Long Term CARING – Introduction

This is an introductory blog for an ongoing discussion on Long Term Caring.   It is NOT a discussion you expect from an insurance agent specializing in these products.  The goal is to paint a picture of caring for the aged and point out short comings in the current system.  To understand the need to prepare everyone for the imminent onslaught of baby boomers that are about to enter this arena.  Education needs to start now.  Employers need to employ tactics to prepare for the business interruption and how they can help their employees. 

Note: I have always been and will continue to be supportive of Long Term Care Finance Planning.  However, financing and legal preparation are not the topic of this particular conversation.   Please feel free to reach out for a discussion on the several routes to attack this looming financial issue.  You may be able to shore up your liabilities by simply moving your existing life and annuities around.  Existing cash value policies can be used to fund new life policies that include Long Term Care benefits.


My parents did everything right.    I can’t imagine the additional stress and issues that we would have had to tackle had they not done the groundwork.   They set aside money to pay for their long term care needs.  They kept up the most comprehensive PPO healthcare options.  They even made sure all legal documents were in order so that we could make decisions and transactions on their behalf.  With all of the obvious boxes checked on the the road to long term care planning, future caregivers need so much more education and preparation for what may lie ahead.  Through our story, I would like to enlighten you on things that we have learned and suggest how we can prepare future generations on these overseen aspects.

Caregivers have a myriad of levels of responsibility.  From taking over the physical care of one or more individuals to overseeing and directing hired care workers and facilities.  Every day you need to take the time to review the situation, seek out new information, find new resources, weigh care options and make decisions.   In all of the conversations I have with people, I get the idea most people don’t understand the reality of the situation.  It’s not about the money, the time investment or the hard work.    It is personal, it is heart-wrenching, it is about your family…….it’s about caring.

Although we had been introduced to the issue years ago when we assumed the oversight of care of our grandparents, we never expected what we have and are continuing to experience today.  When we look back, the experience with our grandparents went as predicted and was on one end of the long term care spectrum.

When we became empty-nesters, we moved into a home with the proverbial “parents room” downstairs.   We had always promised to bring my parents home when and if they ever needed the help.  There was no way MY parents would go to a nursing home with strangers!  In almost every conversation on the topic, clients tell me they don’t need much LTC insurance because they are just going to take care of their parents at their home.  It’s the master and universal plan for most American families.   I don’t know the numbers, but it doesn’t always go down like that and it certainly didn’t go down that way for us!  Before you start making pronouncements and promises, here are a few reasons this plan may be problematic.

  • Your parents may not want to move in with you because “they can take care of themselves”.  When they need you, they will likely need medical oversight and/or professional nursing care.
  • The issue could come up under catastrophic/emergency conditions.  It may not be a planned event.  Many things in your life will be set aside until further notice.
  • If there is any issue with Alzheimers or Dementia, you aren’t offering someone a place to live, you are offering to be someone’s shadow 24/7.  Day and night, every second of every day.  If they are a fall risk due to physical limitations, there is NO wiggle room on this 24/7 shadowing.  You had better have back up even if you just want to run to the bathroom or walk outside to get the mail.  You will need to make sure your bed is right next to theirs because nighttime no longer means anything.
  • You may need to make adjustments to make your home ADA accessible or at least safe.
  • All hands on deck.  You can’t assign this to one spouse to handle.  It’s takes a team.

With the same mindset as most Americans, the following is how this journey launched for us.

My parents would not be told where they need to live or that they need any intruders in their home.  We took them on tours of wonderful Assisted Living Facilities and even tried in-home visiting caregivers.   As members of the Greatest Generation, they are tough, self sufficient and have withstood everything the world has thrown at them in the last 80 years.   We couldn’t force them to move to safety and we were less inclined to push it because they had mastered hiding their mental and physical decline.  My dad was quick to admit years prior that he could no longer take care of financial duties and immediately turned that over to us, but that was the end of their request for help.

It wasn’t lost on us that they were lacking in personal care, acting forgetful, ignoring illnesses and becoming increasingly fragile and physically unstable.  With this in mind, for years we had ramped up our oversight by making the countless 100 mile drives after work.  Even predicting something was going to happen, we had no idea how traumatic and overwhelming it was going to be for everyone.

Just hours after returning home from the Thanksgiving dinner we had taken to their home, we get a phone call from the ER in the middle of the night.  Both of my parents had fallen in the kitchen and had been brought to the hospital with a myriad of injuries.

My father was immediately hospitalized with a fractured pelvis where he would remain for months.  After a frantic search for my mom at the hospital, we found the unbelievable.  Due to preexisting conditions that precluded any surgical intervention and my mother’s insistence on getting home, the hospital didn’t see a need to admit her.  She was discharged into a taxi with a crushed shoulder that had been put in a cloth sling and was whisked off with no surgery, no painkillers, no notice to family.   She was off in the care of a random taxi driver that had set her in a chair in her home where we found her the next day.  She was scared, incapable of moving (or being moved), broken and bruised, partially blind, very confused, in excruciating pain, dependent on oxygen and in need of a multitude of cardiac and pulmonary drugs.

That was Day 1.   Thanksgiving 2014.

LESSON TO LEARN:  Be prepared to be available on the spur of the moment.  Have a plan for your family and business responsibilities.  Have all legal documents, insurance and personal health data available in various formats on hand.  Do it now.


2018 ACA Update – Clearing up Common Misunderstandings

It’s seems like only yesterday that the Affordable Care Act (aka ACA, ObamaCare) was signed into law.   In fact, the law will celebrate it’s 8th anniversary on March 23, 2018…….and it was a big deal.   Yet, in all of this time and all of the front page conversations, so much is still not clear to so many.

Many misunderstandings are creating frustration for individuals, employees and employers.   Insurance and Benefit professionals spend countless hours providing service and guidance to those caught up in this ongoing learning curve.   I would like to take some time to highlight the most common, and often costly misunderstandings.

For Employers

The Employer Mandate to provide Affordable Coverage is in effect

Employers (and Controlled Groups) with 50 or more Full Time Equivalents must offer their eligible full-time employees health insurance that provides minimum essential coverage that is both affordable and provides minimum value.   Just this week, the IRS has released information to remind employers that they are going to be collecting penalties.   The Wall Street Journal (2-13-18) is reporting here that:

The financial impact on businesses could be significant. The nonpartisan Congressional Budget Office estimated in 2014 that companies would owe about $139 billion in penalties from fiscal 2016 to 2024.

“There are penalties of three, four, five million dollars,” said Alden Bianchi, an attorney at the firm Mintz Levin. “There is a smaller group of employers that really didn’t understand how the rules applied and didn’t offer coverage or sufficient coverage in 2015. … To a smaller company, a half-million is an existential threat.”

Employers need to offer coverage to at least 95% of their eligible full-time employees.  Penalties apply for non-compliance.  For additional information on affordability,  minimum value and penalties please contact Paula Wilson at paula@paulawilson.com.     (IRS Employer Mandate Penalties)

The Individual Mandate is still  in effect

Employers should remind their employees that the individual mandate is still in effect as well as the penalties for non-compliance through the end of calendar year 2018.  Employees declining coverage in 2018 should be warned.  Employers accepting employee declinations without proper counsel should provide time for employees to meet with your benefit advisor/agent.  We are always happy to provide this time to our clients.

Overwhelmed by 1095-C Tracking and Reporting on your Age Rated plan?

Employers subject to 1095 reporting in an age rating environment can often make their life easier with a bit of planning.    Employers offering more generous plans can often offer a Bronze level plan at no copay to the employees.   This would allow the 1095-C to be easily completed as the cost to the employee for a qualified plan would always be $0.  Because California considers groups from 1-100 to be small group, this reporting nightmare is a reality for employers with 51-100 employees.

Employers can make this reporting easier with thoughtful benefit planning and the advice of experienced benefit agents.

Plan Documents (WRAP) Documents

Employers must update and distribute a complete set of Plan Documents to all employees per ERISA.  These important Plan Documents will include but are not limited to Summary Plan Descriptions, Summaries of Benefits and Coverage as well as other documents needed based on your employee benefit package.   Simply offering an Employer Sponsored medical insurance plan constitutes an Employee Welfare Plan and you must comply with ERISA.  Be sure to ask your agent or administrator about these documents.

For Individuals and Employees

Preventive Care is covered at 100%. 

I am still shocked at the number of people who are not taking advantage of this benefit, if not for themselves….for their children.  As a society, we are living in a time when lifestyle related diseases can be caught and dealt with if you just know your numbers.  Make time to know your numbers.

Surprisingly, we spend a good part of our customer service hours explaining uncovered expenses that many thought were covered under this important benefits.   Blue Shield recently provided an excellent illustration to understand the coverage.  You can find that link here.

Even if you’re feeling fine, scheduling an appointment with your doctor for preventive care services is important. Through a preventive exam and routine health screenings, your doctor can determine your current health status and detect early warning signs of more serious, costly problems.

What’s covered in a preventive care visit

During your visit, your doctor will determine what tests or health screenings are right for you based on factors such as your age, gender, health status, and health and family history.  Plus, your medical plan covers 100% of the costs for preventive health services when care is provided through network providers. Be sure your physician understands your expectations of the free visit and testing.   IF the physician orders tests that are not covered within the limitations of ACA YOU WILL BE responsible for the charges.

What’s not considered a preventive care visit

If you discuss new medical concerns or a current illness, the entire visit may be considered a medical treatment visit and would not be covered as preventive care.  Copayments, Deductibles and Coinsurance will apply. You will be required to pay the plan’s physician office copayment or coinsurance.

The complete definition and detail of what is covered under the Preventive Benefits can be found at  the Healthcare.gov website here.

If your employer offers you Affordable and Minimum Value Coverage you cannot go to the State or Federal Exchange and receive a subsidy.

Employers may charge the employee up to 9.69% of his pay as a contribution to the employee only coverage.   Employees often look to the State Exchanges for lower cost coverage when employers require employee contribution.

You will be asked to make repayment if you are receiving subsidies in error.   This often occurs when:

The Employee does not disclose the offer of the employer based coverage at the time of application to the Marketplace, or,

The Employee does not advise the Marketplace in which they are already enrolled of any change of income or employment status to justify continued eligibility.

It is important that employers utilize their benefits professional/agent at the time of open enrollment to review needs and address these issues with the employee.


Paula Wilson, RHU, REBC is a insurance agent specializing in benefits for employers in the Southern California area.


The Next ACA Victim – How Mid Sized Employers are about to be blindsided

The Next ACA Victim – How Mid Sized Employers are about to be blindsided

Paula L. Wilson, RHU, REBC

Paula L. Wilson, Inc.

updated June 2016

Much has been said about the market changes brought about during the implementation of ACA and how those changes continue to affect how health insurance is distributed.  From large corporations to Mom and Pop shops, employers are doing what they can to keep the coverage flowing.  When you know where you stand, it’s easy to plan ahead for predictable market changes and upcoming compliance issues.

However, a large sector of the current “employer market” is about to be blindsided with more change at once than any other employer sector since the inception of ACA.  These employers think they are members of the large employer market and are acting as such.  Nothing could be further from the truth.  No market sector is less prepared for the change ahead.  Employers with 51-99 employees are being thrown into the small group market while simultaneously becoming subject to the large employer “Shared Responsibility” and “Reporting” mandate.  California insurers, so far, are not offering to relieve these employers from the age rating that is sure to wreak havoc on their administration and 1095 IRS reporting duties.

In the past, these “51-99 employers” have enjoyed the ability to negotiate rate and benefit levels for their employees.   Benefits are designed for their specific employee population and rates are computed and issued on a “composite” basis.  (Meaning one rate applies to all employees regardless of age.)  Strategies are then put in place to help keep employees healthy to reduce claims in order to maintain the high ground during annual rate negotiations.

On January 1, 2016, employers with 51-99 employees are going to find themselves unprepared for their new market and compliance requirements.  Just a few of their new required tasks include:

1) Determine PPACA impact with the completion of their measurement period tracking, per IRS guidelines.

2) Complete new PPACA required reporting forms IRS 1095-C and 1094-C for every month of 2015.  Conscientious tracking now will save overwhelming re-creation of the data later.    The  IRS has prepared a 14-page instruction manual for completion of these forms.  .

3) Go to market in the newly expanded Small Group Market to find things work a bit different.  One thing is certain – you can’t keep your current plan.   In the small group market, rates are non-negotiable, plans are limited to four approved “metal” tiers as determined by ACA guidelines and billed rates are based on the actual age of each employee! ( In one year age brackets.)

4) Determine a plan (or plans) that are appropriate and competitive for all* of your employees based on the “affordability” rules of ACA.   This large employer now has 45+ age rating categories PER PLAN!   Rethinking your contribution scenario that fulfills ACA rules, is palatable to your employees, AND makes monthly tracking of the 1095-C detail reasonably possible will take some time and specialized knowledge.

This is overwhelming, but not an impossible task when prepared and fully armed with the facts.  However, the lack of media coverage of this potential time bomb for mid sized employers is tragic.  Health Insurance Agents, Financial and Tax Advisors are already going to be overwhelmed during the national open enrollment when all of this hits during 4th quarter and these employers are out there scrambling for help.   The time to help these employers is now.  The time for them to help themselves by seeking proper planning advice is now!

The American Academy of Actuaries predict that this new segment of the redefined “Small Group Market” will account for 30% of that new small group market.  The impact on the small group market could be catastrophic in short order.   Employers thrown into this new system have some decisions to make.   Historically, employers with high risk, high claim populations tend to head for the fully insured market.   Employers with healthier populations may consider the self funding options available to them.   This adverse selection will put rapid upward pressure on small group market rates.

Keeping in mind that we entering a national election cycle, all of this is subject to delays, twists and turns over the next few months. Getting to the right benefits expert for planning advice is imperative for this sector.   We should all be working to get this word out now!

Paula L. Wilson, RHU, REBC is owner/agent of Paula L. Wilson, Inc. An insurance agency specializing in employee benefit in Southern California since 1986.  paula@paulawilson.com  951-694-1009

ACA Repeal and Replace – Word on the Street

When is ObamaCare going to be repealed?

This is the question I hear in almost every conversation I have with a client.   My answer remains the same as it has for years.   You can’t put the toothpaste back in the tube. Especially after you smeared it all over the walls.

This law is engrained; not only throughout the healthcare system, but employers see it creeping into their lives through the DOL and IRS. Entire systems have been reprogrammed to determine how physicians are paid, how rates are determined and offered and tax dollars are collected from every end of the spectrum and spread out among unending national, state and local entities.

MediCaid expansion put more people on public health care.   (MediCal here in California) The MediCaid system, working differently in each state, has expanded its reach in ways that has taken people out of the insured pool. This not only affects insured rates, but also resulted in a massive expansion in MediCaid costs nationally. The Kaiser Family Foundation, Medicaid spending accounts for one in six dollars spent in the health care system. The additional funding for this is coming from taxes and penalties.

Any outright repeal of ObamaCare would send the MediCaid and Private Market into chaos.

Possible quick changes I hear on the street

  • Although I have heard the Individual and Employer Coverage Mandates will not be repealed, I have heard that the removal of the penalties for them may come soon.   If this happens, and I have my doubts, there will be no reason for the 1094/1095-C to continue. Employers subject to tracking and reporting will be overjoyed if that happens.
  • The Budget Reconciliation move is not going to spawn an all-in-one repeal of ObamaCare.   Even a simple majority is not going to make that move.
  • Dependents will get to stay on their parents plan to age 26, although there is almost never a benefit in doing so.  This is a throwaway media talking point from ACA proponents and it’s bone to give them. With age rating, putting your healthy 26-year old on a lower cost plan makes far more sense. Using that stand-alone 26-year-old income to qualify for premium and coverage subsidies…even better.
  • People will not be turned away from coverage due to a pre-existing condition. Warning: don’t be confused when you hear them talk about pre-existing conditions not being a roadblock to coverage.   There is talk of instituting “waiting periods” during which time a pre-existing condition can be excluded from coverage.   You will see this caveat when they are discussing penalties for not staying continuously insured.   BUT, they will say with a straight face, that your pre-existing condition will not limit your ability to purchase insurance.

Example of ongoing piecemeal bills to come

Currently on deck we have the “Middle Class Health Benefits Tax Repeal Act” (S. 58 and H.R. 173). This bill repeals the so-called “Cadillac Tax,” which will impose a 40% excise tax on health plans that exceed certain cost thresholds ($10,200 for employee-only and $27,500 for family coverage) beginning in 2018.

Why is this so important? The Executive Director of the National Association of Health Underwriters Janet Trautwein explains it best in her recent congressional testimony, “When the law was created, it was marketed as a tax on the richest benefit plans, but that is not the case. Not only does it not actually identify plans with ‘Cadillac’-type benefits, but it’s structured in such a way that many employers, from the smallest employer to the largest corporation, may have to reconsider their ability to offer coverage to employees at all. The reality is that this tax will weigh heavily on a majority of American businesses that can’t afford it and will have to make severe cuts to stay above water. Many of these employers, even after reducing benefits and premiums, will still not be able to lower their annual costs under the Cadillac-tax thresholds. The Cadillac tax hits especially hard those employers with an aging workforce, those with high claims and those in areas with high medical care costs.”

Repeal and Replace is a long and slow process

At a recent industry meeting we were told that legislation would continue to roll out throughout the summer. Lamar Alexander (R-Tenn.) said, “That means, as Ryan has said, we will do most of our legislation on it this year,” Alexander said. “Most before summer,” but the full change and implementation of it will take up to six years.”

“(First) We have to send a rescue team in on the individual market,” he said. “[HHS Secretary Tom] Price will start with some administrative fixes to stabilize it and once we stabilize it — say, for three years — we can move along and make long-term changes to the individual market and have discussions with state governments about Medicaid.

I agree that stabilizing the sick market is the priority. In California, we are lucky to have 5 or 6 strong carriers in most areas of the State.   Other States have little or no competition.   Some even have NO insurers offering coverage throughout a region.

I expect President Trump will sign many health care related bills

Health Care legislation has been up to the White House many times over the past eight years with no hope of a Presidential signature.   I believe the Congress and President Trump will work to pass legislation in an attempt to help consumers and small business. The main focus has to be on 1) The cost of health care and 2) Create an atmosphere to return competition to a healthy insurance market.   At least that will be their intention.

Depending on legislation passed, California Legislators have NO desire to see any repeal of ACA and will pass look-alike legislation when they can.

Patience is mandatory here. We don’t want anyone repealing ACA for bragging rights. We DO want a smooth transition to a healthier market and we need to get moving on it now.   Don’t expect to see any movement that directly affects you any time before 2019.



The Effect of ObamaCare on Health Care Buying Decisions


Paula L. Wilson, RHU, REBC

June 7, 2016

ObamaCare has fundamentally changed the health insurance market, and not for the better. Between the mandates to policy provisions and the ongoing way in which Americans use health care resources like an unending trough, insurers are having to take drastic measures to provide a product that is affordable to anyone.

Whether you are purchasing in the individual market or the small group insurance market, ObamaCare (ACA) has changed how you purchase health insurance.   As time goes on, market changes spurred on by the legislation, make the process even more complex.

ACA desired to make things easier for the public. Categorizing individual and small group plans into 4 major categories, Platinum, Gold, Silver and Bronze.   Each metallic level suggesting that plans found within a category could be considered to be of equal actuarial value. We are to believe that the benefits within a category are simply equal and that how benefits are paid is simply rearranging the deck chairs on the Titanic. But that is simply not true. There is more to health care than a percentage payable or the amount of your deductible.

How, when and where you purchase your coverage is now not so cut and dry. What will be covered and from whom you receive your care is of upmost importance.

Tax Treatment

In the past, HSA qualified plans have stood out as a great option for many. The combination of the tax-free savings and lower priced high deductible plans were a win-win.   Now that ACA plans have made $2,000 deductibles and $6,850 out of pocket maximum the norm, HSA Qualified plans with similar requirements and no upfront benefits, just don’t stand out from the crowd.

Of course, those who want to put away those tax-free savings for themselves or encourage it in their employees ($3,350 single/$6,750 family 2016) may find the HSA is still the best for their situation. Beware, that many of the reasons you purchased the HSA qualified plan pre ACA may no longer be of value.

A brief look a the current market will show the HSA plan options have dwindled as insurers have either reduced the number of qualified plans available or left that market completely. ACA was clearly not designed to embrace this market. As a matter of fact, I am sure it was designed to destroy personal choice and enhanced the idea of personal responsibility for your own wellness.

Provider Access

In order to remain competitive, insurers must reduce payments to physicians.   ACA may require that certain items must be covered and that everyone must be accepted, but the insurer can negotiate with physicians as to what they are willing to pay for each procedure.   Large medical groups with thriving practices may be able to demand higher reimbursement while some must succumb to restricted contracts.   This leveraging has spurred the expansion of “limited networks”.   For example: Insurance Company A may have a single plan that is offered with several different levels of provider networks. The rate for the full network could be 50%* more than the rate for the exact plan with the smallest network.   This is how you will pay your way into those best medical groups.

When you see advertisements or offers within your own insurance renewal offering savings, the network is going to be key. If you are lucky enough to find your physician inside one of these smaller networks don’t be so quick to jump on the offer.   There is more to medical access than primary care physicians.   Be sure to check ancillary carriers, urgent care centers and hospital access.

Most important, everyone should be asking his or her insurer if there is any change in the provider network or prescription formulary at the time of renewal.

Prescription Needs

 Spending on prescription drugs rose 12.6 in 2014 and is expected to rise 7.3% a year through 2018. In order to combat the effect of this single cost item in your health plan, insurers develop formularies. Formularies are simply a list of the drugs covered under your plan. Most insurers have several regional and national formularies that could be attached to your particular insurance plan. It is important for you to gain access to that list and ask each year for the formulary to be used before accepting a new plan. It is the law that this be provided to you.

Many of my clients receive a single digit renewal with no obvious change in the benefit structure and proceed to jump on the easy option to renew.   Not so fast. You must check for changes to your provider and prescription formularies.

When you buy insurance

ACA limits when you can buy insurance.   If you are in the individual market, you can only purchase insurance during the annual open enrollment period. (November 1 to January 31) If you decide in July that you have made a mistake and that your physicians are not in your chosen plan, you have wait until the next open enrollment to choose the proper plan.

Small employers have far more leeway in their ability to change plans. Employers with 50-100 employees should note that they are considered small employers in 2016 and must purchase coverage within that market.   Employers previously considered large group are in for some big changes.

Government Premium Assistance/Where you buy insurance

All of these buying decisions have to be made whether you are purchasing your coverage direct from an insurer or indirectly from the insurer via your state or federal health care exchange. In states with a private market still in tact, there is no reason to purchase through an exchange unless you are to receive premium assistance. To see if you qualify for premium assistance you can local your exchange at healthcare.gov.

Use a professional experience insurance agent whenever possible. Unlike exchange employees, they are small business owners that will provider personal ongoing service.   Local professional agents can be found at nahu.org/consumer/findagent.cfm.   Many are willing to help you even if you are applying for premium assistance.

A note to Employers

Small employers must now purchase their employee benefit plans through the small group market.   ACA prohibits employers from purchasing or even reimbursing employees for individual (non-group) plans. Employers who reimburse employees for individual non-group health plans face a $100 a day or $36,500 per year, per employee excise tax. This rule applies to all employers. Creating anything that looks and smells like an employer sponsored plan is not only disallowed under ACA, but it also becomes subject to laws including ERISA.   Individual policies just don’t fulfill the requirements.

Employers who are aware of employees or families with special concerns and needs should do their best to make sure important coverage is not interrupted. Loss of coverage to a specialist or lifesaving specialty drug will have far reaching affects. A problem that can be avoided with proper care.

Regardless of the avenue you choose to purchase insurance, how you make the decision requires far more planning than before ACA. Primary considerations must now include thoughtful planning and research on needs involving tax treatment, provider access and prescription needs.


Paula L. Wilson, RHU, REBC is an independent insurance agent in Southern California since 1985. She specializes in health insurance and benefit plans for employers as well as providing life, disability and long term care insurance to individuals. She can be contacted at 888-447-2852 or paula@paulawilson.com.



My thoughts on the status of Wellness Programs

With a bit a research you will find that nearly every report, from bloggers to Rand, clearly report that Wellness Programs that have a Disease Management program AND effectively communicates with the employees, will see the most return for their investment.

Spending a lot of money on Healthy Lifestyles is warm and fuzzy and may help the country out in the long run, but there isn’t so much of a bang for a buck.  Especially for the average 100 employee group.

True wellness companies just aren’t in that small employer (<500) market any longer and the costs associated with putting one together just don’t make sense.   

In a time where the competition lies in the bells and whistles, most carriers have built in a wellness program for their clients.   Anthem Blue Cross of California has one of the best I have seen.  Their Wellness Program is called “Time Well Spent” is turnkey.   It provides the employer and the employee with the following:

  • Wellness calendar with links to print or download 3 different flyers on the topic of the month.  This allows for quick distribution to employees.
  • Provides an introductory brochure to let employees know that it is time to get online and create an account for their health plan.
  • They are reminded to get their annual exam so they know their numbers.  Risk Assessments require current cholesterol, blood pressure and sugar
  • Provides a free Health Risk Assessment.
  • Employees with identified risks will be contacted in some manner by the carrier to jump into their disease management program.

I cannot detail the cornucopia of information that is available through this program.  I can say that Anthem of California’s is very impressive and user friendly.

Frankly, most carriers have these program.   In order to stand out to our clients, I try to pass the information on to both employer and employees.  Although, without the commitment from the employers, they won’t get much traction.   In the case of Anthem Blue Cross, it is VERY simple for an employer to decide if this effort will work for them.   I only need print out the calendar, a few sample brochures, some of the reports backing up the efficacy of this particular route and get them going.    

During this time of national change, employees are a bit worried about hearing from HR departments and Benefit Agents on their health plans.  Employers looking for ways to bring some sunshine into their benefit program should consider this opportunity to spread a little positive action.

ObamaCare: It’s not Working, It’s Winning

Professional health insurance agents have a front row seat to the carnage that ObamaCare is creating as it rolls out on top of Americans.   We are the referees on the field.  Over the next year, as our small business clients receive their 2014 cancellation notices, which every single one of them will, the pain inflicted is going to be hard to watch and a constant moving target to overcome.   Nonetheless, we will fight to continue to deliver a winning result.

I’ve always thought of my “game” as another way of casually addressing my profession, a profession that I take very seriously.   I have worked very hard for over 30 years to ensure the financial health and access to health care for all of my clients.   There is an army of agents in this country who have remained very involved in health care legislation over the years to protect our clients from what is happening now.  Because of this ongoing commitment to be involved on a daily basis, we also know this law better than anyone.   No professional agent has been surprised by anything that has unfolded in the past 2 years as issues come to light.  The complete and total destruction of access to affordable health care is in process.   Continued financial health is being ripped from the hands of all of my clients.

As the dismantling continues and public outcry ensures, the administration makes minor gestures to settle the roar to a rumble.   Moves to extend coverage on non-grandfathered plans, delaying the penalties of the employer mandate and blaming the chaos on the computer system are nothing more than distractions.

I truly believe that President Obama, his administration and their followers think this is a real “game” in the true sense of the word.  Their primary goal is not to expand coverage to the masses or reduce the cost of health insurance.   If it were, they would hang their heads in shame, not to be seen in public for years.     Their goal is to win.  They are out banging their chests in victory because they are winning the game.

Where there are winners, there are losers.   Insurance agents see the effect of the bullying that has been perpetrated on the losing public every day.  The scene plays out over and over with every phone call and every visit.   An insured comes in because their plan has been cancelled and they need to replace it with an “ObamaCare approved metallic plan”.   In most instances, the new market presents a plan of options that include twice the premium, twice the out-of-pocket risk and an overall reduction in benefits.

Consumers who have long become accustomed to dozens of choices in health care options, are shocked to find only 4 basic choices in this new world.   It is truly heartbreaking as I watch the client walk in and go through the phases of denial.   Their shock and anger are quickly turned into acceptance as I pat their hand and assure them that I am showing them all of their choices.  There is no longer anywhere to go for reasonable options.  At least we are around to show them the entire market.  (Exchanges only show you exchange plans)

When I get to the point in the conversation where I have to tell them that more than half of the top rated physician and hospital groups are no longer included within their plan, they shrug their shoulders in complete and total surrender.   They complete the application process and move on with their day.    The problems they are about to face as they enter the exchange or overloaded insurer online systems is not their biggest problem.   The technical problems are just convenient cover for the myriad of real problems.   Their real problem is that they are living in a country that is retreating and accepting the beating that has been unleashed on them.  This isn’t only redistribution of wealth; it’s retaliation on the successful middle class.

As I move around my business circles, I am amazed by how many people think this is all just going to go away and be fixed.   American’s who think people are going to stand up and fight this national plague need to think again.   No one is fighting this!  Every single person that goes through process this gives up.  They have no choice but to accept the increases in premium, thousands of dollars more in out-of-pockets costs and in most of my cases, a complete loss of access to the care that they and their children deserve.

If you are in the “sit back and do nothing while it implodes” crowd, you are in the same surrender mode.   Have you considered what an implosion looks like?   You need only to understand that many of the winners will lose their jobs, face a reduction in hours or be forced in and out of MediCaid as the Exchanges find their sweet spot.   Thousands will find themselves on a medical access seesaw.   At that point, we will all be on the losing team.

Has anyone stopped to consider what the effect of this complete surrender to a government imposed hardship is going to do to the working class people in this country?   My clients are the majority.  These are not people asking for handouts from the Exchanges or MediCaid.   These are the people who make those programs solvent.   They are too busy working to fight.

This President and his followers are nothing more than schoolyard bullies, dancing in the end-zone as the rest cower en masse.   They got their win and they don’t care about the pain they are inflicting on the multitudes or the type of transformation of America they are causing.     

Mr. President.  Congratulations on your win.  What are you going to do next?

Employers Canceling Health Insurance Coverage – First Do No Harm

PPACA offers expanded coverage to the currently uninsured by subsidizing the cost of health insurance plans from the private market (via Exchanges) and by expanding MediCaid.   Low-income employees currently covered by their small business group insurance plan, are now seeking affordable coverage for their dependents through these new avenues.

These insured employees reaching out to the Exchanges for subsidized dependent coverage are quickly finding out their family is ineligible for federal help solely due to the existence of their employer group insurance plan.   Once clamoring for employer based group health insurance, the employees are now demanding the employer plan be canceled so that Exchange subsidies can be accessed for their entire family.

Many employers may see this as an easy out of the benefit business.   With no barriers to the individual market, the employer may see this as an option for everyone.   Could it be that easy?  Low-income subsidy-eligible employees and their families head to the Exchange while the rest of the group hits the guaranteed coverage options within the individual market?   The answer is not so straightforward.  Any professional benefit agent could point out the obvious problems.

Everyday issues that might be considered include:

  •  Employees age 65 and over need time to prepare for a switch to Medicare and all it entails.
  • Employees with household incomes below FPL levels of 250%-150% need to understand their private Exchange policy will not be issued as applied for.
  • Everyone needs to know new policies both in and out of the Exchanges will be providing substantially reduced provider lists.
  • Those seeking subsidies might get more than they asked for.   Part or all of the family may find they have fallen into a MediCaid plan (MediCal in CA) with no way back to the private market.
  • Individuals, especially those with specific needs, have no guarantee that providers, services, therapies and drugs will be available to them.
  • Employers need to understand the tax consequences of such a move.

Individual needs aside, the markets inside the Exchanges are a mess at best.   Quoted benefits and costs are merely estimates.   Benefits outlined are merely a promise of coverage written on a government spreadsheet.   Most States haven’t even produced specimen policies for the professional to inspect for detail.

The private market is functioning, but only as fast as the State will approve plans for sale.   It could be December before we get a glimpse of what the breadth of private options really looks like.  Do we really want to make decisions based only on what can be seen today?

Before any employer writes that cancellation letter, they need to remember why they had the group plan in the first place.   Canceling coverage and dropping people into an unknown myriad of issues is not going to further your goal to attract and retain quality employees.

Small Employers – The ACA Creates The New Employee Benefit!

Small Employers – The ACA Creates The New Employee Benefit!

Paula L. Wilson, RHU, REBC

Paula L. Wilson, Inc.




Californians are heading to the internet in search of the golden ticket to low cost insurance through Covered California.  Covered CA is the name of California’s version of the Affordable Care Act  (ACA).   In most cases, they are finding this search leads only to confusion.  Instead of an easy road to clear answers, everyone is finding out that the ACA is nothing more than a set of prepackaged insurance policies with all of the same confusing definitions and options they have encountered in the past.    On the phones they find Navigators are merely community organizations staffed to enroll people.  Navigators are not allowed to make any recommendations and lack the expertise, knowledge and liability coverage to advise anyone on such an important issue.

There’s also a dirty little secret everyone is uncovering.  The law disqualifies employees and most dependents from subsidized coverage if they are eligible to enroll in a group insurance plan – regardless of the cost (with a few exceptions).    For this reason, small employers already struggling to keep up with increasing health insurance costs, may opt to cancel their group insurance and open the floodgates for employees and family members to enroll in the exchanges and receive the hefty premium and benefit subsidies that may be available to them.

Although this option WILL NOT BE THE BEST ROUTE FOR MOST SMALL EMPLOYERS, it could work for many.  Before an employer makes the decision to cancel their group insurance, they are cautioned to consider:

Tax Implications

  • Review Federal Mandate Compliance
  • Eligibility for the Small Business Tax Credit
  • Income/Subsidy level of the employees
  • Special needs of employees/dependents
  • Review the coverage and access loopholes of Exchange plans with a qualified agent
  • Review their overall benefit and compensation strategy with a benefits specialist

The employer that cancels his group insurance program has just cancelled the one golden handcuff that may have created and continued employee loyalty over the years.  What will be the new golden handcuff for the employee?

Providing your employees with access to the professional counseling of a licensed insurance agent is not only a free benefit, but also the best kept secret of the ACA.    Insurance agents continue to provide employers and individuals with free insurance advice regardless of whether it comes direct from the open market or through a vehicle like Covered California.  Allowing employees to meet with a qualified agent during work hours will ensure that golden handcuff feeling that employees have come to expect in employee benefits.

Employees not eligible for subsidies or willing to accept the reduced PPO and HMO networks of Covered CA will appreciate the opportunity to look at this new post ACA world of options.   It’s a new landscape of options and a thoughtful look at all of your options is in order!

Whether you are providing this service to all employees after canceling your group insurance plan, or offering it to those employees already employed but not eligible for your group insurance, it’s a great free employee benefit.  Small businesses that don’t currently offer group coverage will find they can now provide guaranteed coverage for their employees with the free services of their very own agent!

This service with a revised compensation and ancillary benefit structure could be a win-win for your small business.   Your employees will appreciate the fact that you have done your research and found the most qualified, experienced and trusted advisor for them.   Use caution when using any internet agent or agency, the purpose of using an agent is to provide you employees personal service.   Impersonal online order takers are not what is called for here.

Employers are still in the best position to provide access to the right medical coverage whether through their traditional group insurance plan or ACA compliant plans.

IMPORTANT NOTE:  Unlike Navigators, insurance agents provide ongoing support and carry liability insurance to make sure they give you the right advice. There is no recourse for bad advice or ongoing service provided if you proceed directly to Covered California to apply for your coverage.

Juror Number One – What say you?

With not much else to do and with a great need to avoid the CNN blaring in the Jury Waiting Room, I spent my time pouring over the first concrete result of ObamaCare received in our agency.   The results leave me with a very screwed up look on my face. (no jokes)

We need to hear from the entire jury to even begin to reach a verdict.   What I am posting below is an actual set of results from a mid sized employer group plan.   The rates pulled represent different age categories and family combinations.   This one company is different from the rest of the market because the physician list DOES NOT change.   It will be interesting to see the first set of real numbers from a standard PPO or HMO.

The result is a clear reduction in coverage with rates going -/+ 25%!    Assuming the same rate basis, the rates would have been much higher if they had not reduced the benefits.  Frankly, this makes absolutely no sense.  Although I expected this carrier to look good, I did not expect this result.

Those of you who understand the rate compression rule of 3-1 from ages 19-64, would know that we expected to see older folks getting the best result while the under 30s should get increases.  What we have here makes no sense.   The only explanation is going to be found in the drug formulary, lab and specialty drugs.   I have not made that comparison yet.   Without a actual Summary of Benefits and Coverage, I can’t make a final ruling from this juror.

I submit Exhibit 1 for you perusal:

Before ObamaCare After Obamacare
 Contract 8-1-2013  January 1, 2014
Plan A 2013 ObamaCare version Plan A 2014
Plan Type Staff Model HMO Staff Model HMO
Office visits $30 $30/$50
Co-Insurance none none
Annual Max Risk Per Person $3,000 $6,350
In Patient Hospital $400 day $600 day
Prescription $10 gen/ $35 Brandafter $250 $19 Generic $50 Brand
Age 37 $289.00 $350.00   ^
Age 45 $372.00 $408.00  ^
Age 54 $485.00 $604.00  ^^
Age 24 $261.00 $283.00  ^
Age 45 with 2 children $707.00 $547.00  v
Age 48 with Family $1,130.00 $1,066.00  v
 result Lower benefits – Higher Rates Prevail

You may be wondering if I rigged this comparison.   I did not.   In a previous Blog I explained how insurers will MAP or CHOOSE one of the new ObamaCare plans for your renewal.  This must be done for all non-grandfathered plans because all plans must be canceled at their 2014 renewal.   The insurer chose this new plan.

I look forward to receiving and reviewing the details hidden within this plan to see where benefits have been reduced or enhanced.

I hope to bring you some examples for the national small business insurers shortly.