FAQs

Answer:  Yes.  I will need proof of business, State Unemployment Taxes filed for the last quarter, or payroll report, or W-4’s.  A group of 1 can be written if one of the employees is covered through Medicaid, Medicare, Indian Health Services, a spouse’s plan, or a parent’s plan.  Employees in NM can work a minimum of 20 hours and be eligible for benefits by the employer’s choice.  Otherwise, businesses use the federal rule of 30 hours per week for eligibility.

Answer:  Maybe.  You must count all the employees from both businesses to arrive at the correct answer for the purposes of the Affordable Care Act.  If the counting derives 51 full-time equivalent employees, you will have to offer benefits to both businesses.  If the counting derives below 51 employees, you can offer benefits to one business.

Answer:  Employer contribution to employee premium usually requires an in-depth discussion with the employer about the business set-up, purpose of offering benefits, high turn-over business vs low turn-over, white collar workers vs blue collar workers, and ACA affordability calculations for employers with more than 50 employees on payroll.  The 50% contribution is very typical of smaller employers that are in the blue collar category.

Answer:  Offering qualified employee benefits is one of the best ways to attract and retain excellent employee talent.  Job candidates focus on employers who offer a good benefit package.  Qualified employee benefits means that the benefits are tax deductible to the business and offered to the employees tax-free.  Qualified employee benefits include the following insurance options:  medical, dental, vision, life, accidental life & dismemberment, short term disability, long-term disability, and voluntary plans like cancer, hospital indemnity, accident, or gap.  Other qualified benefits are Flexible Spending Accounts, Health Reimbursement Arrangements, or Health Savings Accounts.

Answer:  Offering cash to employees to purchase insurance on their own is a taxable event.  Employers will pay payroll taxes on the cash and employees will receive the cash taxable.  Employers cannot “prescribe” what the employee buys with the cash under federal ERISA rules.  A tax-favored Health Reimbursement Arrangement (HRA) can be set up for health insurance premium as well as healthcare reimbursement, but that set-up must meet IRS rules, ERISA non-discrimination rules, and HIPAA privacy rules, which means the employer will need to contract with an administrator that specializes in HRA to set up the plan.  The biggest downside to cash for individual purchase are the ACA rules for individual medical insurance open enrollment.  A typical group employer insurance plan specifies a waiting period for new hires under HIPAA and it’s called timely enrollment.  You cannot have timely enrollment with cash to purchase individual medical insurance.  The individual will need to wait until open enrollment for January 1^st coverage date.

Answer:  PPO stands for Preferred Provider Organization.  PPO’s allow the insured to access medical care in and outside the network of providers.  PPO’s also allow the insured to access care around the USA and sometimes internationally.  HMO stands for Health Maintenance Organization.  HMO’s provide medical care inside the network and inside their service area, which is usually the one state where the policy is issued.  HMO coverage does not meet the needs of a multi-state employer nor does it meet the needs of an employer who has employees with dependents attending school outside of the state.

Answer:  Yes.  The Affordable Care Act opened the door to multiple plan designs being offered at the employer site.  If the employer group is small to mid-sized (2 – 1,000 enrolled employees), the insurers require that you choose one insurer.  If the enrollment is above 1,000 employees, then you have the option of two medical insurers with multiple plan designs from each.

Answer:  Yes and no.   Self-funding is not the right answer for a number of reasons.  The biggest reason not to self-fund is because the group is too small.  I start looking at self-funding options when the group has at least 25 employees to enroll and has been in business for a while.  Self-funding may require all the eligible employees and their covered dependents fill out medical questionnaires to arrive at the right rate and proposal offering.  Self-funding can save on administration, stop loss insurance, and on state and federal taxes.  But, the buyer needs to be sophisticated with accounting and IRS rules.  Fully-insured plans are easier for the employer to administer but they are loaded with extra fees and the profits always stay with the insurer, not the employer group.  Medical questionnaires are not required for groups of 2-50 for medical insurance as per the Affordable Care Act.

Answer:  Never pay your medical providers based on an Explanation of Benefits (EOB).  An EOB is not an invoice.  Always wait for the invoice from the medical provider, match it to the EOB to see what the insurer paid to the provider, what was applied to the deductible and out of pocket maximum, and what the balance due is.  It may take up to 3 months to get the provider billing right due to procedure codes, time of filing to the insurer, and so forth.  Take your time.  Communicate with your doctor.  And, don’t panic.

Answer:  Your medical ID card should have a toll-free number and website listed to find a doctor in the network.  Also, your Summary of Benefits and Coverage has a toll-free number and website published to find a doctor.  Be sure to research based on your plan design and your network name.  Never call a doctor and ask if they “take” your insurance plan.  Always ask if they are “contracted” with your plan.

Answer:  Surprise billing is a problem in America.  So much of a problem that some states like New Mexico have passed legislation to protect consumers from wrongful surprise billing.  Get your broker involved.  Your broker will get the New Mexico Office of the Superintendent involved and it may get resolved quite quickly and in your favor.  Likewise, the federal government recently passed a surprise billing law.  It is quite complicated to maneuver.  But, all states will need to adhere to the federal law.  New Mexico will adhere to the federal law as the “floor” and will improve on that law with its own statute and regulations.

Answer:  Medical insurance in America is a foreign language.  Once an insured understands the foreign language and the definition of the words, then navigation becomes a little easier.  An insurance broker like myself acts as an interpreter as well as an advocate for clients.  Interpretation and advocacy go with the job and commission paid to the broker.  So, don’t hesitate to ask your broker for help.

Answer:  The 1095-C form documents your health insurance coverage for the calendar year.  Prior to 2019, the form was used to assess IRS penalties for not having health insurance.  That purpose is not valid under the IRS code now.  Currently, the 1095-C is used by employers to prove that they offered the health insurance benefits to you and whether you accepted them or not.  Employers with over 50 employees are required to offer health insurance to their eligible employees working on average 30 hours per week.

Answer:  The Affordable Care Act requires health insurance plans cover annual physicals @ 100%.  But you must adhere to the www.healthcare.gov guidelines for the free physical.  Those guidelines are written by gender and age.  If you are outside of the www.healthcare.gov guidelines for an annual physical or lab tests, the physical will not be free.  Also, patients talk too much in the doctor’s office.  They ask questions about their health that are beyond the purpose of the physical.  Once the doctor starts answering questions or prescribing or recommending treatment, then a procedure code goes on the bill making the event billable rather than free.

Answer:  FSA allows you to set aside pre-tax dollars for unreimbursed medical expenses.  In other words, you elect an amount that you know you will spend on medical care in a year.  The elected amount will be parsed out by pay period and taken from your gross pay making your gross pay lower and taxes lower.  Make sure you calculate your medical spend in an upcoming year for an annual deductible that needs to be met, copayments that need to be paid, out-of-pocket coinsurance that needs to be paid, or over-the-counter medications that need to be purchased.  Don’t speculate.  Set aside the right amount so that you are assured to use what gets set aside into your FSA.  If you don’t spend the balance in your FSA during the plan year, the money reverts back to the employer.  If your medical spend is high, the FSA is worth it.  If your medical spend is low, it may not be worth the accounting effort.

Answer:  The Health Insurance Portability and Accountability Act (HIPAA) has 4 specified enrollment periods.  All employer insurance plans must adhere to those periods.  Open enrollment is the annual anniversary date of the policy and it is the time when employees can add or change their enrollment.  Special enrollment allows an employee to enroll or change enrollment through a special event like birth, adoption, marriage, divorce, death, job loss, etc.  Special enrollment requires the applicant to enroll within 31 days of the special event and show proof of the special event like a marriage certificate.  Timely enrollment is for the new hire who has satisfied his/her new hire waiting period and then enrolls.  Late enrollment is when an employee enrolls in the middle of the plan year for no apparent reason.  Late enrollment has an 18-month pre-existing condition clause.  Because of this pre-existing condition clause, most insurers don’t administer late enrollment.  So, don’t expect that you can enroll onto an employer plan when you want to.  HIPAA precludes you from doing so.

Answer:  Medical necessity is becoming THE most important part of understanding the American medical system.  The medical community must “prove” that the treatment that they are prescribing for you is medically necessary for the insurance plan to pay or for Medicare to pay or for Medicaid to pay.  Always ask your doctor if the treatment that he/she is prescribing for you is medically necessary.  This way, you are protecting yourself from getting turned down for insurance payment.

Answer:  The pre-authorization process for MRI is becoming the bane of the insured in America.  Many of the insurers have outsourced to pre-authorization companies to investigate the medical necessity of the MRI.  Many times, the MRI is not necessary, and the insurer doesn’t want to pay for something that is not needed.  Sometimes a simple Xray will diagnose the situation just fine.  But, if that is not your case, then pursue what the insurer instructs.  Perhaps a peer-to-peer review needs to take place with the authorization company to determine the usefulness of the MRI.  I sometimes get involved with pre-authorization claims because I know the right people at the insurer to call.  Don’t give up hope and pursue all your avenues for what you need for medical care.

Answer:  In a response to the pandemic whereby many Americans lost health coverage due to job loss, President Biden ordered that the public exchanges reopen their enrollment starting February 15^th, 2021 through May 15^th , 2021 for 1^st of month coverage dates.  Some states may vary from these dates, but the majority are following this schedule including New Mexico.

Answer:  No.  I am not certified to sell products on New Mexico’s public exchange.  I do recommend that you look at New Mexico’s participating plans and subsidies on an anonymous website:  www.healthsherpa.com  On this site you will be able to get plans and rates without having to identify who you are.  You will also be able to calculate premium assistance based on your household size and household income.  And you can enroll for a plan on this site.  I offer “off exchange” individual insurance through Blue Cross Blue Shield of NM.

Answer:  No.  Don’t trust them.  You should work with a broker who is licensed in your state, who has errors and omissions insurance, and is not selling based solely on price.  Unfortunately, since the ending of the Affordable Care Act (ACA) IRS penalty for not having proper ACA individual insurance, many new “sham” policies have entered the marketplace.  Buyer beware of low-cost medical insurance!  The correct plan under the ACA guidelines will not require you to answer medical questions.

Answer:  No.  While insurance companies are waiving out-of-pocket expenses for diagnostic testing, you may still owe other applicable copayments, coinsurance, or deductible costs for the treatment of COVID-19.

Answer:  Yes.  In most cases insurance will cover 100% of the COVID-19 vaccine.  Be sure to use your in-network provider or use a state-sponsored provider.  If you receive the vaccine from your doctor or practitioner rather than a public site, don’t ask for additional medical services while there.  That visit will no longer be free.

Answer:  Yes.  I sell Medicare Supplement plans and my husband is certified to sell Medicare Prescription Drug Plans and Medicare Advantage Plans.  Medicare supplemental coverage requires that you be covered for both Medicare A and B.  So, be prepared to present your Medicare card for proof of that coverage through the government before asking for a supplemental plan.