• Ambulatory patient services
• Emergency services
• Hospitalization
• Laboratory services
• Maternity and newborn care
• Mental health and substance use disorder services, including behavioral health services
• Pediatric services, including oral and vision care
• Prescription drugs
• Preventive and wellness services and chronic disease management
• Rehabilitative and habilitative services and devices

However, lifetime and annual limits can be placed on “Non-Essential Health Benefits” such as:

• Acupuncture
• Dental services (accidental)
• Food / nutritional supplements
• Hearing aids
• Hospice
• Infertility (including Rx)
• Obesity surgery
• Orthotic braces
• Ostomy supplies
• TMJ
• Vision exams
• Wigs

Health plans in or out of the Colorado Health Insurance Exchange must cover Essential Health Benefits. At Sage Benefit Advisors, we are closely following all the coming changes and regulations so we’ll be able to help you through the process of selecting the most appropriate plan for your situation. Give us a call! 970.484.1250

Employer Penalties Flow Chart

Not sure how you’re gonna navigate through the Colorado Health Insurance Exchange in 2014?

Need help making sure your health insurance ducks are in a row so you avoid penalties?

Give us a call and we can help! 970.484.1250

While most of us can understand the basic meanings of our health insurance terminology such as deductibles, co-pays, co-insurance, etc., there is a whole new language being spoken within Health Care Reform.

Wondering what in the world an EHB or QHP is? This list should help.

ACA – Affordable Care Act, fully known as PPACA or the Patient Protection and Affordable Care Act, is the federal statute signed into law on March 23, 2010.

ASO – Administrative Services Only, commonly referring to a Self-Funded insurance plan that an employer funds itself. Self-Funded groups will not be required to meet all or the same mandates as Fully-Funded insurance carriers.

EHB – Essential Health Benefits, the key components of what a health insurance plan must offer beginning January 1, 2014.

FPL – Federal Poverty Level, this will determine who is eligible for a government subsidy within the Colorado Health Insurance Exchange as well as who is eligible for Medicaid.

FTE – Full Time Equivalent, this determines an employer’s group size and whether or not the employer qualifies for government subsidies within the Colorado Health Insurance Exchange.

HHS – Health and Human Services, the federal government’s principal agency that is administering the  Patient Protection and Affordable Care Act.

OPM – Out of Pocket Maximum, this amount determines the maximum dollar amount that you’ll end up spending in a year on your healthcare costs while using your insurance plan. It will apply across the board, to all qualified health insurance plans in or out of the Colorado Health Insurance Exchange but the exact amount has not been released yet.

SBC – Summary of Benefits and Coverage, this is intended to be a short, easy-to-read document that will help you better understand the terms of your coverage. Read our post specifically about SBC’s here.

SHOP – Small Business Health Options Program, this is the exchange that Small Business Employers will operate within come 2014.

QHP – Qualified Health Plan, a certified health plan that provides Essential Health Benefits, meets required mandates and is offered by a licensed health insurer.

This list is just the beginning of the new language that will be spoken in 2014 but fortunately, we speak it fluently so you don’t have to! We can help you decode those acronyms and find your way through the Colorado Health Insurance Exchange.

The fee is to cover administrative costs of the new markets, which were designed to be self-supporting.

Like most administrative and/or regulatory costs imposed upon businesses, who do you think will actually end up paying for this fee? You guessed it…you and I as consumers (in the form of higher premiums).

What do you think about this? Are we heading in the right direction?

Their pitch sounds appealing — just set up a fixed dollar benefit for employees and then let employees pick their own individual health insurance policy. They say that the employer can still deduct this contribution as a business expense, and the benefit is also tax free to the employee. Sounds great, huh? But, there are a couple problems with this approach:

1. Currently, and for the remainder of 2013, individual health insurance plans are still medically underwritten. This means that there is no guarantee that your employees and/or their families will qualify for an individual health insurance plan. In fact, some employees may find out that they are uninsurable. Ouch.

2. Even though this “pitch” claims that by setting up an HRA, the employer is “getting out of the insurance business”. That is not just misleading…it is dead wrong! By setting up an HRA and paying individual health insurance premiums through the HRA, the employer is actually jumping even deeper into the health insurance business. Why? Because HRAs ARE HEALTH PLANS and THEY ARE SUBJECT TO THE SAME RULES AND REGULATIONS AS ANY OTHER HEALTH PLAN OFFERED IN THE STATE OF COLORADO. Specifically:

• HRAs would be subject to the part of the health care reform law that prohibits group health plans from establishing “lifetime limits on the dollar value of benefits for any participant or beneficiary” (PHSA §2711(a)(1)(A)). HRAs are account-based benefits which by their very nature impose upper limits on the dollar value of benefits. HRAs are in direct conflict with this part of the law.
• HRAs would be subject to HIPAA portability, privacy & security requirements.
• HRAs would be subject to ERISA requirements for disclosure, claims and fiduciary liability.
• HRAs would be subject to Federal benefit mandates including the Family and Medical Leave Act, Mental Health Parity and Addiction Equity Act of 2008, Women’s Health and Cancer Rights Act of 1998, and the New Borns’ and Mothers’ Health Protection Act.
• HRAs would be subject to Colorado mandated benefits as well. There are a slew of these, so I will spare you the details, but here is a Summary of Colorado’s Mandated Health Insurance Benefits.

1. Are you eligible for health insurance through your employer?

If you are eligible for group health insurance, then you are likely not eligible for the premium tax credit UNLESS the coverage offered by your employer is unaffordable (costs more than 9.5% of your income) OR the coverage is inadequate (covers less than 60% of medical costs).

2. Are you eligible for health insurance through another government program?

If so, then you are likely not eligible for the premium tax credit.

3. Are you a lawful citizen of the United States?

You must be a lawful citizen of the United States to be eligible for the premium tax credit. Illegal immigrants are not eligible for these credits.

4. Do you file your taxes?

To claim the Advanced Premium Tax Credit, you need to be an “applicable tax payer”and NOT be claimed as a dependent on anyone else’s tax return. The applicable taxpayer’s family, which is also covered by the tax credit, includes all persons that the taxpayer claims a dependent tax deduction.

5. Are you incarcerated (in jail or in prison)?

If you are currently incarcerated (other than if you are awaiting disposition of charges) then you are not eligible to claim the advanced premium tax credit since your health care is already provided for by the facility that you are incarcerated in.

6. Is your modified adjusted gross household income (MAGI) between 133% and 400% of the federal poverty level?

For 2012, this means less than $44,680 for a single person and less than $92,200 for a family of four. If you’re income is greater than these levels, you will not be eligible for the premium tax credit. If your income is lower than that you will likely be eligible for other government health care options.

Again, these tax credits will be available starting January 1st of 2014 for insurance plans purchased through the Colorado Health Insurance Exchange or other state health insurance exchanges. The average tax credit for eligible taxpayers is expected to exceed $4600 per year. These tax credits are also advanceable, meaning that you can start taking advantage of them as soon as you enroll in a qualifying health insurance plan in 2014. The initial credit will be calculated based upon your projected income, but will be trued up when you file your 2014 tax return (in the spring of 2015). That being so, it is important that you conservatively estimate your income so that you are not hit with a substantially lower tax credit which would mean that you would owe substantially more in taxes.

If you have any questions, please give us a call at 970.484.1250. Sage Benefit Advisors will be able to assist with health insurance offered through the Colorado Health Insurance Exchange. These services and our advice are are available at no additional cost to you.

How can the same procedure from the same surgeon cost $27,000 less at this surgery center rather than the local hospital? The answer:

1. The surgery center has much lower overhead costs than the hospital.

“In 2010, the top 18 administrative employees at Integris Health received an average of $413,000 in compensation, according to the not-for-profits’ 990 tax form. There are no administrative employees at the Surgery Center.”

2. The surgery center offers market driven, transparent pricing.

Perhaps a little competition is just what the doctor ordered to help solve the U.S. health care crisis.

Individuals may be eligible for subsidized premiums for insurance policies purchased through the Colorado Health Insurance Exchange. The average subsidy is expected to be $4600/person in 2014.

If you have questions about whether you will qualify for the health insurance exchange subsidy, give us a call at 970.484.1250. We can help to estimate your premium subsidy.

What is the Colorado Health Insurance Exchange?

Colorado’s health insurance exchange will be a competitive and transparent marketplace where you can purchase health insurance (even if you have pre-existing conditions). Health insurance plans sold through the Colorado health insurance exchange will have to meet certain benefit and cost standards as required in the Affordable Care Act. Sage Benefit Advisors will have access to and will be able to support all health insurance plans offered in the Exchange.

Health Insurance Tax Credits for Colorado Families

If you are not eligible for other affordable health insurance, starting in 2014 you may be eligible for Advance Premium Tax Credits to help you pay the premiums for insurance purchased through the Exchange. In order to qualify, your income needs to be between 133% and 400% of the poverty line (roughly less than $45,000 for an individual or $90,000 for a family of four). This tax credit is advanceable, meaning that you can start taking advantage of it immediately in 2014 without having to wait for tax time. This being so, the tax credit amount will be estimated based upon your projected income for 2014. The actual tax credit will be trued up with your actual income when you file your 2014 tax return. So, just like you manage your withholding’s  it is best to be conservative when estimating your income so that you don’t get hit with a big tax bill because you underestimated your income.

In addition to the Advance Premium Tax Credit, lower income families may also be eligible for other “cost-sharing reductions” (i.e. lower co-pays, deductibles, and co-insurance). While this is part of the Affordable Care Act, the details of how this cost-sharing reduction program will work are still to be determined. It is likely that there will be plans designed specifically for this demographic (rather than some onerous reimbursement process administered by the federal government).

Purchasing Colorado health insurance from the Health Insurance Exchange will be one of the ways that you can comply with the health insurance mandate as required in 2014 by the Affordable Care Act.

The Colorado Health Insurance Exchange should be online for the open enrollment period beginning in October of 2013. Until then, and even after that time, Sage Benefit Advisors WILL be able to help you to enroll in the best health insurance plan for yourself, your family, and/or your business (i.e. Colorado Group Health Insurance). If you have any questions, please call us at 970.484.1250. 

If you would like to review Colorado health insurance quotes right now, with no obligation, please feel free to use our Colorado Health Insurance Quoting Tool.