Health Care Reform Update


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An update on Health Care Reform and the Affordable Care Act. Find out what employers like you need to know to implement changes while staying in compliance and avoiding penalties and unexpected costs.

Presented by Mike Gurowski, Sharon Pappas and Ed Hilton of Titan Insurance & Employee Benefits Agency, LLC.

This seminar is part of the 2013 CPE Series, a series of seminars sponsored by Insero & Company CPAs P.C. dedicated to providing financial professionals and business owners with relevant, up-to-date information and networking opportunities at an affordable price. For more information on our CPE Series visit

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  • Health Care Reform Update

    1. 1. Health Care Reform Update Presented by Michael Gurowski, President Sharon Pappas, Compliance and Benefits Technology Specialist Ed Hilton, Underwriting Manager Titan Insurance and Employee Benefits Agency, LLC July 23, 2013 Insero & Company’s 2013 CPE Series Presents
    2. 2. Health Care Reform: Guidance for 2014 and beyond Presented by: Titan Insurance & Employee Benefits Agency, LLC 2
    3. 3. • 2010 – 2013 in Review Mandates Already in Effect 3
    4. 4. Mandates Effective in 2010: – Change in tax treatment for over-age dependent coverage – Accounting impact of change in Medicare retiree drug subsidy tax treatment – Early retiree medical re-insurance – Medicare prescription drug “donut hole” beneficiary rebate – Break time/private room for nursing moms 4 2010 – 2013 Review
    5. 5. Mandates Effective in 2011: – Dependent coverage to 26 – No lifetime dollar limits – Restricted annual dollar limits, phased amounts until 2014 – No pre-existing condition limitations for enrollees up to age 19 and no rescissions – No health FSA/HRA/HSA reimbursement for non-prescribed drugs – Increased penalties for non-qualified HSA distributions – Additional standards for new or ”non-grandfathered” health plans including preventive care in network with no cost sharing, appeal and external review, provider choice, and non-discrimination rules for insured plans – Income-based Medicare Part D premiums – Pharmaceutical importers and manufacturer’s fees start – Medicare Advantage benefit and payment reforms to begin – Insurer’s subject to Medical Loss Ratio rules 5 2010 – 2013 Review
    6. 6. Mandates Effective in 2012: – Employers to distribute uniform summary of benefits and coverage (SBC) to participants (deadlines vary with group of recipients) – 60 day advance notice of mid-year material modification to SBC content – Form W-2 reporting for health coverage (track in 2012 for W-2 form provided in early 2013) – Coverage for additional women’s preventive care services begins (plan years on or after August 1, 2012) – MLR rebates from carriers 6 2010 – 2013 Review
    7. 7. Mandates Effective in 2013: – $2,500 health FSA contribution cap (indexed) – Comparative effectiveness group health plan fees begin – Medical device manufacturers’ fees start – Higher Medicare payroll tax on wages exceeding $200,000 per individual or $250,000 per couple – Change in Medicare retiree drug subsidy tax treatment takes effect – Exchanges initial open enrollment period to begin by end of year 7 2010 – 2013 Review
    8. 8. 8 Preparing Your Company 2014 - 2018
    9. 9. Employer Notification Regarding Exchanges • Employers must provide existing employees and new employees on their hire date with information about the existence of state insurance Exchanges, including information on employee eligibility for an Exchange if the actuarial value of the health plan is less than 60% and the employee’s contribution towards the cost of employee-only coverage exceeds 9.5% of his/her household income, and the loss of employer contribution toward the value of coverage if the employee purchases coverage through the Exchange. • Notice due to ALL employees by October 1, 2013, and all new hires thereafter. Note: Model notices available at: and 9 Due October 1, 2013
    10. 10. 10 Employer Notification – Required Information for Both Notices
    11. 11. 11 Employer Notification – Required Information for Employers Offering Coverage
    12. 12. 12 Employer Notification – Required Information for Employers Offering Coverage
    13. 13. – Individual mandate – Health insurance industry fees begin – Limit on employee deductible $2,000 single/$4,000 family (small employer 100 or less) and out-of-pocket expenses $6,350 single/ $12,700 family – 90 day limit on waiting periods – Automatic enrollment for employers over 200 – Non-discrimination in favor of highly compensated employees – HIPAA wellness limit increases to 30% – No annual dollar limits on essential health benefits for any plan – New York State Exchanges open – Small business tax credit – Medicaid expansion – Required coverage for clinical trial for life threatening illnesses – Changes to Grandfathered Plans: • Dependent coverage to age 26 for any covered employee’s child • No annual dollar limits • No pre-existing condition limits • No waiting period over 90 days 13 Effective January 1, 2014
    14. 14. – Pay-or-Play/Employer Shared Responsibility – Additional reporting and disclosure requirements 14 Effective January 1, 2015
    15. 15. 15 Effective January 1, 2014 Taxes and Fees
    16. 16. Health Care Reform requires individuals to obtain “minimum essential coverage” (i.e. Medicare, Medicaid, CHIP, individual insurance and eligible employer sponsored plans) for themselves and their dependents or pay a monthly penalty tax for each month without coverage. The monthly penalty is 1/12 of the greater of the dollar penalty or the gross income penalty amounts. In 2017 the dollar penalties will be indexed for inflation. Waivers are allowed for specified individuals and circumstances. Individual Mandate 16 Penalty will be the greater of: Annual Dollar Amount Single / Family: Percent of Income: 2014 $95 / $285 1% 2015 $325 / $975 2% 2016 $695 / $2,085 2.5% 2017 Indexed for inflation
    17. 17. • Patient-Centered Outcomes Research Institute (PCORI) fee, formerly the comparative effectiveness research fee, on plan sponsors and issuers of individual and group policies. – $2 PMPY beginning in 2014, indexed to Health Care Expenditures through 2019 – These fees apply to self insured plans such as HRAs – Health insurers and health plan sponsors can deduct fees as a business expense • Reinsurance fee for state-based exchanges assessed on insurers. – Amount based on a national per capita contribution rate to be determined by HHS for a benefit year, ending in 2016 – 2014 charge will be $5.25 PMPY • Health Insurer Tax – Current estimate is 1.5% of annual rate Health Insurance Industry Fees 17
    18. 18. 18 Effective January 1, 2014 Plan Design Changes
    19. 19. • Group health plans must limit out-of-pocket costs to $6,350 for single coverage and $12,700 for family coverage. • Groups health plans must limit deductible levels to $2,000 for single coverage and $4,000 for family coverage. Applicable only to Small Group Plans (Under 100). 19 Limit on Out-Of-Pocket Expenses Note: Carriers have indicated they have filed plans with higher deductibles in order to meet actuarial value levels required to operate on the NYS exchange.
    20. 20. • 90 days means 90 days within the first day they are eligible – If employees can elect within 90 days but fail to elect within 90 days, it is not a violation – If employee is clearly eligible, must be enrolled on or before 90th day • If employee is not clearly eligible, employer may use a reasonable period to determine eligibility if: – A. Period is not designed to avoid the 90 day period – B. Individual becomes eligible within 90 days of being assessed eligible, or, if earlier, within 13 months of start date (plus the days to the first day of the next calendar month if the employee’s start date is the middle of the month) 90 Day Enrollment Requirement 20
    21. 21. Employers with more than 200 employees who maintain one or more group health plans must automatically enroll all full-time employees (defined as employees who work more than 30 hours per week) as soon as they are eligible for coverage. The employer must give affected employees notice of this automatic enrollment procedure and an opportunity to opt out. Note: Effective date to be determined upon release of final regulations. 21 Auto Enrollment
    22. 22. Employers are required to offer the same level of tax-free coverage to all classes of employees. If any employer offers additional benefits only to highly compensated employees, those benefits will be taxed. Note: Effective date to be determined upon release of final regulations. 22 Non-Discrimination
    23. 23. • Law increases wellness incentives from 20% to 30% of total premium (employer and employee shares) – 30-50% of the total premium can be shifted to participants: • who don’t participate in screening, • who fail biometric screening and who either don’t engage in the wellness program or • fail to improve their health via the program – New guidance enables 50% differential for tobacco cessation Tobacco usage surcharge applied inclusively (e.g. 30 + 20) – Premium differential from a Wellness Program does not excuse the employer from the affordability test • Can be imposed on family members • Wellness regulations / HIPAA nondiscrimination continue to apply 23 HIPAA Wellness Limits Change
    24. 24. Essential health benefits must be covered at no cost share on all plans: • Ambulatory patient services • Emergency services • Hospitalization • Maternity and newborn care • Mental health and substance abuse disorder services; including behavioral treatment • Prescription drugs • Rehabilitative and habilitative services and devices • Laboratory services • Preventive and wellness services and chronic disease management • Pediatric services, including oral and vision care Essential Health Benefits 24
    25. 25. Requirement Penalty for non-compliance Limit on Out-of-Pocket Expenses $100/day for each affected individual 90 Day Limit on Waiting Periods $100/day for each affected individual Automatic Enrollment $100/day for each affected individual Non-Discrimination $100/day for each affected individual No Annual Limits on Essential Health Benefits $100/day for each affected individual Summary of Benefits and Coverage $1,000 fine for each willful failure to issue 25 Non-Compliance Penalties
    26. 26. 26 Effective January 1, 2014 Small Business Impact
    27. 27. SHOP = “Small Business Health Options Program” • Every state may establish a health insurance Exchange for use by the uninsured and small employers with 100 or fewer employees (although states may set the cap at 50 employees, as NYS has). Those states that do not establish their own will defer to a federally-run exchange. – Federally-run state exchanges have been delayed until 2015. • Initial Open Enrollment Period October 1, 2013 thru March 31, 2014 – Annual Open Enrollment period October 15 thru December 7 for effective date of January 1st • Coverage will be available based on a scale corresponding to precious metals: – Platinum (90% Actuarial Value) – Gold (80% Actuarial Value) – Silver (70% Actuarial Value) – Bronze (60% Actuarial Value) – Catastrophic-Only Coverage available to those under 30 27 New York SHOP Exchange
    28. 28. • Qualified Employers may buy coverage through the SHOP Exchange • Though the SHOP Exchange, employers can offer coverage to employees through one of the following options: – One metal level and all products with level – One specific health insurer and a specific product offered by insurer – One specific health insurer and offering multiple products from the insurer – All metal levels and all health insurer products • The SHOP will also permit the ability to offer an “ employee choice” model through defined contribution mechanisms. • Small Employer Tax Credits lost if insurance is not purchased through the Exchange. 28 Note: NYS exchange information will be located at New York SHOP Exchange
    29. 29. • Do you meet the requirements for the Small Business Tax Credit? — 25 or fewer employees — Average annual wages are less than $50,000 per FTE — Offer health insurance to employees *New for 2014* Insurance must be purchased through SHOP — Pay at least 50% of single-only coverage — Owners are excluded from employee count and wage calculation • Applications due by 4/1/14 for 2013 plan year Small Business Tax Credit 29 Note: National Tax Credit Calculators are publicly available at:
    30. 30. • Maximum Credit — Up to 50% of a small business’ premium costs in 2014 for two years — Up to 35% for tax-exempt employers (refundable via payroll tax) for two years • Credit is reduced on a sliding scale — As average wages increase from $25,000 to $50,000 — As FTEs increase from 10 to 25 Small Business Tax Credit 30 Note: National Tax Credit Calculators are publicly available at:
    31. 31. 31 Effective January 1, 2015 Pay or Play Mandate
    32. 32. On July 9, 2013, IRS Notice 2013-45 formally delayed the Pay or Play mandate and the related employer reporting requirements until 1/1/2015. The Notice repeats the initial government observations that the delay will: (1) provide an opportunity for the government to receive input on how the reporting can be simplified, (2) allow employers and insurers to adapt their reporting systems, and (3) permit employers an opportunity to voluntarily comply with the requirements. The latter will allow employers to work on compliance without the specter of penalties during 2014. 32 IRS Notice 2013-45
    33. 33. • Applicable Large Employer (ALE) are groups subject to Pay or Play Mandate • An employer is an ALE for a calendar year if it employed average of at least 50 Full-time equivalent (FTE's) during preceding calendar year – Full-time equivalent employees (e.g., part-time employees) are counted only for purposes of determining ALE status – Full-time equivalent employees are NOT counted for penalty purposes under Pay or Play • To determine ALE status, count the employer's full-time employees (using a 30 hour per week standard) plus the result of dividing the hours of service of employees who are not full-time employees by 120 for each month • NOTE TO EMPLOYERS THAT MAY SHARE COMMON OWNERSHIP: Consult legal counsel to determine if you are part of a control group. 33 What Is An "Applicable Large Employer" Pending further guidance; subject to change based on IRS Delay Notice 2013-45.
    34. 34. • Scenario: During each calendar month of 2013, an employer has 20 full-time employees who average 35 hours per week, and 40 part-time employees who average 90 hours per month. – Each of the 20 employees who average 35 hours per week count as one full-time employee. – To determine full-time equivalent employees, take total hours of the part-time employees (up to 120 hours of service per employee) and divide by 120. • In the example, the employer has 30 full-time equivalent employees each month (40 90 120 = 30). • Result: Employer has 50 FTEs during each month in 2013 and is an ALE for 2014. 34 Example of ALE Calculation Pending further guidance; subject to change based on IRS Delay Notice 2013-45.
    35. 35. • All counting done on a “Controlled Group” basis – EIN is irrelevant – Controlled group relationships exist if the business has one of the following relationships: • Parent-subsidiary • Brother-sister • Combination of the above • An employer may determine whether it is an ALE for 2014 by determining whether it employed an average of at least 50 FTE’s on business days during any consecutive six-month period in 2013 • Employers may subtract seasonal employees from FTE count if count included seasonal employees employed no more than 120 days during the preceding calendar year 35 Notes on ALE Calculation Pending further guidance; subject to change based on IRS Delay Notice 2013-45.
    36. 36. Small Employers (50 or less) • Employers with fully insured plans will be completed by the carrier. • Employers with self insured plans will have to complete the IRS Filing. Applicable Large Employers (50 or More) • Effective for plan years beginning after December 31, 2013, every applicable large employer must file a return with the IRS a report describing terms and conditions of the health care coverage provided to the employer's full-time employees for the year. • No later than January 31 following the calendar year of a plan, employers must certify that all full-time employees were offered health care coverage. • The certification should specify the length of the waiting period under the plan, the time period during which coverage was available, the premium charged, as well as the employer’s share of the cost. • The Secretary will use this certification to enforce the individual mandate. 36 Employer Certification/Reporting Requirements Pending further guidance; subject to change based on IRS Delay Notice 2013-45.
    37. 37. • Employers with 50 FTE’s or more will be required to offer “minimum essential coverage” to all full-time employees (working 30+ hours) plus dependents through a group health plan. – Dependent is defined as children under the age of 26 – Guidance gives relief to employers – 5% margin of error, regardless if error was inadvertent or not. • Minimum essential coverage is considered coverage that both provides minimum value and is affordable : – Plan has an actuarial value of at least 60% – The employee’s cost share does not exceed 9.5% of W2 box 1 income – At least single coverage for the lowest cost plan must meet these guidelines 37 Employer Shared Responsibility Pending further guidance; subject to change based on IRS Delay Notice 2013-45.
    38. 38. PENALTY 1 – EMPLOYER DOES NOT OFFER COVERAGE PENALTY 2 – EMPLOYER OFFERS COVERAGE THAT IS UNAFFORDABLE = $2,000/yr x (Total Number of FT Employees minus the first 30) = lesser of: $3,000/yr x Total Number of FT Employees receiving premium credit on exchange -or- $2,000/yr x (Total Number of FT Employees minus the first 30) 38 Penalty is ONLY triggered when a FT employee receives a premium tax credit to purchase insurance off the individual exchange. Employees are only eligible to receive a credit if they are not offered “affordable coverage” from their employer. Employer Shared Responsibility – Penalties Pending further guidance; subject to change based on IRS Delay Notice 2013-45.
    39. 39. • Full-Time is defined as: – Averages at least 30 hours per week or 130 hours per month. – Vacation, holidays, paid leaves of absence must be included. – Different tests apply for on-going employees and new employees: • Count on-going employee’s hours during the standard measurement period and determine employee’s status as FT or PT. That determination governs the employee’s status during the stability period. • If a new employee is reasonably expected to work at least 30 hours per week when hired, they are considered full-time. If it is unclear, an employer may use an initial measurement period to evaluate hours and determine FT status. 39 Determining Full Time Employees Pending further guidance; subject to change based on IRS Delay Notice 2013-45.
    40. 40. • Standard Measurement Period – a period of between three and 12 months, as designated by the employer for determining full- time status of ongoing employees. • Initial Measurement Period – a period of between three and 12 months, as designated by the employer for determining full-time status of new variable hour or seasonal employees. • Administrative Period – optional period of time after standard measurement period and before stability period which cannot exceed 90 days. Gives employers time for determining FT status and enrollment of eligible FT employees. Initial Measurement Period + Administrative Period cannot be more than 13 months plus fraction of a month. • Stability Period – period designated by employer that lasts between six and 12 months that begins after, and is no shorter than, the standard measurement period where the employee’s status is “locked in.” 40 Determining Full Time Employees
    41. 41. 41 11/1/13 – 10/31/14 Standard Measurement Period to determine FT status of on-going employees 11/1 – 12/31/14 Administrative Period to perform measurements and enroll FT employees 1/1/15 – 12/31/15 Stability Period wherein employees who were determined to be FT are enrolled in plan 11/1/14 – 10/31/15 1/1/16 – 12/31/16 11/1 – 12/31/15 Example: Measuring for FT Status Pending further guidance; subject to change based on IRS Delay Notice 2013-45.
    42. 42. 2015: Electronic claims processing, enrollment and premium payment mandatory 2017: States can allow larger employers (<100 employees) to use exchanges 2018: Cadillac plan excise tax starts 42 Effective 2015 – 2018
    43. 43. • 40% non-deductible tax on excess over threshold premium levels — $10,200 Single and $27,500 Family annual cost for 2018 — Increased by $1,650 Single and $3,450 Family: —For non-Medicare eligible retirees age 55+ —If majority of employees covered by the plan are engaged in a high-risk profession (listed in statute) — Includes HRAs, HSAs, and FSAs — Threshold amounts increase by CPI+1% first year and CPI every year thereafter • Tax is paid by insurer or administrator, not by participant Cadillac Tax 43
    44. 44. 44 PPACA: A Moving Target
    45. 45. Team Contact Information: Michael Gurowski, President • • 270-5761 ext. 109 Eric Gilbert, Executive VP • • 270-5761 ext. 105 Ed Hilton, Underwriting Manager • • 270-5761 ext. 103 Sharon Pappas, Compliance & Benefits Technology Specialist • • 270-5761 ext. 113 45 Rochester Syracuse Long Island Canandaigua
    46. 46. The information contained in the presentation is for informational purposes only and should not be used to replace medical, legal or tax advice. 46 Please visit us at: