• The Public Option is Back – We Hadn’t Seen It Since the Advent of the ACA| by Jordan Shields, Partner

    August 2, 2021

    Nevada is gambling on the success of a public private partnership, where the state government will now compete with insurance carriers while using those same insurance carriers to provide a more affordable health care option for state citizens.   They follow in the footsteps of Colorado and Washington, both of which just passed similar legislation.  Illinois, New Mexico and Oregon are considering the same.

    The Nevada law requires some insurers to bid to offer plans starting in 2026, with the goal to have these plans priced 5% less than other popular plans, and 15% less over four years.  The enforcement mechanism has not yet been established.  The law is intended to achieve lower costs by paying doctors, hospitals and other providers less than what they are currently being reimbursed by insurers.  This may end up resembling some of the “skinny networks” which have already become notorious in California and other states.  Not exactly a solution, but a start…and we may see more of the same within the halls of Congress, as the public option may return there as a compromise measure to ward of Medicare for All.

  • Exploring Benefits Lingo

    August 2, 2021

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    We all know how confusing and complex benefits and healthcare terms can be- the difference between deductible and co-insurance is a common question for many and there are plenty of others like it.  When you are comfortable and confident in how your plan works, you can make an informed decision on HOW to use and take advantage of your benefits!

    We have created a list and explanation of the most common terms to help you understand and better utilize your health benefits:

    • Co-payment:  An amount you pay as your share of the cost for a medical service or item, like a doctor’s visit.  Co-pays are most common for emergency room, urgent care and prescription drugs. In some cases, you may be responsible for paying a co‐pay as well as a percentage of the remaining charges.
    • Co-insurance:  Your share of the cost for a covered health care service, usually calculated as a percentage (like 20%) of the allowed amount for the service. For example, if your plan has a 30% co-insurance rate, the carrier will pay 70% of the allowed amount while you pay the balance.
    • Deductible: The amount you owe for covered health care services before your health insurance or plan begins to pay.  For example, many plans require an individual to pay $1,000 in cumulative deductibles before they begin paying out.
    • Dependent coverage:  Health insurance coverage extended to the spouse and unmarried children up to age 26 who are totally or substantially reliant on their parents for support, thereby defined as “dependent children”.
    • Explanation of Benefits (EOB): Every time you use your health insurance, your health plan sends you a record called an “explanation of benefits” (EOB) or “member health statement” that explains how much you owe. The EOB also shows the total cost of care, how much your plan paid and the amount an in-¬network doctor or other healthcare professional is allowed to charge a plan member (called the “allowed amount”).
    • In-Network Provider: A provider who has a contract with your health insurer or plan to provide services to you at a discount. In-Network Providers have contracted with the insurance carrier to accept reduced fees for services provided to plan members. Using in-network providers will cost you less money. When contacting an In-Network Provider, remember to ask, “are you a contracted provider with my plan?” Never ask if a provider “takes” your insurance, as they will all take it. The key phrase is contracted.
    • Open Enrollment: A period during which a health insurance company is required to accept applicants without regard to health history.
    • Out-of-Network Provider: A provider who doesn’t have a contract with your health insurer or plan to provide services to you at a pre-negotiated discount. You’ll pay more to see an out-of-network provider, sometimes referred to as an out-of-network provider.
    • Out-of-Pocket Maximum: The limit or most you’ll pay out of your own pocket for services during your insurance plan period (usually one year).
    • Premium: The amount you pay for your health insurance or plan each month.
    • Qualifying Life Event (QLE): A change in your life that allows you to make changes to your benefits’ coverage outside of the annual open enrollment period. These changes include a change in marital status (marriage, divorce, death of spouse), a change in the number of eligible children (birth, adoption, death, aging-out), and a change in a family member’s benefits eligibility under another plan (losing a job, Medicare or Medicaid eligibility, etc.)

    In addition to understanding these common terms, there are other ways to utilize your benefits, save money and make an informed decision based on your specific needs.

    • Flexible Spending Account (FSA): Funded through pre-tax payroll deductions, an FSA is a cost-savings tool that allows you to pay for qualified healthcare-related expenses with pre-tax dollars. Funds deposited in an FSA must be spent in the same year in which they are set aside, or they are forfeited. This rule is often referred to as “use it or lose it”.
    • Health Reimbursement Account (HRA): An employer-funded savings plan that will reimburse you for out-of-pocket medical expenses. Unlike an FSA, however, you don’t “use it or lose it” – unused balances will roll over and accumulate over time, though the account cannot be “cashed-out.”
    • Health Savings Account (HSA): A savings product that serves as a substitute for traditional health insurance. HSAs enable you to pay for current health costs. They also allow you to save for future medical and retiree health costs tax-free. Unlike an FSA, however, you don’t “use it or lose it” – unused balances will roll over and accumulate over time and can be “cashed-out.”

    Understanding all of the terms and acronyms can feel like learning a new language, so it’s helpful to have a basic reference chart.  With a good understanding of what some healthcare “benefits lingo” means, it will be easier to find a plan that meets your needs and budget. To explore more healthcare terms, visit

  • Another ACA Victory – the United States Supreme Court Refuses to Hear the Challenge| by Jordan Shields, Partner

    July 30, 2021



    In CA vs. TX, a challenge was made to whether or not the Affordable Care Act was constitutional.  The Supreme Court isn’t saying it is or it isn’t, which means that they have said that, for now, it is, because they refused to hear the case.

  • IRS: Monthly Child Tax Credit payments begin

    July 28, 2021

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    WASHINGTON —TheInternal Revenue Service and the Treasury Department announced today that millions of American families have started receiving monthly Child Tax Credit payments as direct deposits begin posting in bank accounts and checks arrive in mailboxes.

    This first batch of advance monthly payments worth roughly $15 billion reached about 35 million families today across the country. About 86% were sent by direct deposit.

    The payments will continue each month. The IRS urged people who normally aren’t required to file a tax return to explore the tools available on These tools can help determine eligibility for the advance Child Tax Credit or help people file a simplified tax return to sign up for these payments as well as Economic Impact Payments, and other credits you may be eligible to receive.

    Under the American Rescue Plan, each payment is up to $300 per month for each child under age 6 and up to $250 per month for each child ages 6 through 17. Normally, anyone who receives a payment this month will also receive a payment each month for the rest of 2021 unless they unenroll. Besides the July 15 payment, payment dates are: Aug. 13, Sept. 15, Oct. 15, Nov. 15 and Dec. 15.

    Here are further details on these payments:

    • Families will see the direct deposit payments in their accounts starting today, July 15. For those receiving payment by paper check, they should remember to take into consideration the time it takes to receive it by mail.
    • Payments went to eligible families who filed 2019 or 2020 income tax returns.
    • Tax returns processed by June 28 are reflected in these payments. This includes people who don’t typically file a return, but during 2020 successfully registered for Economic Impact Payments using the IRS Non-Filers tool or in 2021 successfully used the Non-filer Sign-up Tool for Advance CTC, also on
    • Payments are automatic. Aside from filing a tax return, including a simplified return from the Non-Filer Sign-Up tool, families don’t have to do anything if they are eligible to receive monthly payments.

    Additional information is available on a special Advance Child Tax Credit 2021 page, designed to provide the most up-to-date information about the credit and the advance payments.

    Originally posted on

  • It Could Happen Here – Things Move Down the Coast – Washington’s LTC Law| by Jordan Shields, Partner

    July 27, 2021

    The State of Washington has created a mandatory long term care plan, funded by employees, and it takes effect January 1, 2022.  Payment is made through payroll tax deduction.  The amount will be 58 cents for every $100 earned.

  • Let Every Community Create COVID Compliance – Sonoma County Ordinance| by Jordan Shields, Partner

    July 26, 2021


    The Sonoma Emergency Paid Sick Leave ordinance is not only in effect for 2021 but it is enacted retroactively to January 1, 2021.  It remains in effect through September 30, 2021.

    Essentially, employers are required to provide 80 hours of paid leave for those working 40 or more hours per week on a regular basis (other employees worked as a proportion)  The amount may be offset by what is already being provided employees under the California 2021 supplemental paid sick law.

    If an employee has at least 80 hours of accrued paid sick leave or 1260 hours of paid sick leave, vacation and paid time off, as of June 8, 2021, they have met the requirement.  If by this date the employee has fewer than these minimums, employers must make up the deficiency.

    From a practical standpoint, any employer with more than 25 employees is already subject to the California law and this replicates it – those with fewer than 25 employees will need to get up to speed on this law.

  • No Surprises Among the Prizes You Receive When You Get Medical Care| by Jordan Shields, Partner

    July 23, 2021


    The appropriations act passed earlier this year contains a provision that expands the traditional Explanation of Benefits to what is now called an Advanced EOB.  Starting with plan years with a renewal of January 1, 2022, group health plans must provide this on request.  This must contain

    1. Whether or not the provider or facility is in network – if so, the contracted rate under the plan for the provider or service
    2. Good faith estimate of the cost of services to be provided, which includes the total cost of services, the amount of participant cost sharing, the accrued amounts already met and the amount the plan is responsible for paying (yes, just like EOBs are supposed to already)
    3. Disclaimers that this is only an estimate

  • COBRA Subsidy Clarification| by Jordan Shields, Partner

    July 20, 2021



    No the initial information was insufficient, as with any hastily contrived rules.  Fortunately, the IRS issued Notice 2021-31, which clarifies in a brisk 86 questions what everyone has been wondering, but which most of us had surmised.  Highlights are:

    • The new Forms 941 (quarterly wage report, along with Schedule R) and 7200
    • The tax credit taken on the quarterly wage report is against the Medicare amount due
    • Employer may rely on individual attestation that they are not eligible for other coverage
    • Availability of other coverage does not preclude extension if they cannot yet enroll in it
    • Second qualifying events merely continue coverage and thus the subsidy – no break
    • All basic coverage is eligible for a subsidy EXCEPT a health FSA (HRA IS included)
    • Retiree coverage is included for purposes of the subsidy
    • Reduction in hours is definitely seen as an involuntary termination

    Most importantly, the notice makes clear what constitutes Involuntary Termination which, along with reduction in hours, are the two qualifying events that allow for receipt of the subsidy:

    The Notice defines an involuntary termination of employment as a severance from employment due to the independent exercise of the employer’s unilateral authority to terminate the employment, other than due to the employee’s implicit or explicit request, where the employee was willing and able to continue performing services.  An employee initiated termination of employment constitutes an involuntary termination of employment for purposes of the Subsidy if the termination of employment constitutes a termination for a good reason.

    The notice is specific about some termination scenarios that qualify as involuntary termination

    1. Non renewal of an employee’s contract if the employee was otherwise willing to enter into a new contract or continue employment without a contract, assuming the employee knows that the contract would only be for a limited amount of time
    2. Participation in a window program that meets appropriate Treasury requirements
    3. Employer initiated action to end an individual’s employment while the individuals is absent from work due to illness or disability if, before the action, there is a reasonable expectation that the employee will return to work after the illness or disability subsides.
    4. Involuntary termination for cause, provided, however, if the termination is due to gross misconduct of the employee, the loss of coverage due to a termination of employment for gross misconduct will not result in an individual becoming eligible for the subsidy

    The notice is equally specific about what is NOT involuntary termination – and thus employees in these situations are NOT eligible for the subsidy

    1. An employee initiated termination of employment due to the employee’s child being unable to attend school or childcare facility due to COVID. If, however, the employer maintains the ability to return to work so that the event is a temporary leave of absence, then the employee could qualify for the premium subsidy as a voluntary reduction in hours
    2. An employee initiated termination of employment due to general concerns about workplace safety (unless employee can demonstrate that the employer’s actions resulted in a change to the employment relationship analogous to a constructive discharge)
    3. Termination due to gross misconduct (note – be careful here, as the definition of what constitutes gross misconduct is extremely narrow)
    4. Retirement, unless the facts indicate that the employee was willing to work and knew the employer was planning on terminating the employee
    5. Death of the employee

  • PCORI Fee Continues as Part of How the Affordable Care Act Lives On – Due Soon| by Jordan Shields, Partner

    July 19, 2021


    The due date for filing and paying the Patient Centered Outcome Research Institute fee is August 2 this year.  For plan years that ended 1/1/20 through 9/30/20, the fee is $2.54 per covered life.  For plan years 10/1/20 through 12/31/20 the fee is $2.66 per covered life.

    The fee is for all self funded medical and Health Reimbursement Arrangements.

  • How to Stay on Track While on Vacation

    July 15, 2021

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    Summer is here and so many of us work hard to lose a few pounds before summer vacation but then get to our vacations and ‘’want to live it up!’’ The problem is that then we end up bloated and unhappy with those decisions.  Vacation is supposed to be a time to relax and unwind and shouldn’t make you worrisome or apprehensive about your fitness goals.  Here are a few tips to stay on track with your goals while still being able to enjoy yourself:

    Make a Plan

    What are you looking forward to the most? Eating at a certain restaurant? A certain food in general? Try to make good choices with your food and activity all day so that you won’t feel guilty if you indulge in eating your favorite burger. Allow yourself a splurge, enjoy it, but then move on and get back on track.

    Drink Water

    Drinking enough water may be the last thing you are thinking about on vacation but it is essential for your health and to help you stay on track. Drinking water not only helps your body function properly but also helps you feel full before and during meals so you eat less.  Even the slightest bit of dehydration can cause you to believe you need food when, in reality, you just need some water.

    In addition, water is a great choice to substitute for alcohol.  Drinking water is also a good way to slow down the amount of alcohol you’re drinking and helps you to avoid hangovers or getting the ‘’munchies’’ later that night and the next day.

    Schedule in Movement

    Make a commitment to schedule in daily movement.  The goal isn’t to make strength improvements or lose weight but rather to stay consistent to keep momentum. If you enjoy walking, jogging, or biking, it’s time to take go into the great outdoors to enjoy your new surroundings. You can also engage in new opportunities to move your body in ways that aren’t available to you at home, like:  surfing, swimming, rock climbing and paddle boarding.

    Don’t Skip Meals

    Whether you’re rushing to tourist sites or heading to the beach for the day, it’s easy to lose track of time and skip a meal.  But, skipping a meal can easily lead to overeating at your next meal.  Keeping your hunger in check is key so pack a few nutritious, protein packed snacks whenever you head out.

    Remember Your Goals

    When you are struggling to turn down that second serving of dessert, remember why you wanted to get healthy in the first place.  Is it to feel confident? Get your cholesterol numbers down? To be able to run and play with your kids? Find something that you find motivating and remind yourself several times a day.

    Take a breath and enjoy life!

    Go dancing, biking, swimming or go hiking! Vacation is the time to slow down and enjoy the little moments.  This time away is important to your wellbeing and mental health.

    Staying on track on vacation doesn’t have to mean perfection – it just means you have to strike a balance. It is possible to have a great time without sacrificing fun or sabotaging all that hard work you put in before your trip.  Even with these tips, your diet progress may stall on vacation (and that’s ok!).  As long as you’re not gaining weight, you’re still on track toward meeting your goals. Relax, enjoy yourself, and focus on making healthy choices when you can.

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