Affordable Care Act Scene 2 - Insurance Premiums

<p>Not the doc, LF: the insurance company, for selling you a network so narrow it could be argued substandard. Maybe because you can’t get there (a common complaint about abortion access, for instance) or because the doctors may tend to be a little sub-par. That breaking new legal ground is the reason some lawyers get up in the morning isn’t exactly news and now that healthcare’s a right it’s not unreasonable to expect that it’ll be as litigated as every other recently bestowed one has been.</p>

<p>We’ll see.</p>

<p>

I recall similar predictions as to how few imaginary friends were included in those enrollment numbers, calmom, so I’m kind of skeptical.</p>

<p>Cat, I have no clue what you are talking about. There are more than 8 million people currently enrolled in marketplace plans. That’s 1 million more than the CBO projected in 2013. </p>

<p>As to the potential overpayment scenario that was hypothesized: </p>

<p>You have to assume that </p>

<p>(1) two marketplace providers set premiums low enough so that they are significantly below the premium set for the policy purchased by the taxpayer the previous year, when the policy-holder and all family members were a year younger, thus resetting the benchmark low enough so as to created an overpayment situation.</p>

<p>and, </p>

<p>(2) you have to assume that this cost differential is high enough that it is cannot be fully recouped via clawback --meaning that it has to be a premium differential of more than $12.50/month per person at the low end, and more than $104/month at the high end. </p>

<p>And then you have to look at the flip side of the coin: IF the benchmark premium in year 2015 is a significant reduction over the benchmark in 2014 – then that is (a) good news for all the consumers who are seeing their cost of insurance go down rather than up, and (b) even better news for the federal government which will see a reduction in outlay of premium assistance credits overall.</p>

<p>Sure there are a handful of people who didn’t bother to shop around and take advantage of the lower premium, accepting and paying their full annual age-related premium increase (which is built into the system and applies across the board to all insurance companies) – but that is going to be more than offset by the fact that the government is saving money on the policies for every single subsidized or credit-eligible participant in every single exchange where benchmarks go down in year #2. </p>

<p>It’s pretty simple math. Premiums go down, the government saves money. </p>

<p>Cat, a narrow network in itself can’t be presumed substandard, if the patients have access to doctors licensed to practice, with records free of open censures. You’re assuming they are sub-par because the number of choices is/may be limited. Are they? (Have people checked?) And you’re going for deep pockets, which has led many a potential plaintiff astray.</p>

<p>If there is a regulation that x doctors should be available per the population, that’s one thing (and discussed earlier.) Same for when there are not enough specialists. But assuming the docs on your newly narrowed lists are unqualified is simply the flip side of the same coin, “I want Cedars, not my community hospital.” </p>

<p>If you’ve got a quality source for how many of those “8 million” enrollees aren’t repeats and artifacts, please share it calmom. Otherwise, I haven’t a clue as to what you’re talking about either.</p>

<p>LF: “Access” is the operative word, for the scenario I brought up and what constitutes limits to it would be for a jury to decide. Depending on how they’re picked, they tend to be kind of rational most of the time. Lest they fall for that “send a message” plea from consul.</p>

<p>Granted, our jury of PO’d consumers might also find an insurer guilty of having a network composed of nothing but docs who earned their boots in the Caribbean but that’s just speculation and not worthy of any more electrons.</p>

<p>Cat, the exchanges processed more than 13 million applicants through the point of an eligibility determination. (So that’s the number left after eliminating the many applications that were not completed for whatever reason). Of those, 8.7 million were determined eligible for premium assistance, and another 6.7 million were Medicaid-eligible. As of mid-April, 8 million had selected plans (the end stage of the enrollment process) – and as of the end of July, 7.95 million had paid. There have been close to another million enrollees since the close of open enrollment (people who are eligible because of qualifying life circumstances, such as moving to a new state, changing jobs and losing employer-based insurance, etc. - so the 7.95 “paid” number includes those. Insurance companies have reported an average 85% pay rate from exchange enrollments. </p>

<p>BTW, Calmom, thanks for explaining where the pre-ACA group rule about employee number for eligibility came from. Indeed in our case that “no exclusion” issue was why we needed group at the time ;)</p>

<p>Dietz, I was not aware that an LLC structure instead of a C-corp meant that an H &W could qualify as a group.
I’ve been making a push to ditch the c-corp in favor of an s-corp with H for years now and think this year might be the year :wink: </p>

<p>I had dinner the other night with the owner of a benefit brokerage that was quite interesting on a number of ACA fronts. I wish I’d known this woman before I’d decided to cancel the plan and give our employee the equivalent raise. I’d still have cancelled the plan, but instead of the full raise I would have done a combo reimbursement and HSA I think. </p>

<p>Apart from the FICA/employer carrying expense etc., she pointed out that if I expand and go back to group, how does one “undo” a raise? A simple but excellent point, especially now that I’m planning to hire another.</p>

<p>Live and learn ;)</p>

<p>In other news, I’ve found the most ridiculous glitch on Healthcare.gov that would take any low-functioning moron a nanosecond to fix, but that also explains why TexasPg’s immigrant employees may have had a nightmare time with eligibility.</p>

<p>When asking for an upload of eligibility documentation, a Greencard for permanent residents is required. However, none of the pull down options refer to a Greencard, and instead, refer to citizenship or naturalization documents only. It literally would have taken a nanosecond to add the field while programming this interface. I’m not kidding – I do this stuff every day.</p>

<p>When mcson had applied, by attrition he called his Greencard something else. So three months later, they said he wasn’t verified, and to upload his documentation again…so he did. The still couldn’t seem to verify him, so finally I called and walked them through their idiot error on the upload selections via phone.</p>

<p>They STILL needed him to snail mail the doc because somehow they “couldn’t” manage to retrieve the upload because it didn’t match the upload name. </p>

<p>If my kid, who happens to be both an English native and technically what they call a poetic genius in terms of his IQ due to strong verbal IQ score can’t manage to correctly upload a Greencard for verification, I cannot imagine what its like for an immigrant with lesser deftness with the English language. I hope that my escalated call on this topic was recorded…because it was pretty hilarious. Remember the movie “Brazil”?</p>

<p>Seriously. Humans are delicious!</p>

<p>Back when the enrollment numbers meant something, calmom, maybe half-way back in the thread, the opinion was offered that the totals trotted out every few weeks were good and duplicate enrollments were rare, if not impossible. Now, the true count’s said to be 8MM, with somewhere in excess of 4MM supposed enrollments never… what?.. gestating to term? Some would be because they didn’t pay but there are ample reports of stalled-out applications (duplicates) being included in those earlier, supposedly golden, numbers that we were arguing about 500 or so pages back. </p>

<p>It might very well be that there’s a slim to no chance of people getting caught by a change in base (as you described above) but predicting the future is a risky business – observe the dreams of our ACA architects running into reality, for instance.</p>

<p>@kmcmom13

</p>

<p>Don’t rely on what is posted here. An LLC can be structured as a corporation or partnership, but not both. If a husband/wife form a LLC and a K1 form is used to report income, then it is partnership. So the info that has been posted her is internally contradictory – the spouse in a partnership is not going to be treated as a “shareholder” for any specific benefit. </p>

<p>Be careful that you understand tax implications of various structures, and the interplay between business income and the self-employed health insurance deduction.You don’t want to inadvertently cut yourself out of the ability to write off health insurance premiums, either as a business expense or as an above-the-line deduction on your tax return. You should be able to find the info you need easily with Google searches online. </p>

<p>@catahoula – it’s now August, 2014. I am working with numbers reported from mid-April through the end of July. Many exchanges simply purged numbers reflecting incomplete or stalled apps from their reporting. I have no clue what the numbers might be if you tried to account for those - I’m guessing about 15-17 million? You’d have to go back and review earlier reports and compare them to later to get a sense of those - but I only looked at completed-application numbers. There’s a huge difference between creating an online account and completing all steps toward enrollment. The big surge in apps came closer to the March enrollment deadline, well after most of the early glitches would have been addressed. </p>

<p>Calmom: Neither H nor I are lawyers and as such probably at a disadvantage. What I can say with certainty is this…our LLC has qualified for group coverage. When asked if the business is ‘owned’ by H and W I have truthfully answered ‘no’. We do not OWN a business we own shares in an LLC. I will leave it to those legal minds who pull the big $$$ to label the answer as wrong or to challenge its’ legal standing. Again, I love love love legal speak…it is so malleable, open for interpretation, subject to POV and open for ‘reinterpretation’. Of course, one will need the deep pockets to see such actions through to the end…which just adds more $$ to certain pockets. In our case…I have a plan B and C in the wings. #:-S And, I may be sending our tax consultants offspring through college. But hey, it’s all a game … right! :)) </p>

<p>Dietz, presumably you have a business attorney who should be clarifying this, your own $$$ lawyer.<br>
I don’t know what’s correct, but this alone would send me to my attorney:</p>

<p><a href=“http://business-law.freeadvice.com/business-law/llcs/llc-shareholders-2.htm”>http://business-law.freeadvice.com/business-law/llcs/llc-shareholders-2.htm&lt;/a&gt; Rather than shareholders, an LLC has owners. Essentially, the partners become the “owner” of the LLC.</p>

<p><a href=“LegalZoom: Start Your Business, Form Your LLC or INC”>LegalZoom: Start Your Business, Form Your LLC or INC; Ownership interests in a limited liability company business structure are not represented by shares. Shares in a company are only issued for businesses that use the corporate structure. The owners of an LLC are called members, and each has a membership interest representing an undivided claim in all assets of the business and the right to a portion of business profits.</p>

<p>To me, looks confusing enough to get the right final advice.
If I am wrong and throwing in an idiot wrench, apologies- but this forum isn’t the place to clarify the precise intentions behind words like owner, shareholder and member.</p>

<p>^^ Hee Hee…yup…confusing…so…one just needs to find the lawyer that will give the answer that one wants. Really, what a game.</p>

<p>Well, one needs to find the lawyer who will give the answer that keeps one out of trouble, which may or may not be the answer that one wants. ;)</p>

<p>^ It’s crazy.<br>
All this shrugging of shoulders would be fine with me if it were just someone taking their own risk- with their business or with their health plan choices. Fine by me, go ahead and say you’re not owners and see what happens. Choose insurance without confirming your kid is covered away from home. But don’t then heap outrage on the rest of us. Figure it out or don’t. Make your own messes. Or don’t.</p>

<p>

You’d better talk to a lawyer ASAP. </p>

<p>If you and your husband are the only LLC members, then you are owners. </p>

<p>From what you have descried here, the only possible truthful answer to whether you own the business is “yes”.</p>

<p>Incorporating a business doesn’t change your ownership interest- the point of incorporating is to limit liability. It is a way of protecting your personal assets from the reach of business creditors. Even a regular C corporation has “owners” if it is closely held. That’s the reasoning behind the recent Hobby Lobby decision – the corporation could assert a religious freedom claim because it was "owned and controlled by members of a single family.” </p>

<p>It is not legally gobbledygook – these are basic principals and if you are sophisticated enough to form a LLC then you are going to be expected to know what that means. </p>

<p>Again, go talk to a real lawyer and get accurate advice. Based on what you’ve posted online in this thread, you could end up getting yourself in serious trouble, if you haven’t already done so. </p>

<p>Thanks, Calmom. I’ll dig into it. The only reason I was suggesting we convert the c-corp to an s-corp was to reduce the double tax dividend phenom…not related to healthcare but the issues you raise are all good considerations ;)</p>

<p>Keep in mind that each different structure also has its own costs and tax considerations. So insurance is just one of many elements to consider. I do think that an s-corp is generally better for very small companies than a c-corp - but that’s really something to discuss with an expert because the issues can also be variable from one state to another. </p>

<p>“so…one just needs to find the lawyer that will give the answer that one wants.”</p>

<p>Some one has been giving you terrible advice and/or information if you believe this. </p>

<p>kmcmom - we still have 2 visa employees who are paying in full because they are not “verified” despite multiple uploadings and mailings. </p>

<p>Meanwhile a citizen who was also being verified missed making the first payment on time, the insurance cancelled it after one month (despite whatever rule protects them for 3 months), the market place and insurer could not come to an agreement on who is at fault or what can be done to fix it but the insurer magnanimously offered to provide the same insurance outside of marketplace for the full price. So he is being covered outside of marketplace for now.</p>

<p>Meanwhile, one of our older employees with health issues chose to retire now that the insurance costs are so low for him! </p>

<p>We do have lawyer(s) for consultation. Also, as far as anyone being in big trouble…if it were decided that our interpretation of the question and the subsequent answer wedeemed incorrect the end result would be moving to a different policy. It’s all guaranteed issue now, right.</p>

<p>Yesterday I applied for the annual waiver of insurance offered through S’s college. What was a 5 minute done deal last year was a lengthy process. First off, our waiver will most not be approved because the university has set new policy requirements. The silver level is their minimum base requirement. We currently have a 35% co-insurance with a $2500 deductible. They require a 20% co-insurance and their policy has a $300 deductible (but allows for a $2000 I believe). The university policy is actually quite attractive and depending on what our renewal options are come this fall, I may move S over to the school policy.</p>

<p>I spoke with the insurance coordinator regarding our waiver. It was another learning experience. The school based their plan and waiver requirements on the ACA - the law - as it was a year ago. They wanted their ‘exchange’ up and running smoothly when it came time for the 2014-2015 school year. However, the ongoing changes made to ACA - reinstatement of cancelled plans, extensions to existing non-conforming plans, exemptions allowing certain individuals to get catastrophic plans etc. - have left them in a situation where they are slogging through 1800 waiver requests. Can a State institution (UC) require its students to carry a policy which has much much higher requirements than the State requires of it’s other citizens? </p>

<p>

I couldn’t agree more! I feel the same way about any one who COULD have gotten insurance and didn’t in the past. Let them get out of their own messes. But, that’s not how we work here, is it? We like to protect others from the consequences of their choices. </p>

<p>So, for anyone who thinks any of this is clear, straight forward or that questions have only one correct answer…the real world points to a different conclusion. Oh, and there wouldn’t be 1023 pages of discussion on the subject - many containing much outrage.</p>