Author Archives: Reeve Conover

Judge says U.S. is on the hook for Obamacare subsidies for insurers

The federal government had a clear obligation to reimburse insurers for assistance provided to low-income people under the Affordable Care Act, a federal judge says.
By ROBERT PEAR / The New York Times
A federal court ruled this month that a Montana insurer is entitled to federal compensation for subsidy payments under the Affordable Care Act (ACA) that President Donald Trump abruptly ended in October, a ruling that could reverberate through insurance markets and cost the government hundreds of millions of dollars.
At issue are payments for cost-sharing reductions, discounts that enhance the value of health-insurance policies purchased from the ACA’s marketplaces by reducing deductibles, co-payments and other out-of-pocket costs for low-income consumers. Trump ended the payments in October, one of a series of executive actions intended to undo President Barack Obama’s signature domestic achievement.
But Judge Elaine Kaplan of the U.S. Court of Federal Claims ruled this month that Trump’s actions violated a government promise to insurance companies participating in the health law. Although Congress never explicitly provided money for the subsidies, the court said, the government had a legal obligation to pay them.
The decision could have broad ramifications for health insurers. Several similar cases are pending in the Court of Federal Claims, a specialized tribunal that handles a wide range of monetary claims against the government. In April, another judge, Margaret Sweeney, certified a class action that allows insurers as a group to sue the government over Trump’s termination of the cost-sharing payments.

DPO Approves CINGA-Express Scripts Merger

The action brings together a major health insurer and a pharmacy benefit manager that some analysts say should help control costs by merging drug and medical benefits management.

To date, Cigna and Express Scripts have obtained clearances from departments of insurance in 16 states. The companies are working constructively with regulators in the remaining jurisdictions to obtain clearance for the merger. Cigna and Express Scripts continue to anticipate that the deal will close by year-end 2018, subject to the satisfaction of all closing conditions.

Part D Prescription plan changes

On Thursday, August 30, the Centers for Medicare & Medicaid Services (CMS) issued two guidance documents to provide clarification to plans participating in the Medicare Part D prescription drug program.

  • Step therapy and Part B drugs: CMS recently announced Part D plans would be permitted to establish “step therapy” programs for Part B drugs starting in 2019. However, CMS’s announcement raised many questions for Part D plans considering participation in this program in 2019. A new Q&A attempts to answer those questions.
  • Indication-based formularies: CMS also released separate guidance that permits Part D plans to develop “indication-based” formularies starting in 2020. Many medications have multiple uses. However, Medicare rules currently require Part D plans to cover a prescription drug without differentiating the conditions for which it is most appropriate. The new rules would change that starting in 2020.

These guidance documents reflect the Trump Administration’s continued interest in reducing prescription drug costs. We expect CMS to announce additional actions in the next several weeks.

Are you getting money back from your Medical Carrier?

Its rebate time in New York. Under the MLR Rules of the Affordable Care act,  Carriers have to return “excess” premiums received.

Oxford- Large Group Rebate only

United Healthcare- Large Group Rebate only

Horizon- no rebate for large groups

Aetna-right now the word is no rebate in NY and NJ large, although they said most likely there will be rebates in small group NY and NJ

Cigna- no rebates

Emblem- no rebates

Empire- no rebates

Make Sure You Take Sufficient Steps to Find Missing Participants

One more reason why discount 401k plan administrators are often not enough… Preferred TPA’s automatically roll your missing participants out according to the rules…

“When searching social media sites, it may be necessary to follow the trail to the missing participant’s family and friends, known affinity groups or professional organizations, as well as any book, sporting, and retirement clubs the missing participant may have connected with…. Work with the company’s legal department to subscribe to a robust public records database to assist in finding missing participants, their family members, and friends. Such lists may include telephone numbers…. Piggyback on the investigative tools and contracted resources already established by the company’s security team and fraud department.” – DOL Guideline when terminating a plan

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Reeve Conover is a Registered Representative. Securities offered through Cambridge Investment Research, Inc., a Broker/dealer member FINRA/SPIC. Cambridge and Conover Consulting are not affiliated. Licensed in SC, NC, NY, CT, NJ, and CA.
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