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HealthNet Reduces Participation Requirements for Q2, Sell More Medical Today!

HealthNet wants to give you more choices and opportunities to make more during Q2. With new lowered participation requirements, it now only takes participation of 35% for groups with 6–100 eligible employees and only 66% for small groups with 1-5 employees to offer Health Net. For more information on their guidelines, please click here.

5 takeaways from CMS’ final 2019 ACA marketplace rule

Click here to read the article online

By Shelby Livingston, April 10, 2018, Modern Healthcare

The CMS issued a 523-page final rule late Monday that agency officials said is meant to give states more power to regulate their individual and small-group health insurance markets. The rule also furthers the Trump administration’s agenda of chipping away at Affordable Care Act rules in lieu of a full repeal, which congressional Republicans haven’t been able to pull off.

Here are five highlights:

States’ choose-your-own-benefits adventure

The CMS handed states the reins to determine which essential health benefits individual and small-group plans must offer, starting in 2020. States will be able to either adopt another state’s 2017 benchmark plan; replace one or more of its benefit categories with that of another state’s; or completely build a new essential benefits package from scratch so long as the new plan is not too generous and is in line with a “typical employer plan.” The CMS defines a typical employer plan as either one of the state’s 10 base-benchmark plan options from the 2017 plan year, or one of the five largest group health insurance products by enrollment, not including self-insured plans.

Even with this extra leeway, plans will still have to offer the 10 essential health benefits required by the Affordable Care Act, such as maternity care or mental health coverage. When the change was proposed in October, policy experts were wary of giving states greater power over essential benefits, saying the move could lead to skimpier coverage in the marketplace. The CMS made adjustments to the proposal, such as tweaking the definition of a typical employer plan, to relieve some of their concerns.

Only rate hikes of 15% or more will get a review

The CMS is upping the rate increase threshold that triggers a review by state regulators to premium hikes of at least 15% for 2019. This is seen as way to reduce states’ and insurers’ regulatory burden given the significant rate increases over the past few years. Currently, insurers who planned to increase rates by 10% were required to submit their rates to regulators for review. The agency is also exempting student health insurance coverage from rate review requirements, effective July 1.

More ‘Get Out of Health Insurance Free’ cards

HHS is allowing a big chunk of Obamacare customers to drop their insurance in 2018 without having to pay an individual mandate penalty. The CMS is allowing insurance exchanges to extend exemptions to the penalty based on a lack of affordable coverage available in an area. And additional CMS guidance released Monday allows anyone who lives in a region with just one health insurer or none at all to claim a “hardship” exemption from the penalty for as far back as 2016. Those who only have access to an insurance plan that covers abortion may also get out of the penalty if they object to abortion coverage.

The individual mandate penalty was zeroed out starting in 2019, but the new exemptions would affect all those still subject to the penalty for 2018 if they don’t buy coverage. Though there were some close calls leading up to the last open-enrollment period, there are no counties without at least one insurer offering exchange plans in 2018. Still, eight states and about a quarter of ACA enrollees have only one insurer to choose from. Three states—California, Oregon and New York—require nearly all their insurance plans to cover abortion services, according to the National Women’s Law Center.

License to innovate

The CMS went ahead with its proposal to promote innovative plan designs by eliminating standardized options from the federal marketplace in 2019. “We believe that encouraging innovation is especially important now, given the stresses faced by the individual market,” the agency said in its proposed rule. Standardized options share cost-sharing structures and benefit designs, and were initially proposed as a way to simplify shopping for consumers.

This is a major win for the health insurance industry, which opposed introducing standardized options to the exchanges in 2017, viewing them as stifling competition and creativity. Insurers previously were not required to offer standardized plans, though the CMS encouraged them to do so and displayed the plans on

Loosening up the MLR

Starting next year, the CMS is relaxing the rules surrounding how much of an insurer’s premium income must be spent on medical claims and quality improvement activities, a figure known as the medical-loss ratio. Insurers covering individuals and small businesses today must spend at least 80% of their premiums on healthcare and quality improvement.

In 2019, states will be able to request changes to the minimum individual market MLR that insurers must meet if states can demonstrate that a lower MLR would help stabilize their markets. At the same time, to relieve insurers of the burden of identifying, tracking and reporting actual expenses related to quality improvement activities, the CMS will allow insurers the option of reporting a standard 0.8% of earned annual premium for a minimum of three consecutive years.

Wrap Documents for Welfare Benefit Plans

The Employee Retirement Income Security Act of 1974 (ERISA) now allows employers the use of wrap documents in conjunction with the insurance certificate or benefit booklet to satisfy ERISA’s requirements. This new document, called a “wrap document,” essentially wraps around the insurance certificate or benefit booklet to fill in the missing ERISA-required provisions. When a wrap document is used, the ERISA plan document or SPD is made up of two documents— the insurance certificate or benefit booklet and the wrap document.

For more information on wrap documents and the updated ERISA requirements, please click here.


Healthcare leaders, get ready for blockchain

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By Scott Goodspeed, March 30, 2018, Modern Healthcare

Is there an industry that stands to benefit more from blockchain than healthcare? Granted, we’re still learning how this disruptive technology could improve our businesses and our lives. But so far, it appears blockchain is likely to have a major impact on many aspects of healthcare, including improving clinical outcomes, reducing the cost of care, sharing clinical data with smart patient wearable devices, processing claims, and broadening access to clinical trials.

Blockchain is digital ledger technology developed in 2008 and most known to date for underpinning Bitcoin, yet its potential goes far beyond the crypto-currency. The technology is a database of transactions–each cell is a timestamped “block” that connects to the cell before it, creating a chain of blocks that can’t be edited or deleted. A blockchain isn’t relied on primarily for storing information, but instead for certifying the existence of a specific piece of information–a health record, a vote, a loan agreement, or a digital identity, for example.

A study from IBM, found that 16% of surveyed healthcare executives had solid plans to implement a commercial blockchain solution in 2017, while 56% expected to by 2020. Healthcare companies, tech innovators and the rest of the healthcare industry are grappling with what’s possible now, and what blockchain could solve in the future.

It appears that blockchain could impact our lives on the same scale as the Internet. As summarized by Roberto Tamassia, a computer science professor at Brown University in a podcast last summer, “Blockchain technology has significant potential to revolutionize the way business is conducted online by enabling consensus and trust in a distributed way without having to rely on a trusted third-party entity.”

However, as with any disruptive technology, organizations will need hard proof of the benefits of blockchain before deploying it and, equally important, reassurances regarding security and privacy. While the technology promises to increase the integrity of and control over healthcare information in general, promises won’t be enough. Healthcare deals with the trifecta of sensitive information–financial, personal and medical. The industry will need to be convinced of the technology’s merits before discarding decades-old platforms that their business success and reputations have become dependent upon.

Concerns aside, the growing interest suggests that it’s worth the time to investigate the benefits of blockchain. Here are a few examples of how it can be leveraged in healthcare:

  • Improving clinical outcomes and cost of care by allowing access to one shared data base of timely, comprehensive and accurate clinical information.
  • Sending and receiving shared data on smart patient wearable and implantable devices to monitor, send alerts and deliver care.
  • By automating the process of authenticating identities, data and transactions, blockchain could allow many healthcare events–paying or denying a healthcare claim, for example–to occur without requiring human intervention. This could save healthcare companies from having to pay employees to do mundane tasks, while speeding up transactions for customers.
  • For clinical trials, blockchain would be able to provide anonymity by creating a layer of de-identified data that researchers could access without fear of identities being revealed.
  • By running certain “smart contracts,” or applications that sit on top of a blockchain, patients would be able to authorize or deny a third-party access to their personal information, giving them greater control over their own data and, perhaps, greater faith in its integrity.

Those are just a few examples; the list goes on. What leaders in healthcare IT should be focused on right now is gaining a better understanding of blockchain so they can determine how it might benefit their organizations. They also need to be prepared to explain the pros and the cons to their C-suite colleagues. With enough understanding and insight, leaders will be well-poised to answer the question if adopting blockchain will benefit their organizations. Given the current excitement around the technology, it’s likely to be a matter not of if, but of when.

Oscar for Business is coming to LA and OC

Oscar for Business, coming soon to Los Angeles and Orange counties, will give you yet another carrier choice for your clients with headquarters in these areas. With the same robust EPO network for which Oscar individual plans are known, plus competitive commissions and mobile-compatible member interface, Oscar is sure to be a hit with your clients.

Watch for more information about products and underwriting guidelines coming soon, and click here for a sneak peek at Oscar for Business, California.




Blue Shield Reduces Minimum Group Size for Life Quick Match Program

Blue Shield’s Life insurance Quick Match Program is now available to new and existing small business groups, adding life insurance with 10 to 100 eligible employees. This is a limited-time opportunity, so make sure you don’t miss out!

Effective dates for the program are March 1, 2018, through December 31, 2018. Click here for an informational flyer with more program details.

CMS Develops Continuation Coverage Training for Agents

The Centers for Medicare and Medicaid Services (CMS), together with the Center for Consumer Information & Insurance Oversight (CCIIO), conducted a webinar today for insurance agents about coverage alternatives for people who lose their group health plan coverage. The webinar included clear-cut explanations, from a Federal perspective, about COBRA, Marketplace coverage and Qualified Small Employer Health Reimbursement Arrangements or QSEHRAs.

Click here for a copy of the presentation.


article: Republicans give up on Obamacare repeal

Altering Obamacare is “still being looked at. But not with the intensity it was.”

Click here to read article online.

Politico, February 1, 2018 by Burgess Everett

WHITE SULPHUR SPRINGS, W.Va. — Republicans are giving up on their years-long dream of repealing Obamacare.

Though the GOP still controls both chambers of Congress and maintains the ability to jam through a repeal-and-replace bill via a simple majority, there are no discussions of doing so here at House and Senate Republicans’ joint retreat at The Greenbrier resort. Republicans doubt they can even pass a budget providing for the powerful party-line “reconciliation” procedure used to pass tax reform last year, much less take on the politically perilous task of rewriting health care laws in an election year.

“I don’t think leadership wants to,” said Sen. Bill Cassidy (R-La.), who worked with South Carolina Sen. Lindsey Graham (R-S.C.) on a last-ditch repeal effort last fall. “In the sense of Graham-Cassidy, a partisan exercise? Doesn’t look like it.”

Republicans’ decision to abstain from another attempt at gutting Barack Obama’s health law — at least this year — goes back on a pledge the party has made to voters since 2010. And it underscores how Republicans overpromised in their ability to reform the nation’s health care and never fully recognized how divided the party is over key Obamacare planks like protecting pre-existing conditions and preserving the law’s Medicaid expansion.

And now the GOP is facing reality. Senate Republicans would struggle to pass a bill slashing at Obamacare under the best circumstances this year. They lost a Senate seat in Alabama in December and are down another vote as Sen. John McCain (R-Ariz.) undergoes cancer treatment. GOP leaders would rather put the debacle of last year’s failed attempt behind them.

“It would be a heavy lift. I think everybody knows,” said Sen. John Thune (R-S.D.), the No. 3 GOP leader. “We sort of tested the limits of what we can do in the Senate last year. And we’re one vote down from where we were then.”

Republicans very well may lose the House or Senate this fall, which would officially stick a fork in their efforts to move a partisan agenda item like Obamacare repeal while President Donald Trump is in office. But there appears to be no urgency to capitalize on unified Republican control: None of the lawmakers interviewed for this story believe that Congress will pass a budget this year that would allow Republicans to use reconciliation to evade the Senate’s supermajority requirements.

And rather than make a major play to the frustrated conservative base on health care, Senate Majority Leader Mitch McConnell (R-Ky.) has charted a bipartisan approach in his comments when asked about the matter.

“I don’t think we’re going to get a budget. And without a budget I don’t think we can do reconciliation,” said Sen. Shelley Moore Capito (R-W.Va.). “When you hear the leader speak, he’s speaking about bipartisanship. So I think that’s the direction we’re going to go in this year.”

The news is not being taken well in some corners of the party. Rep. Mark Meadows (R-N.C.), who leads the conservative House Freedom Caucus, winced when reminded of the party’s failure to repeal Obamacare and the lack of formal discussion on undermining the law at the retreat.

Yet he was hopeful that Republicans can pick up Senate seats in November and try again with a bigger Senate majority.

“Do I see a full repeal of Obamacare happening on a reconciliation vehicle this year? No. And to suggest otherwise would be to ignore 51 votes in the Senate,” Meadows said. “If we keep the majority in the House and they get a larger majority in the Senate then you might look at a reconciliation vehicle after November.”

Republicans took some heart in having recently passed laws that repealed Obamacare’s individual mandate and delayed some Obamacare taxes. And most GOP lawmakers said that they believed those provisions are as far as they can go given the political constraints and the ugly nature of last year’s attempt, including a failed Senate vote and months of party infighting.

But Graham, for one, is not willing to give up. After a herculean, if failed, effort in September to push legislation repealing Obamacare and block granting federal health care funds to the states, Graham said the GOP will be savaged by its voters if it tries to give up on fully scuttling the law.

“We’re coming back at it. Republicans have no choice but to try to replace Obamacare after repealing the individual mandate,” he said, citing an obligation to GOP voters to try again. “I’m certainly not giving up without a fight. And to any Republican who thinks you can avoid the consequences of Obamacare collapsing, you’re kidding yourself.”

Asked about Graham’s latest push, Thune responded: “We’ll believe it when we see it.”

“If he’s got 50 for it, more power [to him],” Thune said. “The leader’s not going to bring that up if he can’t get it through.”

In the meantime, some members of both parties are pushing bills to help stabilize the insurance markets, hoping to bring down premiums after Trump eliminated key payments to health insurers. But even that effort has flagged in recent weeks as conservatives have fought any effort seen as propping up Obamacare, most notably the stabilization bill written by Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.).

“It’s on the backburner too,” Capito said. Altering Obamacare is “still being looked at. But not with the intensity it was.”

Senate confirms Azar as HHS secretary

The Senate on Wednesday approved Alex Azar to head HHS, where he’s expected to reshape the ACA exchanges that face uncertain futures after executive and legislative efforts to dismantle them.

By Susannah Luthi of Modern Healthcare

January 24, 2018

The Senate on Wednesday approved Alex Azar to head HHS, where he’s expected to reshape the ACA exchanges that face uncertain futures after executive and legislative efforts to dismantle them.

Azar fills a vacancy left by former HHS secretary Dr. Tom Price, who 
resigned in September over his use of private jets on the government’s dime.

Many Democrats voted against the nominee citing his record as a drug company executive who oversaw sharp price spikes during his tenure at pharmaceutical giant Eli Lilly & Co. 

Azar takes over at HHS after a tumultuous year on the healthcare policy front. Although congressional Republicans 
ultimately failed to repeal the Affordable Care Act after three attempts, they eliminated the individual mandate penalty and delayed key ACA taxes meant to offset the costs of the program. 

President Donald Trump’s executive order to 
expand association health plansleaves the door open for substantial changes to the law’s coverage mandates. As HHS secretary, Azar has vast authority to dictate terms of 1332 waivers states can use to reshape their exchanges.

Azar vowed over the course of his Senate confirmation hearings to address escalating drug prices, but he limited specific recommendations to a pharmaceutical benefit manager model to negotiate drug prices 
for Medicare Part B’s physician-administered sales and expanded generic competition

Senators have begun to release Azar’s written testimony for the record as well to shed further light on his policy bent and how his work will align with the Trump administration’s work over the past year and shift away from past currents.

One example is his neutral stance on a recent recommendation from the HHS Office of the Inspector General to add medical device identifiers to billing claims after the office found the government had spent $1.5 billion in Medicare funds to treat people who had failed cardiac implants. 

Murray noted in her questions that providers have said the addition wouldn’t add undue burden, but Azar didn’t commit to following the OIG recommendation before talking to all stakeholders involved “to understand the potential benefits and talks.”

Advocates of the billing system change are already worried his noncommitment signals that it won’t happen since the forms get a redesign only once every 10 years.

As former general counsel at HHS, Azar brings administrative chops to the job that his embattled predecessor Price lacked. He helped launch the Medicare Advantage program as HHS general counsel under President George W. Bush.

Former colleagues praise Azar’s efficiency and leadership — traits that make Democrats who oppose his policies wary of the direction he is likely to take the department.

“This nomination is about more than just the administration’s failure on prescription drug prices,” Sen. Ron Wyden (Ore.), ranking Democrat on the Finance Committee, said on the Senate floor Tuesday. “It’s a referendum on an entire healthcare agenda.”

Wyden went on to say that he has “no confidence Mr. Azar will change course at HHS” from the Trump administration’s current actions.