Category Archives: Health Insurance

Grandfathered Plans Part II – Health Net

What types of changes can a plan make without losing grandfathered status?
Health Net Clients be advised of these changes in regard to employer Health Plans. Contact Jeremy for information about other carrier plan changes.

Grandfathered health plans (policies in effect prior to March 23, 2010) will be able to make routine changes to their policies and maintain their status. These changes include making cost adjustments to keep pace with medical inflation, adding new benefits, making modest adjustments to existing benefits, voluntarily adopting new consumer protections under the new law, or making changes to comply with state or other federal laws.

Grandfathered plans:

• Cannot significantly cut or reduce benefits.
• Cannot raise coinsurance charges.
• Cannot significantly raise copayment charges.
• Cannot significantly raise deductibles.
• Cannot significantly lower employer contributions.
• Cannot add or tighten an annual limit on what the insurer pays
• Cannot restructure the company
• Cannot move employees to a plan with lesser benefits.

Among the changes that will not result in the loss of grandfathered status are the following:
• Changes in premiums
• Addition of family members of an individual who is enrolled in a grandfathered plan
• Addition of new employees (whether newly hired or newly enrolled) in a grandfathered plan
• Disenrollment of one or more individuals enrolled on March 23, 2010, (provided that the plan or coverage has continuously covered at least one person since March 23, 2010)
• Changes required to conform to federal and state laws and regulations
• Voluntary adoption of consumer protections as articulated in the new reform laws or increases in benefits
• Changes in a third-party administrator (TPA)

Patient Protection and Affordability Care Act (ACA) 2014 – Health Net

Health Net recently released a number of changes in coverage effective as of January 2014 as the result of the Affordability Care Act.  Here are some of the changes that may affect you.

Guaranteed availability of insurance.

Requires guarantee issue and renewability of health insurance for individuals and business groups.  Prohibits annual dollar limits on coverage for Essential Health Benefits.

Allows rating variation in the individual and small group market and Health

Insurance Exchanges based only on:

•  Age – limited to a 3:1 ratio. This means that the rate for a 64-year-old can’t be more than three times (i.e., 300 percent) the rate for a 21-year-old.

•  Geographic area.

•  Family composition – with member-level rating applied. Instead of composite rating, each family member will be rated individually. Carriers can charge only for the three oldest children in the family who are under 21. For example, in a family of six, the rate would be the subscriber rate + spouse rate + the 0–21 rate x 3.

•  tobacco use (limited to 1.5:1 ratio).

Note: Health Net will not be factoring tobacco use into our rates.

Group health plans and health insurers may not apply a waiting period that exceeds 90 days. California law limits the waiting period to 60 days.

The annual cost-sharing incurred must not exceed the maximum out-of-pocket amounts of $6,350 / $12,700 for self-only and family coverage.

The annual deductible for small group plans may generally not exceed $2,000 for self-only coverage or $4,000 for family coverage (certain exceptions apply).

Plans may not impose any pre-existing condition exclusions.

Call Jeremy with questions – (310) 486-7625

Open Enrollment Dates – Affordable Care Act Exchange

The open enrollment periods for the Affordable Care Act Exchange have been announced.

HCR  Annual  Open Enrollment period, AOE

October 1st  2013       till       March 31 2014

October 15th  2014       till       December 7th 2014

October 15th  2015       till       December 7th 2015

October 15th  2016       till       December 7th 2016

Contact Jeremy to ensure that You are prepared for the enrollment dates. (310) 486-7625

Area Plan announced for Affordable Care Act

At a recent seminar regarding the Affordable Care Act hosted by Anthem Blue Cross, the following plans were announced as participating in the exchange.  All information is open to change as more negotiations are underway.

As of June, the plans selected, in alphabetical order, are:

1. Alameda Alliance for Health   HMO     Hospitals: 12    Physicians: 3,100

2. Anthem Blue Cross of California   *EPO  HMO   Hospitals: 300    Physicians: 30,000

3. Blue Shield of California   PPO       Hospitals: 223    Physicians: 22,048

4. Chinese Community Health Plan  HMO  Hospitals: 9        Physicians: 315

5. Contra Costa Health Plan  HMO        Hospitals: 10      Physicians: 5,000

6. Health Net  PPO  HMO       Hospitals: 204    Physicians: 44,000

7. Kaiser Permanente  PPO        Hospitals: 35      Physicians: 14,219

8. L.A. Care Health Plan  HMO         Hospitals: 35      Physicians: 1,005

9. Molina Healthcare  HMO         Hospitals: 29      Physicians: 4,568

10. Sharp Health Plan  HMO  SAN DIEGO ONLY  Hospitals: 7 Physicians: 2,600

11. Valley Health Plan  HMO  SANTA CLARA ONLY    Hospitals: 4        Physicians: 993

12. Ventura County Health Care Plan HMO  VENTURA    Hospitals: 6        Physicians: 176

13. Western Health   HMO  8 NORTH COUNTIES   Hospitals: 1  Physicians: 3,000

*An EPO is a plan wherein you may choose your providers as long as they are in that network.

Contact Jeremy at (310) 486-7625 for more information on the plan that works the best for you.

Metal level plans Available as of January 1

Beginning in 2014, all non-grandfathered Individual and Small Group health plans will be organized in four levels of coverage:

Bronze, Silver, Gold, and Platinum.

The levels are based on actuarial value calculations, and define the split between what the consumer pays and what the health plan pays. As the metal category increases in value, so does the percent of medical expenses that health plans cover.

Guaranteed availability and renewability

Health insurers must accept any individual or business group that applies for coverage.

Percentage of Expenses:

Paid by  health plan    Paid by individual

Platinum      90%                          10%

Gold             80%                          20%

Silver          70%                           30%

Bronze         60%                          40%

California Health Insurance Exchange Plan Approved

The State of California has received conditional approval to provide a health care exchange program to residents, according to an article in the LA Daily News, dated January 4, 2013.

According to the article, seven states have now received the “go-ahead” from the US Dept. of Health and Human Services. The goal is to provide a “direct-to-consumer” market and allow residents to compare insurance plans at competitive rates.

This program is slated to begin in October and is available to all residents who meet the criteria for federal citizenship requirements. Actual plan effective dates will begin in January, 2014.

The exchange program will be overseen by Covered California, a state board appointed by Gov. Jerry Brown and state legislators.

Consumers will be able to access this site or contact the exchange to determine whether or not they qualify for federal assistance to offset the costs of their premiums. Additionally, consumers can evaluate other public insurance programs, as well.

Families earning up to $92,000 a year, a government subsidy will be available to help pay for coverage costs.

“Nearly one in three people in L.A. is uninsured,” according to Howard Kahn, president of the LA Care Health Plan, the nation’s largest public health plan. “The exchange will help provide the health care that they so desperately need and deserve. This is a necessary step to cover working uninsured Californians,” said Kahn.

Those who qualify for federal tax subsidies to help pay a portion of their insurance costs include those with incomes between 133% and 400% of the federal poverty level and businesses with under 50 employees.

Please continue to visit this site for more information regarding the ever-changing and exciting developments of “Obamacare,” more formally known as the Affordable Care Act. You can also visit for additional information.


Jeremy Smith (dated, January 10, 2013)

Ca Ins. Lic. #0771110