Category Archives: Health Insurance

New York’s new Paid Family Leave (PFL) law will go into effect on January 1st, 2018.  This is a mandatory benefit for all New York employees, and employers have the option to approach their employees to make early deductions.  Beginning July 1st, 2017 employers can start making these deductions.  In the interest of sharing more information, Petschauer Insurance would like to answer some pressing questions to help readers understand how this law impacts you. 

What is PFL & who qualifies for this benefit? 

PFL supplements part of an employee’s income while they are out of work.  Full-time employees who have worked 26 consecutive weeks and part-timers who have worked a minimum of 175 days are all eligible. 

When can you take PFL? 

Paid Family Leave can be taken for newborn bonding and/or foster adoption (within one year of birth/placement), the caring of a seriously ill family member, or family exigency/military leave.  The need for exigency leave will arise if a covered military family member is on covered activity duty or active duty status. 

How much will PFL pay? 

In 2018, employees will be eligible for 50% income replacement for a maximum of 8 weeks.  An employee’s approved time off and income replacement percentage will continue to increase through 2020. 

How much will PFL cost? 

Employees fund PFL through payroll deductions.  The premium or contribution will be equivalent to .126% of an employee’s weekly wage, capped at $1.65 per week for New York’s average wage of $1,305.92. 

Will you have job protection? 

All eligible employees have job protection while out on Paid Family Leave. 

The holiday season is one filled with laughter, songs, good food and even better company.  As you celebrate with family and friends, we wish you happy holidays and hope that you create wonderful memories together. 

The forthcoming new year also provides all of us an opportunity to reflect back upon the highlights of the past twelve months.  As we do, join us in looking back at some of our favorite blogs and a special video from 2016.  Once again, happy holidays from all of us at Petschauer Insurance. 

When filing your 2016 tax returns, you could face a sizeable fine if you and/or your family are without health insurance. 

The Affordable Care Act mandates that anyone that has gone without health insurance for a span of three months or more is subject to paying a fine.  The penalty this year has increased to equal the greater amount of $695.00 or 2.5% of an adult’s income.  For every child under 18 without health insurance, the penalty is half that of an adult’s. 

This penalty is deducted from any income tax refund you may be eligible for.  It would be unfortunate to be burdened by such a penalty and have it get in the way of the potential tax refund you look forward to receiving every year. 

There are, however, exceptions to the rule. 

You may qualify for an exemption if you fall under any of the following categories:

Individuals and families who fall under the income-tax federal threshold would be exempt, or receive the necessary subsides to offset the costs of the health insurance. 

If you are unemployed and are unable to find coverage costing less than 8% of your adjusted gross income, you would be exempt from penalties as well. 

You may also qualify for a hardship if you are homeless or have been evicted in the last six months. 

We encourage you to review this information carefully so that you can make good decisions for you and your family. 

Please note, Open Enrollment for 2017 begins on November 1st 2016.  Feel free to contact us today to discuss the options that best fit the needs of you and your family, as the penalty will be the same for next year. 

Is this the first time you are presented with the option to purchase your own health insurance? 

Let us help you get started by defining some of the most misunderstood health insurance jargon along with 6 categories to pay close attention to when selecting a plan. 

1) Network: This outlines the group of hospitals and doctors being offered to you by a particular insurance company; including primary care physicians and specialists. 

2) Type of Plans:

a) HMO (Health Maintenance Organization) plans cover medical care provided by doctors and hospitals inside a specific network.  HMOs often require members to get a referral from their primary care doctor before going to see a specialist. 

b) EPO (Exclusive Provider Organization) plans allow you to access doctors that are only included in your specific network, and generally do not need referrals before going to see a specialist. 

c) PPO (Preferred Provider Organization) plans allow you access to doctors and hospitals inside and outside of your selected network and are typically the most expensive plan option. 

d) Bronze: These plans have the lowest premium and the highest deductibles. 

4) Before benefits are paid, here is what you are responsible for:

a) Your Deductible: The set dollar amount you have to pay before your insurance “kicks” in. 

b) Your Co-Pay: The set dollar amount you will have to pay Primary Care Physicians & Specialists at the time of your appointment. 

c) Your Co-Insurance: Set percentage for certain services you need. 

5) Be aware of your out of pocket maximum. 

This is the total dollar amount you will be responsible for in a given period, either a calendar year or contract year.  This amount will include your deductibles, co-insurance, & co-pays.  Once you have reached this amount in your given period, your medical expenses will be covered 100% until the end of that period.  At that time, it will start all over again.  Please note, you will always be responsible for your premium payments. 

6) Prescription Drugs: they are generally broken down by 3 tiers

a) Tier 1– generic drugs subject to the lowest co-pays

b) Tier 2– brand name drugs subject to higher co-pays

c) Tier 3– non-formulary drugs subject to the highest co-pays with some plans even having a deductible or limit within this

Hopefully, we have provided you with a basic understanding of health insurance so that you are able to make a more informed decision.  Open enrollment for 2017 begins November 1st.  Feel free to contact us today to help you make the choice that best fits the needs and budget of you and your family. 

October isBreast Cancer Awareness month, which serves as a reminder to many women over 40 that they need to schedule their annual mammogram.  For many others, however, it is a real opportunity to spread awareness of the disease and how important early detection plans can be.  While many people realize that breast cancer is something women should be thinking about, the numbers don’t always hit home.  The reality of it all is that breast cancer is the most common cancer among women in the United States. 

Not only is it important to be thinking about Breast Cancer Awareness in October, it should be at the forefront of our minds, and something every woman should be proactively discussing with her doctor.  Creating an early detection plan will help in reminding you to perform routine breast self-exams and to schedule clinical breast exams and mammograms. 

With that being said, we all heard that mammograms are painful.  The systems available to check for cancer are not the most pleasant, so we’re highlighting a few tips to reduce the pain of a mammogram. 

For a more comfortable mammogram:

Don’t wear lotion, deodorant, perfume or anything else your doctor advises against because it may leave marks on the film — and you’ll have to schedule another test! 

Reduce your salt – The more salt, the more bloating and fluid retention in the breast, which causes pain and discomfort. 

Avoid caffeine – Caffeine will increase tenderness in the breast, even more so if you have benign cysts. 

If you are in extreme discomfort, speak up.  Doctors may be able to adjust the machine or the compression to ease your discomfort. 

Petschauer Insurance believes that it is important to be proactive and responsible about your health.  We offer insurance products for you, your family and your business because your health is important.  Having ahealth care planthat is right for you will allow you access to the many preventive screenings and care options you need.  Be sure to speak witha professionalof Petschauer Insurance if you have a question about your health care coverage or if you would like us to review your Supplement Plan. 

Did you file your taxes for 2014 and realize you were penalized for not having health insurance?  If you were, you now have a second chance to avoid a penalty for 2015.  If you did not enroll for health insurance during this year’s open enrollment, and were fined a federal penalty for not having health insurance you still have the opportunity to enroll for health coverage through the Special Enrollment Period starting March 1 and ending April 30, 2015. 

Read the following article on the Special Enrollment Period extended beyond Open Enrollment Period to accommodate those individuals and families penalized:

You are welcome to contact us if you have any questions or concerns.  Our Life and Health Department can assist you with this any of your Health Insurance needs.  Life and Health Account Executive, Narima Prashad, can be reached by phone or email: (718) 386-5050 x 7069 | NPrashad@jpins.com. 

The number one New Year’s resolution around the world is to get fit, lose weight, and overall be healthier.  Sometimes we just need a little more push to make the extra effort to achieve that goal.  What if we informed you that your health insurance may actually pay for your annual gym membership?! 

Yes, you did read that correctly!  There are a number of health insurance providers who will reimburse you for the entire year’s membership.  You will feel better and may even save yourself some money as you live that healthier lifestyle. 

Contact your insurance provider today to find out if they offer this service.  And, if they do, find out what the process is to receiving that reimbursement.  More and more insurance companies are beginning to see the value in taking care of their members. 

This could be the news you have been waiting for! 

And check out these simple tips on how to keep your New Year’s resolution going all year long:

1) Be realistic.  Give yourself an attainable goal.  It’s good to set the bar high, but take it one step at a time. 

2) Make a plan before you start.  Create a work-out calendar that works best for your schedule to keep you feeling successful. 

3) Talk about it with your family and friends.  It will make them aware of your goals which they can support you in. 

4) Understand that Challenges do occur.  Don’t beat yourself up if you do miss a day or two .  So stay positive and remind yourself that tomorrow is another day. 

5) Keep track of your progress.  Keeping a journal will help you acknowledge your smaller accomplishments which will lead to your ultimate goal. 

6) Treat yourself.  Have your favorite food every once in a while as a reward for your hard work.  Or treat yourself to some new clothes to work out in if you want to stay away from food reward until you meet your ultimate goal. 

If you do not have health insurance at this time, November 15th is the quickly approaching date for you to take advantage of the opportunity to be eligible to purchase a policy.  Did you know that as of January 1st 2015, any adult without health insurance earning above the Affordable Care Act (ACA) income threshold, is responsible to pay a penalty of $95.00 or 1% of their annual income (whichever is higher)?  Did you know that there is a limited time for you to apply for coverage? 

So maybe you lost the health insurance sponsored by your employer or you no longer qualify to be on your parent’s plan due to your age.  Beginning on November 15, 2014 you have a chance to be proactive and purchase health insurance for an upcoming January 1, 2015 effective date.  This is called “Open Enrollment”.  If you haven’t applied for coverage by February 15th, 2015 you will need to wait until the next Open Enrollment period scheduled for November 15, 2015. 

•What is Open Enrollment? 

This is a period during which an individual can apply for health insurance with fewer restrictions than at any other time during the year.  It is important for those individuals who are not covered under their employer’s insurance, or simply are uninsured, to pay close attention and remember the dates for Open Enrollment: November 15, 2014 through February 15th, 2015.DuringOpen Enrollment, insurance companies are supposed to waive underwriting guidelines and any requirement for evidence of insurability.  When Open Enrollment ends individuals seeking coverage need to be “qualified” for Special Enrollment, or theywill have to wait until the next scheduled open enrollment period on November 15, 2015!  Special Enrollment or qualifying events include, but are not limited to: divorce, marriage, birth, death and loss of employer sponsored coverage. 

•How can individual insurance be purchased? 

A number of Health Insurance Companies are offering Individual health coverage either directly through health carrier websites, via the New York State Health Exchange, or off the Exchangethrough independent insurance brokers. 

• Whatpenalties will you be responsible to pay if you are not covered? 

In 2014: $95.00 or 1% of income (individual)

$285.00 or 1% of income (family)

In 2015: $325.00 or 2% of income (individual)

$975.00 or 2% of income (family)

In 2016: $695.00 or 2.5% of income (individual)

$2085 or 2.5% of income (family

Although the penalty may seem minimal in 2014, as you can see, it will increase for the upcoming years.  Keep in mind that you will be responsible to pay the greater amount; percentage of income, or fixed dollar amount. 

Some people feel that the premium for a health insurance plan seems unnecessary and excessive for a young healthy individual.  However, we strongly suggest that you keep in mind that “accidents do happen” and the cost of an emergency room visit, x-rays, MRIs, hospital stays and doctor visits add up and can be devastating to you and your family’s financial situation. 

We urge you to take advantage of this opportunity to purchase health insurance during this year’s Open Enrollment. 

About 20% of Americans are currently on a diet according to NPD’s National Eating Trends.  In these times of changing health insurance guidelines, the question is often posed as to whether or not insurance carriers will reimburse consumers for their participation in weight loss programs.  The quick answer is that “it depends upon your carrier and the health incentives provided by your plan.”  You didn’t really think it was going to be a “yes” or “no” answer did you?  Let me explain. 

It would certainly make sense that a lifestyle based on a healthy diet, good nutrition, and an exercise program are all elements that contribute to better health, increased stress reduction, and greater longevity .  In addition, the medical community touts preventative medicine in combination with diet and exercise as a means of thwarting major diseases such as cancer, heart disease, type two diabetes and other serious illnesses. 

Since most weight loss programs require a doctor’s permission before starting, the introduction of a plan for good nutrition, counseling and monitoring of food intake, physical activity and a food plan during, as well as a maintenance plan afterward, it would make sense that every insurer should assist the consumer in paying for their chosen weight loss program.  However, this is not a standard practice and varies depending upon your insurer, your plan and the yearly allowances for healthy lifestyle incentives.  Some insurers do actually pay toward health club memberships while others offer discounts per plan year and still others provide a single lifetime benefit. 

While commercial weight loss programs such as those seen advertised on TV can be accessed online, at work or via attendance at weekly meetings, some carriers have their own online portal which provides resources for assisting their members in his or her efforts at weight loss. 

Regardless of the specific plan providing your health insurance coverage, and the program you chose to support a healthy lifestyle, to find out what reimbursements are available to you, it is always best to consult your policy before you make the choice. 

However, even if your individual health insurance coverage may not cover this, don’t let that affect your determination to participate in a weight loss program because you are definitely worth it! 

With the implementation of the Affordable Care Act, which took effect on 1/1/14, we now hear the constant mention of the term “cost sharing”.  Many consumers of the new health insurance plans are unsure of what the term means and what payments actually constitute “cost sharing.” 
Cost sharing is the payment any consumer contributes toward their health care based on the policy they’ve selected.  These cost sharing payments include, but aren’t limited to:
• Deductibles
• Co-insurance
• Prescription deductible or co-insurance charge
• Primary care doctors or specialists co- payment

Regardless of which plan you select, these costs will be referred to as your “out of pocket maximum” per contract year. 

When selecting a plan it is important to understand that cost sharing determines the premium for that particular plan.  The higher your cost sharing, or put simply, the more you are willing to pay for your share of medical costs, the lower your monthly premium will be.  Similarly, if you need to select a plan with lower cost sharing, where you are paying less of the costs, then, undoubtedly, your monthly premiums will be higher because the carrier will be shouldering more of the burden for payments to doctors, hospitals, pharmacies, etc. 

It is also important to keep in mind that a deductible is a fixed amount that must be satisfied by you, the insured, before the insurance company will consider paying their portion of any covered health claim.  Once the deductible is satisfied, you as the insured are still responsible for the specified percentage of co-insurance and any co-payments outlined in your chosen plan. 

Once you have satisfied your portion of the cost sharing, your insurance company will cover 100% of the covered claims for any given contract year.  When your contract year is over and it is time to renew your plan, then cost sharing starts all over again. 

If you are confused, or have any questions at all, please contact your independent insurance agent for guidance.  They will be able to help you choose a plan that most suits your needs and your budget. 

Post navigation

CONNECT

Ask Sherri

Do you have an insurance question?  If so, e-mail it here and our insurance professional Sherri will give you the scoop on all you need to know.  Your question might also appear in our Ask Sherri video series! 

Ask Sherri
Do you have an insurance question?  If so, e-mail it here and our insurance professional Sherri will give you the scoop on all you need to know.  Your question might also appear in our Ask Sherri video series! 

Sign Up for Our Latest News

First Name:

Last Name:

Email:

Watch videos about some great businesses thathappen to be a Petschauer client!