News and Blog




Monday, 08 May 2017

The Tennessean ran a great story written by Sherri Zink the Chief Data Officer for BCBST this weekend. A few takeaways I think you will be interested in are" 

  • In 2016 BCBST paid out $13.9 Billion for health care services
  • This covered care for 3,4 million members for an average cost of $4,088 each
  • Costs were 8.4% higher in 2016 than they were in 2015
  • Pharmacy costs have increased by 81% from 2013 to 2016
  • In 2016, half of all medical costs were attributed to 25% of the members who were treated for cancer or one of five chronic conditions (diabetes, cardiovascular disease, asthma, COPD or congestive heart failure

What is BlueCross BlueShield of TN doing to combat this trend and try to control costs? First is the direct negotiation with providers and working to shift payment methods to reward better health outcomes. Many complain when the "newest" prescription they ask for is denied but this is an out of control cost and in many cases this "new medicine is no better than the old one for a patient, it only costs 10x more. BCBST is working harder to to stay in touch with those who have chronic conditions to ensure they are getting the care they need and are compliant on medications. 

To read the entire story click here 

Posted on 05/08/2017 1:06 PM by David Moore

Thursday, 13 April 2017

We are getting a lot of questions about the end of Obamacare and “when will my premiums go down?” There have been many changes to our individual and small group health insurance plans over the past five years. The Trump administration has spoken loud and clear that they want to do away with Obamacare, we can already see it won’t be quite that easy. We do expect several changes over the next 12 months but overall we think many of the current provisions will continue.

Trumps healthcare agenda

We don’t expect a full repeal of Obamacare but there are a number of changes we think will happen over the coming year.

  • Allowing carriers to sell insurance across state lines
  • Association health plans and an expansion of self-insured small group plans
  • Delay the Cadillac Tax until 2026
  • Eliminate employer shared responsibility penalties
  • Allow individuals to use subsidy dollars for any health plan
  • Increase HSA contributions to nearly double the current limits

What won’t change even if Trump gets his way?

  • Pre-existing condition exclusion
  • Ability to cover children to age 26
  • Preventive services covered at 100%
  • No annual or lifetime limits
  • Limits on out of pocket maximums for large claims

There are also a few things that could go either way

  • Limiting the pre-tax treatment of employee deductions for medical and dental plans
  • Allowing tax deductions for individual policies
  • Allowing employers to pay for individual policies with deductible dollars
  • Allowing states to made decisions about Essential Health Benefits

You can see, there are a lot of moving parts and with every change there are winners and losers. What we do know is right now is it’s business as usual and you must continue to comply with the current rules. Carriers are making decisions right now about what types of policies they will offer in 2018 and who they will offer them to. Without a clear direction from the current administration we fear most will find it easier to walk away than continue to lose money in the individual market.

It’s important to understand that most of the pain is in the individual market. This is where the huge premium and benefit subsidies are being paid and the lack of enrollment, eligibility and guarantee issues rules have made it all but impossible for insurance carriers to manage claims and losses. Here in Tennessee we have been BlueCross BlueShield of TN pull out of the large markets leaving in many cases just one carrier for people to choose from. As of today, Knoxville and the surrounding counties will not have any insurance companies to choose from leaving them unable to get any coverage at all. Hopefully another carrier will fill the void but at what cost?

Posted on 04/13/2017 2:48 PM by David Moore

Wednesday, 29 March 2017

So, I messed my shoulder up skiing and after two months decided it's not getting better. Went to the orthopedist and he agree, I most have torn something. We need an MRI Post Arthrogram. Ok, that sounds expensive wonder what it will cost and where I should get that done since I have a HDHP and Health Savings Account and will be paying that toward my deductible. The nurse talked to the Imaging Center and got an estimate of $1,200, she agreed it's a lot of money. 

Since I tell our clients all the time to shop around to make sure you are paying a "fair" price I decided I needed to shop around. We use BCBST for our medical coverage here so I started on their website with the new Cost Estimate tool. This knows the plan I have, where I am on my deductible and the discounts. I was pretty excited to use it until I did. I searched for an MRI upper joint with contrast and they did not have enough cost information in the database to help me, bummer. 

Next I let my fingers do the walking with the help of Google. I searched for the MRI providers in my area, very few came up. I called those who did and though most were trying to help me, most could not give me even an estimate. I did have two who took my insurance information and called me back but could not ensure me it was the same test my doctor had ordered (Arthrogram is pretty specialized). 

Heath Care BlueBook - This brought me to a new kind of pricing tool, not perfect but the best I have seen so far. Again, I put in my location and could choose the exact treatment I was looking for. Now I can see a low, medium an high cost and what the "fair" price is for my area. Turns out, $1,150 is a fair price and that is what I paid. Take a look for yourself at 

Posted on 03/29/2017 10:13 AM by David More

Monday, 20 February 2017

There is so much talk about repealing and replacing the Affordable Care Act (ACA) and the fear this kind of broad sweeping statement makes. Yes, there are major problems and coverage is now unaffordable unless you get substantial subsidies from the Government. It’s important to note that there are some good parts of the ACA, there are many that are not so good, let’s work on those.

I am a longtime member of the National Association of Health Underwriters and these ideas/statements are coming from their March, 2017 magazine. The article featured many different recommendations of changes to make immediately and others to implement them over time. These are a few of what I think are the best ideas.

  • Open enrollment – The first thing is to only have one primary open enrollment period rather than an open enrollment every year. There would also credible life events like marriage, divorce, birth, adoption and job changes to create an open enrollment event. If you do not sign up at open enrolment and later sign up as a “late enrollee” you will now be subject to late enrollment penalties, pre-existing conditions and waiting periods. This creates a real incentive to maintain coverage and preserves guarantee issue. This eliminates an easy way to abuse the system with today’s flexible and unenforced open enrollment rules.
  • Create hybrid high-risk pools – These pools would not issue coverage but insure risks for carriers who are insuring those who have not maintained continuous coverage. Late enrollment penalties would be paid to the pool for ceding risk from the carriers. The advantage is late enrollees would not be turned down for pre-existing conditions with this risk being passed to the pool. Because there is a mandatory waiting period before claims will be covered there is additional stabilization to the market.
  • Allow states to increase competition by offering coverage from carriers domiciled in other states. Coverage offered must reflect the same essential benefits and mandates where the coverage is being offered.
  • Allow states to increase competition by allowing association health plans. Coverage offered must reflect the same essential benefits and mandates where the coverage is being offered.
  • Increase flexibility for HSAs by allowing a limited number of office visits to be covered by co-pays before the deductible each year. This will encourage more people to try an HSA qualified plan letting them see the advantages of an HSA combined with a HDHP as the underlying plan.
  • Remove the metallic limitations of plan designs allowing carriers to offer plans they can better control and that make more sense in their specific market.

These are just a few of the ideas and recommendations to stabilize and improve the individual and small group health insurance market. One thing is for sure, we will see many ideas and proposals coming in the next couple of weeks. Hang on, it will be a bumpy ride but in the end we will all be ok.

Posted on 02/20/2017 11:41 AM by David Moore

Wednesday, 15 February 2017

Humana just announced they will not offer individual health insurance in 2018. "There isn't enough money in the ACA as it's structured, even with its fees and taxes, to support the population that needs to be served" say Aetna CEO Mark Bertolini. 

This changes hits Tennesseans especially hard with Humana being the only insurer in thee of the states largest communities. In the Knoxville area alone there would be 40,000 Tennesseans losing coverage says Julie McPeak the TN insurance commissioner. 

Read More

Posted on 02/15/2017 3:51 PM by David Moore

Tuesday, 31 January 2017

While the specific details of what the replacement program for the ACA will look like, there are several ideas you will find very interesting. This is a detailed white paper from Milliman that looks at several important issues that will affect healthcare going forward. These include;

  • continuous coverage provisions
  • the role of high risk health pools
  • open enrollment
  • premium and cost sharing subsidies
  • tax treatment of individual and group premiums, and
  • coverage restrictions

We all know there is much room for improvement with the current ACA plans and regulations. The questions is, what's going to change and how will it effect each of our insurance options and the premiums charged for them. Time will tell but this report gives you a better understanding of what may be coming in the near future. 

Read the Milliman report here

Posted on 01/31/2017 11:06 AM by David Moore

Tuesday, 22 November 2016

On November 18, 2016, the IRS released Notice 2016-70 to extend the due date for employers to furnish Form 1095-C or 1095-B under the Affordable Care Act's employer reporting requirement. Employers will have an extra 30 days to prepare and distribute the 2016 form to individuals. The due dates for filing forms with the IRS are not extended.


Applicable large employers (ALEs), who generally are entities that employed 50 or more full-time and full-time-equivalent employees in 2015, are required to report information about the health coverage they offered or did not offer to certain employees in 2016. To meet this reporting requirement, the ALE will furnish Form 1095-C to the employee or former employee and file copies, along with transmittal Form 1094-C, with the IRS.

Employers, regardless of size, that sponsored a self-funded (self-insured) health plan providing minimum essential coverage in 2016 are required to report coverage information about enrollees. To meet this reporting requirement, the employer will furnish Form 1095-B to the primary enrollee and file copies, along with transmittal Form 1094-B, with the IRS. Self-funded employers who also are ALEs may use Forms 1095-C and 1094-C in lieu of Forms 1095-B and 1094-B.

Extended Due Dates

Specifically, Notice 2016-70 extends the following due dates:

  • The deadline for furnishing 2016 Form 1095-C, or Form 1095-B, if applicable, to employees and individuals is March 2, 2017 (extended from January 31, 2017).
  • The deadline for filing copies of the 2016 Forms 1095-C, along with transmittal Form 1094-C (or copies of Forms 1095-B with transmittal Form 1094-B), if applicable, with the IRS is:
    • If filing by paper, February 28, 2017.
    • If filing electronically, March 31, 2017.

Prior to the IRS announcement, a process existed for employers to file Form 8809 to request a 30-day extension of the due date to furnish forms to individuals. Notice 2016-70 explains that the new extended due date applies automatically so individual requests are not needed. Employers that had already submitted extension requests will not receive a reply.

More Information

Notice 2016-70 also provides guidance to taxpayers who do not receive a Form 1095-B or 1095-C by the time they file their 2016 individual tax return.

Lastly, the IRS encourages employers, insurers, and other reporting entities to furnish forms to individuals and file reports with the IRS as soon as they are ready.

Posted on 11/22/2016 2:16 PM by David Moore

Tuesday, 22 November 2016

We have been getting a LOT of calls about help with individual policies. Unfortunately, the carriers no longer want brokers and consultants helping individuals find and manage their health insurance policies. Just for grins I decided to run a quote for my family with what I consider the best individual option available in Nashville, Farm Bureau. 

My family had a TRH policy several years ago and while very basic coverage, it was affordable and would cover claims if something happened. I just ran quotes for the same policy I used to have and a similar ACA compliant policy. This is not stellar, Platinum coverage, it's a basic $3,000 deductible plan with a $6,000 out of pocket, not bells and whistles. 

My family consists of me (age 55) my wife (age 54) and two sons age 19 and 22. All are healthy non smokers. 

The cost for my old Non Compliant policy $447 per month. This policy requires underwriting and is subject to pre-existing conditions. The cost for a new ObamaCare ACA compliant plan, $2,276.62. Yes, that is not a typo and it's not quarterly that is a monthly number. You can run your own quotes at 

What do I get for the extra $22,000 per year? Guarantee issue with no pre-existing conditions. That is not important to me because we are all healthy. So what if I buy the non-compliant plan? I get to pay the penalty of 2.5% of our adjusted gross income with non deductible dollars. Fortunately we have a small group plan where I pay $1,317 per month for a similar policy. 

Broken? You decide

Posted on 11/22/2016 2:15 PM by David Moore

Friday, 07 October 2016

Great news! After years of trying to find a compromise on out of network Emergency Room charges BlueCross and BlueShield of Tennessee and TriStar Health have come to terms. It's important to know that this is only for true emergency claims. 

The agreement states "Any emergency services provided from January 1, 2015 until now (October 1, 2016) will be subject to the patient's normal in-network co-pay or co-insurance and deductible amounts". If your visit is deemed to be non-emergent visit your charged will be limited to $1,500 for any ER visit and $4,500 for an inpatient admission resulting from an emergency room visit. 

This has been a big time challenge for many of our clients and the new agreement should eliminate many fears from our members. 

See the Press Release here

Posted on 10/07/2016 10:06 AM by David Moore

Tuesday, 27 September 2016

Beginning on January 1, 2017 BlueCross BlueShield of TN will stop selling individual health insurance policies in the three major cities of Tennessee. Nearly 120,000 residents of the Memphis, Nashville and Tennessee regions will have to find other policies from the very few carriers left to sell them. Citing large and continuing losses BCBST is not willing to risk another bad year and will transfer that risk to their competitors.

The challenge for most will be finding coverage suitable for their needs and budget. For those who qualify for subsidies affordable coverage will be there but most may find the networks inadequate. For those who earn too much to qualify for ObamaCare assistance, not only will the networks be very limited the cost will be unbearable. 

What are the options? If you need coverage without pre-existing conditions you will be limited to the exchange and ACA compliant plans. If you are relatively healthy there are some options to consider. Many religious organizations offer comprehensive plans that are NOT subject to the ACA penalties. These policies come with exclusions, limitations and pre-existing conditions but may be an affordable option. If your income is too high for a subsidy but you would not consider yourself "rich", a non compliant TRH policy can be a very affordable option. The thing to know is you will have to pay an ACA penalty of $695 per adult or 2.5% of  your AGI whichever is greater. 

My recommendation is to start looking as early as possible. January 1 rates should be available by mid October. 

Modern Healthcare Article

Tennessean Article



Posted on 09/27/2016 7:44 AM by David Moore

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