Health Decisions Webinar: May 2013 obama care compliance 1 of 3


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  • We want to pose initial questions to participants at this point: Are you a self-funded plan (choose one) __fiduciary __manager __advisor __administrator What is the approximate number of active employees in the self-funded plan you represent? __under 100 __100-1000 __1000 to 5000 __over 5000 What is the approximate number of retirees in the self-funded plan you represent? __ none __under 100 __100-1000 __1000 to 5000 __over 5000
  • Health Decisions Webinar: May 2013 obama care compliance 1 of 3

    1. 1. Presenter:Si Nahra, Ph.D., PresidentMay 30, 2013Pay-or-Play:A Bigger Challenge for TPAs than Plans
    2. 2. 222About Health Decisions, Inc.Pioneering Specialists inPioneering Specialists inGroup Health CareGroup Health CarePost-Payment AdministrationPost-Payment AdministrationFor Over 25 YearsFor Over 25 YearsRespectRespect for Existing Proceduresfor Existing ProceduresEmphasisEmphasis on Customizationon CustomizationFocusFocus on Solutionson SolutionsCustomer Philosophy
    3. 3. Today’s SessionFocus:•Recent “ObamaCare” Pay-or-Play / Shared ResponsibilityRegulations•Employer Plans Generally•Self-funded Plans specificallyTerms:•Plan: Employment-based group health plan•TPA: Administrator paid to operate group health planCopyright Health Decisions, Inc.5/20133
    4. 4. ObamaCare Compliance•For Most Plans No Big Deal•For Some Plans Complicated•For a Few Plans MaddeningCopyright Health Decisions, Inc.5/20134
    5. 5. ObamaCare ComplianceSituation Compliance“Hassle” FactorStable work force working 30+ hours per week 1Stable work force working variable and varying hours 2Work force growing through large acquisitions 3Work force experiencing high turnover 4Fluctuating workforce with fluctuating hours 5Copyright Health Decisions, Inc.5/20135Not All Plans Impacted the Same.
    6. 6. ObamaCare Compliance• Compliance Penalties– Unlikely to occur for most– Less likely to be aggressively enforcedDon’t comply because you have to.Comply because it helps you.Copyright Health Decisions, Inc.5/20136
    7. 7. ObamaCare Compliance• Regulations built around the individual.• Defines the marketplace product.• Standardizes product definitions.• Defines certain administrative procedures.Copyright Health Decisions, Inc.5/20137
    8. 8. ObamaCare ComplianceComponentsPay-or-Play DecisionOut-of-Pocket (OOP) MaximumsTwo-way CommunicationsCopyright Health Decisions, Inc.5/20138
    9. 9. ObamaCare CompliancePay-or-Play Decisions(HINT: Play!)Safe Harbors•Affordability: Same limits on premium sharing for all9.5% of income•Minimum Value: Easily metIf OOP limits tied to pre-tax levelsCopyright Health Decisions, Inc.5/20139
    10. 10. ObamaCare CompliancePay-or-Play DecisionsFTE Counting•Organizes eligibility determination.•Addresses biggest source of error for employersSee prior webinars for 9/2011 & 9/2010 also10/12, 6/11, 4/10, 10/09FTE Calculation•Links to open enrollment.•May impact hours offeredFTE Maintenance•Stability period enforcement new•COBRA coordination (or elimination?)Copyright Health Decisions, Inc.5/201310
    11. 11. ObamaCare CompliancePay-or-Play DecisionsOptimal Plan Features for Employee EligibilityOptimal Plan Features for Employee Eligibility•Premium sharing less than 9.5% of income.•OOP maximums less than $6,500/year.•Eligible at 30 hours per week.•Waiting period 90 days or less.Copyright Health Decisions, Inc.5/201311
    12. 12. ObamaCare ComplianceOOP MaximumsDefines terms•deductible, copay, coinsuranceStandardizes calculations•Deductible + copay + coinsurance•For both medical & RXOOP maximums linked to pre-tax healthaccountsCopyright Health Decisions, Inc.1/201312
    13. 13. ObamaCare ComplianceTwo-Way Communication•Consumer Reporting (see 4/2010 webinar)– W-2, Standard Summary, Information on Coverage•Regulatory Reporting (to and from)– IRS, DOL, State Exchanges, M-1 for MEWA•Financial Reporting (By Member)– $1-$2 PMPM for Comparative Effectiveness Fee/Patient-Centered Outcomes Research– $5.25 PMPY for Transitional Reinsurance ProgramCopyright Health Decisions, Inc.1/201313
    14. 14. ObamaCare ComplianceTougher on Plan or TPA?Copyright Health Decisions, Inc.1/201314Initial On-going Compliance StepPlay or PlayPlan TPA • Safe HarborsPlan TPA • FTE CalculationsTPA TPA OOP MaximumTwo-way CommunicationPlan TPA • ConsumerTPA TPA • RegulatoryTPA TPA • Financial
    15. 15. ObamaCare ComplianceJune 13thEmployer MandateCalculations ExplainedCopyright Health Decisions, Inc.1/201315
    16. 16. 161616Past Webinars AvailableRecordings of past webinars are available upon request, including:• April 2013 - The Most Overlooked Part of Health Reform: Enrollee Communications• March 2013 – Why Cost Sharing is not Working• February 2013 – Loss of Fiduciary Control• January 2013 – Top 10 Do’s and Donts of Data Warehousing• December 2012 – Union Trusts: Health Reforms Most Overlooked Winner?• November 2012 – Year-end Renewal and Bidding: Opportunities for Control and Savings• October 2012 – The 5 Most Important Things an Effective Dependent Audit Should Include• September 2012 – Old Question, New Twist: Is Self-funding Right for Your Group Health Plan?• August 2012 – Are You Ready to Manage Your Health Plan Costs?• June 2012 - Group Health Brokers’ Future: Disintermediation or Re-intermediation• May 2012 – Five Levers of Management Control• April 2012 – How the AMA Can Help You with Plan Oversight• March 2012 – Health Data ControlFor more information, please visit
    17. 17. 171717For More InformationContactsi@healthdecisions.com734-451-2230Connect with me on LinkedInAdd me to your circles on Google+Like us on FaceBookFollow us on Twitter