Dynamic Work/Life Solutions Blog

Qualifying Events for Changing or Cancelling Health Insurance

Posted by Blog Tipster on Wed, Jun 08, 2016 @ 04:24 PM


Since the implementation of the Affordable Care Act, changes have been made to the list of qualifying events in order to make it easier for employees to change insurance before their next open enrollment period.

Employees are now allowed to enroll, cancel, or change plan options under any of the following circumstances:

  • Loss of eligibility for group health benefits, individual health benefits, CHIP, or Medicaid
  • Meeting eligibility requirements for state premium assistance, Medicaid, or CHIP subsidies
  • Adding spouse or dependents through marriage, birth, adoption, or placement for adoption
  • Death of spouse or dependent
  • In the case of the birth of a child, a spouse can be enrolled due to the birth even if the spouse was not previously covered under the plan
  • Change in marital status (marriage or divorce)
  • Change in number of dependents
  • Change in employment status (part-time to full-time or vice versa)
  • Change in residence
  • Change in cost of coverage that permits the employer to automatically increase or decrease employee contributions
  • A significant change in the cost of coverage that permits an employee to add or drop coverage or switch plans
  • A significant reduction of benefits with or without a loss of coverage
  • If a plan adds a new benefit package or coverage option, improves an existing option, adds coverage for a new option, or switches plans
  • Allows for new election or cancelling of coverage when a change is made under another employer plan (i.e. for spouse or dependent)
  • Legal separation, annulment, or child support judgment
  • Employee, spouse, or dependent become eligible for Medicare Part A or B, Medicaid or loses coverage under these plans
  • Employee taking FMLA may revoke their election for insurance and choose another option for the remaining period of leave

Human resources must be notified of these changes within 31 days of the occurrence. Written proof of the event also needs to be submitted.

eni’s BalanceCare  Guides are available to assist our members with questions regarding qualifying events.  Learn more today!

*IRS Section 125

Tags: Health Care, Affordable Care Act, Qualifying Events

2016 Changes to Minimum Essential Coverage

Posted by Blog Tipster on Wed, Dec 09, 2015 @ 04:33 PM


eni’s Health Advocates explain the 2016 changes to Minimum Essential Coverage under the Affordable Care Act:

Small companies are considered those with less than 100 employees (this was formerly 50 employees).

Pediatric coverage is provided to the enrollee until the end of the month in which they turn 19, which aligns with current industry practice.

Drug formularies must be published by insurance companies in a readable format so third parties can create resources that aggregate information on different plans. These formularies must be up-to-date, accurate and have a complete list of all covered drugs including any tiering structure and any restrictions on the manner in which the drug can be obtained. They also must be in a manner that is easily accessible to plan enrollees, prospective enrollees, the state, the Marketplace, HHS, OPM, and the general public.

Insurers must have a process so the enrollee can request and obtain medications not on the formulary.  Decisions must be made within 72 hours of the request. There are detailed procedures for the standard review process and a requirement that insurers have a process in place so an enrollee can request an independent review if the health plan denies an internal request made on a standard or expedited basis.   Cost sharing for such medications must count towards the annual limitation on cost sharing for health plans subject to the EHB requirement.

Most medications need to be available through network retail pharmacies instead of only through mail order. Mail order discounts can still be applied.

Most or all medications for specific conditions cannot be placed on a higher tier level.

Insurers cannot restrict services based on age when services are appropriate for all ages.

Insurers must provide telephonic interpreter services for 15 languages and critical documents must be available in languages spoken by at least 10% of the state’s population.

Provider directories must be up-to-date, accurate, complete, and include which providers are accepting new patients. These must be accessible to plan enrollees, prospective enrollees, the state, Marketplace, HHS, and OPM.

Directories must be easily accessible on a public website through a clearly identifiable link or tab without having to register or create an account or enter a policy number.  Insurers must update directory information at least monthly.

Habilitative services have increased to include health services and devices that help a person keep, learn , or improve skills and functioning for daily living.  These services may include physical and occupational therapy, speech-language pathology, and other services for people with disabilities.

Insurers will no longer be able to define habilitative services themselves.  They cannot impose limits on services and devices that are less favorable than those they impose on rehabilitative services. As of January 1, 2017, insurers will be prohibited from imposing combined limits on both habilitative and rehabilitative services but must treat them separately.

 eni’s Health Advocates are available to help our members navigate the complexities of the healthcare system.


Final HHS Notice of Benefit and Payment Parameters for 2016

Tags: Health Care, Affordable Care Act, Health Advocacy, Minimum Essential Coverage

The Affordable Care Act - What You Need To Know

Posted by Melissa Mayfield on Wed, Jan 28, 2015 @ 04:51 PM

doctor stethoscope resized 600

The Affordable Care Act (ACA) requires that everyone has insurance coverage.  eni’s health advocates discusses the parameters surrounding the ACA. To avoid future tax penalties everyone must have insurance that qualifies as minimum essential coverage (MEC). Tax penalties can affect both employer and employee.

The following types of plans qualify for this coverage:

  • Any Marketplace plan

  • Any individual plan you already have

  • Any employer plan with or without “grandfathered” plan status

  • COBRA 

  • Medicare

  • Medicaid

  • Children’s Health Insurance Program (CHIP)

  • Tricare

  • Veteran’s health care programs [including Veterans Health Care Program, VA Civilian Health and Medical Program (CHAMPVA) and Spina Bifida Health Care Benefits Program]

  • Peace Corp Volunteer plans

  • Self-funded health coverage offered to students by universities for plan or policy years that began on/or after December 31, 2014

 Types of plans that DON’T qualify as coverage:

  • Coverage for vision or dental care only

  • Worker’s Compensation

  • Coverage only for a specific disease or condition

  • Plans that offer only discounts on medical services

 MEC offered through the marketplace must cover the following at minimum:

  • Outpatient care – the kind you get without being admitted to the hospital

  • Trips to the emergency room

  • Treatment in the hospital for inpatient care

  • Care before and after your baby is born

  • Mental health and substance use disorder services: This includes behavioral health treatment, counseling, and psychotherapy

  • Prescription drugs

  • Services and devices to help you recover if you are injured, or have a disability or chronic condition. This includes physical and occupational therapy, speech-language pathology, psychiatric rehabilitation, and more.

  • Lab tests

  • Preventive services including counseling, screenings, and vaccines to keep you healthy

  • Care for managing a chronic disease.

  • Pediatric services: This includes dental care and vision care for kids

Commercial insurance policies have different minimum standards than Marketplace policies.  However, they must cover Essential Health Benefits (EHB), which include:

  • Outpatient hospital care (doctor’s visits)

  • Prescription drugs

  • Emergency Care

  • Mental Health Services including substance use disorder services and behavioral health treatment

  • Hospitalization

  • Rehabilitative and Habilitative Services

  • Preventive and Wellness Services

  • Laboratory services

  • Pediatric Care including oral and vision care

  • Maternity and Newborn Care

When comparing out-of-pocket expenses, look at benefits being offered to ensure you are getting the best value for your premium expenses.

BalanceCare, Health Advocacy is a comprehensive, time-saving benefit that assists your employees in maximizing their healthcare benefits. Our Health Advocacy Services will work with you to fully customize a health advocacy program that will drive the most change for your employees.




Tags: medical plan, Health Insurance, Benefits, Affordable Care Act, Health Care Reform, Health Advocacy

Choosing the Right Health Insurance for You!

Posted by Melissa Mayfield on Wed, Nov 12, 2014 @ 04:36 PM

health guide woman and daughter in hospital resized 600

Purchasing health insurance has become increasingly more confusing with the multitude of choices available. Whether choosing plans offered by your employer or individual plans through the health marketplace under the Affordable Care Act, there are several factors to consider. eni’s BalanceCare Guides review these important factors and how their services are available to assist members.

Are you healthy? One annual routine physical/office visit is covered 100% under all policies due to the Affordable Care Act. Routine visits include pap smears, mammograms, and colonoscopies as long as there are no health issues. Keep this in mind when computing your healthcare costs.

Do you take a lot of medications? Check the co-pays for the medications you are currently taking. Are the costs applied to the deductible before the co-pays?  What “tier” are your medications? Insurance companies can change their formularies up to 2 times every year. Changes also occur when medications have a generic equivalent. BalanceCare Guides are available to assist with the drug formularies to determine the coverage. They can also determine if there is a cost savings for ordering through the mail.

Are your doctors covered under the plan? Doctors that are in-network save you money. Some insurance plans have limited coverage areas and your doctor may not accept that plan.  Once a plan is selected, BalanceCare Guides can furnish you a list of in-network providers.

Do you see a chiropractor or a mental health provider? Are your costs subject to the deductible or do you have a traditional co-pay? Are the number of visits limited? These factors should be taken into consideration when comparing plans.

Are you eligible for Medicare? Some group plans will penalize you if you don’t sign up for Medicare when you turn 65. BalanceCare can offer information to assist you with your decision to keep your group plan with or without Medicare. 

What are the premiums? Compare the approximate costs of your annual healthcare (prescriptions, office visits, etc) with the premium you’ll be paying. If you are healthy, you may want to choose a plan with a higher deductible and lower premium payment. If you take a lot of medication and frequently visit the doctor, a lower deductible and higher premiums payment may be more cost effective in the long run.

eni’s BalanceCare Guides are available to assist our members navigate the complexities of choosing health insurance!

Tags: Health Care Exchanges, Health Insurance, Affordable Care Act, Health Care Reform, Health Advocacy

Affordable Care Act Update from eni’s Health Advocates

Posted by Melissa Mayfield on Wed, May 08, 2013 @ 11:17 AM

Now that the Individual Mandate portion of the Affordable Care Act has been ruled constitutional, what does that mean to you?  Let’s take a look!

The following applies to individuals with insurance: 

  • If you already have coverage, you can’t be dropped if you become sick or disabled

  • Insurance companies must justify rate increases of 10% or more

  • Insurance companies can’t place lifetime limits on your policy

  • After 2014, insurance companies can’t place annual limits on your policy

  • Preventive care is now covered, which includes screening for diabetes as well as for certain types of cancer (breast, colorectal, etc)

  • Pre-existing clauses end beginning 2014

  • Coverage is available for dependents under 26 years of age even if they are married, don’t live at home, or no longer go to school. You do not have to include them on your tax return but parent’s coverage must offer family plan.

  • If the dependent is offered medical insurance through their employer, they must enroll under employer’s plan

  • All health plans must provide their members with clearly stated summary of their benefits

The following applies to individuals who are uninsured:

  • Marketplaces/Exchanges become available in October 2013 which will make it easier to buy insurance

    • Several levels of coverage will be available

    • Comprehensive benefits available

    • Must cover core health benefits which include hospitalization, medical, mental health, prescriptions, and rehabilitation.

  • Members will be able to compare benefits and costs side by side

  • Applications available on line, toll free number will be available and there will be area organizations available to help

  • Coverage begins in 2014

  • Depending on your income, tax credits will be available to assist in offsetting health care costs purchased through marketplace

  • If you are eligible for coverage through a marketplace and don’t buy it, you will be financially penalized

The following applies to individuals who are unemployed:

  • It’s not mandatory for states to expand coverage through Medicaid so it depends on where you live

  • Subsidies are available

  • Some may be exempt from medical coverage depending on income level, complete marketplace forms to see if this is the case

The following applies to those covered under Medicare:

  • Protects guaranteed Medicare benefits

  • Improves Medicare benefits as it lowers the costs of prescriptions in the donut hole

  • Adds free annual wellness visit in addition to the “Welcome to Medicare” visit

  • Additional tests may be added to wellness visit in the future by the Secretary of Health and Human Services

The following applies to those covered under Medicare Advantage Plans for age 65 and under:

  • Pre-existing condition clause may still apply

The following applies to those covered under Medicare Advantage Plans for over age 65:

  • With pre-existing condition, there’s no guarantee a Medigap plan will be offered to you for the first 6 months of Medicare eligibility

  • You cannot be charged more than Original Medicare for certain services (chemotherapy administration, dialysis , and skilled nursing care)

  • For each dollar paid in premiums, no more than $.15 may be spent on administrative costs

The following applies to Long Term Care:

  • Inspection records are now published

  • Makes it easier to file complaints

  • Website will show the ratio of resident care to administrative care as well as staff turnover rate www.Medicare.gov/NHcompare

  • There are no “death panels”

  • Wellness visits are designed to map out a plan to stay healthy and how best to treat any illness you have

  • There is a group of doctors who investigate treatments that work best in different situations. This information is then given to doctors so they know the best treatment options available to patients.

Check out these resources for additional information:

General or specific Medicare coverage:

Compare Medicare Health Plans and Prescription Drug Plans:

State health coverage resources and additional information on ACA:

State Health Insurance Assistance Program (SHIP):
*Offers assistance with Medicare claims, billing, and appeals
*Offers free counseling about Medicare coverage in your state
*Offers programs for people with limited incomes and resources

eni’s Health Advocacy service is a comprehensive, time-saving benefit that assists your employees in maximizing and navigating their healthcare benefits. 

Tags: medical plan, Health Insurance, Health Care, Affordable Care Act, Health Care Reform, Health Advocacy