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Update: Oxford/United and Mt Sinai Health Systems Split

Update: Oxford/United and Mt Sinai Health Systems Split

by | Feb 20, 2024 | group health insurance, Hospitals, NY News, Small Business Group Health, United Healthcare

Recently, UHC/Oxford and Mt Sinai Health System had split effective January 1, 2024.  Since that time there have been a state-required cooling-off period and ongoing talks on resolution but that has not yielded a positive outcome yet.  The Mount Sinai Hospital, Mount Sinai Queens, and their related hospital outpatient locations will remain in-network for all patients until at least Friday, March 1.

According to UnitedHealthcare/Oxford: 

  • People enrolled in UnitedHealthcare fully insured commercial plans have continued network access to all of Mount Sinai’s hospitals through Feb. 29, 2024, due to New York cooling-off requirements.
  • Unless they obtain admitting privileges to another in-network hospital, the majority of Mount Sinai’s physicians will no longer participate in our network for employer-sponsored and individual plans, including the Oxford Health Plan, effective March 22, 2024.
  • This negotiation only impacts our relationship with Mount Sinai for employer-sponsored and individual commercial plans, including Oxford. All other active contracts, including Medicare Advantage and the Empire Plan, remain in place with no change.

The two organizations had a three-year agreement that took effect on Jan. 1, 2022, which was canceled before it was supposed to expire amid a dispute over payment rates. Both institutions are blaming one another for the standoff.

Mount Sinai claims UnitedHealthcare compensates it an average of 30% less for care than other health systems in New York. The insurer pays New York-Presbyterian $25,911 for a normal vaginal birth, and Mount Sinai $15,989, Mount Sinai said.

“Mount Sinai must be paid fairly,” spokeswoman Lucia Lee said in a statement. “As Mount Sinai costs substantially less than our peers, UHC/Oxford will actually end up paying more for patients to get care at other systems in New York. This cost — estimated to be at least $140 million more over the course of a year — will be passed on to employers and patients.”

UnitedHealthcare says Mount Sinai sought “outlandish price hikes” that would increase costs for services an average of 50% over three years or $600 million — an estimate disputed by Mount Sinai. For example, a regular, outpatient colonoscopy at South Nassau costs about $6,000 and would be about $8,700 in three years under Mount Sinai’s proposal, according to UnitedHealthcare.

    Mt Sinai Hospitals & Health System

    Facility NameCounty
    Mount Sinai Beth IsraelNYC
    The Mount Sinai HospitalNYC
    Mount Sinai MorningsideNYC
    The Mount Sinai WestNYC
    Mount Sinai-Union SquareNYC
    Mount Sinai Kravis Children’s HospitalNYC
    Mount Sinai-Behavioral Health Center (MSBHC)NYC
    Blavatnik Center, Medical CenterNYC
    New York Eye and Ear Infirmary of Mount Sinai NYC
    Mount Sinai BrooklynBrooklyn
    Mount Sinai QueensQueens
    Mount Sinai South NassauLong Island

     

    Neighboring Hospitals

    Bellevue Hospital Center

    		NYC

    New York Presbyterian Queens

    		Queens

    Elmhurst Hospital Center

    		Queens

    New York Presbyterian Weill Cornell

    		NYC

    Flushing Hospital Medical Center

    		Queens

    North Shore University Hospital Manhasset

    		Long Island

    Lenox Hill Hospital

    		NYC

    NYU Langone Hospital Brooklyn

    		Brooklyn

    Long Island Jewish Medical Center

    		Brooklyn

    NYU Langone Hospital Long Island

    		Long Island

    Maimonides Medical Center

    		Brooklyn

    St. Francis Hospital

    		Long Island

    Mercy Medical Center

    		Long Island

    St. Johns Episcopal Hospital

    		Queens

    New York Presbyterian Columbia

    		NYC

    St. Joseph Hospital

    		Queens

    New York Presbyterian Lower Manhattan Hospital

    		NYC

    Wyckoff Heights Medical Center

    		Brooklyn

     

    Both sides need each other as both are market leaders in their fields. It is our hope and most of our clients that they get this resolved soon. In the meantime, please bookmark our site for the latest updates.  And do reach out to us and learn the steps that you can take to smoothen this temporary roadblock.

    Resources:

    https://www.uhc.com/sinai

    https://keepmountsinai.org/

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    FEDERAL JAN 2024 SMALL GROUP ANNUAL OPEN ENROLLMENT WAIVER

    FEDERAL JAN 2024 SMALL GROUP ANNUAL OPEN ENROLLMENT WAIVER

    by | Oct 18, 2023 | group health insurance, Health Care Reform, healthcare, Small Business Group Health

    Federal Open Enrollment (FOE)

    Great news, during FOE groups will not be subject to any enrollment participation requirements!

    FOE will run from 11/15 through 12/15. ​See below for submission timelines:

    • 12/1 effective date groups must be entered by 11/24
    • 1/1 effective date groups must be entered by 12/15​

    A little-known requirement but most important under the Affordable Care Act (ACA) is that Health Insurers must waive their minimum employer-contribution and employee-participation rules once a year. ACA requires a one-month Special Open Enrollment Window for January 1st coverage.

    The special open enrollment period occurs November 15th through December 15th of each year, allowing eligible small group employers to enroll for coverage effective January 1st of the following year.

    Background

    The ACA has a section in it called the “guaranteed issuance of coverage in the individual and group market.” It stipulates that “each health insurer that offers health insurance coverage in the individual or group market in the state must accept every employer and individual in the state that applies for such coverage.” The section also states that this guaranteed issuance of coverage can only be offered during (special) open enrollment periods and that plans can only be offered to applicants that live in, work in, or reside in the plan’s service area(s).

    Participation and Contribution Requirements

    In many states (including California and Nevada), carriers can decline to issue group health coverage if fewer than 70% of employees elect to enroll in coverage. Some carriers may have even tighter participation requirements.

    Generally speaking, employees with other coverage (Medicare, other group coverage, individual coverage through the Exchange, etc.) are removed from the participation requirement calculation – though it varies by insurance carrier.

    Furthermore, employer contribution rules require employers to contribute a certain percentage of premium costs for all employees in order to attain group health coverage. Some businesses struggle to meet these contribution requirements for a variety of financial reasons.

    Problem Solved: Special Open Enrollment Period

    Many employers want to offer coverage to their employees but are denied because they struggle to meet participation and/or contribution requirements. Employers cannot force employees to enroll in coverage unless the employer pays for 100% of the employees’ premiums, which many employers cannot afford. Even with moderate to generous employer contributions, many employers still find young and lower-income employees waiving coverage. 

    The U.S. Department of Health & Human Services provides final guidance on this in regulation 147.104(b)(1): “In the case of health insurance coverage offered in the small group market, a health insurance issuer may limit the availability of coverage to an annual enrollment period that begins November 15 and extends through December 15 of each year in the case of a plan sponsor that is unable to comply with a material plan provision relating to employer contribution or group participation rules.”

    If your employer groups are struggling with participation and/or contribution, the Special Open Enrollment Window is the time to enroll them in coverage.

    Newsletter Sign Up Now

    For more help with the Special Open Enrollment Window contact us at info@medicalsolutionscorp.com or (855)667-4621.

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    NYS DFS 2024 Rates Approved

    NYS DFS 2024 Rates Approved

    by | Aug 31, 2023 | group health insurance, Health Care Reform, healthcare, individual health insurance, latest health insurance news, NY News, Small Business Group Health

    Earlier today, the long-awaited NYS Dept of Financial Services approved 2024 health insurance rate requests. And it was worth it with small groups stabilized.  Small group rates increased by 7.4% and  12.4% for individuals.

    As per NY State Law, Health Insurers are required to send out early notices of rate request filings to groups and subscribers. Despite only 3 months of mature claims data experience for 2023  health insurers’ original requests were noticeably above the average of 22%/individuals and 15.3% for small groups.

    State Department of Financial Services officials asserted the rising cost of medical care — including in-patient hospital stays and rapid increases in drug prices — continued to be the main driver of health insurance premium increases. The final approved rates for 2024 would keep health insurers’ profit provisions at 1%, state officials added, noting they sought to limit those returns in light of ongoing inflationary pressures harming consumers. That said, in anticipation of spikes in claims submissions + overall inflation, a larger-than-average increase is needed. This is in addition to increases in pricing by hospitals, consolidated IPA groups, and pharmaceuticals.

    Rate Factors

    The state noted that the premiums increase main drivers are medications.  “Rising medical costs and inflation continue to put upward pressure on premiums,” said Superintendent Harris. “With our rate actions announced today, we continue to prioritize the financial well-being of consumers while ensuring that New Yorkers have access to a robust, stable health insurance market.”  Also, DFS, recognizing the continued uncertainty of the pandemic’s effect on consumers’ healthcare costs and the economy, held insurers’ profit provisions to a low 1%. 

    Health Insurers

    Oxford/Unitedhealthcare, notably, got only a 4.7% rate increase approval for next year. This is a sharp reduction from the original 15.5% request in part to disagreed anticipated costs, held reserves, overall market pricing, and reinsurance gained from ACA’s Risk Corridor.  See more info here, https://medicalsolutionscorp.com/risk-adjustment-reinsurance-and-risk-corridors/.

    Small Group Market   

    Almost 800,000 New Yorkers are enrolled in small group plans, which cover employers with up to 100 employees. Insurers requested an average rate increase of 15.3% in the small group market, which DFS cut by 52% to 7.4% for 2024, saving small businesses $607 million. A number of small businesses also will be eligible for tax credits that may lower those premium costs even further, such as the Small Business Health Care Tax Credit.

    DFS SMALL GROUP MARKET RATE ACTIONS   

     

     

     

     

     

     

     

     

     

     

     

     

     

     

    *Indicates the Company will offer products on the NY State of Health Marketplace in 2024.

    PEO Alternatives to Small Group

    Before you consider renewing automatically, you should first find out what is a PEO so that you can know exactly what to expect from it. PEOs are large-group markets underwritten.  With the right PEO, you will be able to manage your business’s demand for growth and your employees as well.

    Clients on average save 15-40% off the small group market. If you are looking for a complete insurance solution for your business, go to our website and check out our business insurance solutions. Contact us for more information today.

    Learn how a PEO can make a difference for your group. For more information on how Employer-Sponsored Insurance and a PEO can make a difference for your small business please contact us at info@medicalsolutionscorp.com or 855-667-4621.

     

     

     

     

    Put You & Your Employees in Good Hands

    Get Started

    Get In Touch

    For more information on PEOs or a custiomized quote please submit your contact. We will be in touch ASAP. 

    2023 Innovations That Will Change Business

    2023 Innovations That Will Change Business

    by | Nov 10, 2022 | Cybersecurity, Small Business Group Health, Technology

    New technologies, evolving customer demands, societal shifts, and the COVID-19 pandemic are rapidly changing the business landscape. These factors paved the way for new innovations that can help companies cope with the demands of their target audience using technology and modern resources.

    2023 Innovations that will change businesses

    1. Adoption of Disruptive Technology

    Robots that have Artificial Intelligence powers are said to be rising this year. Now that these robots can now accomplish tasks previously completed by humans only, employers are left to figure out the balance between the robots and their human employees.

    When employers properly know what roles and responsibilities robots and humans have respectively, their business will surely flourish.

    Now that everything seems to be possibly done online, cyber security has been strengthened.

    However, since work has been almost done entirely remotely, different kinds of cyberattacks have been destructing the systems and software of businesses, whether they may be start-ups or have been in the industry for years.

    3. Professional Employer Organization

    Professional Employer Organizations, aka PEO, will be on the rise this 2023.

    PEOs provide companies with HR and admin tasks and functions. Some of these functions are but are not limited to payroll, benefits, taxes, training, and compensation.PEOs are considered to be co-employment to companies. With these arrangements, start-ups no longer need to worry about mastering the whole aspects of human resource management. Instead, businesses can now focus on improving their growth.

    PEOs for start-ups are considered to be one of the most important innovations for this year because it allows businesses to focus on marketing and strategizing their products or services. Removing the unnecessary burden that HR tasks and functions bring to employers and employees.

    4. Remote Work

    OK not new but trending nonetheless. This trend is real because it serves vested interests on both sides of the equation, especially as US continues to fail to manage traffic (and associated pollution), healthcare and childcare, which are all intertwined with remote work.

    5. Going Virtual

    Virtual Interfaces via AR(artificial reality), VR (virtual reality) or even Metaverse will be evolving. This is at the nexus of the natural progression of digital evolution and easy adoption especially true with hardware costs expected to fall below the $400 threshold. “You got your goggles?” will be the new “can we Zoom?” call to action.

    Coronavirus Dashboard
     

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    Learn how our PEO Partnership can help your group please contact us at info@360peo.com or (855)667-4621.

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    For more information on PEOs or a customized quote please submit your contact. We will be in touch ASAP.

    FEDERAL JAN 2024 SMALL GROUP ANNUAL OPEN ENROLLMENT WAIVER

    Federal Open Enrollment Exclusion Deadline

    by | Oct 6, 2022 | Health Care Refrom, healthcare, Small Business Group Health

    A little-known exception for small businesses but most important under Affordable Care Act (ACA) is for Health Insurers must waive their minimum employer-contribution and employee-participation rules once a year. ACA requires a one-month Special Open Enrollment Window for January 1st coverage.

    Background

    The ACA has a section in it called the “guaranteed issuance of coverage in the individual and group market.” It stipulates that “each health insurer that offers health insurance coverage in the individual or group market in the state must accept every employer and individual in the state that applies for such coverage.” The section also states that this guaranteed issuance of coverage can only be offered during (special) open enrollment periods, and that plans can only be offered to applicants that live in, work in, or reside in the plans’ service area(s).

    Participation and Contribution Requirements

    In many states (including California and Nevada), carriers can decline to issue group health coverage if fewer than 70% of employees elect to enroll in coverage. Some carriers may have even tighter participation requirements.

    Generally speaking, employees with other coverage (Medicare, other group coverage, individual coverage through the Exchange, etc.) are removed from the participation requirement calculation – though it varies by insurance carrier.

    Furthermore, employer contribution rules require employers to contribute a certain percentage of premium costs for all employees in order to attain group health coverage. Some businesses struggle to meet these contribution requirements for a variety of financial reasons.

    Problem Solved: Special Open Enrollment Period

    Many employers want to offer coverage to their employees, but are denied because they struggle to meet participation and/or contribution requirements. Employers cannot force employees to enroll in coverage unless the employer pays for 100% of the employees’ premiums, which many employers cannot afford. Even with moderate to generous employer contributions, many employers still find young and lower-income employees waiving coverage. This was even more evident in 2019 with the ACA’s federal Individual Mandate non-compliance penalty reduced to $0.00.

    The U.S. Department of Health & Human Services provides final guidance on this in regulation 147.104(b)(1): “In the case of health insurance coverage offered in the small group market, a health insurance issuer may limit the availability of coverage to an annual enrollment period that begins November 15 and extends through December 15 of each year in the case of a plan sponsor that is unable to comply with a material plan provision relating to employer contribution or group participation rules.”

    Timeline:

    The annual Federal Employees Health Benefits (FEHB) Open Season is taking place from November 14, 2022 – December 12, 2022 this year. The annual open season provides federal employees, annuitants, and other eligible individuals the opportunity to review their plan options, make changes, and enroll for the upcoming benefit year that begins January 1, 2023.

    Employers, if your group struggling with participation and/or contribution, the Special Open Enrollment Window is the time to enroll them in coverage.

    Contact us today.

     

    Newsletter Sign Up Now

    For more help with the Special Open Enrollment Window contact us at info@medicalsolutionscorp.com or (855)667-4621.

    Put You & Your Employees in Good Hands

    Get Started

    Get In Touch

    For more information on PEOs or a customized quote please submit your contact. We will be in touch ASAP.

    NYS 2023 Final Rates Approved

    NYS 2023 Final Rates Approved

    by | Aug 18, 2022 | group health insurance, Health Care Reform, healthcare, Individual Exchanges, NY News, Small Business Group Health, United Healthcare

    Yesterday, NYS Dept of Financial Services approved 2023 health insurance rate requests yesterday. Small group rates increased by 7.9% and  9.7% for individuals.

    As per NY State Law, Health Insurers are required to send out early notices of rate request filings to groups and subscribers see original –2023 NY Small Group Carrier Rate Filings.  Despite only 3 months of mature claims data experience for 2022  health insurers’ original requests were noticeably above the average of 16.5%/individuals and 19% for small groups. For example, regulators last year approved average rate increases of 3.7% for individuals and 7.6% for small group plans. Over 1.1 million New Yorkers are enrolled in individual and small group plans impacted by the rate increases, the state agency noted.  

    The recent COVID-19 surge irony reflected a lower cost utilization due to COVID-19. The average medical-loss ratio, which represents the portion of premiums spent on medical claims and quality improvement, was 70% in recent years years. That said, in an anticipation of spikes in claims submissions + overall inflation, a larger than average increase is needed. This is in addition to increases in pricing by hospitals, consolidated IPA groups, and pharmaceuticals.

    Rate Factors

    The state noted that the premiums increase main drivers are medications.  “Rising medical costs and inflation continue to put upward pressure on premiums,” said Superintendent Harris. “With our rate actions announced today, we continue to prioritize the financial wellbeing of consumers while ensuring that New Yorkers have access to a robust, stable health insurance market.”  Also, DFS, recognizing the continued uncertainty of the pandemic’s effect on consumers’ health care costs and the economy, held insurers’ profit provisions to a historically low 0.5%. 

    Health Insurers

    Oxford/Unitedhealthcare, notably, got only a 6% rate increase approval for next year. This is a sharp reduction from the original 16.8% request in part by disagreed anticipated costs, held reserves, overall market pricing, and reinsurance gained from ACA’s Risk Corridor.  See more info here, https://medicalsolutionscorp.com/risk-adjustment-reinsurance-and-risk-corridors/.

    Small Group Market   

    Almost 850,000 New Yorkers are enrolled in small group plans, which cover employers with up to 100 employees. Insurers requested an average rate increase of 16.5% in the small group market, which DFS cut by 52% to 7.9% for 2023, saving small businesses $632.4 million. A number of small businesses also will be eligible for tax credits that may lower those premium costs even further, such as the Small Business Health Care Tax Credit.

    DFS SMALL GROUP MARKET RATE ACTIONS   

    NYS DFS Approval 2023 Health Insurance Rates

    *Indicates the Company will offer products on NY State of Health Marketplace in 2023.

    PEO Alternatives to Small Group

    Before you consider renewing automatically, you should first find out what is a PEO so that you can know exactly what to expect from it. PEO’s are large-group markets underwritten.  With the right PEO, you will be able to manage your business’s demand for growth and your employees as well.

    Clients on average save 15-40% off the small group market. If you are looking for a complete insurance solution for your business, go to our website and check out our business insurance solutions. Contact us for more information today.

    Learn how a PEO can make a difference for your group. For more information on how Employer-Sponsored Insurance and a PEO can make difference for your small business please contact us at info@medicalsolutionscorp.com or 855-667-4621.

     

     

     

     

    Put You & Your Employees in Good Hands

    Get Started

    Get In Touch

    For more information on PEOs or a custiomized quote please submit your contact. We will be in touch ASAP.