Tag Archives: New York City

New Contraceptive Regulations Announced by Governor Cuomo

“Governor Andrew M. Cuomo today announced a series of actions to firmly secure access to reproductive rights in New York State. Through regulatory action, the State will ensure that contraceptive drugs and devices are covered by commercial health insurance policies without co-pays, coinsurance, or deductibles regardless of the future of the Affordable Care Act; contraceptives are available in amounts exceeding one month’s supply at a time; and all medically necessary abortion services are covered by commercial health insurance policies without co-pays, coinsurance, or deductibles.”

Links to the circular letter and regulations can be found below.  High Deductible Health Plan deductions will apply to abortion services.




Jeffrey R. Ungvary President

Jeffrey R. Ungvary

What Don Draper taught us about the Modern Man

Don Draper is the ultimate 1960s ad man from AMC’s Mad Men, which came to end today.  Don is a man with perfect style. He is supremely confident, cool under pressure, and admired by everyone for his creative genius and ability to close a deal.

Don’s ambition and drive overcame a traumatic childhood and a less than honorable tour of Korea with the US Army. At the height of Don’s success he had everything – a beautiful wife and children, a Manhattan apartment and the ultimate job, a successful leader of his own agency and a legend of his industry.  Don was a perfectionist, which seemed to be driven more by what he thought other people expected of him than his own priorities. With that, people came to expect perfection from Don. He was “the man.”

Don, however, was also a man whose emotions were in lockdown, as he obsessed with being successful and in control. As seen in the show’s opening credits, after his success came his spiraling downfall, triggered by a series of events: the loss of his second marriage to Megan, a daughter who disowned him, the decline of his agency, and eventually, the loss of his job.

To read more, click here.

Jeffrey R. Ungvary President

Jeffrey R. Ungvary

FAQs For Small Group Expansion to 1-100 Employees

Q-1. What is the definition of “small group” as of January 1, 2016?

A. Under New York law and the Patient Protection and Affordable Care Act (ACA), the definition of “small group” will be 1-100 employees as of January 1, 2016. See Q-6 thru Q-11 below for who is an employee.

Q-2. Will New York adopt the ACA definition of “small group” as of January 1, 2016?

A. Yes. All non-grandfathered groups with 1-100 employees renewing on or after January 1, 2016 must be issued small group coverage.

Q-3. Will New York adopt the Department of Health and Human Services “transitional policy” (available athttp://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/transition-to-compliant-policies-03-06-2015.pdf) permitting groups with 51-100 employees to retain their existing large group coverage for an additional plan year after January 1, 2016?

A. No. Allowing groups with 51-100 employees to choose whether or not to enter the small group market could allow for adverse selection, which would have a negative impact on small group premiums.  Therefore, all non-grandfathered groups with 1-100 employees renewing on or after January 1, 2016 must be issued small group coverage.

Q-4. Do the guaranteed renewability provisions of the ACA allow an employer to keep its current coverage if it is reclassified as a different size group?

A. No. Pursuant to 45 C.F.R. 147.106(h), guaranteed renewability rights do not allow a group to continue its existing coverage if it would not otherwise be permitted to enroll in such coverage per federal law.  Consequently, any group experiencing a reclassification as a large or small group on renewal is required to be issued coverage appropriate for that size group.

Q-5. Should groups with 51-100 employees which are covered under a large group policy in 2015 be issued small group policies on their renewal date occurring on or after January 1, 2016?

A. Yes. Pursuant to Insurance Law §§ 3231(a)(1) and 4317(a)(1) all groups with 1-100 employees renewing on or after January 1, 2016 must be issued small group coverage. This includes 2015 calendar year policies.

An insurer is required to provide the group policyholder with at least 30 days prior written notice of nonrenewal of the large group policy due to the group ceasing to meet the requirements for a large group.  If a longer notification period is provided for in the group policy, an insurer must provide notification within the contractual time frame.  However, in all cases, insurers are encouraged to provide at least 45 days prior written notice.  See Insurance Law §§ 3221(p)(2)(E) and 4305(j)(2)(E); 11 NYCRR 52.18(c)(1).

An insurer is not required to send notification of proposed rate adjustments to a group not currently covered under a policy that is subject to the rate adjustment notification requirements of Insurance Law §§ 3231(e)(1) and 4308(c).

If an insurer writes coverage in the small group market, it must offer the 51-100 group policyholder the option to purchase all other comprehensive hospital/medical coverage currently being offered by the insurer in the small group market. In addition to offering all of its available coverages, an insurer may opt to designate or automatically assign a default replacement policy that is the most similar to the group’s existing large group coverage. Groups must be provided with the option to opt-out of the designated replacement policy and choose another policy.

If an insurer does not write coverage in the small group market, it does not have an obligation to replace the terminated large group policy with a small group policy. In such case, the notice of nonrenewal should:

  1. advise the group policyholder of its options to purchase small group coverage through the New York State of Health’s Small Business Marketplace (“the Marketplace”) or directly from another health insurer or through a broker; and
  2. may also designate or automatically assign a default replacement policy offered by an affiliate of the insurer that is the most similar to the group’s existing large group coverage.  Groups must be provided with the option to opt-out of the designated replacement policy and choose another policy.

Who is an employee?

Q-6. Who is an “employee” eligible for coverage under an employer group policy or contract?

A. Pursuant to the ACA, New York adopted the federal definition of employee in Insurance Law § 4235(d). Common law employees who are “employees” as defined in 42 U.S.C. 300gg-91(d)(5) are eligible for coverage.

Q-7.  Who is a common law employee?

A. Generally, anyone who performs services for an employer is an employee if the employer can control what will be done and how it will be done. The common law test to determine control would look at behavioral control, financial control and the type of relationship between the parties. An “employee” does not include the sole owner of a business or a spouse of the business owner.  More information on determining who is a “common law” employee is available at on the IRS website at http://www.irs.gov/Businesses/Small-Businesses-&-Self-Employed/Employee-Common-Law-Employee andhttp://www.irs.gov/Businesses/Small-Businesses-&-Self-Employed/Independent-Contractor-Self-Employed-or-Employee.

Q-8. Are 1099 workers (i.e. independent contractors) considered employees eligible to be covered under an employer’s group policy or contract?

A. All individuals who are “employees” as defined in 42 U.S.C. 300gg-91(d)(5) may be covered by a group policy or contract. Insurers may not prohibit a “1099 Employee” from being treated as an employee eligible for coverage. U.S. Department of Labor regulations and the Internal Revenue Code apply a common law definition of employee based on a case-by-case factual analysis. Department of Financial Services Office of General Counsel opinions on coverage for independent contractors are available at http://www.dfs.ny.gov/insurance/ogco2005/rg051117.htm andhttp://www.dfs.ny.gov/insurance/ogco2008/rg081001.htm.

Q-9. Are leased employees eligible to be covered under an employer’s group policy or contract?

A. Whether a leased employee is eligible for coverage should be made on a case-by-case basis. If the leased employees are “employees” of the lessee as defined in 42 U.S.C. 300gg-91(d)(5), then they will be considered employees of the lessee.

Q-10. Will individuals who were previously covered under an employer group policy be permitted to stay on that policy if they are not considered “employees” of the policyholder?

A. Individuals who were previously covered under a group policy but are not considered a common law employee are not eligible to be covered on the group policy when such policy is renewed on or after January 1, 2016, except for COBRA participants, retirees and owners.  These individuals may be eligible for conversion coverage pursuant to the terms of their policy.

Q-11. Do employees need to be United States citizens to be eligible for coverage?

A. No. All employees who are “common law” employees as defined in 42 U.S.C. 300gg-91(d)(5) are eligible for coverage regardless of whether they are U.S. citizens.

Group Size Determinations/Counting Methodology

In determining group size an insurer shall ask and may rely upon the information provided by employers, including appropriate tax documentation.

Q-12.  How should employees be counted when determining group size?

A. The “full-time equivalent” (FTE) employee counting method in 26 U.S.C. 4980H(c)(2) must be utilized to determine group size.  This method is the same calculation used to determine employer liability under the “Shared Responsibility for Employers” provisions of the ACA and Internal Revenue Code.

Q-13. How should part-time employees be counted when determining group size?

A. When determining the employer’s group size, part-time employees should be counted using the FTE counting method in 26 U.S.C. 4980H(c)(2).

Q-14.   Should part-time employees of an employer be counted towards group size if they are not being offered coverage by the employer?

A. Yes.  Part-time employees are counted using the FTE counting method in 26 U.S.C. 4980H(c)(2).

Q-15.   What period of time is considered when determining group size?

A.  Pursuant to 42 U.S.C. 18024(b), group size is determined based on the average number of employees employed by the employer on business days during the preceding calendar year.

Q-16.   How should group size be determined for an employer group that was not in existence in the previous calendar year?

A.  Pursuant to 42 U.S.C. 18024(b)(4)(B), the calculation of group size is based on the “average number of employees the employer is reasonably expected to employ on business days in the current calendar year.”

Q-17. Do fluctuations in the number of employees during a group’s plan year change what market the group is in?

A.  No. Mid-year fluctuations in the number of employees do not affect a determination of group size.   Pursuant to 11 NYCRR 360.4(j), group size is only determined on issuance and at the time of renewal.

Q-18. Are retirees included when determining group size?

A.  Generally, retirees are not “employees” under 42 U.S.C. 300gg-91(d)(5) and thus not counted in the group size.   However, exceptions should be considered on a case-by-case basis under 42 U.S.C. 300gg-91(d)(5).

Q-19. Are individuals enrolled in COBRA included when determining group size?

A.  Generally, individuals enrolled in COBRA are not “employees” under 42 U.S.C. 300gg-91(d)(5) and thus not counted in group size.  However, exceptions should be considered on a case-by-case basis under 42 U.S.C. 300gg-91(d)(5).

Q-20. Are employees who are receiving coverage through another source (e.g. spousal coverage, VA coverage) included when determining group size?

A.  Yes. Regardless of whether an employee has coverage through another source, an employee as defined in 42 U.S.C. 300gg-91(d)(5) will be included when determining group size.

Q-21. When an employer designates different classes of employees for purposes of health insurance coverage as permitted by the Insurance Law, are all classes combined for purposes of counting employees?

A.  Yes.  For example, union employees are counted together with other employees in determining group size.

Q-22. If two or more corporations are under common control, are the employees of each corporation counted separately or combined?

A.  All entities treated as a single employer under 26 U.S.C. §414(b) are treated as one employer and all employees are counted together to determine group size.

Q-23. When companies merge, combine, and/or consolidate into a single company, how is group size calculated?

A. Group size determinations must be made on a case-by-case basis. The facts of each case should be reviewed to make a reasonable determination of group size.

Group Eligibility

Q-24.   How many common law employees must be enrolled for coverage to be considered group coverage?

A. For a group health plan to be considered a “group health plan” under the Employee Retirement Income Security Act (ERISA), there must be at least one common law employee enrolled.  Pursuant to 29 C.F.R. 2510.2-3(b), an “employee benefit plan” does not exist if no “employees” are covered by the plan. Pursuant to 29 C.F.R. 2510.3-1 and 29 C.F.R. 2590.732(d) an “employee” does not include the sole owner of a business or a spouse of the business owner.

Q-25.   Will groups with 51-100 employees be permitted to purchase stop-loss insurance?

A. Insurance Law §§ 3231(h) and 4317(e) prohibit the sale of stop-loss insurance to any group subject to community rating.  These sections are extended to groups with 51-100 employees beginning on issuance or renewal on or after January 1, 2016.

2016 Actuarial Value (AV) Calculator

Q-26.   How are changes in coverage necessitated due to the change in the 2016 AV calculator treated?

A. Some insurers are planning to discontinue policies that are no longer AV compliant for the existing metal tier while others plan to make cost sharing changes to keep the policy within the existing metal tier. For insurers opting to discontinue non-AV compliant policies, discontinuance notices need to be issued. Changes to keep a policy at an existing metal tier that are due solely to the mandatory application of the 2016 AV calculator will be treated as a uniform modification. Renewal notices should explain the cost sharing changes necessitated due to the application of the AV calculator and advise that plans with lower cost sharing options are also available.

Jeffrey R. Ungvary President

Jeffrey R. Ungvary

Shopping Limited Networks to Save Money

In all the turmoil in health care, one surprising truth is emerging: Consumers seem increasingly comfortable trading a greater choice of hospitals or doctors for a health plan that costs significantly less money.

“Are they willing to trade choice and access for price? There’s no question about that,” said Mark Newton, the chief executive of Swedish Covenant Hospital, a Chicago hospital that recently teamed with an Illinois insurer, Land of Lincoln Health, to offer a health plan.

This year, nearly half of the plans offered on public health care exchanges are so-called narrow network options, which sharply limit the medical providers whose services will be covered, new data shows. Furthermore, nearly a fifth are considered “ultranarrow networks,” which offer even fewer choices. At the same time, more employers are also embracing the plans for their workers, largely as a way to lower health care costs.

The data, gathered by the McKinsey Center for U.S. Health System Reform, is significant, given early criticism from some providers and patients who reacted to these plans last year by arguing they were like the overly restrictive health maintenance organizations, or H.M.O.s, of the 1990s, which were ultimately rejected by consumers.

The financial strategy is relatively simple. Insurers say one way to lower the price of a plan is to limit the number of hospitals and doctors in their networks. They can then ask providers to discount their prices in return for a potentially higher volume of patients; some also say they are trying to pick a select group that provides better care.

To read more, click here.

Jeffrey R. Ungvary President

Jeffrey R. Ungvary

Small Business Tasked to Tally Employee’s Health-Care Costs

Small employers are facing an unexpectedly onerous task: tallying their individual employees’ monthly health-care costs.

Starting in 2016, under the Affordable Care Act, employers with 50 or more full-time workers are required to file new tax forms laying out what individual employees are being charged for their employer-sponsored plans. The Internal Revenue Service released the new forms on Feb. 8.

Though completed forms aren’t due until next January, many employers are scrambling to get procedures in place now to collect the data. The new process entails measuring every individual full-time worker’s total monthly out-of-pocket cost for an employer health plan this year.

The IRS says tax officials will use this information to figure out whether employers are complying with the law’s requirement that businesses offer affordable health coverage to full-time employees and their dependents. Federal penalties for failing to provide an affordable health plan can run up to $3,000 an employee.

But small employers, especially those who keep their own books and prepare their own tax returns, say they’re finding the task of tracking employee costs for the plans to be confusing and time-consuming.

Rather than simply ask employers to record the price tag for a given health plan, the forms require employers to calculate the lowest-cost plan available to each full-time worker on a month-by-month basis—a figure that can vary as wages or working hours change, tax lawyers and workplace benefits consultants say.

That can be especially hard for retailers, restaurants, day-care services or other businesses where workers’ hours can vary from part-time to full-time, or so-called variable hour employees, they add. Under the law, employers aren’t required to offer coverage to part-timers.

“It’s a labor intensive process,” says Adam Okun, a senior vice president of Frenkel Benefits in New York, about completing the new IRS paperwork, Form 1095C. Employers who don’t start collecting this information today are heading for a “real nightmare next year,” he adds.

To read more, click here.

Jeffrey R. Ungvary President

Jeffrey R. Ungvary

Single-Payer Health Care Bill Gets Wide Support

The Affordable Care Act has made an unwieldy system of health insurance even more complicated, and should be replaced with a centralized, tax-funded health care system.

That was the prevailing view at Tuesday’s all-day hearing on the New York Health Act, Assemblyman Richard Gottfried’s bill to create statewide single-payer health insurance that stands almost no chance of passing in the state Senate.

The handful of insurance representatives who testified for a wait-and-see approach followed their speeches with a swift exit, often to the tune of hisses and groans from patients, health care workers and unions in the audience who far outnumbered them.

“No one advancement is big enough to bend the cost curve in itself,” said Lawrence Thaul, president of Millennium Financial, an insurance brokerage. “It took many years to improve Medicare. Let us not be shortsighted and impatient—and you’ve been anything but that, chair,” he hastily added to Mr. Gottfried, who chaired the hearing.

Mr. Gottfried, who heads the Assembly’s committee on health, has carried a version of his single-payer legislation since 1999.

Many doctors and health care workers bemoaned the amount of time spent billing and collecting payment for medical care.

“I employ 24 separate billing people,” said Dr. Neil Calman, president of the Institute for Family Health, “each of whom develops a relationship with one or two paying companies.” Dr. Donald Moore, who recently stopped accepting commercial health insurance, said he used to spend the equivalent of three to four weeks every year billing for his work.

But without this back-and-forth between providers and insurance companies to drive down providers’ charges, health care would cost even more, argued insurance executives.

“Price controls would not work because there would be no one on whom to shift the excess costs,” said Craig Hasday, the legislative chair of the New York State Association of Health Underwriters. “Over time, the issue of affordability will return, but as a tax issue.”

To read more, click here.

Jeffrey R. Ungvary President

Jeffrey R. Ungvary

No Fines for Sick-Leave Complaints

In the nine months since Mayor Bill de Blasio approved an expansion of the paid-sick-leave law, the city has received 289 complaints of violations. But so far, the city is on track to fine only seven of those potential violators, though probably not until 2015.

Of the 289 complaints, 204 are still being investigated or mediated by the Department of Consumer Affairs, according to a spreadsheet provided by the agency. Seventy-eight complaints have been closed, while seven have either resulted in a hearing at DCA’s adjudication tribunal or are currently awaiting a hearing. That’s up from five businesses that were facing fines in October.

Fines for violating the law, which requires businesses with as few as five employees to provide paid time off for workers who are ill or have ill family members, start at $500 and can rise to $750 and $1,000 for repeat offenders. The amount of money the city is spending to investigate and adjudicate the paid-sick-leave law is unclear, although it seems likely to far exceed what it collects in fines. DCA hired 13 employees this year to help with enforcement.

Of the 78 closed complaints, 59 were resolved with the complaining employee recorded as satisfied. Nine complaints were deemed invalid, while another nine were withdrawn by the employee or because the employee was not located. The 289 complaints do not include others deemed irrelevant to the law.

A majority of the complaints—191—were for employers’ failure to notify workers of the paid-sick-leave law. Ninety-three employees complained of not receiving pay for their time off; 49 complained that their employers did not accrue sick time accurately; 38 claimed retaliation by their employers for taking sick time; and 13 said their employers requested a doctor’s note, which the law does not require.

To read more, click here.

Jeffrey R. Ungvary President

Jeffrey R. Ungvary

Counting Calories Will be Easier in 2015

Now it’s official. Starting next November, menus in many places where Americans eat — like chain restaurants and some movie theaters, convenience stores and amusement parks — will have to list calories.

Consumer health advocates were jubilant when the Food and Drug Administration announced the new policy on Tuesday. Many had fought for the rule for more than a decade, believing it would be a major weapon in the fight against obesity.

But will it?

The evidence on whether menu labeling works — either to move the national needle on obesity, or to reduce the number of calories an individual consumes after looking at a menu — is pretty skimpy, in part because the practice hasn’t been around that long.

In the few places where menu labeling exists, like New York and Philadelphia, most studies have observed a few thousand people over just a few weeks and months — too small a group and too short a time to detect the subtle changes that economists expect the policy will prompt.

Brian Elbel, associate professor of population health at New York University’s School of Medicine, has spent weeks outside fast food restaurants talking to customers and collecting their receipts.

The findings have been uninspiring so far. In a study he did in 2008 in New York City, only slightly more than half of consumers even saw the posted calories, and of those, a little over a quarter (around 15 percent of the total) said the information changed what they ordered. He conducted a larger study in 2010 in Philadelphia after that city started requiring chain restaurants to post calories, and the results were similar.

To read more, click here.

Jeffrey R. Ungvary President

Jeffrey R. Ungvary

Mayor de Blasio Incentives Unions to Reduce Health Costs

When Mayor Bill de Blasio announced his first labor agreements with New York City unions this spring, he was sharply criticized for granting long-awaited wage increases in exchange for promises of unspecified though sizable savings on health care expenses.

Now, some of the specifics are coming into focus: City officials and union leaders say they hope to push municipal workers to use walk-in clinics more and emergency rooms less, order generic drugs more often than brand-name ones, and buy them through the mail rather than at retail pharmacies to achieve bulk discounts.

The city hopes the unions will agree to steer workers to use centralized, cheaper centers for blood tests, X-rays or M.R.I.s, rather than having those tests performed in doctors’ offices or at costly physician-owned facilities. Patients who resist could face higher copayments, while savings would be passed on to the city in lower premiums.

The cost-cutting comes with high stakes: If the city and unions are unable to save a total of $3.4 billion on health care by 2018, a mediator will be empowered to order increases in workers’ premiums to cover the shortfall, officials said.

As an added inducement, if the unions help the city exceed that goal, the first $365 million in additional savings would be distributed as lump-sum bonuses to workers, officials said. Any savings beyond that would be split evenly between the city and its employees.

In interviews, Harry Nespoli, chairman of the Municipal Labor Committee, the umbrella group of city unions, and Robert W. Linn, the city’s labor relations commissioner, disclosed several of the cost-saving measures being discussed as the two sides draw closer to a deal.

For example, union officials are meeting with EmblemHealth, an insurer that covers many municipal union members, to negotiate increased access for employees to EmblemHealth’s more than 40 walk-in clinics across the city.

Arrangements like that could reduce costly emergency-room visits not only for the city’s 350,000 workers but also for their dependents — a total of about one million people, the officials said.

Missing from the labor contracts with teachers and other city workers that were announced beginning in May was any requirement for union members to begin contributing toward their health insurance premiums. That prompted some critics to say Mr. de Blasio was not being tough enough at the bargaining table.

Earlier this month, the Metropolitan Transportation Authority and the unions representing 5,400 Long Island Rail Road employees agreed that those workers would begin paying 2 percent of their wages toward their health coverage.

To read more, click here.

Jeffrey R. Ungvary President

Jeffrey R. Ungvary

New York to Create Medical Record Highway

In a much-anticipated move, the New York state Legislature recently agreed to spend $55 million to create a statewide digital highway for New Yorkers’ medical records.

Known as the State Health Information Network of New York, and called “Shiny” for its acronym, SHIN-NY, the project will connect millions of patients, thousands of doctors and scores of health care systems in New York state.

A completed network will also be a boon to dozens of small businesses, including biotech startups—both through directly creating jobs related to building the network, and opportunities that will come with access to a new big data mine.

Health systems and hospitals will be among the first to benefit from SHIN-NY. They’ve already spent tons of money on computerizing health records, and are under federal pressure to continue doing so.

“Hospitals have made investments in health-information technology,” said Zeynep Sumer, vice president of regulatory and professional affairs for the Greater New York Hospital Association, a trade group. For now, access to that data is available only within local networks. There are currently 10 such systems, known as Regional Health Information Organizations, or RHIOs.

Economic engine

Completing the network will mean that these regional systems will be able to talk to each other. That will allow hospitals “to securely communicate important clinical information with a patient’s entire care team,” Ms. Sumer said.
A less-noticed benefit is that its completion will give scores of small businesses an economic boost.

One such company is Mana Health, a startup near Times Square whose co-founder and chief executive, Chris Bradley, won a state competition to design the best patient portal for SHIN-NY, followed in August by a contract.

Mana Health’s software for the portal is due to be tested when the program is rolled out in June, though Mr. Bradley said, “I’m not at liberty to discuss contractual details.”

At the New York eHealth Collaborative, a nonprofit that will oversee the network, Chief Executive David Whitlinger said completing SHIN-NY will create about 160 jobs in New York City, many at the existing regional organizations. They will need more software developers, clinical specialists, project managers, and sales and marketing representatives.

“Each of the RHIOs is essentially a small business,” he said.

To read more, click here.

Jeffrey R. Ungvary


Jeffrey R. Ungvary