Health Care News

When Mergers go Horribly Wrong

2017 is proving to be the year of the failed Health Insurance Merger. These Insurance Behemoths are being blocked by Federal judges, siting Anti-Trust laws. Several organizati... Read more

2017 is proving to be the year of the failed Health Insurance Merger. These Insurance Behemoths are being blocked by Federal judges, siting Anti-Trust laws. Several organizations, most notably, the American Medical Association have even petitioned against these mergers with concerns over a lack of consumer protection as a result of reduced competition. We did see Kaiser Permanante acquire local Washington HMO, Group Health officially on February 1st of this year. In that instance, neither organization was competing against one another as Kaiser didn’t have a footprint in Washington within Group Health’s service area and that seems to be the overarching sticking point in these decisions.

There is a lot of money at stake when these mergers go horribly wrong. While the circumstances of each of the following failed mergers are similar, the reactions by each carrier are drastic.

Aetna and Humana

In January, a federal judge ruled against the proposed acquisition of Humana by its larger rival, Aetna. This coming on the tail of a lawsuit filed by President Obama’s Justice Department, attempting to block the acquisition by alleging that merger would hurt competition in the health care market, leading to higher prices for consumers and fewer options, specifically for Medicare patients. As a result, Aetna and Humana called off their planned merger, with Aetna agreeing to pay the $1 Billion fee for backing out of the agreement. Aetna CEO Mark Bertolini issued a statement - “While we continue to believe that a combined company would create greater value for health care consumers through affordability and quality, the current environment makes it too challenging to continue pursuing the transaction.”

There was much speculation regarding Aetna leveraging their position with the Justice Department by reducing their footprint in Individual exchanges throughout the country. Aetna subsequently exited 11-of-the-15 markets they were participating in last year. Just this past month, a few months removed from the Federal Judge’s decision, Aetna pulled out of the remaining four markets.

Anthem and Cigna

Unlike the amicable ending the failed Aetna and Humana merger resulted in, Anthem and Cigna’s break-up is a bit more contentious. Like the aforementioned, their Merger was blocked by in February when a Federal Judge ruled against it, citing anti-trust. Subsequently, a U.S. Appeals court upheld the ruling in April. On May 12th Anthem announced they were ending the merger and not going to pay $1.85 Billion break-up fee. Anthem issued a statement, clearly asserting that Cigna was to blame for the failure:

“Cigna has failed to perform and comply in all material respects with its contractual obligations. As a result, Cigna’s repeated willful breaches of the Merger Agreement and its successful sabotage of the transaction has caused Anthem to suffer massive damages, claims which Anthem intends to vigorously pursue against Cigna.”

Aetna and Humana are walking away from the Merger attempt arm-in-arm - not in the vein that they had hoped, but at least from an imperturbable manner. Whereas, Anthem and Cigna are destined to be locked into court battles for next few months/years determining who was at fault for the merger failure.

Aetna and Humana Mutually Agree to End Merger Agreement. May 18, 2017 http://investor.aetna.com/phoenix.zhtml?c=110617&p=irol-newsArticle&ID=2245780

Anthem Comments on Decision of the Delaware Court of Chancery on Acquisition of Cigna; Terminates Merger Agreement http://ir.antheminc.com/phoenix.zhtml?c=130104&p=irol-newsArticle&ID=2272685

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Federal Regulations Transform Short Term Medical Market

Effective April 1st, new Federal Regulations require a reduction in the coverage duration of Short Term Medical plans to a maximum of three months. To understand the impact and... Read more

Effective April 1st, new Federal Regulations require a reduction in the coverage duration of Short Term Medical plans to a maximum of three months. To understand the impact and reasoning behind these new compliance measures, we provide a bit of context and history regarding this market.

Short Term Medical plans originally were created as a stop-gap coverage for individuals trying to obtain insurance for a limited or specific period of time. These plans were extremely useful for a person who had recently changed jobs and were subject to a waiting or probationary period before they were eligible to join their new employer’s health insurance offering. Before the Affordable Care Act (ACA) was passed, employers could stretch out this probationary period up to 6 months. Now, under the ACA, that waiting period is limited to a maximum of 60 days.

However, over the past few years the Affordable Care Act has pushed numerous clients into the Short Term Medical market in an unforeseen ways. With double-digit premium increases in many markets, folks have chosen to enroll in Short Term Medical plans and pay the penalty for not carrying ObamaCare compliant coverage because it would be much less expensive going that route compared to enrolling an Individual plan. Short Term Medical plans don’t cover pre-existing conditions or preventive care – therefore, what you get is a fairly healthy population gravitating towards these options as a way to circumnavigate paying top premium dollars for a more comprehensive health plan. Ultimately, pushing out some of the healthier risks exchanges are trying and have failed to fully attract.

Conversely, there are also those folks that enrolled into a Short Term Medical option thinking that they were satisfying the Individual Mandate, only to find out at tax time that they were going to have to pay the penalty for not carrying compliant coverage. In the past two years, we’ve really seen Short Term Medical carriers become more transparent and forthright regarding language relating to their product lines not being ACA compliant in an effort to limit this circumstance from occurring. Federal Regulators, banded together to address the issues of driving more healthy folks to the Individual Market and limiting the negative consumer experience of enrolling into this product mistakenly. Because employers can only implement a 60 day waiting period, they used that as the backbone to come up with a maximum duration for these Short Term Medical options – they settled on 90 days.

While the overall market share of US citizens participating in these markets is fairly minimal, the impact will be firm, forcing them into the Individual market – or that is the hope behind these new regulatory policies.

In Washington State, as Short Term Medical has become more popular over the past few years, we’ve really seen adverse effects at the carrier level. Specifically, premium increases and several carriers dropping from the market. At the time of this writing, there is now only one carrier offering Short Term Medical plans in Washington State. You can still enroll into a Short Term Medical plan at any point throughout the year, but now, you won’t be able to stretch it around the calendar as was able to be done previously.

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Your 2016 and 2017 HSA Contribution Maximums

It’s tax season! Many HSA utilizers make a one-time annual contribution at this time. Here are your contribution limits for 2016! And, while we’re at it, let’s go ahead and t... Read more

It’s tax season! Many HSA utilizers make a one-time annual contribution at this time. Here are your contribution limits for 2016! And, while we’re at it, let’s go ahead and throw in 2017 as well! The contribution limit for an individual went up $50 from 2016 to 2017 – all other contribution amounts and plan minimums remain unchanged.

2016 contribution limits (employer and individual combined)
• Maximum contribution limit for individuals - $3,350
• Maximum contribution limit for families - $6,750
• Age 55 catch-up contributions - $1,000

2016 Minimum HDHP limits
• Minimum deductible for self-only coverage - $1,300
• Minimum deductible for family coverage - $2,600
• Maximum out-of-pocket expenses for individual - $6,550
• Maximum out-of-pocket expenses for family - $13,100

2017 contribution limits (employer and individual combined)
• Maximum contribution limit for individuals - $3,400
• Maximum contribution limit for families - $6,750
• Age 55 catch-up contributions - $1,000

2017 Minimum HDHP limits
• Minimum deductible for self-only coverage - $1,300
• Minimum deductible for family coverage - $2,600
• Maximum out-of-pocket expenses for individual - $6,550
• Maximum out-of-pocket expenses for family - $13,100

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Kaiser Officially Acquires Group Health

It’s been a long process (initiated in Late 2015), but on February 1, 2017, Kaiser officially acquired Group Health with the final stamp of approval coming from Washington State... Read more

It’s been a long process (initiated in Late 2015), but on February 1, 2017, Kaiser officially acquired Group Health with the final stamp of approval coming from Washington State’s Office of the Insurance Commissioner.

Kaiser and Group Health share many values when it comes to delivering healthcare – both heavily leaning on an HMO/integrated health care model. With the acquisition, Kaiser added 651,000 Group Health Members, now serving a total 11.3 million across eight states and the District of Columbia.

As part of the deal, Kaiser has pledged to invest one billion dollars over the next decade to expand and modernize facilities and technologies to improve care and service. Immediately, the most noticeable change users will experience simply is in the name – speculated to take place in early March. You’ll begin seeing ‘Kaiser Permanente” plastered on the side of the 25 primary care clinics, three urgent and four outpatient surgery centers in Washington State. Group Health collateral will be gradually phased out as well. No immediate changes to operations, health care plans or care is expected – at least for the duration of 2017.

For most Washingtonians, Kaiser is only known by reputation. Kaiser does have medical centers in Southwestern Washington, but this acquisition gives them a substantial footprint in Washington State, specifically along Puget Sound’s I-5 corridor. Not much is known about what changes Kaiser is expected to impart upon Group Health’s Infrastructure and health care delivery system – both sides have been quite mum on the topic. However, from our standpoint, from the health insurance perspective, there are a few differences between the two organization’s health care plans and operations that we are anxiously waiting to see how they pan out:

Alternative Care – While you won’t find a Group Health or Kaiser HMO plan offering containing coverage for Naturopathic care, those on Group Health plans may have become accustomed to GHC’s adequate coverage and network of alternative medical providers – specifically, chiropractors and acupuncturists. Kaiser doesn’t share the same level of enthusiasm for alternative care – it will be interesting to see if they budge on this and what will happen with those provider’s contacts.

Access PPO plans – This really is the big question from our standpoint. Group Health offers true PPO plans that utilize the First Choice Health Network, which is the largest network of physicians in Washington State. Plans on both the individual and group sides have garnered significant market share over the past few years. How will Kaiser approach these large PPO offerings? Will they scale them back? Flush them down the toilet? Keep them in place? It will be late April/early May when filings are due for 2018 that we will likely get our first glimpse into what the future holds for these products.

Infrastructure – True to any organization, across any industry, any time a local business gets gobbled up by a large conglomerate, there is a moment of pause and wonder what will be the ramifications to their customer service model? What sort of claims and billing support will there be? When I have a problem am I now going to have contact a Call Center in California (Kaiser is California-based)? What about this online patient portal I’ve been using? How will the overall user experience be impacted?

These are interesting times in the world of health care delivery. This acquisition is sure to directly impact on our local system – Group Health has developed a substantial homegrown presence in Washington State. To learn more, see the link below that will direct you to Group Health’s press release.

“Kaiser Permanente, a National Leader in Integrated Health Care and Coverage, Completes Acquisition of Group Health Cooperative in Washington State.” https://www.ghc.org/html/public/news/2017-02-01-kaiser?utmcampaign=17kpacq&utmsource=direm&utmmedium=email&utm_content=pd. February 1, 2017.

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Your Individual Health Insurance Options Outside of Open Enrollment

With the individual health insurance market transitioning to open enrollment periods (ended on January 31, 2017), a common misconception has developed in that potential ins... Read more

With the individual health insurance market transitioning to open enrollment periods (ended on January 31, 2017), a common misconception has developed in that potential insureds believe they don’t have an opportunity to enroll into any sort of individual health insurance plan at this time.

Some may find that they qualify for a special enrollment period if a qualifying life event has occurred.  Events include:

-          Getting married or divorced

-          Having a baby, adopting a child, placing a child for adoption or foster care

-          Moving into a new state, gaining citizenship or being released from incarceration

-          Or most commonly, the following, including losing employer based  coverage via job         change/loss/retirement, COBRA expiration, losing eligibility for state programs or turning 26 and losing coverage from parent’s plan

It is worth noting that if you have a qualifying event, you have a sixty day window from date of event to complete enrollment into an individual plan.  Additionally, most carriers (as well as state exchange) do require a “proof of loss” or “proof of event” letter demonstrating the qualifying life event.

The Healthplanfinder (state exchange) periodically grants special enrollment periods for certain groups of people to take advantage of premium subsidies.  So far, special enrollment periods have permeated for those who were unable to complete their application due to technical errors during open enrollment (ended May 1st), folks currently enrolled in COBRA (ended June 30) and currently those who had their domestic partnership transitioned into a marriage (ending August 31st).

For those who do not fall into one of the aforementioned categories, your options are more limited outside of open enrollment.  The good news is that our office can help you enroll in a Short Term Medical plan.  These plans are specifically designed to bridge the gap between richer plans, offering peace of mind that coverage is in place and providing cost sharing benefits.  Give us a call for more information about these plans.

One of the major adopted provisions of Obamacare is expanded Medicaid.  In Washington State, a person or family that qualifies can enroll into Washington Apple Health (state’s Medicaid program) anytime throughout the year. 

Group plans can still be shopped anytime throughout the year.  Some carriers do have a uniform renewal period which does not affect a group’s ability to enroll into the plan – just when their open enrollment period will be.   Small groups can be put together with as few as two employees.

As an independent broker, our office can present you will all of your health insurance options for individuals and small business owners, inside and outside of open enrollment.

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Explanation of ACA taxes for Employers

For Employers, there are three fees associated with the deployment of Obamacare.  What we are finding is that most carriers have these fees and taxes embedded into the rate... Read more

For Employers, there are three fees associated with the deployment of Obamacare.  What we are finding is that most carriers have these fees and taxes embedded into the rates, so in some cases the employer may not be aware they exist.  However, occasionally, you will actually see separate line items on your invoice.

The PCORI Fee affects both fully-insured and self-funded group plans.  The fee funds research that evaluates and compares health outcomes, clinical effectiveness, risks and benefits of medical treatments.  It is an annual fee that is indexed against medical costs.  The fee for plans ending on or after October 1, 2014 and before October 1, 2015 is $2.08 per covered life, a slightly higher PCORI fee than the previous plan year.  As in previous years, health insurance carriers will pay the PCORI fee on behalf of fully-insured group health plans.  Plan sponsors of self-insured group health plans, including some HRAs and health FSAs, must complete the filing process themselves using IRS Form 720.

Under the Affordable Care Act, group health plans must pay an annual fee to fund the Transitional Reinsurance Program, designed to stabilize premiums in the individual health insurance market from 2014-2016.  For 2014, the Transitional Reinsurance Fee is $5.25 per covered life per month and in 2015, the fee drops to $3.67 per member, per month.

The Insurer Fee affects fully insured customers only.  The fee will help fund tax subsidies for individuals and families who purchase health insurance through an exchange.   Industry sources estimate this fee will be around 3% for 2015.

For more information related to the fee schedule, fee payments and exclusions visit:

http://www.uhc.com/live/uhc_com/Assets/Documents/TaxesFees.pdf

 

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Donald Trump’s plan to reform Healthcare and "make it great"

Donald Trump’s plan to reform Healthcare and "make it great" While Donald Trump’s main initiatives have been widely discussed, mocked, opposed and virtually dissected... Read more

Donald Trump’s plan to reform Healthcare and "make it great"

While Donald Trump’s main initiatives have been widely discussed, mocked, opposed and virtually dissected from every angle, the issue of Healthcare has been relatively mum, comparatively.  Like his right wing contemporaries, presumptive Republican Presidential Nominee, Donald Trump has taken the position to repeal and replace healthcare reform.  Not surprisingly, Donald Trump favors a healthcare system that emphasizes free market principles, provider transparency and decentralized decision-making.[i]

On his website, Trump presents a seven point model to improve our healthcare industry and – dare I say, “make it great!”  His vision closely represents the pre-ObamaCare world, with a few added twists.  By applying free market practices, enabling carriers to sell across state lines (would require law modification), and removing barriers for entry for pharmaceutical companies to enter the market, increased competition will lower costs and broaden healthcare access.

Trump spends some time hitting on some changes valued by both sides of the spectrum – the need for transparency from all healthcare providers and calling for substantial improvement in our mental health programs and institutions in this country.  However, he presents a few wrinkles in healthcare reform that differ significantly from what has been presented by the other presidential hopefuls and our current Speaker of the House’s (it is widely speculated that Ryan and Trump will forge their relationship over healthcare reform – more on that later) .  Most notably:

·         Allow individuals to fully deduct health insurance premium payments – Businesses are allowed to     write off the premiums, so why wouldn’t Congress allow individuals to do the same?

·         Remove barriers to entry into free markets for drug providers that offer safe, reliable and cheaper products

·         Enforcing immigration laws that would relieve healthcare cost pressures on state and local governments

While some candidates went to great lengths to explain how their reforms will be funded and rolled out (see Bernie Sander’s “Medicare for All”), Mr. Trump’s presentation doesn’t present many statistics or steps to be taken.  His focus seems to mostly singular in the sense that creating a platform for competition will lower healthcare costs and improve satisfaction for Americans.  He does recognize that a repeal of ObamaCare and his outlined reforms are simply the starting point. 

To read his healthcare reform position in its entirety, go here.

 

 



[i] Trump, Donald. "Healthcare Reform to Make America Great Again." Make America Great Again. Web. 18 July 2016.

 

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Hillary for America – Focus on re-tooling and expanding the ACA

Hillary for America – Focus on re-tooling and expanding the ACA Hillary Clinton has a long track record of advocating for Universal Health Care, the CHIP program and ... Read more

Hillary for America – Focus on re-tooling and expanding the ACA

Hillary Clinton has a long track record of advocating for Universal Health Care, the CHIP program and bringing expanded care to rural areas.  The ACA undeniably has brought these things to the majority of the American people, especially with the expanded Medicaid program.  However, it is no secret that the ACA does have a number of issues that need to be addressed for it to be both sustainable and deliver quality affordable health care to Americans.  Democratic nominee, Hillary Clinton has made a pledge to patch a few of the holes in the ACA, while expanding on its principles.[i]

Hillary’s health care proposal reads more like a resume, then a reform piece.  As tenured as she is, for better or worse, there is a long list of health care transformations that she has been involved with.   As first lady, she was instrumental in lobbying for the creation of the Children’s Health Insurance Program (CHIP).  This program provides medical insurance for kids, whose families don’t qualify for medical assistance (non-Medicaid eligible) and cannot afford private health plans.  Her hopes are to continue expanding access to affordable health care to families.  Here are her main reforms:

·  Fix the “family glitch” – an glaring hole in the ACA where family members are prohibited from qualifying for tax credits if they are offered coverage by an employer

·  Support new incentives to encourage all states to expand Medicaid – currently, there are 19 that have not adopted the expansion[ii]

·  Slow the rise of prescription drugs, copays and out-of-pocket maximums

Mrs. Clinton has always been consistent with her stance on woman’s reproductive health care – access to emergency contraception, preventive care and legal abortion.  She has always remained true to Arkansas roots, by making sure that rural Americans have access to quality, affordable health care by federally funding rural health clinics and streamlining licensing for telemedicine.

She has made it clear she intends to furiously defend the Affordable Care Act against any opposition. 

In summary, the Hillary Care model is not much different than what is currently in place (albeit there has been discussion of bringing down the Medicare age to 55, offering a state run plan).  A few of the glaring consumer holes are addressed, but no real effort is put forth in describing how escalating premiums and out-of-pocket maximums are going to be curbed.  Expanding Medicaid into the 19 remaining states will no doubt bring down the uninsured rate significantly, making health care much more “Universal.”  It goes almost without saying that the ACA, as it stands, is not a sustainable model and with escalating premiums, more and more healthy folks will no doubt be forced to drop out, further pushing carriers out of the individual market.  It’ll be interesting to watch in the upcoming months if she elaborates on her plans to get the insurance carriers out of the red, while simultaneously stabilizing soaring premium costs.   



[i] Clinton, Hillary. “Health Care – Affordable health care is a basic human right.” Hillary for America.  Web. 19 August 2016.

[ii] Kaiser Family Foundation. “Status of State Action on the Medicaid Expansion Decision.” Kaiser Family Foundation. Web. 24 May 2016

 

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Narrow Network and Less Costly Plans: Yes, Please!

“Overall, more prefer expensive broad-network plans over cheaper narrow-network plans, but potential ACA exchange customers lean in the opposite direction.”[1]  Those who a... Read more

“Overall, more prefer expensive broad-network plans over cheaper narrow-network plans, but potential ACA exchange customers lean in the opposite direction.”[1]  Those who are uninsured or buy their own insurance prefer lower cost, limited network plans over broad and expensive options.

The discussion on narrow vs. broad networks is not new to the health insurance industry.  Recently, the topic has re-sprouted as consumers began navigating the health insurance exchanges, evaluating their options – those with lower premiums and cost-sharing opportunities have shown to be more popular in the individual market.  As the Kaiser Health Tracking Poll shows below, 54 percent versus 35 percent, prefer the narrow network, less costly plans.

   



[1] “Kaiser Health Tracking Poll: February 2014” www.kff.org March 11, 2014.

 

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The Young Invincibles

There has been a lot of emphasis on getting the “young invincibles” (Americans aged 18-34) to enroll in health insurance plans.  Risk pooling has changed tremendously since... Read more

There has been a lot of emphasis on getting the “young invincibles” (Americans aged 18-34) to enroll in health insurance plans.  Risk pooling has changed tremendously since the adaptation of The Affordable Care Act.  In essence, the individual market has created a system where young individuals premium payments will be used to cross-subsidize those of older people.  In other words, the system needs young people to enroll in health insurance plans to help offset the medical costs of older people who generally incur greater expenses.

So, how does it work?  Premiums cannot vary based on health status or gender anymore – gone are the days of pre-existing condition questionnaires.  Premium variations are now solely based on age.  For this system to work, young people need to enroll in sufficient numbers to produce a surplus in premium revenues to prevent insurers from raising premiums in upcoming years.

Insurers typically set their premiums to achieve a profit margin of 3-4%.  Some insurers are optimistic about young enrollees and have set premiums accordingly (lower).  Others, do not share the same optimism and have set higher premiums across the board.  The important point here is that insurers still expect to earn a profit and will adjust rates accordingly.  Obamacare is predicated and reliant upon the young invincibles to enroll, to keep health insurance costs affordable.[1]

It should be noted that risk pooling occurs state by state.  Therefore, we will likely see some states with more stable markets at year end - The states that are able to attract and enroll young adults into individual health plans.

The State of Washington has employed several marketing tactics to appeal to the young invincibles.  Originally, the state’s Washington Healthplanfinder ran commercials showing young people getting into freak accidents, including one involving a vicious raccoon.  Healthplanfinder has now partnered with giant concert promoter, Live Nation.  With the use of traditional marketing tactics, Healthplanfinder hopes to appeal to Washington concert goers (typically comprised of a younger demographic) by leveraging trust and encouraging enrollment.  The integrated program will include an interactive presence through Live Nation’s websites, print, radio advertising and social media channels.[2]

The key component of the Affordable Care Act to work is to achieve a balanced risk pool.  This will attract insurers to the market, and more importantly, keep insurance costs down over time.

 

 

 



[1] www.kff.org “The Numbers Behind “Young Invincibles” and the Affordable Care Act” January 15, 2014

[2] www.wahbexchange.org “Washington Healthplanfinder Teams Up with Live Nation to Reach ‘Young Invincibles’” January 15, 2014

 

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Preventive Servies

Health insurance has completely shifted modes over the past few years, with the help of a major provision of the ACA - private carriers are now covering recommended prevent... Read more

Health insurance has completely shifted modes over the past few years, with the help of a major provision of the ACA - private carriers are now covering recommended preventative services with little or no patient cost-sharing.

Evidence has shown that preventative screenings and exams have saved lives and allowed patients to detect and manage illnesses more effectively.

These preventive measures have been broken into 4 different categories: 

I.                    Evidence-based screening and counseling - screening for cholesterol, obesity, various cancers, HIV, drug and tobacco use and others

II.                  Routine Immunizations – including but not limited to, influenza, meningitis, tetanus, HPV, hepatitis A and B, measles, etc .

III.                Preventive Services for Children and Youth – immunization and screening services for both behavioral and developmental assessment.

IV.                Preventive Services for Women – well-women screenings, contraceptives and related services, breastfeeding support and supplies, etc.

For a comprehensive list of covered services for both adults and children, see the tables put together by Kaiser Family Foundation.  As always, consult with your carrier about their preventative and wellness programs.

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FAQ: What is self-employment tax?

Self-employment tax is a tax combining Social Security and Medicare taxes due on net self-employment income.  It is similar to Social Security and Medicare taxes withheld f... Read more

Self-employment tax is a tax combining Social Security and Medicare taxes due on net self-employment income.  It is similar to Social Security and Medicare taxes withheld from pay of most wage earners.

So how do you figure your self-employment (SE) tax?  Using form 1040 and Schedule SE, you will find instructions for calculating and claiming the deduction and how this figures into your adjusted gross income.  This calculation affects only your income tax – it does not affect either your net earnings from self-employment.

So how does this relate to health insurance?  One of the moving parts of Obamacare health plans involve a handful of deductions that one can include on their health insurance application to maximize their tax credit.  This calculated deduction (SE tax) can be used by self-employed individuals to lower the gross income calculation, thus increasing the potential tax credits availalble through the state exchange to help lower health premiums.

For clarity, and verification on numerical values, we advise phoning your accountant.

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Health claim denied? Here's what you need to know.

Health Insurance denials can happen for a number of reasons.  A simple cause can be a billing error from the provider's office.  If the claim is submitted using the wrong t... Read more

Health Insurance denials can happen for a number of reasons.  A simple cause can be a billing error from the provider's office.  If the claim is submitted using the wrong treatment or diagnostic code, the claim can be denied.  More serious reasons can involve treatments considered "experimental" or "pre-existing".  Both of these reasons can be appealed if you feel the insurance company's decision is wrong.

If your healthcare claim is denied, you have the right to appeal.  Health Insurance carriers are required to provide an appeals process.  Typically there are a few levels of appeal, each moving more 'independent' by involving impartial medical professionals.  The Patient's Bill of Rights also provides an independent third-party review of your appeal, if the standard appeals process is unsuccessful.

Washington Health Insurance Agency provides assistance through the appeals process, by walking their health insurance clients through the steps, carefully tracking the appeal deadlines, recommending the best supporting documents, and even participating in the appeal discussion board via conference call on behalf of their clients.

The most important thing to remember is that if you feel the denial is wrong, you have to appeal.  Many people just assume there is nothing they can do.  The New York Times recently reported a story about this very point.  

Remember, if you have the right Health Insurance Agent, you don't have to go through the appeal process alone.

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