Out-of-Pocket Maximum for 2014

Did you do a double take on page 4 of the Benefits Guide? 
Third column down on both Value and Buy-Up Plans reads Annual Out-of-Pocket $6,350 for an Individual and $12,700 for a Family. Gee didn't that say "none" in 2013? Don't be alarmed by the number ... It's not that there were no out-of-pocket expenses for in-system copays in 2013 it's just that there was no requirement for specified maximums. Due to Healthcare Reform in 2014, maximum out-of-pocket expenses now must now be specified. $6,350  is the maximum out-of-pocket you can spend on your in-system copays for yourself and $12,700 is the maximum you can spend on your in-system copays for your family.

Who Figures This Stuff Out?
Rest assured these figures were derived by Actuaries, not the Benefits Team. Actuaries analyze the financial cost of risk and uncertainty. They use mathematics, statistics and financial theory to assess the risk that an event will occur and help businesses develop policies that minimize the cost of that risk.
There! Don't you feel better knowing that?

Employers Evaluate Spousal Coverage

You may be wondering "why this new spousal charge of $1040 for 2014". After all you have been claiming your spouse as a dependent for years. The reason behind the surcharge is based on the health system's goal to align with the initiative of Healthcare Reform. Many other organizations are either implementing or have implemented a spousal surcharge. According to Towers Watson up to 60% of hospital employees will have a spousal surcharge by 2015.

In comparison, there are a few large companies that skipped the surcharge and simply excluded a spouse's coverage when they have access to a medical plan through their own employer, referred to as Spousal Exclusion. According to benefits consulting firm Mercer, 6 percent of companies now exclude spouses who can get healthcare through their own employers, up 3 percent since 2008. That number is likely to grow.

Keep in mind, North Shore-LIJ will continue to cover your spouse if he or she is not eligible for health insurance through their own employer. In 2014 no one's spouse will be forced to purchase their own coverage on the State Exchange.

Here are some examples.

Benefits Eligible Employee at North Shore-LIJ	Spouse’s Status	Surcharge Status
Mary is married to Rob.	Rob is currently unemployed.	No surcharge - If Rob finds employment in 2014 and chooses to stay on Mary’s plan no surcharge will be incurred due to the fact that his employment status will not be considered a Qualifying Life Event (QLE).
Alex is married to Susan.	Susan is on Medicare.	No surcharge – Alex can enroll Susan in the medical plan with no surcharge because she is on Medicare.
Joe is married to Robert.	Robert is eligible for a medical plan through his own employer, but chooses to stay on Joe’s plan because his employer’s plan is much more expensive than the North Shore-LIJ plan.	Surcharge - If Joe continues to claim Robert as a dependent on his North Shore-LIJ medical plan he will see a surcharge of $1,040 in 2014.
Carol is married to Steven.	Steven, who is self-employed, wants to continue on Carol’s plan at North Shore-LIJ and not seek insurance on the State Exchange.	No surcharge – Carol can continue to cover Steven. He will not have to seek health insurance on the State Exchange because an employer is not offering him a medical plan.
Bob is married to Alice.	Alice, who just needs dental coverage, is eligible for a medical plan through her own employer and plans to enroll.	No surcharge - If Bob is electing just the dental plan for Alice he will not see a surcharge in 2014, but he will have to adjust his elections on Employee Self Service.

Read recent article from Newsday, The New Insurance Landscape for Spouses.