Category: Blog

Little charges count, too. READ YOUR insurance company’s EXPLANATION OF BENEFITS details on your bills!

October 10, 2018

Today I personally “saved” myself a $35 charge.  Unfortunately, the “billing error that is sometimes generated” was a mistake that would not have been caught without calling the (largest) HMO and questioning, and staying on hold 4 minutes while “Kelsey” talked with billing to correct the error and remove it from my account.

Details:  At time of annual eye exam, I made my regular office visit copay.  The exam went as usual, with a clean bill of health and a new prescription for “reading glasses”  but a month later I got an additional copay for the same amount previously paid.  Inspecting the bill revealed this detail:   Procedure 92012, “eye exam” was credited what I had paid with nothing more owed. However, additional Procedure 92015 LENS EYEWEAR PRESCRIPTION ASSESSMENT” included a new charge for $35.

Guess what?  My doctor had no clue..her manager had no clue…and even after 40 years of servicing health insurance, I had no clue why there would be a charge for writing a prescription.   The HMO’s claims department representative, Kelsey, had no idea either but kept saying that extra billing was “sometimes generated”.  She would not say how many times people had called in; nor whether they would find and remove the mistake if someone did not call in..only that in my case, she would take it away as it was an error.

Moral of the story is two-fold.  The first moral is in the title.  READ your statements and REVIEW for errors.  Don’t pick up the phone and complain to the doctor, broker, or State insurance commissioner…unless you do not get satisfaction after picking up the phone and complaining to the actual insurance billing office.     The second moral is just a suggestion…publicize.  I’ve put the billing error out on my Nextdoor.com, social media accounts, and just wrote this blog for the business.  If everyone shines the bright light of publicity, maybe the insurer will figure out how or why “the system sometimes generates” a billing when it should not do so.  Hint:  someone told it to do this duplicitous billing, and someone is taking credit for a better-than-expected bottom line.  Fight it!   And don’t forget to get your eyes checked annually!

 

 

What Should You Do When Your Part D Prescription Drug Plan No Longer Covers Your Rx?

July 7, 2018

What should you do when your Part D Prescription Drug plan once covered the prescription you currently take but no longer lists it as a covered drug for the current year?

You are entitled to a transition refill or transition fill, which is a one time, 30-day supply of a drug that Medicare drug plans must cover. Transition fills only apply to a drug that you were taking before the plan stopped covering it. You are eligible for a transition fill because your plan took the drug off its formulary (list of covered drugs). You have 90 days from the date the formulary changed (usually January 1) to request a transition fill.

To access your transition fill, your pharmacist will need to call your Part D plan. She or he will explain you want to exercise your transition refill and ask that the plan cover the drug without any restrictions.

Once you get your transition fill, you should speak with your doctor about switching to a drug that is on your plan’s formulary without restrictions. If there is no other drug that will work for you, you can submit a request for an exception to your Part D plan’s formulary. This means you are formally requesting to have your prescription drug covered by your plan. Once you have used your transition fill and while you are waiting for a decision on your request for exception, your plan must provide temporary refills until a decision has been made.

Employer-Funded Individual and Family Health Plans

July 7, 2018

COMPLIANCE Question: Can an EMPLOYER fund Individual & Family Health Plans for employees on a Pre-Tax basis under the Affordable Care Act (ACA)?

Released on September 13, 2013, IRS Notice 2013-54 addresses the legality of offering individual health insurance plans (as opposed to traditional employer-sponsored group plans) as a tax-advantaged employee benefit. The short answer is NO: the IRS determined that such plans are prohibited under the ACA.

Please quickly review the details of the prohibition so that, as a client of Benefits by Design, Inc., you will understand that our priority is to help you obey the law, even though providing individual policies sometimes would fit your need.

The following arrangements and/or plans are now prohibited under the Notice:

  • Any arrangement or plan (Health FSA, HRA) through which an employee’s individual health insurance premium is reimbursed or subsidized by the employer in a tax-free (or otherwise “tax-favored”) manner.
  • Arrangements whereby an employer reimburses employees for individual health insurance premium payments (sometimes called “premium reimbursement arrangements” but referred to in the ruling as “employer payment plans”).
  • Section 125(f)(3) or Premium-only plans (“POP”) through which employees can pay for their individual health insurance on a pre-tax basis.

We at Benefits by Design, Inc. consider this language totally unambiguous. If a client wishes to ignore this ruling and pay for employee-purchased individual health plans, we will require a “hold harmless” signature from the Employer, and will first provide the documentation for the Employer’s legal consultants to review. Paying for individual health plans or other salary pre-tax reimbursement arrangements and plans are strictly and explicitly prohibited with this IRS ruling, and backed by similar rulings from relevant agencies: “The Departments of the Treasury (Treasury Department), Health and Human Services (HHS), and Labor (DOL) (collectively, the Departments) are continuing to work together to develop coordinated regulations and other administrative guidance to assist stakeholders with implementation of the Affordable Care Act. The guidance in this notice is being issued in substantially identical form by DOL, and guidance is being issued by HHS to reflect that HHS concurs in the application of the laws under its jurisdiction as set forth in this notice.”

Final questions regarding employer/individual purchase have been asked since the Notice release last September:

  • The prohibition is NOT limited to individual health insurance plans sold in the “marketplaces” (formerly called “exchanges”.) The prohibition does apply to EVERY individual health insurance plan.
  • For the purposes of the ACA, these sorts of arrangements and/or plans are considered (pursuant to the Notice) to be “group health plans,” even though they are comprised of individual health plans.
  • Specific exceptions apply for limited purpose supplementary plan (e.g. Accident only, Hospital only, etc.), in which “coverage consists solely of excepted benefits.” See Code § 5000A(f)(2) and Treas. Reg. § 1.5000A-2, 78 Fed. Reg. 53646, 53658 (August 30, 2013).

How Much Life Insurance Do I Need?

July 7, 2018

Consider why you need it at all. If, for example, you have young children and are providing protection against early death, figure out how much your family needs per year to survive and then cover at the very least five full years.

Good questionnaires which help you think about covering additional expenses (college, for example) are available to help you determine your life insurance needs.  Here is an example:

whentermmakessense

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