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Presenter:Si Nahra, Ph.D., PresidentNate Wallace, Policy and Data AnalystJune 13, 2013Affordable Care Act (ACA)Employer Ma...
222About Health Decisions, Inc.Pioneering Specialists inPioneering Specialists inGroup Health CareGroup Health CarePost-Pa...
Today’s SessionSecond in a three-part series on Affordable Care Act(ACA) compliance for self-funded plans.Today’s focus is...
Employer Mandate Calculations• Minimum Value Test• Affordability Test• FTE Tests– Large Employer Status– Eligibility Test–...
What do you need?• Plan Documentation and Information• Payroll Data• Enrollment Rosters• Claims Data (medical and Rx)All a...
When do tests occur?Test Initial Annually Adds/DeletesLife EventsMonthlyMinimum Value  Affordability   FTE- Large Emp...
Minimum Value• Plans must cover at least 60% of totalallowed costs of benefits• What do you need?Plan DocumentsMV Calculat...
Minimum Value Calculator - HighlightsHSA/HRAAmount ($)$2000 Annual ContributionTier 1 (In-Network) Tier 2 (Out-of-Network)...
Affordability Test• Employees premiums cannot exceed 9.5% oftheir household income• What do you need?Plan DocumentsPayroll...
Affordability TestEmployeeIncomePremiums Paid by EmployeeCopyright Health Decisions, Inc.6/201310
FTE TestsLarge Employer50+ FTEs•What do you need?Payroll data•Full-Time Equivalent100 variable hour employees = 50 FTEsCop...
FTE TestsEligibility Test– Average of 30+ hours of service per week•What do you need?Payroll dataOrder Period Length(min.)...
ACA Complete Cycle“Look-Back” PeriodAdmin.Period“Look-Back” PeriodAdmin.PeriodStability PeriodStability PeriodOngoingOngoi...
FTE Complex Categories• Seasonal Workers• Temp Workers• Commission based Workers• Leave of Absence• New EmployeesCopyright...
Offer TestMaybe not a “test” but something to be documented.Need to show coverage offer made to all eligible people.Requir...
Member Counts2 applicable taxes based on member countsComparative Effectiveness Research Fee (CERF)$1PMPY due in July $2 n...
OOP Accumulation• New definitions• New rules• Requires– Claims data– Medical and Rx• Requires integration of cost sharing ...
ObamaCare ComplianceNext Webinar: June 27th“Obamacare” Compliance: How ItHelps Self-funded PlansClick to registerCopyright...
191919Past Webinars AvailableRecordings of past webinars are available upon request, including:• May 2013 – Pay or Play: A...
202020For More InformationContactsi@healthdecisions.com734-451-2230Connect with me on LinkedInAdd me to your circles on Go...
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Health Decisions Webinar: Employer Mandate Calculations Explained

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This is the second in our three-part webinar series on health reform support around the employer mandate regulations. This webinar focuses on the four levels of calculations associated with Pay-or-Play decisions every plan must make. How to count FTEs and relate those rosters to current enrollment will be covered. Also, simple ways to perform minimum value and affordability tests will be presented.
For more information, please visit: http://www.healthdecisions.com

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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
  • Transcript of "Health Decisions Webinar: Employer Mandate Calculations Explained"

    1. 1. Presenter:Si Nahra, Ph.D., PresidentNate Wallace, Policy and Data AnalystJune 13, 2013Affordable Care Act (ACA)Employer MandateCalculations Explained
    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 PhilosophyCopyright Health Decisions, Inc.6/2013
    3. 3. Today’s SessionSecond in a three-part series on Affordable Care Act(ACA) compliance for self-funded plans.Today’s focus is on calculations to be performed as partof ACA compliance.Copyright Health Decisions, Inc.6/20133
    4. 4. Employer Mandate Calculations• Minimum Value Test• Affordability Test• FTE Tests– Large Employer Status– Eligibility Test– Offer Test• Member Counts• OOP (Out-of-Pocket) AccumulationCopyright Health Decisions, Inc.6/20134
    5. 5. What do you need?• Plan Documentation and Information• Payroll Data• Enrollment Rosters• Claims Data (medical and Rx)All available to every self-funded plan.Copyright Health Decisions, Inc.6/20135
    6. 6. When do tests occur?Test Initial Annually Adds/DeletesLife EventsMonthlyMinimum Value  Affordability   FTE- Large Employer  - Eligibility Test   - Offer Test   Member Counts  OOP Accumulator   Copyright Health Decisions, Inc.6/20136
    7. 7. Minimum Value• Plans must cover at least 60% of totalallowed costs of benefits• What do you need?Plan DocumentsMV Calculator• Department of Health and Human Services(HHS) and IRS released calculatorhttp://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/index.htmlCopyright Health Decisions, Inc.6/20137
    8. 8. Minimum Value Calculator - HighlightsHSA/HRAAmount ($)$2000 Annual ContributionTier 1 (In-Network) Tier 2 (Out-of-Network)Utilization (%) 70% 30%Medical Drug Medical DrugDeductible ($) $600 $400 $1200 $800Coinsurance (%) 80% 90% 70% 60%OOP Max ($) $4000 $2000 $5000 $3000Copyright Health Decisions, Inc.6/20138
    9. 9. Affordability Test• Employees premiums cannot exceed 9.5% oftheir household income• What do you need?Plan DocumentsPayroll dataPossibly survey of family income• IRS’s W-2 Safe HarborCopyright Health Decisions, Inc.6/20139
    10. 10. Affordability TestEmployeeIncomePremiums Paid by EmployeeCopyright Health Decisions, Inc.6/201310
    11. 11. FTE TestsLarge Employer50+ FTEs•What do you need?Payroll data•Full-Time Equivalent100 variable hour employees = 50 FTEsCopyright Health Decisions, Inc.6/201311
    12. 12. FTE TestsEligibility Test– Average of 30+ hours of service per week•What do you need?Payroll dataOrder Period Length(min.)Length(max.)1 “Look-Back” 3 months 12 months2 (Optional) Administrative 0 days 90 days3 Stability 6 months 12 monthsCopyright Health Decisions, Inc.6/201312
    13. 13. ACA Complete Cycle“Look-Back” PeriodAdmin.Period“Look-Back” PeriodAdmin.PeriodStability PeriodStability PeriodOngoingOngoingCopyright Health Decisions, Inc.6/201313
    14. 14. FTE Complex Categories• Seasonal Workers• Temp Workers• Commission based Workers• Leave of Absence• New EmployeesCopyright Health Decisions, Inc.6/201314
    15. 15. Offer TestMaybe not a “test” but something to be documented.Need to show coverage offer made to all eligible people.Required Communications to Eligible employees usingdefined terms and forms.•Part of any or all of these events– Administrative Period– Open Enrollment Communications– Employee Communication Outside Open EnrollmentCopyright Health Decisions, Inc.6/201315
    16. 16. Member Counts2 applicable taxes based on member countsComparative Effectiveness Research Fee (CERF)$1PMPY due in July $2 next yearReinsurance Assessment$63 PMPY 2014, $45 2015, $30 2016•What do you need?– Enrollment Roster(s) with dependents VERIFIED(non-verified adds 4%-12% ineligible dependents)– CheckbookCopyright Health Decisions, Inc.6/201316
    17. 17. OOP Accumulation• New definitions• New rules• Requires– Claims data– Medical and Rx• Requires integration of cost sharing amountsacross plans.Copyright Health Decisions, Inc.6/201317
    18. 18. ObamaCare ComplianceNext Webinar: June 27th“Obamacare” Compliance: How ItHelps Self-funded PlansClick to registerCopyright Health Decisions, Inc.6/201318
    19. 19. 191919Past Webinars AvailableRecordings of past webinars are available upon request, including:• May 2013 – Pay or Play: A Bigger Challenge for TPAs than for Plans• 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 OversightFor more information, please visit www.healthdecisions.comCopyright Health Decisions, Inc.6/2013
    20. 20. 202020For More InformationContactsi@healthdecisions.com734-451-2230Connect with me on LinkedInAdd me to your circles on Google+Like us on FaceBookFollow us on TwitterCopyright Health Decisions, Inc.6/2013
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