instructions for submitting any additional evidence for consideration by the appeals,

Under 45 CFR Section 155.555(i)(3), the standard of this review is a de novo review. A de novo review means a review of an appeal without deference to prior decisions in the matter.

Under 45 CFR Section 155.555(g), as part of the review process, the employer must be given the opportunity to:

  • provide relevant evidence for review of the determination of the employee's eligibility for advance payments of the premium tax credit or cost-sharing reductions;
  • review the information identifying the employee, information regarding whether the employee's income is above or below the threshold by which the affordability of employer-sponsored minimum essential coverage is measured, and other data used to make the determination, to the extent allowable by law.

The Marketplace's decision is required to be provided to both the employer and employee generally within 90 days of the date the appeal request is received, as provided in 45 CFR Section 155.555(k).
If the employer's appeal is successful, a Marketplace will send a notice to the employee encouraging the employee to update his or her Marketplace application to reflect that the employee has access to or is enrolled in other coverage. Under 15 CFR Section 155.555(k), the employee has the right to appeal the decision.

This appeal decision does not foreclose any future appeal rights the employer may have under the Internal Revenue Code for excise tax liabilities. While an appeal of a notice by the Exchange may be beneficial, employers are not necessarily required to make this appeal to preserve their rights against the later potential assessment of Code Section 4980H liability, as provided under 45 CFR Section 155.555(k)(1)(ii).

For a copy of the employer appeals process regulations, please click on the link below:

Thursday, June 16, 2016

Expect More From Your Broker

In today's world, handing a spreadsheet of options to a client misses the key pieces that employers need. Employers need the following along with an "easy button."
1. Help with making sure the benefits strategy fits with your overall business strategy. Let's face it, benefits are expensive. If you are offering benefits to employees (i.e. health, life, dental, vision, retirement plan, telemedicine, voluntary, short term disability, long term disability, and or wellness), you want a return on your investment. Better recruiting, better retention, and happier and healthier employees. Make sure whatever you do can be communicated in a positive way to your employees via either the broker or positive communications. The conversation with your broker should START with where your benefits strategy fits into your overall business strategy.
2. Assistance with the myriad of regulations the government has imposed on your business and definitely help with compliance with the affordable care act. We offer a full HR library up to and including an HR person to answer an employer's most pressing questions. The library is available day or night via computer or phone and is regularly updated and includes sample policies and procedures. We also offer ACA reporting for the 1094 and 1095 forms along with a Wrap Summary Plan Description.
3. Creative strategies to keep the cost of insurance down while still serving the needs of your employees. This includes determining whether your benefits are better or worse than similar companies. It could mean looking at level or self funding options or health reimbursement arrangements on the medical side. Implementing a wellness program in a cost effective way (we have one that will save you money - we can actually put the numbers to it for you). If you are a large self insured company, offering claims data analysis to see where you can save money. We can even offer actuarial support on your benefits plans for larger companies.
4. Ongoing support as needed. A responsive staff to take care of the little stuff and access to your broker for the big stuff. Employee adds, drops, COBRA, etc. can be handled via your broker or the systems they set up for you.
5. Ongoing reviews. Touching base at least quarterly to make sure we are serving you the best that we can.
6. Taking care of your employees like they are our own. We can come in (or provide webinars) and do financial lunch and learns, arrange talks from the American Cancer Society or American Diabetes Association, and other organizations as it fits the needs of your population.
In short, expect more from your broker. You will thank yourself for it.