We are about to implement the experiment this coming Tuesday Oct 1st 2013. They have pushed back one month the unveiling of the CoveredCA  Small Business Option Plan (AKA SHOP), but the individual plans should be up and running.  I am expecting to receive the go ahead to present the plans by Tuesday. I have done the required training. It wass a full day in Culver City and then 4 hours online in a a private webinar and the I passed a test.  So, I am just waiting for the agent agreement to be approved.  I hope it goes as planned.  I am really looking forward to assisting people to enroll on the plans.


See attachemnt Certificate CoveredCA Completed Mike Reaume

A Few Q & A’s on the ACA

Q: I’m currently on Medicare but pay out of pocket for a Blue Shield  supplement policy. Will insurance companies offer Medicare supplement policies and prescription drug policies on the new health insurance exchange?

A:  No, you won’t be able to buy Medicare plans through Covered California, the state’s health insurance exchange. Covered California specializes in private insurance policies for individuals, families and small businesses. It does not sell plans for government-sponsored health programs like Medi-Cal or Medicare.  On  Oct. 1, 2013 — Covered California will begin offering 12 health plans across the state (not all in each region), with coverage to begin on Jan. 1.   Individuals and families who earn between 138 percent and 400 percent of the federal poverty level will be eligible for sliding-scale tax credits to purchase those plans.


Medicare recipients will have to look outside the exchange for policies, much as you do now.

For Medicare Plans  I suggest searching the “plan finder” on Medicare.gov if you’re looking for Medicare Advantage or prescription policies. If you want Medicare supplement insurance — also called Medigap — she points to California’s Department of Insurance website: www.insurance.ca.gov

Medicare open enrollment runs from Oct. 15 through Dec. 7.


Q: Will Covered California offer plans for dental and vision for adults? I’m 25, and I’m thankfully on my parents’ health insurance for another year, but I’m currently without dental or vision coverage through my job.

A: Under the new health law, all health plans sold to individuals and small businesses must include coverage for 10 categories of services, including emergency care, hospitalization and prescription drugs. These categories are known as “essential health benefits.”

I’m sorry to say, but vision and dental care for adults are not among them.

As a result, Covered California will not be offering dental and vision coverage for adults. That also means you cannot receive tax credit assistance for dental and vision coverage, even if your income qualifies, says Covered California spokeswoman Anne Gonzales.

Covered California may consider linking Californians who shop for its medical plans to adult vision and dental plans elsewhere, but that idea, Gonzales says, is still just that.

So, if you really want dental and vision coverage, you’ll have to buy the policies separately and off the exchange.

Q: What about dental and vision coverage for children?

A: For children, on the other hand, dental and vision coverage are considered “essential.” That means they must be offered by Covered California.

Children’s vision services will be embedded in medical plans (but not all) sold by Covered California, Gonzales says.

Dental is another matter and has been the subject of significant debate. I won’t get into the drama here, but suffice it to say that many children’s advocates are frustrated.


In short, Covered California decided that children’s dental plans will not be embedded in medical plans. They will be sold separately by the exchange and will be offered by five insurance companies.

Depending on the plan and your region, premiums will range from $10 to $30 a month per child. The rate maxes out at three times the single premium, so if you have more than three kids, that’s the most you will pay, Gonzales says.

And even though they’re considered essential health benefits for kids up to age 19, families won’t be required to buy them.

Theoretically, some families may have tax credit dollars left over from buying medical plans to apply toward children’s dental plans, but that’s not likely to happen often, Gonzales says.

Eileen Espejo, health policy director for Children Now, says the children’s dental contracts only last a year and that she and other advocates will push for dental plans to be embedded in medical plans in the future.



100-a-day penalties: ACA non-compliance can be expensive

By Keith R. McMurdy

September 13, 2013

While a lot of employers are focused on the penalties associated with not offering appropriate coverage (the $2,000 penalty) or not offering affordable coverage (the $3,000 penalty), what can get overlooked is the myriad of daily penalties that come with non-compliance. Take the Oct. 1 exchange notice requirement as an example. While the regulations do not identify a specific penalty for failing to comply with the notice requirement, the Affordable Care Act has a $100-a-day general non-compliance penalty.

This general penalty requires employers to correct compliance failures within 30 days of discovery or self report a $100-a-day penalty for failing to comply on IRS Form 8928 for each day the employer failed to comply with an ACA mandate. .

Some other things that can result in $100-a-day penalties:

  1. Violating the non-discrimination rules (when they are finally written for insured plans)
  2. Violating the limits restrictions
  3. Failing to extend coverage to dependents to age 26
  4. Having retroactive rescission of benefits
  5. Failing to cover preventative care
  6. Failing to have a revised appeal process (including external appeals)
  7. Failing to provide timely notices
  8. Violating the restrictions on emergency room visits
  9. Violating restrictions on designation of primary care physicians
  10. Improper pre-existing condition exclusions
  11. Having excessive out-of-pocket costs
  12. Violations of the 90-day waiting period limit

Employers who simply assume that an insured plan complies with these requirements, or who assume that their self-funded plan already complies, could find themselves in a sticky (and costly) situation if an audit reveals they have failed to comply. This is particularly important now that employers are required to self-report penalties. Both the internal Revenue Service and U.S. Department of Labor could become involved.

The solution is to sit down with your plan and go line by line, requirement by requirement, to make sure there are no violations. Even though there is an extension on the employer mandate, there is no extension on offering a compliant plan.

So get with your professionals and get the answers. Don’t let the $100-a-day penalties catch you by surprise.

Our 2014   Individual and Family Plans (IFP) product   launch is truly “history in the making” with a new marketplace, a   new medical plan portfolio, new dental and vision plans, and new market   changes.Our new IFP portfolio
Today we’re unveiling our brand new portfolio of ACA-compliant PPO and EPO   products, available for you to sell to a marketplace with millions of new   potential IFP customers. We are also introducing new provider networks, our   first-ever stand-alone IFP vision plan, and expanding our dental plan   portfolio with five new plan designs to broaden your clients’ options for a   total health package.
Get all the information you need     for your individual health plan at www.ECALHP.COM  .
Everything you need to know about our new plans and provider networks can be   found in our Online Broke Guide. You’re just a click away from discovering   all the reasons why Blue Shield is uniquely positioned to be your recommended   carrier of choice for the new market.Plan withdrawals and client retention
All non-grandfathered plans will be withdrawn from the market effective 12:00   a.m. on January 1, 2014. For most members in these plans, we will recommend   one of our new ACA-compliant plans for an easy transition. More information   on plan withdrawals and retaining your clients is available in our Online   Broker Guide.New sales materials coming soon!
We have a variety of new marketing materials to help you sell our new plans,   including a new sales brochure, the Plans at a Glance (PAAG) brochure, and   the Benefit Summary Guide. Download what you need from Producer Connection.   Printed copies of the PAAG will be available for order the week of September   16. Printed PPO and EPO sales kits will be available for order the week of   September 23. Refer to the Online Broker Guide for a more complete list and   description of materials.


New DOL FAQ says No Penalty on Employers Who Do Not Send Exchange Notices to all Employees

 contact us at  www.ECALHP.COM

Yesterday, (September 11, 2013),  the Department of Labor (DOL) issued a new Frequently Asked Question (FAQ) – clarifying that employers subject to the Fair Labor Standards Act (FLSA) should provide all employees a written notice about the Health Insurance Marketplace (“Exchange Notice”) by October 1, 2013, but that there is no penalty under the law on an employer that does not send out the Notice of Coverage Options.   (The FAQ is at http://www.dol.gov/ebsa/faqs/faq-noticeofcoverageoptions.html)


Industry experts would encourage all employers who are subject to FLSA to send Exchange Notices to all employees by the October 1 deadline, even if no penalty applies, however, the decision is up to each employer.  We are moving forward with preparing and sending the notices to COBRA beneficiaries  – as planned unless you inform us otherwise by September 18, 2013.


To simplify the process, we will eliminate Part B, and instead issue only Part A:  General Information. (Part B is optional, at this time, and would generally be used for active employees, if required)


The full DOL FAQ is below,  and the direct link to The FAQ is below



FAQ on Notice of Coverage Options

Q: Can an employer be fined for failing to provide employees with notice about the Affordable Care Act’s new Health Insurance Marketplace?

A: No. If your company is covered by the Fair Labor Standards Act, it should provide a written notice to its employees about the Health Insurance Marketplace by October 1, 2013, but there is no fine or penalty under the law for failing to provide the notice.

The notice should inform employees:

  • About the Health Insurance Marketplace;
  • That, depending on their income and what coverage may be offered by the employer, they may be able to get lower cost private insurance in the Marketplace; and
  • That if they buy insurance through the Marketplace, they may lose the employer contribution (if any) to their health benefits

No, Virgina, you won’t go to jail for lack of insurance, but you will pay a penalty


SEPTEMBER 11, 2013 • 


Consumers who fail to sign up for insurance won’t go here, but PPACA fraudsters might (AP Photo/Matt York)

Health insurance agents, make sure all of your licensing is up to date.

The National Association of Insurance Commissioners (NAIC) is warning that that people posing as insurance agents or representatives of the federal government are trying to obtain sensitive information like Social Security and bank account numbers in attempts to sell fake policies under Patient Protection and Affordable Care Act (PPACA).

The organization of state regulators is telling people to confirm agent licensing with the state regulatory officials.

The warning of fraudsters poised to take advantage of consumers reveals just how much consumers do not know about the PPACA.

As most in the industry know, open enrollment in the new marketplaces begins Oct. 1., but a man-in-the-street poll would reveal many people have no idea aobut the plan, thus creating the need for a PR blitz such as the kind Covered California has implemented, with its $45 million to be spent on “paid media” from now through March, and another $35 million from April through the end of 2014 to get the state’s uninsureds to sign up.

Taking advantage of that lack of awareness are bogus websites that purport to be part of the exchanges, which have been appearing online for more than a year.

The NAIC is thus warning people to not enter any personal or financial information into a website that says you can purchase a policy before the open enrollment period.

Another myth the NAIC fears is that some consumers believe they could go to jail for not having health insurance.

“You will not face jail time if you do not purchase health insurance,” the NAIC consumer alert states comfortingly (perhaps).

However, for those who remain uninsured and do not qualify for any exemptions, there will be a tax penalty that increases each year from 2014 through 2016.

One worrisome trick can quickly be parried by remembering something a bit unsettling for many consumers these days: “(A)nyone who is a legitimate representative of the federal government will already have your personal and financial information and should not ask you to provide it.”

That’s what the NAIC says in its consumer alert in response to what it calls a common ploy that involves unsolicited calls from scammers who claim to have your new “Obamacare insurance card” — they just need to get some information before they can send it to you.

In this ploy, the caller then asks for credit card numbers, bank account information or your Social Security number. Sadly, a variation of this trick specifically targets seniors on Medicare.

No, citizens, you are not required to obtain a new insurance or Medicare card under PPACA.

Another misconception that may make consumers vulnerable is that the premium a fraudster may offer is only good for a limited time.

“Be skeptical of someone who is trying to pressure you into buying a policy because the rate is only good for a short time,” the NAIC is telling consumers.

The best way to protect yourself from insurance fraud is to research the agent and company you’re considering through one’s state insurance department and confirm the agent and the company are licensed, the NAIC says.

However, if someone claims to be a health insurance exchange navigator, he or she won’t necessarily be licensed because the navigator is not acting in all instances as an insurance agent, but as more of a guidepost for consumers in the exchanges.

PPACA requires state health insurance exchange to hire navigators — who are not paid by health insurers — to help consumers understand how to use the exchange system. Navigators will be hired in the 34 states in which the federal government is running the marketplaces or where the state is engaged in a partnership with the federal government. The administration has said that navigators do not have to be licensed agents or brokers and may not be paid by insurance companies.

The Department of Health and Human Services (HHS) did not respond when asked what it is doing to alert consumers of fraud pertaining to the exchange enrollment, although it is heavily involved in Medicare and Medicaid fraud prevention and awareness.


The Patient Protection and Affordable Care Act (PPACA), also referred to as health care reform, set forth several new laws and regulations that impact business organizations of all sizes. The following health care reform checklist outlines 10 key PPACA compliance issues employers may need to complete in 2013.

Whether a business needs to complete each item depends on the type of employee health benefits offered, and business size. For example, if a small business offers an employer-sponsored group medical insurance plan, the requirements are different than if the business organization offers a stand-alone HRA (HRA).

1. Grandfathered Plan Status

A grandfathered group medical insurance plan is defined as being in existence when health care reform was made into law on March 23, 2010. If you make sure changes to your plan, your plan is not grandfathered.

If you have a grandfathered plan: Does it qualify to keep grandfathered status?

If you have changed to a non-grandfathered plan, confirm it meets PPACA requirements for 2013.

See: What is a Grandfathered Health Plan?

2. Annual Limits

PPACA restricts health plan plans from imposing annual or lifetime limits on essential health benefits (EHB). For plans beginning 9/23/12 – 1/1/14, the annual limits cannot be less than $2 million. Beginning in 2014, annual limits are prohibited.

If you offer a group plan: Confirm the plan’s annual limits are actually in compliance with 2013 amounts, and anticipate 2014 when annual limits are banned. See: ACA Annual and Lifetime Limits Requirements.

If you furnish a stand-alone HRA: Confirm the HRA plan design meets the definition of one of the five HRAs excluded from annual limit requirements. See: Annual and Lifetime Limits for HRAs.

3. Summary of Benefits & Coverage (SBC).

The Summary of Benefits and Coverage (SBC) is a required, easy-to-understand summary of the benefit. Generally speaking, your insurance company, HRA provider, or third-party administrator will provide the SBC. Give the SBC to eligible participants at least thirty (30) days before plan year begins.

4. Decide Your “Play or Pay” Strategy for 2014.

Starting January 1, 2014, PPACA requires all applicable big employers (50+ FTE employees) to either provide qualified, affordable medical insurance or pay a penalty based on full-time employees.

If you have at least 50 full time equivalent employees, administer a cost test to decide if you will play, pay, or play differently:.

Play: Provide a qualified, competitively priced group health insurance plan.

Pay: Elect to not provide a group medical insurance plan, and pay applicable fees.

Play Differently: Opt to not offer a group medical insurance plan, pay penalties, and offer a defined contribution major medical (aka a stand-alone HRA).


IMPORTANT: Employers with less than 50 FTE employees are immune to this requirement. For employers with less than 50 FTE, the “play differently” allows a business to offer a cost-effective health benefit, and take advantage of the individual premium tax subsidies.

See: Affordable Care Act: Play or Pay?


5. W-2 Reporting Requirements.

Setting in motion with the 2012 tax year, companies with 250 or more W-2 Form Employees must report the aggregate cost of employer-sponsored group health coverage on employees’ W-2 Forms. Determine if this requirement applies to you. W-2 filing for smaller employers, and for stand-alone HRAs, is optional until further guidance is issued.


6. Sixty (60) Day Notice of Plan Changes.

A health insurance or issuer must provide 60 days advance notice of any mid-year “material modifications” to the plan. Notice can be provided in an updated SBC or a separate summary of material modifications.

7. Notice of Coverage Options through the Marketplaces.

Employers must provide written notice to all current employees (regardless of full-time/part-time status) about coverage alternatives through the Marketplaces by October 1, 2013. The Department of Labor has provided two designs employers can use: one for businesses offering a group health plan, and one for companies not offering a group health plan.

For features on the notice see: Employer ACA Marketplace Notice Requirements.

8. CER Plan Fees.

PPACA created the Patient-Centered Outcomes Research Institute (PCORI) to help patients, clinicians, payers, and the public make informed health decisions by advancing comparative effectiveness research. The Institute’s research is to be funded, in part, by fees paid by major medical issuers and sponsors of self-insured health insurance. These fees are called comparative effectiveness research fees or CER plan fees.

Self-funded plans and major medical issuers (including stand-alone HRAs) have to pay a $1 per covered life fee for comparative effectiveness research. Fees are effective for plan years ending on or after Oct. 1, 2012. Fees increase to $2 the next year and will be indexed for inflation after that. Full payment of the research fees will be due by July 31 of each year. It will ordinarily cover plan years that end during the prior calendar year.

In May, the U.S. Department of Labor launched model notifications that employers need to complete and give to their employees regarding the state medical insurance exchange.  Like much of the  materials created by government, the notifications are long and  full of complicated ideas.  They’re enough put you to sleep.

But disregarding the model notifications would be a bad tip. That’s because under the regulation, every company is required to give to each employee the notifications by Oct. 1, 2013. If you are late, that is better than not doing it at all.

For starters,  the state health exchanges are now called “Health Insurance Marketplaces.”  Many individuals will benefit by a monthly subsidy. Many, many people will  be able to buy health insurance at a lower rate than they currently have.

The letter that is linked here illustrates what the Exchange is and illustrates if the employer has group coverage that it offers of if it does not offer coverage.

Here is the  Model notice with health benefits  : Model Notice WITH plan FLSA Model notice without healthbenefits:  Model Notice without health plan plan FLSAwithoutplans

Open the document and scroll down and fill in the appropriate areas.

Below is  how you can approach managing the requirement based on 2 possible situations:

Scenario 1: You already supply insurance and will remain to doing so. Fill out Model Notice with plan.

People are unsure of what to think about the law. They fear that they will be audited, examined, and taxed to death.  That should go away as time passes. It will become more easy to understand once you understand the basics.

Basically it states that the amount of premium that the employee contributes on his or her behalf is less than 9.5% of their income. Most plans and employers will fit into that scenario easily.

Scenario 2: You do not offer a health insurance now. Fill out the Model Notice without  plans.