Health Plan Enrollment Deadlines

This is a friendly reminder of several deadlines that are approaching.

Deadlines for INDIVIDUAL & FAMILY HEALTH PLANS (Either On-Exchange Covered CA plans or Off-Exchange plans)

(1) Deadline to enroll or change plans for a Jan. 1st effective date is Monday, Dec. 15th

(2) Open enrollment runs from 11/15/14 to 2/15/15. The deadlines corresponding to each effective date are:

Deadlines for each Effective Date

12/15/14 for 1/1/15

1/15/15 for 2/1/15

2/15/15 for 3/1/15

(3) If you are currently receiving a subsidy, then you must Renew by logging into Covered CA with your User ID and Password in order to re-certify to continue receiving the subsidy. (4) If you are uninsured, you may enroll by Dec. 15th to avoid a penalty in 2015.


(1) Groups on Grandfathered or Grandmothered plans will already have renewed on Dec. 1st.

(2) All groups, whether Grandfathered or Grandmothered will have a chance to change to new ACA plans with another insurance carrier on Jan. 1st.

(3) If you are dissolving an Employer Group plan and allowing employees to buy individual plans, they need to enroll by Dec. 15th for a Jan. 1st start. (Note that Individual health plans have significantly smaller Provider Networks than Group plans, and smaller Drug Formulary lists. Each of your employee will need to research their providers and formularies carefully before making a switch. Not all employees will qualify for subsidies. Employers are not allowed to use pre-tax dollars to pay for employees’ Individual plan premiums.)


(1) The deadline to change from a Medicare Advantage MA-PD plan (HMO or PPO) to another is Dec. 7th.

(2) The deadline to change from a Medicare Prescription Drug PDP Plan to another is Dec. 7th.

(3) For Medicare Supplement (or Medicare Gap) Plans there is no deadline and no renewal is necessary. These plans will continue as long as you continue paying the premium.

(4) For those of you who received termination notices from Scan Health and Health Net Medicare Advantage plans, you must enroll before Dec. 31st for a Jan. 1st effective date. Since some carriers will be closed during the holidays, you should submit these applications 2 weeks before Dec. 31.

(5) If you are on a Medicare Advantage MAPD plan and wish to switch to a Supplement plan and a PDP plan, you may do so, guarantee issue, only under 13 specific conditions. Otherwise, underwriting approval may be required and the timing of the switch can be tricky. The ideal time to make a change is between Oct. 15 and Dec. 7th, and as early as possible during this window. This should not be done without the assistance of a knowledgeable agent.

Please contact us, Lee Health Insurance Services, at 925-284-2000 if we can be of assistance.

Phil Lee

Implementation of ACA (Health Care Reform)

California Health Care Insurance Exchange Updates
Many developments have occurred since my last update. I will give a brief recap of the most important items that may impact your personal health care insurance situation.
Due to the large number of regulations and sheer volume of information related to health care reform. I will give you brief summaries of the most important items, in bullet point fashion. I have divided the items into 4 categories so that you only need to read the category that’s relevant to you.
You may choose to buy health plans either inside the California Exchange (Covered California) or outside. The only difference is that if you want either a subsidy or a tax credit, you have to choose an Exchange plan.

Your objective should be to:
1. Be insured.
2. Find the most affordable plan for your needs.
3. Qualify for a subsidy or tax credit, if you are eligible.

Individuals and Families
1. Major carriers participating in the Individual Exchange will be Anthem Blue Cross, Blue Shield, Health Net and Kaiser.
2. The guarantee-issue rule for individual health plans will go forward as planned on Jan. 1st. Individuals and Families may enroll between Oct. 1st 2013 and March 1st 2014. Enrollment effective dates will be Jan. 1st or later.
3. Starting on Oct. 1st, Individuals and Families may start choosing and applying for Individuals health plans within Covered California (the State Individual Exchange) or from plans available outside the Exchange. Plan choices within the Exchange are likely to be more limited than plan offerings outside of the Exchange. However, if one needs a federal subsidy based on their income, they may only apply for plans within the Exchange.
4. Agents who are certified by the Exchange may offer health plans both inside and outside of the Exchange, and may assist consumers in applying for subsidies.
5. Federal and Cal Cobra will continue to be offered to terminated employees.

Small Groups (under 50 employees)
1. Major carriers participating in the Group Exchange, aka SHOP, will be Blue Shield, Health Net and Kaiser.
2. Tax credit will be available to employer groups with low salaried employees.
3. Most insurance carriers allow existing groups to renew early in Nov. or Dec. of 2013 so that they will not be subject to the new Jan. 1st ACA-compliant plans and rates for another 12 months.
4. 2 employee groups consisting of only the owner and spouse will no longer be allowed.
5. 1099 employees will not be considered employees for group eligibility.
6. Employer groups in CA must have 51% or more of its employees in CA in order to qualify. Out of State employees may enroll in an Individual/Family plan in their own state.
7. Agents who are certified by the Exchange may offer health plans both inside and outside of the Small Group Exchange, known as SHOP.
8. Flex Spending Account Salary Deferral limit of $2500 for 2014.
9. Employer Model Notices requirement – On Oct. 1st or within 14 days of hire.

Large Groups (50+ employees)
• The employer mandate to provide a minimum level of health insurance to employees, along with the associated penalties; have been delayed to Jan. 2015.

• ACA and the Exchanges are not expected to affect Medicare.

For More Information:
Please go to the official website for the California Exchange, aka Covered California, at You will find:
• Summaries of Exchange plans that will be available.
• Sample rates for Exchange plans for your age in your zip code.
• A calculator to help give you some idea if you might qualify for a subsidy.

Phil Lee

Medicare Introduces New Competitive Bidding Program

Medicare (CMS) just announced great success at saving hundreds of millions of dollars in a limited pilot bidding program for Durable Medical Equipment by reducing prices and curbing inappropriate uses.  Kathleen Sebelius, Secretary of the U.S.  Dept. of HHS, who is in charge of CMS credits this success to the Affordable Care Act, ACA, or Health Care Reform.

This raises the following questions:

·         Why did CMS not already have a competitive bidding process in place?  Don’t all Government programs (including the not so frugal Pentagon) routinely use competitive bidding to curb fraud, waste and abuse?

·         Why did CMS wait so long for ACA before implementing such an obvious cost-saving procedure?

·         What other Medicare benefits, other than oxygen tanks, are also experiencing rampant fraud, waste and abuse?

·        Would a private insurer, if they were operating such a program, have allowed such rampant abuse to occur unchecked for so long?

Medicare was originally designed to be an insurance program.  This is more evidence why this program is inflating the nation’s deficit.  It’s become an unfunded Government program with out-of-control spending at Pentagon prices.

More details and links to full story below:

NAHU Newswire April 19, 2012:

Medicare To Expand Bidding Program After Pilot Saved $202 Million In First Year.

USA Today (4/19, Kennedy) reports, “A new competitive bidding pilot program that replaces Medicare fee schedules for durable medical equipment – such as wheelchairs, oxygen tanks or diabetic test strips – has saved Medicare $202 million in its first year,” according to a report by the Centers for Medicare and Medicaid Services (CMS). “Beneficiaries also saw 42% in savings in their co-insurance payments for medical equipment.” The CMS report also projects that “the program, if expanded nationwide, could save seniors and people with disabilities $17.1 billion over the next 10 years.”

The New York Times (4/19, B1, Pear, Subscription Publication) reports that Secretary Sebelius “said the pilot program had reduced Medicare costs by 42 percent, or $202 million, by securing lower prices and curbing ‘inappropriate utilization’ of personal medical equipment.” She added that “the savings showed the value of the” Affordable Care Act. The story says, “the bulk of the savings came from oxygen equipment, power wheelchairs and mail-order test strips for people with diabetes.” CMS deputy administrator Jonathan D. Blum “said the switch to competitive bidding had not compromised beneficiaries’ access to the items they needed,” and that “Medicare had received few complaints from beneficiaries in the last year.”

The AP (4/19, Alonso-Zaldivar) reports, “The nine-city crackdown targeting waste and fraud has drawn a strong protest from the medical supply industry, which is warning of shortages for people receiving Medicare benefits and economic hardship for small suppliers. But the shift to competitive bidding has led to few complaints from those in Medicare.” It will be expanded “to a total of 100 cities next year, along with a national mail order program for diabetes supplies.” The story quotes Blum saying, “Costs are lower and there is no impact on the health status of our beneficiaries.”

CQ (4/19, Reichard, Subscription Publication) cites Blum saying that “contrary to the claims of critics, the program hasn’t led to disruptions in access to products … Nor has it led to adverse health effects requiring more hospital, doctor, or skilled nursing care.” In response, “Michael Reinemer, spokesman for the American Association for Homecare (AAH), said ‘we don’t find that credible,'” adding, “We documented four or five hundred complaints from patients or clinicians.”

The Hill (4/19, Pecquet) in its “Healthwatch” blog cites the CMS report and the AAH dissent.

How to reduce Medicare Prescription Drug Costs Using Mail Order

We assisted a client in reducing her out of pocket costs for Medicare prescription drugs simply by switching from buying 30 day supplies from her her local pharmacy to using Express Scripts, the mail order service used by Anthem Blue Cross. Her projected annual expense for copay, co-insurance, deductible and premium for the next 12 months will drop from $1,971 to $1,099.
After you switch to mail order, the reduction may even allow you to downgrade to a less expensive prescription drug plan, increasing your savings.

Use the Medicare Rx calculator to compare drug plans:

Compare health plan rates at:

© Philip W Lee,,


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Lee Health Insurance Services | Healthcare Insurance Agency, Individual Health Insurance, Family Health Plans, Group Medical Insurance, Small Business Health Insurance, Whole & Term Life Insurance, Dental Insurance, Health Care Reform Assistance, Covered California Insurance Exchange Plans, Medicare Supplement Insurance, Medicare Advantage, Medigap Plans, Anthem Blue Cross, Kaiser Permanente, Blue Shield of CA, Health Net, Cigna, Aetna, Contra Costa County CA, Pleasant Hill, Danville, Concord, Berkeley, Martinez, Albany, Oakland, San Ramon, Alameda, Santa Clara, Campbell, Milpitas, Cupertino, Sunnyvale, Saratoga, Fremont, Palo Alto, Newark | 935 Moraga Road, Suite 240, Lafayette CA 94549 (925) 284-2000 or Toll-Free, (800) 286-7445