Tag: Health Insurance

  • Hospitals cry foul over latest Anthem fare…definitions change and definitely cause harm

    June 15, 2018

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    Anthem has changed their policy regarding imaging performed in hospitals on an outpatient basis and will expand this into fourteen states.  Hospitals are not happy, nor amused and have filed suit.  Anthem stakes its claim on the idea of medical necessity, and hospitals are saying that doctors have the right to show necessity, not carriers.  And so the battle continues as carriers continue to try to dictate care but those who are responsible for care are not responsible for the payment.  No winners here…

    And as if that were not enough, Anthem has also begun pushing back on patients who visit the emergency room for ailments the carrier deems minor – called the “avoidable ER program” (as in avoiding payment).  While Anthem has lightened up on their procedures somewhat, they are refusing to pay some ER visits as non emergency (after the fact) which is not making patients and doctors particularly happy.  Stay tuned.

  • Independents may not be so depending on the interdependence of employment status

    June 11, 2018

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    The California State Supreme Court, in the case of a suit against Dynamex Operations West, said simply that “when a worker has not independently decided to engage in an independently established business but instead is simply designated an independent contractor – there is a substantial risk that the hiring business is attempt to evade the demands of an applicable wage order through misclassification.” In short, to be independent they must be, you know, independent.  Businesses must show that the worker is free from the control and direction of the employer, perform work that is outside the hirer’s core business and customarily engage in an independently established trade, occupation or business

    On April 30, 2018 the California Supreme Court determined that California employers must always start with the presumption that a worker is a common law employee.  They may classify them as independent ONLY IF ALL of these criteria are being met:

    Worker is free from control and direction in connection with the performance of the work

    The worker performs work that is outside the usual course of the hiring entity’s business

    Worker customarily engaged in independently established trade, occupation or business

    This gives common sense to what the Department of Labor has long used as their “twenty questions” to determine the independence of an independent contractor.  The only question remaining now is that, if the DOL finds an employer responsible for an “employee” who may have previously been misclassified, if all rights and benefits that apply will be made retroactively

  • Always ask the real price before you pay…prescription drugs need a prescription for action

    June 6, 2018

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    This should be apparent, but apparently it isn’t.  Sometimes prescription drugs, so often dispensed as generics, have a lower price than the copayment stated on the benefit card.  A new study, however, shows that consumers aren’t asking, thus not only paying a higher amount than necessary, but this amount is then “clawed back” by the Pharmacy Benefit Manager (no, the pharmacy does not keep the difference, nor does the insurance carrier) which acts as a middleman between the carrier and the consumer.  During a study period comprising the first half of 2013, a USC study found that overpayments totaled $135 million.  A good example – hydrocodone acetaminophen (that would normally be called “Vicodin”) was prescribed 120,000 times and there was an average overcharge of $6.94.  It is not just generics, moreover.  The brand name drugs of longer standing also often fall under the brand name co payment (Ambien was cited as the most egregious example)  So next time, don’t just reach for the card…

  • Are retirees given any guarantees? The issue keeps going back and forth

    June 4, 2018

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    The Supreme Court has once again found that retiree benefits are not vested.  So the employer can promise but…     Actually, the Court simply clarified the need for clarity.  In the absence of specific language that vests retiree health benefits, the retirees may no longer assume that silence or ambiguity allows a lifetime contract.  Instead, the contract itself must state the case.  Seems simple, but this has been kicking around, even though the Supreme Court said the same thing in 2015.  Now it will show the unions that what they want needs to be negotiated and then put in writing (we will call this the “common sense” doctrine)

  • The new normal – see our White Paper – everyone is buying everyone – can we buy their act?

    May 31, 2018

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    Walmart is in preliminary talks to buy and partner with Humana

    CIGNA is buying Express Scripts

    CVS bought Aetna

    And the list goes on…

  • Beware of Tech Overload | Petaluma Employee Benefits

    May 3, 2018

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    Technology has certainly made the workplace faster, smarter and more productive. New apps and systems continuously offer new ways to create, manage and collaborate. However, just as with many good things, workers can get too much of office tech. With each digitization of traditional job and team functions comes a cost in diminishing associated skills. Many forward-thinking companies are taking heed of the potential pitfalls of tech overload. Check out some particular hazards culled from across the Web.

    Loss of Interpersonal Skills — Video chats, group chats, IMs, DMs, texts, pings, not to mention old-fashioned email certainly afford a multitude of ways to communicate, even collaborate. However, there’s no replacement for face-to-face interaction. Over-reliance on digital channels can diminish the opportunities and ability to collaborate in the most free-form manner, that being when folks share the same room.

    Inhibits Big Thinking — Unlimited information flow can sometimes turn into overflow. Continuous text alerts, IMs and other pings can inhibit completion of the task at hand. They can also cause mistakes due to lack of concentration. While pressing issues can be quickly resolved, continual interruptions leave little or no time for working through larger projects and long-term planning.

    Impaired Security — It’s an unfortunate fact of business life that the more freely information flows, even behind firewalls, the more susceptible it is to hacking, corruption and theft. As well-publicized incidents have shown, corporate information is not the only data at risk, but also financial and personal data of employees and customers. It’s vital that when companies upgrade their business tech, their security tech and protocols keep pace.

    Time and Maintenance Costs — The only sure bet with a new application or system is that it will require updates. Also, while out-of-pocket expenses can be quantified, less-obvious costs of downtime devoted to system maintenance and training can pose significant drag on productivity, and in some cases job satisfaction. More companies are discovering that not every tech wave is worth catching, especially if it crashes against strained budgets.

    Encroachment on Personal Time — Certainly boundaries of normal working hours have been significantly extended. While tech has indeed freed workers from cubicle and office tethers, it can also tempt managers and team members to infringe, often unknowingly, on the personal lives of their reports. Yes, emergencies may arise. But workers repeatedly besieged with after-hour queries may seek other places to use their devices.

    It May Be Unhealthy — Work is stressful enough. While technology has certainly speeded operations, it’s concurrently raised everyone’s expectations. Some research indicates that over-reliance on devices may increase stress levels with potentially adverse health consequences. For better health, occasionally put down the phone!

    Find out more:
    Small Business Chronicle: Pros & Cons of Technology in Business Today
    CIO: Americans Suffer Technology Overload, But We Want More
    Northeast Valley News: Technology Overload Causing Health Problems

    By Bill Olson

    Originally published by www.UBABenefits.com


  • Will wellness make you sick? Well, no, but it won’t cure you either, say studies

    April 20, 2018

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    The first problem in proving the value of wellness programs, of course, is that the data, while considerable, is also anecdotal.  Further, the use of wellness does not necessarily correlate to some of the results claimed. Finally, though this is one good reason to do it anyway, is that you can’t quantify the results based on what diseases or injuries you would have prevented.  A recent study in Health Affairs, which is the leading journal for health care theory and practice, said care coordination and management initiatives have not been drivers of savings in Medicare, and an earlier study shows that even if 90% of consumers utilized preventive services (much higher than the current takeup rate) the total effect on health care spending would be just under 0.2% – a lot of money overall, but not much money as part of the system.  Cynics also point out that if we let people live longer, they will consume more health care services.  This is, of course, a good societal thing, but if you want to look purely at how to save money and how to improve care, there is always contention with the “law of unintended consequences’  Overall, the argument should be about improving quality and not saving costs. Oh, well.

  • Don’t worry…we’re going to fix it now

    April 20, 2018

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    Well, now the concerns are over.  Jamie Dimon JP Morgan, Jeff Bezos from Amazon and Warren Buffet from Berkshire Hathaway have all teamed up to solve our nation’s health care problems.  There are no details at this point, of course, but they say they plan to hold down costs by bringing “their scale and complementary expertise to this long term effort”  They will create an independent company “free from profit making incentives and constraints” to focus on technology solutions”  This is great, except for the fact that technology is only one part of the problem (but definitely worth fixing) and that the scale these companies bring will really only benefit a narrow slice of consumers – their companies.  By the way, Steve Case of AOL tried this years ago and failed miserably, but who remembers Steve Case any more?

  • Higher Satisfaction Through Higher Education | California Benefit Advisors

    April 18, 2018

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    When evaluating employee benefits, essentials such as health and dental plans, vacation time and 401(k) contributions quickly come to mind. Another benefit employers should consider involves subsidizing learning as well as ambitions. Grants and reimbursements toward advanced degrees and continuing education can be a smart investment for both employers and employees.

    Educational benefits are strongly linked to worker satisfaction. A survey by the Society for Human Resource Management revealed that nearly 80 percent of responding workers who rated their education benefits highly also rated their employers highly. While only 30 percent of those rating their higher education benefits as fair or poor conversely rated their employer highly.

    These benefits are popular with businesses as well. In a survey by the International Foundation of Employee Benefit Plans, nearly five of six responding employers offer some form of educational benefit. Their top reasons are to retain current employees, maintain or raise employee satisfaction, keep skill levels current, attract new talent and boost innovation and productivity. Tax credits offer additional advantages. Qualifying programs offer employers tax credits up to $5,250 per employee, per year.

    At the same time, companies should offer these benefits with care as they do pose potential pitfalls. Higher education assistance can be costly, even when not covering full costs. Workers taking advantage can become overwhelmed with the demands of after-hour studies, affecting job performance. Also, employers would be wise to ensure their employees don’t promptly leave and take their new skills elsewhere.

    When well-planned, educational benefits will likely prove a good investment. Seventy-five percent of respondents to SHRM’s survey consider their educational-assistance programs successful. To boost your employee morale, skill levels and job-satisfaction scores, consider the benefit that may deliver them all, and more.

    Find out more:
    IFEBP: Why Educational Assistance Programs Work
    EBRI: Fundamentals of Employee Benefit Programs

    By Bill Olsen

    Originally published  by www.UBABenefits.com

  • Disability Insurance and why you need it! | CA Benefit Consultants

    April 9, 2018

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    “Your most valued asset isn’t your house, car, or retirement account. It’s the ability to make a living.”

    No one foresees needing disability benefits.  But, should a problem arise, the educated and informed employee can plan for the future by purchasing disability insurance to help cover expenses when needed.

    When you ask people what is the number one reason disability insurance is needed, most will answer that it is for workplace related injuries. However, the leading causes of long-term absences are back injuries, cancer, and heart disease and most of them are NOT work related.   In addition, the average duration of absences due to disability is 34 months.  So how do you prepare for an unplanned absence from work as a result of an injury or illness? Disability insurance is a great option.

    Disability insurance is categorized into two main types.

    • Short Term Disability covers 40-60% of the employee’s base salary and can last for a few weeks to a few months to a year. There is typically a short waiting period before benefits begin after the report of disability. This plan is generally sponsored by the employer.
    • Long Term Disability covers 50-70% of the employee’s base salary and the benefits end when the disability ends or after a pre-set length of time depending on the policy. The wait period for benefits is longer—typically 90 days from onset of disability. This plan kicks in after the short-term coverage is exhausted. The individual purchases this plan to prevent a loss of coverage after short-term disability benefits are exhausted.

    While the benefits of these disability plans are not a total replacement of salary, they are designed for the employee to maintain their current standard of living while recovering from the injury or illness. This also allows the individual to pay regular expenses during this time.

    There are many ways to enroll in a disability insurance plan. Often times your employer will offer long-term and short-term coverage as part of a benefits package. Supplemental coverage can also be purchased.  Talk with your company’s HR department for more information on how to enroll in these plans.  Individuals who are interested in purchasing supplemental coverage can also contact outside insurance brokers or even check with any professional organizations to which they belong (such as the American Medical Association for medical professionals) as many times they offer insurance coverage to members.

    As you begin planning for your future, make sure you research the types of coverage available and different avenues through which to purchase this coverage. For more information on disability and the workplace, check out:




  • Federal Employment Law Update – March 2018 | California Employee Benefit Brokers

    March 28, 2018

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    FLSA Amendments to Tip Sharing Provisions

    On March 23, 2018, President Trump signed legislation (H.R. 1625) amending the federal Fair Labor Standards Act (FLSA) by prohibiting employers from keeping tips received by employees for any purpose. This includes prohibiting managers or supervisors from keeping any portion of employees’ tips, regardless of whether the employer takes a tip credit. Employers in violation of these protections are liable to the affected employee(s) for the sum of any tip credit taken, and all tips unlawfully kept, in addition to an equal amount as liquidated damages. Regarding willful violations of the employment of minors provisions (at 29 U.S.C. § 216(c)), any person in violation of the law will be subject to a civil penalty of up to $1,100 for each violation and will be liable to the affected employee(s) for all tips unlawfully kept and an additional equal amount as liquidated damages.

    The law is currently effective.

    Read US H.R. 1625

    Postponement of E-Verify Temporary Unavailability

    On March 15, 2018, the U.S. Citizenship and Immigration Services (USCIS) announced via fact sheet that E-Verify and E-Verify Services would be temporarily unavailable from 12 a.m. March 23 to 8 a.m. March 26 Eastern Time for system enhancements. However, on March 22 the USCIS released an email stating that the enhancements were “still in the works,” and the modernization launch was postponed. Subsequently, E-Verify will remain available, and all regular employment eligibility verification timelines continue to apply.

    Read about the planned enhancements

    IRS Adjusts 2018 Inflation Amounts for Health Savings Accounts

    On March 5, 2018, the federal Internal Revenue Service (IRS) announced 2018 annual limits on deductions for individuals covered under a high deductible health plan (HDHP) in Rev. Proc. 2018-18. The deduction limit is $3,450 for an individual with self-only coverage and $6,850 for an individual with family coverage.

    Additionally, for calendar year 2018, an HDHP is defined as a health plan with an annual deductible that is not less than $1,350 for self-only coverage or $2,700 for family coverage, and the annual out-of-pocket expenses (deductibles, co-payments, and other amounts, excluding premiums) do not exceed $6,650 for self-only coverage or $13,300 for family coverage.

    Read Rev. Proc. 2018-18

    EEO-1 Reporting and Employees Who Regularly Report to Client Sites

    The portal for 2017 EEO-1 reporting is open and reports must be submitted and certified by March 31, 2018 at the latest.

    The federal Equal Employment Opportunity Commission (EEOC) has addressed the issue that there may be some confusion as to how employers are to report employees working at client sites (a workplace the employer does not own but where the employee reports for work). According to the EEOC’s 2017 EEO-1 User Guide (see page 132), employers must still submit an EEO-1 report under the address of the client site for those employees, as opposed to the employer’s own address.

    See How to File an EEO-1 Report

    IRS Updates Withholding Calculator and Releases New Form W-4

    On February 28, 2018, the federal Internal Revenue Service (IRS) released an updated Withholding Calculator and a new version of Form W-4 following passage of the Tax Cuts and Jobs Act in December.

    The Tax Cuts and Jobs Act made changes to the tax law, including increasing the standard deduction, removing personal exemptions, increasing the child tax credit, limiting or discontinuing certain deductions, and changing the tax rates and brackets.

    If changes to withholding should be made, the Withholding Calculator gives employees the information they need to fill out a new Form W-4, Employee’s Withholding Allowance Certificate.

    More information is available at the IRS page, Withholding Calculator Frequently Asked Questions.

    Read the press release

    NLRB Vacates Hy-Brand and Browning-Ferris Joint Employment Standard Reinstated

    On February 26, 2018, the National Labor Relations Board (NLRB) announced that it vacated its December 14, 2017 decision in Hy-Brand Industrial Contractors regarding the joint employment standard. As a result, the Obama-era, employee-friendly joint employment standard established by Browning-Ferris Industries was reinstated. Under the reinstated Browning-Ferris standard, a company can be found to be a joint employer based on the potential of its ability to exercise control over terms and conditions of employment, regardless of whether the actual authority is exercised. This is an “indirect control” standard and is considered the main factor in determining whether a joint employer relationship exists, and thus liability, under the National Labor Relations Act (NLRA).

    According to the NLRB, Hy-Brand was vacated due a determination by the board’s designated agency ethics official that member William Emanuel is, and should have been, disqualified from participating in the Hy-Brand proceeding. In a memorandum issued on February 9, 2018, the U.S. Inspector General found that Emmanuel’s former law firm was involved in the original Browning-Ferris decision, and subsequently, he should have recused himself from the Hy-Brand decision.

    Because the Board’s Decision and Order in Hy-Brand has been vacated, the overruling of the Board’s decision in Browning-Ferris Industries, 362 NLRB No. 186 (2015), is of no force or effect.

    Read the press release and order

  • The ACA still makes its way but maybe in the wrong direction

    March 26, 2018

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    Enrollment has dropped nearly 4% in those areas covered by the Federal Exchange, but remained about the same in states that ran their own (e.g. California).  Meanwhile, a“Treasury watchdog” reported that the IRS overpaid the ACA tax credits by $3.5 billion in 2017.  The good news is that the total was actually $5.8 billion but they were able to get recovery on the amounts that can be recovered – but the rest seems to be lost.  Oops.

  • It ain’t over til it’s over – the mandates may live on in states

    March 20, 2018

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    Insurance carriers are dismayed  that the individual mandate is being repealed for the simple reason that the ability of individuals to opt out of coverage will cause a negative spiral in health care costs, as the pool of covered people devolve into those who are more in need of services.  Some states, however, including California, are fighting back and considering a state mandated mandate. We shall see.

  • 6 Ways to Keep the Flu from Sidelining Your Workplace | CA Employee Benefit Brokers

    March 2, 2018

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    This year’s flu season is a rough one. Although the predominant strains of this year’s influenza viruses were represented in the vaccine, they mutated, which decreased the effectiveness of the immunization. The flu then spread widely and quickly, and in addition, the symptoms were severe and deadly. The U.S. Centers for Disease Control and Prevention (CDC) reported that the 2017 – 2018 flu season established new records for the percentage of outpatient visits related to flu symptoms and number of flu hospitalizations.

    Younger, healthy adults were hit harder than is typical, which had impacts on the workplace. In fact, Challenger, Gray & Christmas, Inc. recently revised its estimates on the impact of this flu season on employers, raising the cost of lost productivity to over $21 billion, with roughly 25 million workers falling ill.

    Fortunately, the CDC is reporting that it looks like this season is starting to peak, and while rates of infection are still high in most of the country, they are no longer rising and should start to drop. What can you do as an employer to keep your business running smoothly for the rest of this flu season and throughout the next one?

    1. Help sick employees stay home. Consider that sick employees worried about their pay, unfinished projects and deadlines, or compliance with the company attendance policy may feel they need to come to work even if they are sick. Do what you can to be compassionate and encourage them to stay home so they can get better as well as protect their co-workers from infection. In addition, make sure your sick leave policies are compliant with all local and state laws, and communicate them to your employees. Be clear with the expectation that sick employees not to report to work. For employees who feel well enough to work but may still be contagious, encourage them to work remotely if their job duties will allow. Be consistent in your application of your attendance and remote work rules.
    2. Know the law. Although the flu is generally not serious enough to require leaves of absence beyond what sick leave or PTO allow for, in a severe season, employees may need additional time off. Consider how the federal Family and Medical Leave Act (FMLA), state leave laws, and the Americans with Disabilities Act (ADA) may come into play for employees who have severe cases of the flu, complications, or family members who need care.
    3. Be flexible. During acute flu outbreaks, schools or daycare facilities may close, leaving parents without childcare. Employees may also need to be away from the workplace to provide care to sick children, partners, or parents. Examine your policies to see where you can provide flexibility. Look for opportunities to cross-train employees on each other’s essential duties so their work can continue while they are out.
    4. Keep it clean. Direct cleaning crews to thoroughly disinfect high-touch areas such as doorknobs, kitchen areas, and bathrooms nightly. Provide hand sanitizer in common areas and encourage frequent handwashing. Keep disinfecting wipes handy for staff to clean their personal work areas with.
    5. Limit exposure. Avoid non-essential in-person meetings and travel that can expose employees to the flu virus. Rely on technology such as video conferencing, Slack, Skype, or other platforms to bring people together virtually. Consider staggering work shifts if possible to limit the number of people in the workplace at one time.
    6. Focus on wellness. Offer free or low-cost flu shots in the workplace. If your company provides snacks or meals for employees, offer healthier options packed with nutrients.

    Get it all

    AGENCY RESOURCES: Get the latest weekly flu stats from the CDC. Learn more about how the FMLA and ADA may be used during pandemic flu from the U.S. Department of Labor.

    By Rachel Sobel

    Originally posted by www.ThinkHR.com

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