Health insurance is essential to protecting your health but the high cost of coverage may leave you feeling sick. Even after employers pick up a substantial amount of the cost, every year Americans spend thousands of dollars on healthcare while costs are continuing to rise. By taking certain steps, you can stretch your healthcare dollars and still receive the care you need to stay healthy.
- Understand How Your Health Plan Works
Review your plan to learn how to maximize your benefits. You need to know what is covered (and what is not!) and what procedures you need to follow to ensure your claims will get paid. Know what your copayment, coinsurance and deductible costs are before your visit.
Most health insurance plans cover more of your costs if you use their preferred or in-network doctors. If you visit an out-of-network doctor or medical facility, you’ll pay more and may end up being responsible for 100% of the bill. Use your insurer’s online tools to search for in-network providers.
- Choose the Right Places to Get Care
Running to the emergency room when you get sick after hours could drain your wallet. All too often, those suffering from minor illnesses or injuries visit the ER when they don’t need to. The ER should be your last resort – consider using more affordable options like telemedicine or an urgent care center instead. You can still get the care you require in off-hours without having to schedule an appointment.
If you need surgery, you may save money by having it done at an ambulatory surgical center (ASC) which is a modern healthcare facility focused on same-day surgical care, including diagnostic and preventive procedures. Typically, these centers charge less than a hospital.
- Use a Health Savings Account (HSA) or Flexible Spending Account (FSA)
Opening a HSA or an FSA is a handy way to save for medical expenses and reduce your taxable income. They are like personal savings accounts but the money in them is used to pay for health care expenses. HSAs are owned by you, earn interest, and can be transferred to a new employer. FSAs are owned by your employer, do not earn interest, and must be used within the calendar year.
- Ask Your Doctor About Remote Patient Monitoring (RPM)
RPM is the use of digital technologies to monitor and analyze medical and other health data from patients and electronically transmit this information to healthcare providers for assessment and, when necessary, recommendations and instructions. This type of monitoring is often used to manage high-risk patients, such as those with acute or chronic health conditions such as those with diabetes, hypertension and heart conditions.
- Use Your Preventive Care Benefits
Many health plans pay the full cost for important preventive care. These regular screenings, exams, and immunizations help detect or prevent diseases and medical problems early when they are easier to treat. Annual check-ups, mammograms (usually after the age of 40), flu shots and colonoscopies (usually 1 every 10 years after the age of 50) are examples of preventive care. These checks can save you a lot of money because they catch problems early.
Health insurance isn’t mandatory – there’s no law requiring you to buy it – but, health insurance is an important part of staying healthy, financially and physically. Since most people who don’t have insurance made that decision based on money instead of what is best for their health, they usually don’t have doctor appointments for the same reason – it’s too expensive. But skipping routine care can end up being more expensive than your premiums, especially if you have serious health issues that aren’t caught early. Think of it like care maintenance: regularly changing your oil might be a hassle but it is essential to prevent a major breakdown down the road.
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
Question: Our company offers group medical and dental plans for all employees. We also have an executive-only medical plan that covers out-of-pocket expenses that the regular group plan does not pay. Does COBRA apply to the executive-only plan? Do we have to include it in our summary plan description (SPD)?
Answer: The coverage continuation requirements of the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) pertain to group health plans sponsored by employers with 20 or more workers (except certain church plans). This is referred to as federal COBRA, which is enforced and regulated by the Internal Revenue Service (IRS) and the Department of Labor (DOL).
Any employer-sponsored plan or program providing health benefits (medical, dental, vision, etc.) is a group health plan under COBRA. Briefly, if the employee’s access to the program or benefits is based on the person’s current or past relationship with an employer, it is a group plan. An executive-only medical plan is a group health plan – and subject to COBRA – since eligibility for the plan is connected to employment. (Reference: 26 CFR § 54.4980B-2 )
Next, the Employee Retirement Income Security Act (ERISA) imposes numerous reporting and disclosure requirements on employee benefits plans, including rules for plan documents and summary plan descriptions (SPDs). Plans sponsored by governmental employers and certain church plans are exempt from ERISA, but plans sponsored by private-sector employers must comply with ERISA’s plan document and SPD rules. There is an exception, however, for an executive plan that meets the following conditions:
- The plan primarily provides welfare (e.g., health) benefits for a select group of management or highly-compensated employees; and
- No part of the plan is funded through employee contributions or a trust.
The most common example is an executive-only medical insurance plan for which the employer pays 100 percent of premiums. In that case, an SPD is not required and Form 5500 reporting does not apply. A plan document is required but it does not have to be made available to employees. The plan document does have to be provided to the Department of Labor (DOL) if requested. (Reference: 29 CFR § 2520.104-24)
By Kathleen A. Berger
Originally posted on thinkhr.com
We have entered Open Enrollment season and that means you and everyone in your office are probably reading through enrollment guides and trying to decipher it all. As you begin your research into which plan to choose or even how much to contribute to your Health Savings Account (HSA), consider evaluating how you used your health plan last year. Looking backward can actually help you plan forward and make the most of your health care dollars for the coming year.
Forbes magazine gives the advice, “Think of Open Enrollment as your time to revisit your benefits to make sure you are taking full advantage of them.” First, look at how often you used health care services this year. Did you go to the doctor a lot? Did you begin a new prescription drug regimen? What procedures did you have done and what are their likelihood of needing to be done again this year? As you evaluate how you used your dollars last year, you can predict how your dollars may be spent next year and choose a plan that accommodates your spending.
Second, don’t assume your insurance coverage will be the same year after year. Your company may change providers or even what services they will cover with the same provider. You may also have better coverage on services and procedures that were previously not eligible for you. If you have choices on which plan to enroll in, make sure you are comparing each plan’s costs for premiums, deductibles, copays, and coinsurance for next year. Don’t make the mistake of choosing a plan based on how it was written in years prior.
Third, make sure you are taking full advantage of your company’s services. For instance, their preventative health benefits. Do they offer discounted gym memberships? What about weight-loss counseling services or surgery? How frequently can you visit the dentist for cleanings or the optometrist? Make sure you know what is covered and that you are using the services provided for you. Check to see if your company gives discounts on health insurance premiums for completing health surveys or wellness programs—even for wearing fitness trackers! Don’t leave money on the table by not being educated on what is offered.
Finally, look at your company’s policy choices for life insurance. Taking out a personal life insurance policy can be very costly but ones offered through your office are much more reasonable. Why? You reap the cost benefit of being a part of a group life policy. Again, look at how your family is expected to change this year—are you getting married or having a baby, or even going through a divorce? Consider changing your life insurance coverage to account for these life changes. Forbes says that “people entering or exiting your life is typically a good indicator that you may want to revisit your existing benefits.”
As you make choices for yourself and/or your family this Open Enrollment season, be sure to look at ALL the options available to you. Do your research. Take the time to understand your options—your HR department may even have a tool available to help you estimate the best health care plan for you and your dependents. And remember, looking backward on your past habits and expenses can be an important tool to help you plan forward for next year.
Curious about when you should notify a participant about a change to their health care plan?
The answer is that it depends!
Notification must happen within one of three time frames: 60 days prior to the change, no later than 60 days after the change, or within 210 days after the end of the plan year.
For modifications to the summary plan description (SPD) that constitute a material reduction in covered services or benefits, notice is required within 60 days prior to or after the adoption of the material reduction in group health plan services or benefits. (For example, a decrease in employer contribution is a material reduction in covered services or benefits. So is a material modification in any plan terms affecting the content of the most recent summary of benefits and coverage (SBC).) While the rule here is flexible, the definite best practice is to give advance notice. For collective practical purposes, employees should be told prior to the first increased withholding.
However, if the change is part of open enrollment, and communicated during open enrollment, this is considered acceptable notice regardless of whether the SBC, SPD, or both are changing. Essentially, open enrollment is a safe harbor for all 60-day prior/60-day post notice requirements.
Finally, changes that do not affect the SBC and are not a material reduction in benefits must be communicated and summarized within 210 days after the end of the plan year.
By Danielle Capilla
Originally Published By United Benefit Advisors
As the costs of health care soar, many consumers are looking for ways to control their medical spending. Also, with the rise of enrollment in high deductible health plans, consumers are paying for more health care out-of-pocket. From medical savings accounts to discount plans for prescriptions, patients are growing increasingly conscious of prices for their healthcare needs. Price shopping procedures and providers allows you to compare prices so that you are getting the best value for your care.
Why do you need to look beyond your nearby and familiar providers and locations for healthcare? Here’s a hypothetical example: Chris is a 45-year old male in good physical health. During his last check-up he mentions to his doctor that he’s had some recent shortness of breath and has been more tired as of late. His doctor orders an EKG to rule out any problems. If Chris went to his local hospital for this procedure, it would cost $1150. He instead looks online and shops around to find other providers in his area and finds he can get the same procedure for $450 at a nearby imaging center. His potential savings is $700 simply by researching locations.
So where do you start when shopping around for your health care? A good place to begin is by researching your health plan online. Insurance companies will post cost estimates based on facility, physician, and type of procedure. Keep in mind that these are just estimates and may vary based on what coverage you are enrolled in. Another way to shop is by checking out websites that have compiled thousands of claims information for various procedures and locations to give an estimate of costs. However, deciphering whether a site is reporting estimates based on the “medical sticker price” of charges or rates for private insurance plans or Medicare is difficult. There are huge differences in prices at different providers for the exact same procedure. This is because contracts between insurance agencies and providers vary based on negotiated amounts. This makes it hard to get consistent pricing information.
Check out these sites that do a great job comparing apples to apples for providers:
- Healthcare Blue Book
- What Kelly Blue Book is to cars, Healthcare Blue Book is to medical pricing
- New Choice Health
- Reports on pricing of medical procedures, providers, quality of facilities, and customer feedback for healthcare in all 50 states
- The Leapfrog Group
- Publishes data on hospitals so patients can compare facilities and costs for treatments and procedures
After compiling all the information on prices and procedures, you can still call and negotiate costs with the location of your care. Fair Health Consumer has tips on how to negotiate with providers and plan for your healthcare needs.
Knowledge is POWER and when you spend time researching and comparing healthcare costs, you are empowering yourself! Exercising due diligence to plan for you and your family’s medical needs will save you money and give you confidence in your decisions for care.