Medicare

Upon turning 65 years old, you'll be eligible for Medicare coverage, as a way to supplement or completely replace you existing health insurance coverage. Through the use of your Medicare card, the government provides Original Medicare at this time; also known as Medicare Part A and Medicare Part B. 

In addition, you have two options to further enhance your Medicare coverage. 

1) Medicare Part C or Medicare Advantage- Health Insurance plans provided by private insurance companies that offer at least the same level of benefits of Original Medicare but can also include additional ancillary services and protections. With this arrangement, you forfeit Original Medicare as your network and agree to accept the terms and conditions of the private insurance company's provider network. 

2) Medicare Supplement Insurance or Medigap- Administered by various private insurance companies, different coverage levels will help pay for additional out-of-pocket costs not covered by Original Medicare. Typically, the more expensive the Medigap plan is in premium( denoted by letters such as Plan F or Plan K), the more of Original Medicare it covers. 

With Medigap, you might have to buy Part D coverage as well. Part D coverage helps cover the costs of prescription drugs for Medicare-eligible consumers. 

Individual Coverage 

Special Enrollment vs. Open Enrollment- Do I qualify?

  • Unless it’s the Open Enrollment Period, November 1st- December 15th for 2018, a "special circumstance" is needed to enroll into a health insurance plan. That qualifies as a Special Enrollment.

What qualifies as a "Special Enrollment"?

  • Certain Life events Include:

Losing Health Coverage

Moving

Getting Married

Having a Baby

Adapting a Child

  • If you qualify for a Special Enrollment Period, you usually have up to 60 days following the event to enroll in a plan.

Using the Health Insurance Exchange-

For certain people looking for Individual health insurance, getting insurance through the Health Insurance Marketplace or Exchange is potentially more affordable, depending on whether you qualify for an Advanced Premium Tax Credit (APTC) or short-handedly known as your subsidy. For people who qualify for subsidies, using the Exchange is mandatory. For people who don’t qualify for a subsidy, there’s no reason to go through this channel and although its considered allowable, it unnecessarily complicates enrollment and other forms of coordination.

How do I know if I qualify for a subsidy?

The Health Insurance Exchange or Marketplace is a government-run servicing department which helps individuals and families shop for health insurance after determining their Advanced Premium Tax Credit (APTC) or subsidy.

Figuring out your APTC?

1) Is your income within 400% of the Federal Poverty Level 

2) Also consider Family size or the # of dependents on your tax return

2018 Federal Poverty Level Chart: 

 https://www.acf.hhs.gov/sites/default/files/ocs/2018_hhs_poverty_guidelines.pdf

How do I report my income?

  • Rule #1: Report expected household income for the year you’re applying for coverage, not last year’s income.
  • Rule #2: On you tax return, report EVERYONES income, even if certain members aren’t applying for health coverage.

How do I estimate my income?

  • Step #1: Find your household adjusted gross income (AGI).
  • Step #2: Add the following kinds of income: Tax-exempt foreign income, tax-exempt social security benefits, tax-exempt interest.
  • Step #3: Estimate changes throughout the year.

Examples include: pay raises, employment changes, changes in supplemental income, etc.

 

Association Self-Funded

Association Self-Funded coverage is setup like Commercial Self-Funded coverage but instead of an employer directly funding their own claims, you join and become part of a bargaining union, as members pay into a common health fund. The premiums are therefore based on the expected claims costs for the enrollment of everyone within the health fund, not just your own employees. 

Advantages 

  • PPO national network so you can see doctors who only accept out-of-network coverage for your network. 
  • Not being subject to state mandates; i.e. less underwriting regulation usually means lower premiums.
  • Health Status WON'T Affect Premium Rates

Disadvantages

  • Medical Underwriting is required 
  • Extra fees for Union participation
  • Unlike Commercially Self-Insured, Low-Claims utilizers won't get money back
  • ID#'s are difficult to obtain before cards arrive. 

 

 

What You Need to Know

Phone #'s- 

1) Problems with Claims or Billing- Cook Associates- Third Party Admin.- #646-381-8851. 

NOTE: Do Not Call Cigna or UnitedHealthcare for this!

2) Problems with Proof of Coverage- Union- #516-741-5564

 

Payment Method- 

Required: 

  • Bank Account #
  • Routing #
  • Voided Check 

Note: Request for Paper Invoice is an extra $20/month

Association Fee- 

  • Upon enrollment, an added $125 processing fee is included and $20/month for participating. 

Eligibility- 

  • Must be an Employer Sponsored Plan or Sole Proprietorship. Employer Group Size doesn't apply. 
  • You must join the Premier Association
  • For Employer Sponsored Plans- Full-Time Employees Only may apply for coverage

Who is a full-time employee?-

  • Full-time employees work 30 hours per week for at least 120 days in the calendar year

Occupational Eligibility-

Industry Status is required for coverage

Call or Email Us for Industry Eligibility Page.

FTE Inclusion-

Doesn't apply- N/A

FTE Calculation- 

Doesn't apply- N/A

Employer Contribution- 

  • For other than sole proprietors, payment of premium MUST be withdrawn from an employer sponsored account. 

Participation- 

Doesn't apply- N/A

Deadlines- 

13th or 15th of the month depending on the Association health plan for a subsequent 1st effective date. 

 

 

 

Fully-Insured

Traditionally-funded insurance arrangements typically works like this:

The consumer contracts with an insurance company as the consumer agrees to pay a specified premium for medical claims coverage and administrative expenses. Most self-insurance arrangements also work like this, except for 1 big difference. Unlike most self-insurance arrangements, fully-insured applicants are not medically underwritten. Rather, underwriting is estimated off 2 factors, your age and geographic location ONLY, otherwise known in the insurance industry as community-rating.

 

 

What You Need To Know

Payment Method-

  • Mailed check for 1st month premium OR
  • Set-up ACH with:

Account #

Routing #

  • Credit cards are not allowed

Eligibility-

  • Full-Time Employees ONLY but Employer group size does not apply- N/A.
  • At least 1 employee on payroll and enrolling into the plan is needed! Can't be spouse of controlling owner. 

Who is a full-time employee-

  • Works 25 hours per week, (30 hours for the purposes of the Full-Time Equivalent Calculation), for at least 120 days in the calendar year.

FTE Inclusion-

Include

  • All full-time employees of a group if the business is affiliated with another employer, under common ownership or part of a controlled group 
  • Part-time employees 

Don’t Include

  • Union employees partners
  • Shareholders or Owners without Common Law Employee Status
  • Family Members or Dependents
  • Seasonal Workers- Worked Full-time LESS than 120 days per year
  • Independent Contractors who are not common law employees- 1099 workers

FTE Calculation-

  • Use the following full-time equivalent calculation to determine appropriate group size:

a) Employees working 30 or more hours per week are full-time employees and each full-time employee counts as 1.

b) Employees working fewer than 30 hours per week are part-time and counted as the sum of the hours each part-time employee works per week multiplied by 4 and the product divided by 120 and rounded down to the nearest whole number.

c) Add a and b. This gives you the employer FTE.

Note: Only 1 person on payroll needs to be working 30+ hours per week. 25+ hours per week is used for insurance eligibility and participation requirements.

Example 1: 15 employees working 30 hours or more=15. 5 employees working 20 hours per week= 100 hours x multiplier of 4= 400/120= 3.33= 3... 15+3= 18 FTE's 

Average number of FTE Employer Contribution-

  • At least 10% of the total premium.

Participation-

  • 75% including valid waivers unless applying within the Open Enrollment Period

Non-Contributory Plans (self-funded employer pays all plan contributions)- 100% participation excluding valid waivers

Contributory Plans (plan contribution is paid by both the employer and enrolled employee)- 75% including valid waivers

Tax Documentation Needed, (Required for Groups under 5 full-time employees)-

  • Most recent Quarterly Wage and Tax Statement (QWTS), WR-30 or most recent payroll information if not available.
  • Documentation demonstrating employer business status:

Need 1 of the following-

IRS Form 1120

Form 1040

Schedule C

Form 1065

Schedule K-1