by Johnson and Dugan | Mar 17, 2023 | Health & Wellness, Hot Topics
Author: Michael Mulqueeney, Vice President of Business Development, Johnson & Dugan
Back in 1989, when I was 29 years old, I went through a six-month period where I had a rapid onset of symptoms that impacted my ability to feel anything from my waist down to my toes. My doctors eventually settled on three probable diagnoses: Multiple Sclerosis (MS), Amytrophic Lateral Sclerosis (ALS), or Epstein-Barr. These possible diagnoses rocked me.
Six months with no feeling from the waist down
I didn’t know much about what was happening to my body. I wasn’t a doctor or nurse, and this was long before I worked in employee benefits, which now gives me more insight into health and wellness. But I did have a close relationship with a family friend who had MS. She was retired and living a reasonably normal life, with what appeared to be little impact on her day-to-day activities. So, I thought, “Well, if it’s MS, I can probably deal with that.” But the idea of ALS freaked me out. I knew it wasn’t good, so I kept my fingers crossed that I didn’t have that.
During this 6-month period, I was numb from the waist down—hips to toes. I had zero feeling though I could still move around with significant effort. I was so stiff I could barely walk, and when I did, it felt like I was walking on stilts. Walking considerable distances was out of the question, which was really discerning, but I just pushed forward and hoped for the best.
I wasn’t really in pain, so I didn’t take medication. I was told that the medicine would “hopefully” relieve some of my symptoms, but it wasn’t clear if it would improve the stiffness, and it wouldn’t be a cure. So, I skipped the drugs and just made heavy lifestyle changes, mainly with my diet.
Fast forward six months later: I was driving a long commute in southern California between Huntington Beach and Tarzana when I noticed tingling in my legs. Two to three weeks later, I got all the feeling back, and my symptoms subsided.
Symptom-free for 10 years. Was it MS or a misdiagnosis?
Ten years later, in 1999, I was still symptom-free but decided to have a new doctor review my medical history. He didn’t think I had MS because he thought it would have presented itself again. He said my symptoms ten years prior could have stemmed from something else, such as a virus like Guillian-Barre syndrome. The doctor said to let him know if the symptoms ever came back. But they didn’t. That is, until 2019.
30 years later: A concrete diagnosis—then the anxiety set in
Back in 1989, I’d only been given a “probable” diagnosis because my MRI scans were all clean. I had no signs of degeneration of the myelin on my spinal cord that you typically see with MS. While my spinal tap indicated that it could be MS, doctors said they needed to see another round of symptoms before providing a diagnosis. Three decades later, the doctors got just that.
So, we’re talking about 30 years without symptoms when suddenly, I started having issues with my walking again. Things progressed rapidly from there, and I finally got concrete answers. Doctors confirmed that I had MS through an MRI I had completed in the Spring of 2020—just when we were entering the first stages of the pandemic. The medications and treatment options that my doctors suggested for me are the kind that shut down your immune system and restart it. That seemed very scary to me since having a healthy immune system seemed to be an advantage for those who contracted COVID.
Needless to say, I had a lot of anxiety about the treatments my doctors were suggesting. We didn’t have the COVID-19 vaccine yet, and the thought of messing with my immune system made me uncomfortable. So, as in 1989, I decided not to do any medication and went hardcore on lifestyle and dietary improvements instead.
I firmly believe that solid nutrition, regular exercise, and consistent sleep are the primary foundations of good health. So, I changed the way I ate, opting for a Mediterranean diet, plus juicing with fresh, organic raw fruits and vegetables three times a day. I also started taking natural organic supplements and vitamins. I made sure they were highly vetted and from reliable sources—because my experience in employee health and wellness has taught me that many manufactured vitamins don’t have the benefit that people think they do.
I also added stretching and yoga to my daily routine to help with my stiffness and mobility issues. These changes improved some of my symptoms, like my “foot drop,” which prevented my left ankle from moving, causing it to drag while I walked. I seemed to be “treading water” after adapting my diet and lifestyle. I was feeling pretty good for about a year.
Revisiting MS medication options after the COVID-19 vaccine
By 2021, I noticed I was getting worse again and going in a direction I didn’t like. I was vaccinated against COVID-19 at this point, so I revisited the medication options with my neurologist. He said he was glad we didn’t do Rituximab, the medication he’d initially recommended in 2020. It was an IV immunotherapy drug, and they had seen issues concerning the COVID virus. Instead, he recommended a different medication called Tysabri. I completed the testing and pre-work required to qualify for the treatment, but I was still nervous about it, and with good reason: I was told if I’d had something called the JC (John Cunningham) virus at any point in my lifetime, the medication could kill me. Well, that didn’t give me much confidence about moving forward. I had been tested and cleared of the JC virus, but I was still feeling nervous, so I decided to pull the plug on starting that treatment too.
I was looking for hope that my MS symptoms could improve
Fast forward to 2022. I continued to get a little worse, and I wanted some hope. I think that was one of my biggest issues. I was looking for my doctors to give me hope that I could feel better. I woke up every morning feeling like my body had been a punching bag for a boxer. I’d stretch after getting out of bed to reduce soreness and stiffness and increase my mobility, but I wanted some hope that my symptoms could improve. I hadn’t been getting that.
My doctors, as reputable as they were, could only tell me their goal with the medication was to prevent me from feeling worse or to slow the progression of the disease. That’s why I didn’t want to pursue the treatment. I wanted to feel better. I have followed people with MS who share their personal experiences using various strategies, whether medications or more natural means. A wide variety of things have worked for some but not for many.
Undeniably though, my symptoms were going downhill. So, I started doing my own intense research. I went into MS blogs and chatrooms to connect with people who’d been on MS medication and compared our symptoms. I discovered some hope out there. But unfortunately, the medications didn’t work universally for everybody. It seemed hit or miss. Doctors were treating MS in many ways. They’d often start with one medication, and if that didn’t work, they’d try another one, and then another, and so on.
Many people I talked to had been through that trial-and-error process, yet others had one medication in particular that moved the needle for them. One gentleman I spoke to had been in a wheelchair for MS and had dealt with symptoms for about 25 years. It had progressed much more rapidly for him than for me, but many of our symptoms were the same. He’d gone on the same drug (Tysabri) that my doctors wanted to prescribe me. Before the treatment, he could get from his wheelchair to the bed or a chair but couldn’t walk well. He took the medication, and today he’s running 10Ks. Now, that was kind of the hope I was looking for. I don’t expect to be running 10Ks, but even if I could walk a 1K, that would be an improvement because I can’t run at all right now, and walking is labored.
One of the symptoms I have is called MS hug. It’s a tightness around the torso that feels like I just did 500 sit-ups. And it feels like that, 24 hours a day, seven days a week. It’s hard to run when you feel like that. So, in hearing this guy’s story, I got some hope and started thinking about what I could do.
Adios anxiety: the benefit of an expert second medical opinion
In my occupation with Johnson and Dugan, we provide products and services for employers so they can offer employee benefits to take care of their people. I’ve spent much of my career in employee benefits—specifically, partially self-funded plans. I’ve worked with groups to add specific strategies and employee benefits to assist people, reduce claims, and improve health outcomes. That got me thinking about MORE Health.
I liked the idea of an expert second opinion. I’m in a closed HMO, though, so if I go outside the HMO, it comes out of my wallet. I saw that MORE Health has a way to bring in a benefit at a reasonable cost so that employers can give their employees an option for a second opinion. Now, I really started thinking about a second opinion. I wanted one for myself because, after all this time, I still felt unsure about what treatment option to try—if any. This experience also led me to question why most health plans don’t offer coverage for second opinions. This is a problem in our healthcare system, I believe. At a recent NextGen healthcare delivery strategy conference I attended, I learned that 1 in 20 adults in American are misdiagnosed every year. Knowing this, it surprised me to dig in and discover that none of the major insurance carriers include a second opinion as a benefit of their coverage for a serious major illness! This surprised me, especially when you look at the significant costs that come along with a misdiagnosis. These costs may not involve money alone, it could mean ones life.
I had doubts about my treatment options for many reasons: I was concerned about how the medications interacted with the COVID-19 vaccines and boosters. My son—who eats a primarily vegetarian diet, does yoga, and is not a firm believer in Western Medicine—has not been a fan of me going the medication route. And given my line of work and what I’ve seen on the news about the pharmaceutical industry recently, I didn’t know how much I could trust any of it.
I thought getting a second opinion from a leading specialist would be helpful. I wanted somebody to look over my shoulder and give me a thumb up, sideways, or down on what my doctors were proposing. So, I reached out to MORE Health.
They did most of the work and paired me with a leading specialist for MS who looked at my entire case. All my records were delivered virtually to that physician through their online technology, including my MRIs and CT scans. I could even provide a report from years prior. I still had my physician’s assessment from 1989 in my files, which had data on the initial findings from my spinal tap and MRIs. Within five days, I got the final report. It came in the day before my first scheduled infusion therapy.
I’d prepared myself to pull the plug on the treatment that morning, but I didn’t have to. I got a detailed report from MORE Health that reviewed all my medical records, their findings of my CT scans, MRIs, and blood work. The specialist they assigned to my case examined everything and commented on it. The report included a conclusion with the physician’s recommendation that I go forward with infusion therapy (Tysabri) every six weeks, which is what my doctors at home had prescribed. The physician also wrote a caveat that if I didn’t see results in a certain amount of time, they would recommend a second medication.
Before getting an expert opinion on my case, I was going through a lot of anxiety about doing the infusion therapy. After receiving the specialist’s final report, I was very relaxed. I wasn’t anxious at all as the report provided through the MORE Health second opinion relieved my apprehension about getting started on this immunotherapy treatment.
As I write this, I am less than 24 hours from my fourth infusion of Tysabri. So far, the physical difficulties I have experienced have remained in check, and my physical symptoms haven’t gotten worse. My focus and productivity at work have improved. I hadn’t considered those issues before treatment. I just struggled along and pushed myself to be productive—all while experiencing various leg pains and on-and-off discomfort that worsened as the day progressed. My doctors say that for some people, the benefits of the drug kick in right away, while for others, it takes 12 months, and for others still, it never works. I’ve always been a glass-half-full guy, though. It’s not in my nature to be a pessimistic person. I’ve always looked forward and believed the future has yet to be created. We will have to wait and see how the treatment shows up for me, but as for the anxiety, adios!
About the Author
Michael Mulqueeney is the Vice President of Business Development with Johnson & Dugan Insurance Corporation, a UBA Partner Employee Benefits Advisory firm that has been in business in the San Francisco Bay Area for nearly 40 years. Mike was diagnosed with Remitting Relapsing MS in 2020. He lives in the hope of feeling better physically and maintaining his ability to play a round of golf—as hard as it may be for others to watch.
About MORE Health
MORE Health is a global digital health company known for giving individuals access to the best medical minds in the world when facing a serious illness or diagnosis. Recognized as a leader in cross-border telemedicine, MORE Health delivers virtual Expert Medical Opinions from world-leading specialists by pairing technology and world-class service. Offered as an employee benefit or on an individual self-pay basis, this service is available to groups of any size in the U.S. and abroad. Since 2013, MORE Health has helped patients on six continents and continues its mission to provide patient advocacy to clients and members worldwide—when they need it most.
by Johnson and Dugan | Sep 30, 2021 | Compliance, Group Benefit Plans, Medicare
Are you an employer that offers or provides group health coverage to your workers? Does your health plan cover outpatient prescription drugs — either as a medical claim or through a card system? If so, be sure to distribute your plan’s Medicare Part D notice before October 15.
Medicare began offering “Part D” plans — optional prescription drug benefit plans sold by private insurance companies and HMOs — to Medicare beneficiaries many years ago. People may enroll in a Part D plan when they first become eligible for Medicare.
If they wait too long, a late enrollment penalty amount is permanently added to the Part D plan premium cost when they do enroll. There is an exception, though, for individuals who are covered under an employer’s group health plan that provides creditable coverage. (“Creditable” means that the group plan’s drug benefits are actuarially equivalent or better than the benefits required in a Part D plan.) In that case, the individual can delay enrolling for a Part D plan while he or she remains covered under the employer’s creditable plan. Medicare will waive the late enrollment premium penalty for individuals who enroll in a Part D plan after their initial eligibility date if they were covered by an employer’s creditable plan. To avoid the late enrollment penalty, there cannot be a gap longer than 62 days between the creditable group plan and the Part D plan.
To help Medicare-eligible plan participants make informed decisions about whether and when to enroll in a Part D drug plan, they need to know if their employer’s group health plan provides creditable or noncreditable prescription drug coverage. That is the purpose of the federal requirement for employers to provide an annual notice (Employer’s Medicare Part D Notice) to all Medicare-eligible employees and spouses.
Federal law requires all employers that offer group health coverage including any outpatient prescription drug benefits to provide an annual notice to plan participants.
The notice requirement applies regardless of the employer’s size or whether the group plan is insured or self-funded:
- Determine whether your group health plan’s prescription drug coverage is creditable or noncreditable for the upcoming year (2022). If your plan is insured, the carrier/HMO will confirm creditable or noncreditable status. Keep a copy of the written confirmation for your records. For self-funded plans, the plan actuary will determine the plan’s status using guidance provided by the Centers for Medicare and Medicaid Services (CMS).
- Distribute a Notice of Creditable Coverage or a Notice of Noncreditable Coverage, as applicable, to all group health plan participants who are or may become eligible for Medicare in the next year. “Participants” include covered employees and retirees (and spouses) and COBRA enrollees. Employers often do not know whether a particular participant may be eligible for Medicare due to age or disability. For convenience, many employers decide to distribute their notice to all participants regardless of Medicare status.
- Notices must be distributed at least annually before October 15. Medicare holds its Part D enrollment period each year from October 15 to December 7, which is why it is important for group health plan participants to receive their employer’s notice before October 15.
- Notices also may be required after October 15 for new enrollees and/or if the plan’s creditable versus noncreditable status changes.
Preparing the Notice(s)
Model notices are available on the CMS website. Start with the model notice and then fill in the blanks and variable items as needed for each group health plan. There are two versions: Notice of Creditable Coverage or Notice of Noncreditable Coverage and each is available in English and Spanish:
Employers who offer multiple group health plan options, such as PPOs, HDHPs, and HMOs, may use one notice if all options are creditable (or all are noncreditable). In this case, it is advisable to list the names of the various plan options so it is clear for the reader. Conversely, employers that offer a creditable plan and a noncreditable plan, such as a creditable HMO and a noncreditable HDHP, will need to prepare separate notices for the different plan participants.
Distributing the Notice(s)
You may distribute the notice by first-class mail to the employee’s home or work address. A separate notice for the employee’s spouse or family members is not required unless the employer has information that they live at different addresses.
The notice is intended to be a stand-alone document. It may be distributed at the same time as other plan materials, but it should be a separate document. If the notice is incorporated with other material (such as stapled items or in a booklet format), the notice must appear in 14-point font, be bolded, offset, or boxed, and placed on the first page. Alternatively, in this case, you can put a reference (in 14-point font, either bolded, offset, or boxed) on the first page telling the reader where to find the notice within the material. Here is suggested text from the CMS for the first page:
“If you (and/or your dependents) have Medicare or will become eligible for Medicare in the next 12 months, a federal law gives you more choices about your prescription drug coverage. Please see page XX for more details.”
Email distribution is allowed but only for employees who have regular access to email as an integral part of their job duties. Employees also must have access to a printer, be notified that a hard copy of the notice is available at no cost upon request, and be informed that they are responsible for sharing the notice with any Medicare-eligible family members who are enrolled in the employer’s group plan.
CMS Disclosure Requirement
Separate from the participant notice requirement, employers also must disclose to the CMS whether their group health plan provides creditable or noncreditable coverage. To submit your plan’s disclosure, use the CMS online tool and follow the prompts. The process usually takes only 5 or 10 minutes to complete. It is due with 60 days after the start of the plan year; for instance, for calendar year plans that will be March 1, 2022. If the plan’s prescription drug coverage ends or its status as creditable or noncreditable changes, submit a new disclosure within 30 days of the change.
By Kathleen A. Berger
Originally posted on Mineral
by Johnson and Dugan | Aug 6, 2021 | Benefit Plan Tips, Tricks and Traps, Employee Benefits, Hot Topics, Human Resources, IRS
Many employees have the option to choose between their employer’s plan and another program where they meet the eligibility requirements (i.e., spouse’s, domestic partner’s, or parent’s plan). A Cash in Lieu of Benefits program, or cash-out option, offers an incentive for those employees to waive the employer coverage and instead enroll in the other plan. The incentive is in the form of a cash payment added to their paycheck. Properly implementing a Cash in Lieu of Benefits program is crucial, as unexpected tax consequences could occur otherwise.
The Internal Revenue Service (IRS) requires a Section 125 plan be in place to be a qualified cash-out option. If the plan is not set up under an IRC Section 125 plan, the plan will be disqualified and employees who elect coverage under the health plan will be taxed on an amount equal to the amount of cash they could have received for waiving coverage.
The IRS has ruled that when an option is available to either elect the health plan, or to receive a cash-out incentive, then the premium payment to the insurance company becomes wages. The reasoning is that when an employer makes payments to the insurance company where the employee has the option of receiving those amounts as wages, the employee is merely assigning future income (cash compensation) for consideration (health insurance coverage). Therefore, the payment is treated as a substitute for the health insurance coverage. By setting up an IRC Section 125 plan, the employer is offering a choice between cash and certain excludable employer-provided benefits, without adverse tax implications.
There must be a Plan Document in place and nondiscrimination requirements must be followed, including annual nondiscrimination testing, in order to be a qualified Section 125 plan. To meet nondiscrimination rules, Cash in Lieu of Benefits must be offered to all employees equitably. To be sure an employer is not over incentivizing employees to drop the plan, which could impact the nondiscrimination participation requirements, the monthly cash benefit should not exceed $200-$300.
When a Section 125 plan already exists (Premium Payment Plan, Health Care Spending Account, Dependent Care Spending Account), the plan can be amended to add the cash out feature. Where no Section 125 plan is in place, it is standard to have an attorney provide this service. It is important to note that, although the Section 125 plan protects the employees electing coverage from taxation, the cash-out incentive is an after-tax benefit.
As always with any IRS-qualified plan, proper documentation is essential. An employee should only be allowed to waive coverage when there is another plan available, and proof of enrollment is provided. If there is a subsequent loss of that coverage, HIPAA Special Enrollment Rights will allow entry onto the plan, and the cash-out incentive will cease.
Cash in Lieu of Benefits funds cannot be used to purchase individual health coverage. For companies over 20 lives and Medicare is secondary coverage, the plan should not be structured to incentivize employees over 65 to opt out of the employer plan to enroll in Medicare.
Another factor to consider is the impact to employers considered Applicable Large Employers (ALE) and subject to the affordability determination and reporting under the Affordable Care Act (ACA). An ALE is an employer averaging 50 or more full-time plus full-time equivalent employees for the preceding 12 months. If a cash out option is offered without an IRS qualified Cash in Lieu of Benefits plan, the payment must be included in the affordability calculation.
There are also Fair Labor Standards Act (FLSA) implications. Any opt-out payments made by an employer to an employee must be included in an employee’s regular rate of pay and therefore is used in calculating overtime compensation for non-exempt employees.
These considerations should be reviewed with a tax expert and/or ERISA attorney to determine if a Cash in Lieu of Benefits program is the right option for your organization. These professionals, along with a Section 125 Plan Administrator, can provide the necessary guidance to ensure the program will satisfy compliance requirements. For further information on this topic, please contact your Johnson & Dugan team.
By Jody Lee, Johnson & Dugan
by Johnson and Dugan | Feb 14, 2020 | Employee Benefits, Human Resources
City and County of San Francisco Minimum Compensation Ordinance
Any company with 5 or more employees and contracts with the City and County of San Francisco needs to be aware of the wage law that has been in effect for several years, and the recent amendment that now includes stricter enforcement. The Minimum Compensation Ordinance (MCO) covers most City service contractors as well as tenants at the San Francisco International Airport. The law generally requires covered employers to provide to their covered employees:
- No less than the MCO hourly wage in effect:
For contracts entered into on or after October 14, 2017, the minimum hourly compensation rates effective July 1, 2019 are:
- $17.66/hour – For-Profit entity
- $16.50/hour – Non-profit entity
- $16.50/hour – Public entity
For contracts in effect prior to October 14, 2017, the minimum hourly compensation rates effective July 2, 2019 are:
- $15.59/hour for work performed within the City of San Francisco (SF Minimum Wage)
- $10.77/hour for work performed outside of the City of San Francisco
Rates are subject to change, refer to the OLSE website for the most current information: www.sfgov.org/olse/mco
- 12 paid days off per year (or cash equivalent)
Time off allowed for vacation, sick leave, or personal necessity, and part-time employees are allocated paid days off on a prorated basis.
- 10 days off without pay per year.
Days off of for part-time employees are allocated on a prorated basis. The PTO accrual rate is 0.04615 hours per hour worked and can be used as vacation or sick leave. PTO hours are vested and can be cashed out at termination.
- The employer must post the Minimum Compensation Ordinance poster in a location where employees can read it easily.
- Employees must be provided a Know Your Rights form for signature.
Failure to meet the requirements could result in penalties, with a look-back period of 10 years when a complaint is filed. If you are not in compliance and want to avoid penalties, there are options to minimize your liability. Any audit based on a complaint will include a review of your employee handbook and your payroll records.
To review the November 21, 2019 amended rules, Click Here.
by Johnson and Dugan | Dec 13, 2019 | Benefit Management, Compliance, Flexible Spending Accounts
California law AB1554, signed into law by Governor Newsom on August 30, 2019, describes a new requirement for employers to advise participants in a Flexible Spending Account (FSA) of claim deadlines before the end of the plan year. Per the law: “This bill would require an employer to notify, in a prescribed manner, an employee who participates in a flexible spending account of any deadline to withdraw funds before the end of the plan year.”
Two different forms must be used, one of which can be electronic. Examples of notification options are “(1) Electronic mail communication. (2) Telephone communications. (3) Text message notification. (4) Postal mail notification. (5) In-person notification.”
Incorporating the claim filing deadline in your annual FSA open enrollment communications would satisfy this requirement as long as it is provided in two forms of the suggested methods. Terminated employees must also be notified of the claim filing deadline. This could be done in exit paperwork, verbally in an exit interview or sent electronically.
A poster could also be posted in an area that is accessible to all employees and should include the annual claim filing deadline as well as the deadline to file after the last day of employment, if mid-year. Click Here for a sample poster.
Your Johnson & Dugan team can work with you to incorporate this notice in your communications and meet this new requirement.