Author Archives | Denise Kaiser

About Denise Kaiser

Mrs. Kaiser is an analytical consultant providing financial analysis, vendor evaluations, market & compliance analysis, as well as national industry trending for group employers.

Big Insurance Companies to remain at a count of four, not three

June 20, 2017


In 2015 one of the insurance industry’s largest mergers started with Anthem agreeing to acquire Cigna.  Anthem’s purchase of Cigna would have created the largest U.S. health insurer. The merger was to close the second half of 2016 covering over 50 million members and was considered to be a $54 billion deal.

On March 2016 California’s insurance commissioner Dave Jones held a hearing to get testimonies and comments regarding the possible implications of the proposed merger between Anthem and Cigna. The discussion noted that Cigna wrote approximately $899,559,897 in premiums in 2014. If the merger occurred, Anthem would have acquired control and ownership of Cigna and 100% of Cigna’s stock.  Other topics discussed were:

  • The impact on competition in California health coverage;
  • The implications for consumers of increased concentration in the California health coverage;
  • The impact on consumer premiums and out-of-pocket health care cost; and
  • The impact on provider and facility network contracting.

If the deal was not approved by the end of April 2017, Anthem would be required to pay Cigna a $1.85 billion break-up fee.

In July 2016, the Justice Department along with 11 states and the District of Columbia sued to stop the merger. The complaint alleged that a combined Anthem and Cigna would substantially lessen competition in the health insurance industry in dozens of markets across the country. According to the Justice News, February 2017, Judge Amy Berman Jackson for the District of Columbia ruled in favor of the Justice Department in its civil antitrust lawsuit to block health insurer Anthem, Inc.’s acquisition of Cigna Corp. This merger would have stifled competition, harming consumers by increasing health insurance prices and slowing innovation aimed at lowering the costs of healthcare.  Anthem’s acquisition of Cigna would violate federal antitrust laws; the court has protected consumers and the competition on which they rely.

In May 2017 Anthem terminated the merger with Cigna. Anthem stated Cigna is not entitled to the $1.85 billion break-up fee because Cigna did not comply with contractual obligations. Cigna is suing Anthem not only for the break-up fees but also $13 billion in damages. The situation continues as Anthem and Cigna blame the other and pursue compensations.

How will the two companies work with each other in the future? Time will tell.

Anthem is the second biggest seller of medical insurance to U.S. companies. Cigna is in third place.

Anthem is a Health Insurance company founded in 1940’s. Prior to 2014 Anthem was known as WellPoint.  Anthem is the largest for-profit managed health care company in the Blue Cross and Blue Shield Association and their headquarters are located in Indianapolis, IN.  Anthem has 52,000 employees and revenue at 85 billion USD.

Cigna is a worldwide health services organization. Its insurance subsidiaries are major providers of medical, dental, disability, life and accident insurance. Headquarters are located in Bloomfield, CT.  Revenue stated at 29.12 billion USD.

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What makes a great workplace?

January 9, 2017


Human beings are social animals, and work is a social institution. Work can be a place where long-term relationships are formed. So what makes someone stay at their job for a long time?  For a company to be successful and retain employees there needs to be trust between the employee and workplace.  Building trust and having respect for employees can make a great workplace.

To build trust, it is heavily relied on the leadership or upper management of a company. As stated in Gallup’s research, “Employees don’t leave companies, they leave managers and supervisors.”  Employees should be able to look up or learn from their managers.  Managers should be able to believe their employee has what it takes to do the job.  Whether you are an employee in customer service or the CEO of the company there should be engagement with one another.

Employees are curious about how their company measures up with other companies. How a company measures up with other companies will determine if the employee stays or goes. Here are some things to help determine if your company is a great place to work and help retain employees;

  • Growth opportunities – Managers should notice the employee’s talent and move them to the direction/position to do their best work.
  • Challenges – Challenges keep employees excited about work. Research or projects should be part of the employee’s task.
  • Respect – Treat all people fairly. Build trust with employees. Be positive. Show recognition.
  • Perks – Not all perks are the same for everyone.  It could be office with a window view or simply having free coffee in the café.
  • Pay– Includes annual reviews with increases.  Bonus opportunities offered.
  • Work/Life balance – Offer flexible hours for employees to work. Work from home option offered.
  • Technology – Tools for employees to do their job and continue to learn.
  • Benefits – Medical, dental, life insurance, tuition reimbursement, retirement, etc.  The difference between what the company and employee pays for each of these.

Not every company will have all of the moral boosting factors listed above.  It is a competitive job market and people are looking into what a company offers before making a job decision.  What a company offers will help someone make a choice in a company but then it is up to company to keep the employee happy.

Every CEO of a company would love to hear their employees leave for the day shouting “I love my job and can’t wait to come back tomorrow!”  But to hear this, the company needs to make the employee feel valued.  The employee must enjoy their work and the company.  It might seem simple but it is not.  And making a great workplace will not happen overnight.  Just remember that having happy employees will retain employees and make the workplace a better company.

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Getting help with College Debt

November 15, 2016


Growing up everyone always ask you, “what do you want to be when you grow up?” They never asked you how you were going to become that person or tell you how much college it would take to become that person. And along with college comes debt.

There are employers that if you are working full time and going to school they offer tuition reimbursement. Tuition reimbursement is a benefit to employees. The amount that employers will reimburse can vary and usually the employee has to earn a certain grade. Employers offer tuition reimbursement to retain current workers and attract new talent.  There are tax breaks for employers for tuition reimbursement on a federal level. But what if you can’t work and go to college at the same time?

Wouldn’t it be nice to graduate from college and get a job that helps lower your student loan?  Good news is employers are starting to do this. Employers are making tuition assistance part of their benefit package. Employees should keep in mind the student loan assistance amounts get taxed as income for the employee.

According to the Society for Human Resource Management (SHRM), only about 3% of companies in the US offer to help employees with student loans.  Also, the contribution that a company offers can vary.  Here are some companies that offer assistance and their contributions;

  • Chegg- annual contribution of $1,000
  • Fidelity Investments- annual contribution of $2,000
  • Aetna – annual contribution of $2,000
  • Pricewaterhouse Coopers – $100 a month

Some of the companies have limits on how many years they will pay the annual contribution. There could also be requirements such as requiring full-time employment or at the company for a certain length of service before the employee is eligible to get the contribution. The companies that offer the contribution understand helping ease the financial burden of college debt can help their employees have more motivation to stay with them.

Paying off a student loan can take years and could possibly make someone miss out on a goal they had for after college.  Studies show that college graduates have an average of $30,000 in student loan debt. Doing research to find a company that offers tuition reimbursement or helps employees with their student loans is something that can benefit someone going to or has graduated from college.  Hopefully, the companies that offer student loan assistance can start a trend so more companies will offer the assistance to employees.

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Summary of Benefits and Coverage

September 9, 2016


The final SBC is the product of over a year long process of revising the original SBC issued in 2012. On April 6, 2016 the Department of Labor issued the final regulations of the new Summary of Benefits and Coverage (SBC) intended for use as of January 1, 2017.

The Summary of Benefits and Coverage is a standardized document required by the ACA that provides individuals with standard insurance information.  All insurance plans and group health plans are required to produce a SBC based on a uniform template to reflect the plans terms. This document will help one better understand the coverage they have.

The changes on the new SBC include:

  • Removed the Q&A about coverage examples which reduced the template to 5 pages
  • An additional cost example for a foot fracture treated in an ER
  • Updated claims/pricing data for the coverage example calculator
  • New minimum essential coverage and minimum value language.  New appeals/grievance rights language
  • Revised language for some sections of the template
  • Updated Uniform Glossary

Now that the changes are listed let’s review some of the basics to make sure they are clear.

If you don’t have at least minimum essential coverage you will pay a penalty when federal income tax return is filed. Minimum essential coverage must be kept throughout the year or a fee will be charged each month you don’t have it. You are allowed less than 3 consecutive months in a row per year without coverage without paying the penalty. Insurance plans must meet minimum essential coverage requirements. It is probably easier to list the types of insurance that are not considered minimum essential coverage:

  • Short Term Health plans
  • Fixed Benefit Health plans
  • Supplemental Medicare like Part D or Medigap
  • Some Medicaid covering only certain benefits
  • Vision only, Dental only and limited benefit plan

According to the ACA, insurance plans must meet one of the four levels of coverage based on actuarial value; bronze, silver, gold and platinum.  A plan must at least meet 60% actuarial value which would be the bronze level. Meeting 60% means a plan to pay at least 60% of the total cost of medical services.

The updated section on the SBC for enhanced language for grievances and appeals has much more information explaining each term and how to submit to your plan. A grievance is a compliant to the health insurer. An appeal is when a benefit has been denied and a request to review that claim is submitted.

Final documents are available on the DOL website here.

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Long-Term Care LTC

March 4, 2016


Do you ever think you will need help with dressing or bathing yourself? Maybe you don’t think about this now but what about when you reach an age that you will need assistance with basic personal things of everyday life. 70% of people turning age 65 can expect to use some form of long-term care. Some might think that long-term care refers to an insurance policy but long-term care involves services to meet a person’s health or personal care during a short or long period of time.

Long-term care can consist of personal tasks called Activities of Daily Living (ADLs) such as:

  • Bathing
  • Dressing
  • Using the Toilet
  • Transferring to or from bed/chair
  • Caring for incontinence
  • Eating

Other common services of LTC are called Instrumental Activities of Daily Living (IADLs) such as:

  • Housework
  • Managing money
  • Taking medication
  • Preparing and cleaning up after meals
  • Shopping for groceries or clothes
  • Caring for pets

These services can be done by a family member, friend, neighbor, a nurse, home health or therapist that comes to the home, and adult day care provider or long-term care facilities. About 80% of care at home is provided by unpaid caregivers. The level of long-term care will vary from person to person. About 20% of people will need long-term care longer than 5 years. And since women usually live longer than males women should plan their long-term care longer.

Long-Term Cost

Now that you are thinking about long-term care you’re probably wondering how you are going to pay for it. Medicare only pays for long-term care if you require skilled services or rehabilitative care in a nursing home for a maximum of 100 days or at home for a short time. And there will most likely be a coinsurance fee after 20 days. You will have to pay for long-term care that is not covered by a public or private insurance program. Medicaid does pay for long-term care but to qualify your income must be below a certain level and you must meet minimum state eligibility requirements. Other federal programs such as the Older Americans Act and the Department of Veterans Affairs pay for long-term care, but only for specific populations and in certain circumstances.

Long-term care insurance pays for services when you need care with the basic activities of daily living. Most policies allow you to choose where and what type of services you receive, for example, home care or care in assisted living facility. LTC insurance premiums vary depending on your age, health and policy. Private insurance companies sell long-term care policies or you can buy an individual policy from an agent. You can also purchase coverage under a group plan through an employer. If you purchase life insurance ask if the policy has a built in benefit to pay for long-term expenses, some do.

Long-term care services help people live independently and safely as possible when they can no longer perform everyday activities on their own. You cannot guess when or if you will need long-term care but things to consider are:

  • Age- risk increases the older you get
  • Gender- females are a higher risk then males
  • Marital status- single people are more likely to need care
  • Lifestyle- Poor diet and exercise habits
  • Family history

It is never too early to start planning for long-term care. The earlier you start the more time you will have to make decisions and possibly check out facilities.

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Pet Insurance

December 7, 2015


How much money would you spend to keep your pet alive? A trip to the veterinarian’s office can cost hundreds or even thousands of dollars. Even a routine examination can cost hundreds of dollars. What would happen if your pet had an accident, an illness, or a need for medicine? Perhaps pet insurance is the answer.

Most people do not realize pet insurance is an available option. Dog and cat policies are most common but there are companies that virtually every animal imaginable. One should be aware of the difference in pet insurance companies. Pet insurance companies vary in covered services, costs, customer service, and claim reimbursement. As a best practice individuals should consider the following prior to purchasing pet insurance:

Coverage- What does the policy cover? What items are excluded? What about preexisting items?
Customer Service- Is there a live person to talk to? Will your questions be answered when you need them to be? How long has the company been in service?
Insurance Premiums- How much can you afford monthly? Get multiple quotes to compare the difference. Are there discounts for multiple pets? If paying annual do they offer a discount?
Out of Pocket expenses- Ask about copays and deductibles you might have to pay.
Network- Will you be able to continue to use your current veterinarian?
Typical premiums vary from $10 to $40 a month for dogs and cats.  The breed, the age, and the home location all make a difference on the monthly premium. For many pet owners paying a manageable monthly fee rather than one large bill for an unexpected emergency or surgical event can significantly smooth the financial burden.

Purchasing pet insurance can help ease financial burdens and worries when your pet gets ill or needs a routine checkup. Pet insurance might not be for every animal owner but most should take the time to evaluate it.

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Summary of Material Modification Examples

October 28, 2015


You might be wondering what material modifications do or do not require the group to provide notice to the members. A material modification is defined under section 102 of the ERISA as-

  • Any coverage modification that alone or combined with other changes made at the same time would be considered by “an average participant” to be “an important change in covered benefits or other terms of coverage under the plan or policy.”
  • An enhancement of covered benefits, services or other more general, plan or policy terms. For example, coverage of previously excluded benefits.
  • A “material reduction in covered services or benefits” or more strict requirements for “receipt of benefits,” including:
    • Changes or modifications that reduce or eliminate benefits
    • Increases in cost-sharing
    • Imposing a new referral requirement

Examples of a material change for a small group-

  • A small group has a renewal date of January 1st. They submit their renewal in the month of December. But January 10th the group has decided to make a plan change to their deductible. The 60-day notice of material modification would not apply since their change is requested in the same month as their renewal. The group would be responsible for sending the members a revised SBC.
  • A small group renews on January 1st but the group submits their renewal confirmation on January 5th with benefit changes. In this case since the SBC has already been sent to members the carrier would have 7 business days to revise the SBC and send to the group. The group would be responsible for sending the members a revised SBC.
  • If the group automatically renews on January 1st then sends a plan change on January 5th but then notifies the carrier they have another plan change on January 20th, the 60 day notice of material modification would apply due to having two changes. The group would be responsible for sending the members a revised SBC. And the change would be effective 60 days after the members receive the revised copy of the SBC.

Examples of a material change for a large group-

  • Material modifications are slightly different for large groups. For example, if the group renewal is January 1st and the group makes a plan change on January 10th the change would be approved but the 60 day notice of material modification would apply since the group must send their renewal changes in advance of their renewal date. The group would be responsible for sending the members a revised SBC. The change would be effective 60 days after the members receive the revised copy of the SBC.

The above examples are only a few that you may have thought about or encountered. It is key to remember that the summary of material modifications to the plan and changes in the information should be included in the summary plan description (SPD) sent to the members.

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Pharmacy Benefit Manager 101

September 22, 2015


Do you think about when it comes to pharmacy drugs? With the price of specialty drugs sky rocketing you might want to consider thinking about your PBM relationship. Perhaps working more closely with your PBM could help you save money in more ways than you think.

So what exactly is a PBM? If your plan includes prescription medication benefits, chances are that your plan contracts with a pharmacy benefits manager (PBM) to administer those benefits. A Pharmacy Benefit Manager (PBM) is a third party administrator (TPA) of prescription drug programs. They can range in size from small to large. PBMs are primarily responsible for developing and maintaining the formulary, contracting with pharmacies, negotiating discounts and rebates with drug manufacturers, and processing and paying prescription drug claims. They can work with self-insured companies, government programs, unions, TPAs and managed care companies.

With the price for prescription drugs continuing to spiral upwards, pharmacy drug solution continues to rank as top cost control priority for many companies. Working in coordination with your PBM provides a number of opportunities to reduce costs and manage risk. Here is a list of things that should be brought up in those discussions::

  • Specialty Drugs- Prior authorization and quantity limits
  • Risk Stratification – limit certain expensive drug therapies
  • Formulary Exclusivity- Formulary is a list of preferred and non-preferred drugs that are covered
  • EGWP – The Employer Group Waiver Program can be a cost savings who offer retiree medical coverage
  • Generic Pricing Comparison- Use of generic drugs
  • Clinical Program Evaluation- Step therapy, compound management, medication therapy management.

Prescription drug coverage can add 30 percent or more to the cost of a health care premium. Selectively bidding and using an independent pharmacy benefit manager to administer a drug plan may help reduce this cost. This is typically called a Prescription Carve-Out Plan. The employer self-funds the actual cost of the prescription claims (often times the medical as well). Then bids the PBM services, often this can result in significant pricing advantages saving anywhere from 7-27% over typical industry shelf rates. Carving-out the pharmacy offers companies the opportunity to save money without cutting employee pharmacy benefits.

There are currently around 60+ PBMs managing drug benefits for companies in the United States. PBMs can be independently owned and operated or subsidiaries of managed care plans or major drug stores. In 2012 the five largest PBMs were:

  • Express Scripts
  • CVS Health
  • Prime Therapeutics
  • United Health/OptumRx – now Catamaran
  • Catamaran Corporation

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Does your benefits plan hit the mark?

July 7, 2015


Workplace benefits are increasingly becoming a subject of focus for HR.  According to the Society for Human Resource Management (SHRM), 61% of employees who were very satisfied with their benefits said they felt a strong sense of loyalty to their employer vs. 24% of employees who were very dissatisfied with their benefits.

Knowing how your company’s benefits program compares to your competitors is an important component of any retention strategy.  J.W. Terrill can help you understand how your plans measure up through the 2015 Mid-Market Benefits Survey. The survey is now open and your participation is encouraged.

One of the key goals of the survey is to provide meaningful information so that employers like you can make better-informed decisions regarding your benefit plans. Participants will receive a customized report providing valuable insight into how your program compares with other employers. As a participant, there is NO COST to you and was designed with your needs in mind:

  • Quick & Easy – in a user-friendly web-based format, you can complete it at any time and even return to your survey for later editing and completion
  • Comprehensive – all of your benefit plans are covered
  • Thorough interpretation – your individual results will be provided in a clear, easy-to-understand format by a qualified and knowledgeable consultant
  • Are you a past participant? Your answers are pre-populated from prior responses
  • Earn HRCI and CPE recertification credits

Questions? Contact Denise Kaiser at 314-594-2793 or send an email to for more information.

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Coordination of Benefits

February 10, 2015


Having insurance is a requirement these days. But what if you and your spouse both have coverage? How does that work? There is something insurance companies use called Coordination of Benefits (COB). This is a method used to ensure that claims are not paid multiple times or claims are not paid in excess.

COB determines which plan is primary and which is secondary. The primary plan pays the claims first and the remainder balance will be paid by the secondary plan.  Take for example a married couple where the husband and wife both work and have health insurance coverage. If the wife goes to the doctor her insurance will pay as the primary plan and her husband’s insurance will become secondary.

Having dual coverage can also maximize your children’s benefits. The “birthday rule” states that the health insurance industry uses the COB when children are listed as dependents on two parents’ health plans. Under this rule, the health plan of the parent whose birthday comes first in the calendar year is designated as the primary plan. It does not matter which parent is older because the year of the birthday is not used. Age is not the determination; it is the date of the birth. When the mother and father have the same birthday the plan that has covered the insurer the longest will be considered primary. Now when the parents are divorced or separated the birthday rule does not apply. A court order about the children’s health coverage after a divorce surpasses the birthday rule.

There can be different COB rules depending on the plan.  Therefore, it is important to identify the sources of payment and review the COB provisions. Self-insured health plans may write their own rules for COB. Coordination is important between a group health plan and a participant’s individual insurance policy. If an individual is injured in an auto accident, benefits might be covered under both the group health plan and the auto insurance policy.

Medicare, Tricare and Medicaid: These federal programs include very long and complex COB rules. These federal programs require insurance plans to be primary when it comes to paying claims. Rules for Medicare parts A, B, and C are known as the Medicare Secondary Payer (MSP) requirements. MSP prohibits employers from offering financial or other incentives to policyholders entitled to Medicare to opt out of the employer group health coverage that would otherwise be the primary payer. Medicare part D has its own set of COB requirements. Part D rules are to pay as secondary, avoid over payment and make sure expenses will count toward the Part D deductible. When dealing with Tricare, the claims would be paid in the following order; policyholders health plan, Medicare then Tricare. For Medicaid state law requires that all available resources be used before Medicaid will pay any claims.

Coordination of Benefits can be great for health care providers and policyholders alike. If one is lucky enough to have more than one insurance plan, the COB provision should help cover most of their health care expenses.

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The Many Faces of Form 5500 Series

October 21, 2014


Form 5500 is not just a single reporting document, but an entire series of forms which play an important role in many parts of the government and the business world. It is an important compliance, research, and disclosure tool for the Department of Labor, a disclosure document for plan participants and beneficiaries, and a source of information and data for use by other Federal agencies, Congress, and the private sector in assessing employee benefit, tax, and economic trends and policies. However, the 5500 forms can be confusing.  Here is a short breakdown of which 5500 Form is used for:

Form 5500, Annual Return/Report of Employee Benefit Plan

Who files?
Pension and welfare benefit plans must generally file the Form 5500 to report their financial condition, investments and operations.

How to file?
Must be filed electronically through EFAST2

Due date?
The last day of the seventh month after the plan year ends (July 31 for a calendar-year plan).


Form 5500-SF, Short Form Annual Return/Report of Small Employee Benefit Plan

Who files?
Plans with fewer than 100 participants

How to file?
Must be filed electronically through EFAST2

Due date?

The last day of the seventh month after the plan year ends (July 31 for a calendar-year plan).


Form 5500-EZ, Annual Return of One-Participant (Owners and Their Spouses) Retirement Plan

Who files?
Certain retirement plans maintained outside the U.S. primarily for the benefit of nonresident aliens must file Form 5500-EZ rather than Form 5500.

How to file?
Must be mailed to:

Department of the Treasury IRS
Ogden, UT 84201-0020

Due date?
The last day of the seventh month after the plan year ends (July 31 for a calendar-year plan).


Form 5558, Application for Extension of Time To File Certain Employee Plan Returns (form and instructions)

Who files?
May be used to file for an extension of time for the following returns:

  • Form 5500
  • Form 5500-SF
  • Form 5500-EZ
  • Form 8955-SSA
  • Form 5330

How to file?
Must be mailed to:

Department of the Treasury  IRS
Ogden, UT 84201-0045

Due date?
This varies by extension request.

Additional information and guidance on 5500’s can be found on the IRS website at

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Introduction to Form 5500 Filing Requirements

June 24, 2014


The 5500 is a form that satisfies the annual reporting requirements under Title I and Title IV of ERISA and the Internal Revenue Code.  Form 5500 is an important compliance, research, and disclosure tool for the Department of Labor and a disclosure document for plan participants and beneficiaries.  It is intended to assure that employee benefit plans are operated and managed in accordance with certain prescribed standards and that participants and beneficiaries, as well as regulators, are provided or have access to sufficient information to protect the rights and benefits of participants and beneficiaries under employee benefit plans.

Who files Form 5500? 

Every group health and pension plan that is subject to ERISA with the exceptions of:

  • Welfare plans with less than 100 participants which are unfunded, insured or a combination of unfunded and insured
  • Certain fringe benefit plans, including group legal services, educational assistance programs and adoption assistance plans
  • Church and governmental plans (since they are not subject to ERISA)
  • Day care centers
  • Certain apprenticeship and training plans
  • Certain employee organization plans

How to file Form 5500?

Plans must file Form 5500 electronically for all plan years with EFAST2 (ERISA Filing Acceptance System, second generation).  Plans must submit Form 5500 by the last day of the seventh month following the end of the plan year. For a calendar-year plan, the deadline would be July 31. A 2 1/2-month extension may be filed with Form 5558.

More information on 5500 filings can be found here.

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