Open Enrollment Archives - ARC Benefit Solutions

Common Mid-Year Qualifying Events and Employee Considerations

November 13, 2024/in ARC Updates, Employee Benefits, Legislation, Open Enrollment/by ARC Benefit Solutions

Employers offering fringe benefits under a cafeteria plan (also known as a Section 125 plan), must follow IRS rules about when benefits can be adjusted outside the annual open enrollment period. Most insurers offering group coverage only allow mid-year changes for these rules under the IRS. Employers don’t have to allow all mid-year election changes, only those allowed under the Health Insurance Portability and Accountability Act (HIPAA) special enrollment rights. This article reviews some items to understand about mid-year qualifying events.

What Is a Mid-Year Qualifying Event?

A mid-year qualifying event is a specific life change that allows a member to alter plan elections outside the group’s open enrollment period. Usually, elections for benefits like health insurance, dental coverage and flexible spending accounts (FSAs) are locked in for the entire plan year once open enrollment ends. However, the IRS recognizes that certain events may necessitate adjustments to your benefits.

When a mid-year qualifying event occurs, employees may be able to adjust benefit elections to suit their new circumstances. This flexibility ensures that benefits continue to align with their needs.

Common Mid-Year Qualifying Events

The IRS identifies the following “change in status” events that enable you to make alterations to your benefit elections during the plan year:

Change in employee’s legal marital status (e.g., marriage, legal separation, divorce/annulment or death of a spouse)
Change in number of dependents (e.g., birth, death or adoption of a child)
Change in employment status (e.g., starting or losing a job, working at a different site or transitioning from part time to full time or vice versa)
Change in dependent status (e.g., when a child reaches the age limit for dependent coverage)
Change in place of residence (e.g., if your family moves to a new location that affects your eligibility for a health maintenance organization plan)

Additionally, employees may be allowed to adjust benefits if there are changes in cost or coverage for their plan’s qualified benefits. Other mid-year qualifying events that may prompt changes include court orders (such as those requiring the addition of a dependent to a health insurance plan), qualifying events under the COBRA, HIPAA special enrollment rights, gaining eligibility for Medicare or Medicaid, Family and Medical Leave Act leave, and Health Insurance Exchange enrollment.

Qualifying Events may allow the employee to do the following:

Add or remove dependents
Enroll in or drop coverage
Change plan options
Adjust coverage levels

While the group health plan must follow IRS rules for mid-year election changes, an employer might set stricter limits on when employees can adjust benefits. If the plan allows mid-year changes, make sure you understand which qualifying events are covered and know that these changes might be more restrictive depending on the plan’s specifics. It’s also important to note that some mid-year changes apply only to certain benefits like health FSAs, and not all IRS-approved changes are available across all benefits.

There is also a strict deadline for changes to be submitted to an insurer. Most only allow 30 days from the date of the qualifying event to modify elections.

SPECIAL NOTICE: Regarding Mid-Year Qualifying Events for Employers

Many medical carriers are now requiring proof of qualifying events in order to make changes. If you update eligibility online, be prepared to upload relevant proof of the life event or the carrier may not approve the requested change. Carriers that require this now are: MMO, UHC, Paramount, and Aetna.

Speak with your ARC client advisor to learn more about qualifying events. We have a flyer that can be posted in a breakroom, used as a payroll stuffer, or included in open enrollment materials.

Here is What You Need to Know About 2025 Open Enrollment and Annual Enrollment

September 27, 2024/in ARC Updates, Individual/Family, Medicare, Open Enrollment/by ARC Benefit Solutions

Oops, you blinked and it’s already September, which means the 2025 Open Enrollment and Annual Enrollment Periods are looming. If you don’t already know, Open Enrollment and Annual Enrollment is a window of time during the year where you can sign up for health insurance, adjust your current plan, or cancel your plan.

With Open Enrollment on the horizon, now is a good time to review your current health insurance plan and make any changes needed. Here are some reminders and tips to help make your enrollment season smooth and constructive:

Know Your Dates (Trust Us, They’re Important)

Open Enrollment Period (individual and family health insurance): November 1 to December 15, 2024

Please note: December 15 is the last day to enroll in or change plans for coverage starting January 1, 2025. For plans that do not start January 1, Open Enrollment ends on January 15, 2025.

Annual Enrollment Period (Medicare): October 15 to December 7, 2024

If you miss the Open Enrollment window, you may need to wait until the next Open Enrollment Period to make changes, or there are additional opportunities throughout the year to update your plan called Special Enrollment Periods (SEPs). However, an SEP is only triggered by particular qualifying life events, including marriage, divorce, loss of coverage, changes in household, a child’s birth or adoption, etc. Generally, you are given 60 days prior to the event and/or 60 days from the day of the event to enroll into a new plan and that new plan will start the first of the following month in which you apply. Contact your ARC client advisor if you think you may qualify for an SEP.

Take Inventory of Your Current Situation

At this time, it’s important to review any changes from throughout the year, including your household income, medications, doctors, facilities, etc., and communicate those changes with your client advisor because they may affect the efficacy of your plan for your current situation or your qualifications for subsidies. If you are currently on a plan with subsidies, a change in household income could significantly impact your monthly premium for 2025. Using current information ensures you aren’t receiving too much or too little in federal assistance with your Marketplace plan.

“What if I’m happy with my current plan and don’t need to make any changes?” Great! Depending upon the plan you are on, your renewal may be automatic. You may receive the Annual Notice of Change from your health insurance carrier that details the plan premium and coverage for the 2025 plan year.

What You Can Expect from ARC Benefit Solutions

If you’re looking for health insurance coverage (for yourself, your family, your employees, etc.) and you don’t know where to start, give us a call! Our licensed health insurance agents are armed with the knowledge needed to find you a plan that works for budget and your situation. Our goal is to help simplify the process for you.

For our current clients…

As we do each year, we will be sending out annual renewal letters in mid-September with instructions on filling out your annual renewal form, either digitally or by using the paper form we include with your letter. We will include a QR code in the letter if you prefer to fill out the form digitally.

If you are interested in reviewing your coverage or shopping for a new plan, be sure to submit your annual renewal form and schedule an appointment with your client advisor as soon as possible!

As you can probably imagine, Open Enrollment is our busiest time of the year, so appointment times fill up fast!

As always, ARC’s client advisors are available to help you sort through your options and walk you through your health insurance plan so you can take full advantage of your benefits. Contact us today with any questions or if you’d like to get set up with a health insurance plan.

GUIDE: What to Expect When Shopping for Group Health Insurance Coverage

July 23, 2024/in ARC Updates, Employee Benefits, Open Enrollment/by ARC Benefit Solutions

When looking for a suitable benefits package, your client advisor works through an exhaustive checklist of considerations and requirements to ensure the plan you choose is optimal for your business, your employees, and their families. There are compliance regulations, carrier requirements, geographic restrictions, and more to consider when choosing a group health plan.

Whether you are shopping for group benefits for the first time or you are conducting your annual benefit review, here’s an overview of the most important details your advisor considers as well as some frequently asked questions we receive from our clients.

What are some considerations to keep in mind when choosing a plan?

The state you’re in geographically. For fully insured plans, the state a group is headquartered in generally drives what products are available. For example, groups with fewer than five employee lives in Ohio have more options than groups with fewer than five in Kentucky. It’s also a challenge if your company is headquartered in one state but all your employees live in another or if there are “pockets” of employees in other areas or states.

Believe it or not, it also matters what part of the state you’re in. There are regional players that can come into play along with “rating areas” that dictate costs in various parts of the state based on access to care and its cost.

Your group’s health. If there are serious, ongoing conditions in your covered population, the cost of those are factored into most options, except for Affordable Care Act (ACA) plans. This is called medical underwriting.

ACA plans are for groups with fewer than 50 employees (full-time plus part-time) and are guaranteed issue, which means that they are not medically underwritten so employer groups can purchase these plans regardless of health status. In some states, ACA options are predominantly all that are available.

Medical underwriting emerged in some states as a way for healthier groups to save premiums by banding together. Sponsored by Chambers or by trade associations, Multiple Employer Welfare Arrangements (MEWAs) have become fairly common in many states. For example, Ohio has four major MEWAs and counting, Indiana has several, and Kentucky has one.

All states have level-funded options available. Level-funded products are designed to give employer groups the benefits and advantages of self-funding, while limiting the disadvantages by offering a “pre-packaged” hybrid of self-insurance for small employers (down to five enrolled locally).

Group size. Options for quoting vary based on the average total number of employees (ATNE) for the prior calendar year, which includes full-time and part-time employees. This is how most carriers determine the quoting process and the products available.

- Quote processes. Group size (ATNE) will also determine the process we follow for obtaining quotes and what information must be provided. Some carriers have been able to embrace census-only quoting, which uses a large database of claims history and algorithms to determine future costs with only basic information about a group. We call this census quoting. Census quoting generally requires the name, ZIP code, date of birth, gender, and coverage type for every member enrolling. This is often only available to groups of 10 or more enrolling. ACA quotes are also done with a member census for groups of two or more.
- Products available. If you’re a group made up of either a husband and wife, sole proprietor, solely covering family members, or, owner-only coverage, this can limit your options. We have to ask a lot of nosy questions to figure out what you can be offered.
- Participation. ACA rules require that, if you offer coverage as an employer, you have to offer it to all full-time, eligible employees working 30 hours or more. There are a handful of exceptions. We attempt to confirm this up front whenever possible. You might feel the questions are intrusive when you just want a quote; however, if possible, we try to determine up front if the option we present is even available to you.

How does medical underwriting work?

If the group is unsure of their population’s overall health or if they know they have a healthy group, your client advisor will need to get applications from all full-time employees so that they can present the group to underwriting to determine if the group is an acceptable risk for the carrier. If the group is not healthy or is declined by the carrier, don’t worry, we still have options.

How do we collect the applications?

We use a data collection site called FormFire. FormFire has each employee create their own account and then it will ask them a series of questions to set their account up and determine if they want to be included in the group quote or if they are waiving coverage. All full-time eligible employees complete the FormFire application. Once the entire group is complete, you just let your client advisor know and we will then send the requests for quotes to all appropriate carriers.

How long will it take to get quotes back?

Every carrier is different, and the time frame is different depending on the time of year you are looking for coverage. During the last three months of each year, it takes the longest to get quotes back as January 1 is the most common date for plans to start and carriers receive a lot more requests. Generally, we can start collecting medical applications as early as September for January 1 effective dates.

Once your quotes come back from the carriers, your client advisor will review each option for the best offers to review with you with a recommendation for what they feel will best fit your group. However, the decision is always yours. If you are able to decide on your plan within 30 days of its effective date, the client advisor will have enough time to conduct employee meetings and preparation of employee materials. For January 1 dates, we like to have decisions around Thanksgiving. If you decide later than that, you run the risk of having a longer “blackout period” where you’re waiting for benefits to be loaded.

From start to finish, we like to have at least 45 to 60 days to get a quote for you and set up your group with a new carrier or work with you on a renewal. If we are looking during the fourth quarter, it is best to start at least 60 to 90 days prior to when you want you plan to be effective.

Group health insurance can be complicated and overwhelming, but your client advisor is there to help take the administrative load off of your plate. After all, you have a business to run.

If you’re interested in finding a health insurance plan for your group or if you’re considering a change, contact ARC Benefit Solutions today!

A Message From ARC’s Director of Employee Benefits: What to Expect Around the 2024 January Renewal Cycle

November 7, 2023/in ARC Updates, Employee Benefits, Open Enrollment/by Kim Kinnaird

As many of you know, January is THE most popular renewal date, which means fourth quarter is ARC’s busiest time of the year. This year, however, there are some major challenges we expect to affect all clients due to Humana’s decision to exit the group medical market. While we’re doing all that we can to ensure this renewal season runs as smoothly as possible, we wanted to make you aware of the season we’re walking in now.

Humana’s decision directly impacts many groups throughout Kentucky and in the Cincinnati area, but could also create a cascade of issues with carrier service statewide. As a result, we expect to see the longer wait times for the following with medical carriers:

Quotes and re-quotes
Updates to eligibility if not done online
Installation of new groups and plan changes
Some member eligibility showing active in the system, ID card generation
Billing updates
Access to care for new members or groups of members. Slow member eligibility means members can’t fill prescriptions unless paying out of pocket and providers can’t confirm coverage or benefits or prior authorize services, and may push back on care delivery.

What can you do to minimize issues for your employees?

ALL CLIENTS: Please attempt to get new hire and enrollment changes to us before the 10th of the month for January effective dates. Let employees know that delays can occur during this time.
If you’re renewing in January, please make decisions on renewals and plan changes as early as possible—ideally in November. We expect our volume of clients making carrier changes to be 30 percent higher this year and we’ll need early December to prepare sold case paperwork and member communications.
Members on maintenance medications should think about obtaining their supply early and getting doctor appointments set up before the end of the year. For clients going through a carrier change, we have a member educational piece called “Waiting for Coverage to Start,” which provides guidance on how to discuss the situation with their doctors and pharmacies.
If you’re making a change in carrier for January, give employees a hard deadline for making their open enrollment decisions. We understand that some changes are necessary and not the member’s fault, however, final enrollment has to match the signed, sold case proposal. That means we have to re-quote your group, wait on underwriting, and when the quote comes back, you have to sign it, and then your group goes to the end of the line again. Last-minute changes impact everyone on the plan.
Note: UnitedHealthcare just announced they will waive the re-quote requirement in some situations. We hope other carriers will follow suit.

Kim Kinnaird, Director of Employee Benefits

If you wait too long to make decisions, that’s okay! But we may advise that you to accept a renewal and then shop for a February or March option simply because we and the insurance company cannot get the work done in time to avoid major issues with member access to care.

This enrollment season will be challenging, but we appreciate your patience as we navigate these immense changes in our industry so we can ensure that your employees are receiving the benefits they need for 2024. ARC’s client advisors are dedicated to continually providing you with the best in service and support, so if you have any questions about deadlines or your renewal, feel free to contact us today.

Why Reviewing Your Monthly Invoice is Important for Your Business and Your Employees

November 7, 2023/in ARC Updates, Employee Benefits, Open Enrollment/by ARC Benefit Solutions

When offering employee benefits polices, it is crucial to review your monthly invoice to ensure your policy is up to date and that you and your employees are properly covered. Groups receive an itemized monthly invoice that includes the due date, the total premium amount due, past due amounts, and any fees that apply. It is important to check the accuracy of each monthly invoice and pay the premium amount listed on your bill. If you have made changes to your policy (adds, terminations, other changes), it’s important to review your invoice to ensure those changes are reflected. Many groups miss adding new hires to employer-paid coverage, such as disability income or life insurance.

A common policy for carriers is that you have a 30-day window to submit any enrollment changes to them for processing. If you have an employee that is newly hired on or leaves your company, then you have 30 days to submit the enrollment paperwork to the insurance carrier. If that enrollment paperwork is submitted after the 30-day window, it can cause administrative issues for the carrier’s billing department, as well as for you. In the case of an employee’s enrollment being sent more than 30 days after their effective date, the carrier could refuse to enroll the employee due to not being submitted in a timely fashion.

If the carrier does approve the enrollment, then they may either (1) retroactively add the for the original effective date, which results in a large invoice adjustment for you, or, (2) if the original effective date is long past, the carrier may only enroll the employee going back 60 days from the request date, which would result in a gap in coverage for the employee.

If the carrier decides to decline the enrollment request, then that employee would have to wait until the plan’s next Open Enrollment Period to then join the policy. Neither of these scenarios have positive impacts for the employee or for your business.

Another common situation that can arise with invoices is adding employees during the end of the month. Many carriers finalize their monthly invoices around the middle of the prior month (usually between the 10th to 15th). If you have an enrollment request that is close to or comes after when the carrier finalizes their invoice, then the enrollment change for that employee may not show up on the following month’s invoice. If it is a new enrollment, then you will typically see two months’ worth of premiums charged for that employee, resulting in a higher than normal invoice. In the event of an employee termination, the following month’s invoice would then display the appropriate credits for that termination.

Reviewing your invoices for accuracy is an important task and responsibility when offering employee benefits, not only for your business, but for your employees. It is recommended that you audit your invoices at least quarterly, if not monthly.

If you encounter any anomalies on your invoice, or if you have any questions, please contact your ARC client advisor for guidance.

Compliance Corner: IRS Issues New Guidance Regarding ACA Premium Tax

October 31, 2022/in Affordable Care Act, Compliance, Employee Benefits, Individual/Family, Open Enrollment/by ARC Benefit Solutions

Background

The ACA provided a way for people to obtain subsidies when purchasing individual health insurance if they met certain income criteria and weren’t eligible for Medicaid/Medicare. For people with group health insurance, the law would only permit them to apply for subsidies if their coverage was deemed “unaffordable” or if it didn’t meet minimum value. Both “affordability” and “minimum value” are defined by the government.

Unfortunately, the government’s guidance on how to apply the ACA rules negatively impacted families with group coverage, called “The Family Glitch.” It said that if the self-only coverage offered by an employer was “affordable” and didn’t exceed a certain percentage of the employee’s income (or other safe harbor measurement), neither the employee nor any dependents would be eligible for a subsidy.

What Changed

The IRS provided new guidance on October 11, 2022, to fix the “Family Glitch” effective January 1, 2023. The new regulations state that a family’s entire income would be taken into consideration for the calculation of affordability for individual health insurance subsidies.

The new guidance also changes qualifying event rules to allow an employee to dis-enroll their covered family members throughout the year if they will be enrolling in individual coverage, as they may now be eligible for subsidies.

REMINDER: Individual Open Enrollment for January effective dates begins November 1, 2022, and ends December 15, 2023.

What Did NOT Change

For Applicable Large Employers (those averaging over 50 full-time equivalent employees), the new regulations do NOT change:

How ACA reporting is done.
How the Pay or Play Penalties are calculated
How employers set up employee premiums. Employers will not receive penalties for dependents of employees who receive subsidies if their other coverage tiers are not affordable.

Small group employers do not have to meet the affordability thresholds required by the ACA nor are they subject to the ACA penalties (keep in mind that insurance companies often have rules around employee premiums). Generally, small groups are those with less than 50 employees. If you are part of an IRS Control Group, employees of all the entities determine whether you must comply or pay the penalties.

What is the Long-Term Impact?

Individual health coverage is very different than group health coverage. The network of health providers is often limited as are prescription drug formularies. However, if the subsidies pay a substantial amount of the cost, it may be a better alternative for spouses and dependent children than the employer-sponsored plan.

The downside is that losing healthy, younger members could potentially make the employer groups less healthy as those who remain on the plan may be family members needing full networks and expanded drug lists due to health conditions.

Your ARC representatives are just a call away to answer your questions about compliance.

Here are the Medicare Enrollment Periods You Need to Know About

January 12, 2022/in Medicare, Open Enrollment/by ARC Benefit Solutions

When it comes to health insurance, most people don’t enjoy taking the time to sit down and unpack the intricate world of rules and regulations about when you can and cannot enroll in coverage. This becomes increasingly more complex once you hit the magic age of 65. When turning 65 and becoming eligible for Medicare, it is crucial to understand the time frames for enrollment because they can be a factor in your Medicare coverage options/decisions.

We will walk through most of the major Medicare enrollment situations and time periods that are available to you, not only when your initially eligible, but throughout the year as well.

Initial Enrollment Period

Your Initial Enrollment Period (IEP) starts three months before the month you turn 65, runs through the month of your birth month, and up to the three months following the month you turn 65. During this time, you can enroll in Medicare Part A and Part B (contact Social Security for enrollment). Once you have Part A and Part B, you are then eligible to enroll into a Medicare Advantage Prescription Drug Plan or a stand-alone prescription drug plan (usually coupled with a Medicare Supplement).

During your IEP, it is important to enroll or make a decision on your coverage to avoid penalties or delay in coverage. In the event you do not signup during this time frame, you may face late enrollment penalties if you do not have other credible coverage elsewhere (e.g., an employer based health plan).

Medicare Supplement Open Enrollment Period

While there are various Medicare Supplement plans available and every client’s budget and situation will be different, the enrollment time frame is the same. The Medicare Supplement enrollment period will start the month an individual turns 65 (assuming they have Medicare Part B in place) and continue for five months following. During this six-month window, your Medicare Supplement enrollment is considered guaranteed issue, which means that you do not have to complete a medical questionnaire to meet eligibility requirements. If you are not enrolled into a Medicare Supplement by the end of this six-month window, then there may be medical underwriting and questions to answer to determine eligibility.

General Enrollment Period

The General Enrollment Period only applies to people who meet both of the following two criteria: you did not signup when you were initially eligible and you are not eligible for for a Special Enrollment Period (which is discussed below). This enrollment period starts on January 1 and runs through March 31 every year. During this time, eligible individuals may enroll in Medicare Part A and Part B. The catch is that the plan year will not start until July 1 of that year. Along with a delayed start date, there may also be late enrollment penalties.

Annual Enrollment Period

The Annual Enrollment Period (AEP) runs from October 15 to December 7 each year and is the time to make changes to your current coverage. Additionally, you can make these changes during AEP:

If you have only Medicare Part A and Part B, you can also pickup a Medicare Advantage plan or switch off a Medicare Advantage plan back to just Medicare Part A and Part B.
You can switch off a Medicare Advantage plan that has drug coverage to another Medicare Advantage plan that does not have drug coverage.
You can join or drop a Medicare prescription drug plan.
Beneficiaries can switch existing prescription drug coverage or Medicare Advantage plans to another plan of the same type.

Changes made during this time will take effect on January 1 of the following year. If no changes are needed or made, the insuring company will generally renew the plan automatically for January 1.

Medicare Advantage Open Enrollment

For those with a Medicare Advantage plan, from January 1 to March 31 every year, individuals can make a change to their current plan. This change can be to go to either another Medicare Advantage plan with or without prescription drug coverage or to Original Medicare. Any changes made will take effect the first of the following month in which they apply.

Special Enrollment Periods

Special enrollment periods come into play when an individual meets certain criteria or a particular event takes place. If you qualify for one of these special enrollment periods you can join, switch, or drop a Medicare Advantage or prescription plan. Below are some of the more common scenarios (see Medicare.gov for a full list)…

You move out of your plan’s service area.
You move back to the U.S. after living abroad.
You move into or out of a skilled nursing facility, psychiatric facility, rehab hospital or long-term care facility.
Your employment or your employer-provided plan ends.

Medicare can be confusing and we are here to be your translators. If you have questions about an existing plan or are looking to get started with Original Medicare, please give us a call today so our licensed agents can walk you through your options and let you know how the rules apply to you.

Resources

https://www.aetnamedicare.com/en/understanding-medicare/medicare-enrollment-periods-what-to-know.html

Employee Benefits are Like a Thanksgiving Meal…

November 4, 2021/in ARC Updates, Employee Benefits, Open Enrollment/by ARC Benefit Solutions

An Employer’s Guide to Open Enrollment

November 4, 2021/in ARC Updates, Employee Benefits, Open Enrollment/by ARC Benefit Solutions

Many group benefit plans renew January 1 so the last quarter of the year is the time when employers hold Open Enrollment.

While Open Enrollment usually competes for our time during the holiday season, it is a very important opportunity for employees to declare their election or waiver of coverage. Most importantly, if an employee is changing their election on the medical coverage from waiver (decline) to enrolled through Open Enrollment, the medical insurance company is required to accept their Open Enrollment application without underwriting or evidence of insurability.

If employees miss the company’s annual Open Enrollment, they likely will not be able to enroll in the employer-sponsored health insurance program until next year unless employees experience a life-changing qualifying event. To learn more about qualifying events, click here.

Here are some helpful tips to make Open Enrollment a meaningful time for your employees:

Use this as a time to educate.

Whether with paper or digital distribution, make sure your employees are provided plan materials in advance. The insurance carrier offers plenty of information, so take advantage of this resource. Perhaps a benefit booklet is more appropriate. Work with your ARC Advisor and assemble the details of your medical plan so your employees can review and make an informed decision.

Give your employees time to consider plan options.

Though one plan may have a higher cost, it may have a lower deductible, and another plan might have a lower cost but more out-of-pocket expenses. Employees should be evaluating their personal situation and match benefits to their needs and that type of consideration should not be done at the last minute and under pressure of a vanishing deadline. Most importantly, be sure to make arrangements with your ARC Advisor to help employees understand the costs and what the health plan will pay.

Quite often the Open Enrollment materials are not shared or discussed with family members. In addition, when both parents work and coverage is available through two employers, the family needs to decide on the best coverage option. Our suggestion is to encourage employees to have their spouses attend the Open Enrollment meeting.

Document your employee’s elections, whether it is by paper or electronically and include the employee’s signature and date signed.

Many companies think they just need to document those enrolling for coverage, but it is equally important to document a waiver/declination of coverage. There are many legal reasons that support a company practice to validate Open Enrollment elections.

Your ARC Advisor is prepared to help your company have a successful and meaningful Open Enrollment. Contact us today to set up a plan of action.