April 2   3 00pm - william stuart
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  • 1. Dodging the  Cadillac Tax
  • 2.  Your presenter is not a lawyer  The information presented should not be construed as legal advice  Your presenter does not endorse any of the specific ideas presented  Please consult with appropriate counsel before adopting a benefits strategy  Continue to monitor information from Washington, DC, that may impact some of these strategies
  • 3. Defining the Cadillac Tax • Established through Section 9001 of the Affordable Care Act • “Excise Tax on High Cost Employer-sponsored Health Coverage” • Goes into effect on renewal in 2018 • Applies a 40% excise tax on premiums above the following figures (in most cases) • $10,200 for individual coverage • $27,500 for family coverage • Figures subject to certain industry-specific adjustments
  • 4. Defining the Cadillac Tax • Figures adjusted annually • 2019: CPI + 1% • 2020 and beyond: CPI • The figure includes the following • Medical premiums (employer and employee share) • Health Flexible Spending Arrangement elections • Health Reimbursement Arrangements • Employer contributions to Health Savings Accounts (employee?) • Excluded from the calculation: • Stand-alone dental and vision and other ancillary coverage
  • 5. Purpose of the Cadillac Tax • Raise money to offset premium subsidies under the ACA • Help reduce the cost of employer-based health insurance • Reduce negative incentives inherent in the current employer-based health insurance model • Tax implications that make additional compensation more attractive as tax-free benefits than taxable cash • Low out-of-pocket member responsibility that encourages overutilization
  • 6. Who Will Be Impacted? • As many as 75% of employers over the next decade – Bradley Herring, health economist at Johns Hopkins • “The last time that we looked . . [a]lmost half of employers had plans that would hit the excise tax in 2018” – Tracy Watts, Mercer • 15% of employers in 2018, 28% by 2021, 56% by 2025 and 76% by 2029 – Former Sen. (and surgeon) Bill Frist, R-Tenn. • Approximately 60% of employers by 2018 – Towers Watson • Many businesses, especially with ACA-fueled premium boosters and adjustments based on CPI
  • 7. $0 $2,000 $4,000 $6,000 $8,000 $10,000 $12,000 $14,000 $16,000 $18,000 $20,000 6% Increase 8% Increase 10% Increase Tax Figures based on 2013 average individual premium, per KFF Impact on “Average” Group
  • 8. The Case for Acting Now • 2018 is only three or four renewals away • The sooner you act, the later the tax impacts you • The sooner you begin a thoughtful action plan • the less disruptive your plan may be • the greater the number of options you’ll have • the more you can engage employees in understanding the issue, options and implications
  • 9. The Ultimate Formula For Success • The most successful strategy will address twin goals: •Reset the Premium Base •Bend the Cost Curve
  • 10. $0 $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 8% Increase Reset ‐10% and 5% Increase Tax The Formula in Action Reset  Base
  • 11. $0 $2,000 $4,000 $6,000 $8,000 $10,000 $12,000 $14,000 $16,000 $18,000 $20,000 Jan‐13 Jan‐14 Jan‐15 Jan‐16 Jan‐17 Jan‐18 Jan‐19 Jan‐20 Jan‐21 Jan‐22 Jan‐23 Jan‐24 Jan‐25 Jan‐26 Jan‐27 Jan‐28 Jan‐29 Jan‐30 Jan‐31 Jan‐32 No ‐10% reset Reset 2015 Reset 2018 Tax The Impact of Timing
  • 12. Divergent Opinions • “[M]ost employers are looking forward to this Cadillac tax in 2018 and realizing they’re going to have to get ready for it now. And you can’t just shift costs to avoid it; you have to cut benefits.” – Bob Laszewski, president of Health Policy and Strategy Associates - “For the most part, very little will change for people getting their insurance through large employers. . . There is nothing in the law that tells you you need to raise copayments or deductibles. In fact, the law limits your ability to shift costs to your workers.” – Jason Furman, President Obama’s chief economic advisor
  • 13. Three Potential Courses of Action • Indirect • Change the law • Direct (account-specific) • Stop offering group health insurance • Continue to offer group insurance with changes that • Reset the Premium Base • Bend the Cost Curve
  • 14. Potential Action: Change the Law • Repeal the ACA • Retain Republican House and elect Republican Senate by 2016 • Elect a Republican president in 2016 • Look to Republicans to repeal the ACA • Modify Section 9001 • Doesn’t require Republican control of power • Already taking place (unions) • This approach neither Resets the Premium Base nor Bends the Cost Curve, but it successfully eliminates the excise tax
  • 15. Potential Action: Stop Playing • Potentially viable option for employers with 50 (soon 100) or fewer employees to terminate group coverage • Employer faces no penalties • Employees probably qualify for taxpayer subsidies • Employer can share savings with employees – optional, but may be necessary in a competitive labor market • Note: Employer contribution through an HRA is fraught with danger! • Less attractive option for large employers, who face penalties for failure to offer affordable group coverage • Uses a sledgehammer to eliminate the need to meet our twin goals
  • 16. Potential Action: Change Group Demographics • Change employee characteristics • More male • More young • More cultures that are reluctant to seek care • Risky approach • Discrimination issues • Moral/ethical issues • Tail (insurance costs) may wag the dog (productivity) • Meets our goal of Resetting the Premium Base (with huge potential negative impact on business), but does little to Bend the Cost Curve
  • 17. Potential Action: Pass Cost to Employees • Adjust employee contributions to premium to pay the excise tax • Example • Premium is $30,000 ($1,000 excise tax on $2,500 * 40%) • You typically pay 70% of premium, which you apply to the $27,500 • So, you pay $19,250 and employee pays $10,750 • Doesn’t address the issue of overinsurance/overutiliation, but shifts the cost to the employee, which may prompt different plan choice • Indirectly helps Reset the Premium Base and Bend the Cost Curve through employee buydown
  • 18. Potential Action: Self-insure • Increasingly viable option for smaller groups • Eliminate/selectively add state-mandated benefits • Can’t avoid growing number of federal mandates, including ACA • Design plans that promotes high performance providers • Create network incentives or restrictions • Mandatory or incented national or international medical tourism • Mandatory or incented regional or national centers of excellence
  • 19. Potential Action: Self-insure • Potential issue: Feds may take a dim view of self-insurance among smaller employers and limit employer ability to shield from risk (reinsurance restrictions) • Meets our goal of resetting the baseline immediately • Immediately Reset the Premium Base with elimination of ACA assessments and some or all state mandates • Changes in care delivery determine whether this strategy Bends the Cost Curve
  • 20. Potential Action: Wellness Focus • Introduce or enhance a robust wellness program to reduce claims • Other potential benefits include greater employee productivity and loyalty to company • Difficult to quantify benefits of a wellness program (ROI) • Not easy to speculate on events that didn’t happen and attribute them to wellness program • Employers with wellness program experience are moving in the direction of offering rewards based on outcomes, not activity • Be careful of legal (discrimination) issues • Little impact on Resetting the Premium Base, but may Bend the Cost Curve
  • 21. Potential Action: Network Design • Offer a high-performance network • Cost-quality based on total cost of care, not contracted rates • Highly integrated networks across continuum of care, including medical home • Under self-insured model, opportunity to negotiate directly with providers • Create competition • Negotiated package rates? Guarantees? • Very select admission to providers outside the network
  • 22. Potential Action: Network Design • Employees in employer-based insurance generally prefer to pay more to access a broader network (55% to 34%) . . . but when told that they can save up to 25%, support drops to 37% overall and 22% of those uninsured or buying nongroup coverage • Congress may limit narrow networks after 2014 public exchange experience • Definitely Resets the Premium Base • Has positive impact on Bending the Cost Curve with more efficient providers delivering more effective care
  • 23. Potential Action: Offer an HSA-qualified Plan  Health Savings Accounts are a tax-perfect vehicle  HSAs have advantages that no other plan can offer • Immediate tax savings • Flexibility • Rollover of unused funds • Employee sets timing and amount (up to set limits) on contributions • Employee determines when to reimburse an expense • Long-term financial asset, including retirement savings  Typically the lowest-premium plans offered
  • 24. Potential Action: Offer an HSA-qualified Plan  Broad up-front deductible engages employees in the cost implications of their diagnostic and treatment decisions • Typically lower cost trend, particularly in early years of adoption  Pass employer premium savings to employees as cash income • Employees then can make employee contributions to their HSAs • Remember, employer contributions are included in premium calculation • Need clarification on whether employee contributions are included  Achieves our twin goals • Resets the Premium Base • Bends the Cost Curve with engaged consumers with “skin in the game”
  • 25. Potential Action: Introduce a Private Exchange  Private exchange • Portfolio of health plans (typically six-12 plans, with 40% spread) • Rich menu of ancillary • Traditional: Dental, vision, life, STD/LTD, voluntary • Nontraditional: Pet, prepaid legal, telemedicine, wellness, identity protection • Decision-support tools to help each employee make best choices  Employer typically sums all benefit costs and divides into a defined contribution for each employee  Employee mindset shifts from insurance renewal to personal risk mitigation opportunity
  • 26. Potential Action: Introduce a Private Exchange  Private exchanges are being offered by • National consultants (AonHewitt, Mercer, Towers Watson, Buck) • National brokers • Regional brokers • Technology companies  Exchanges by themselves don’t eliminate the tax  Employer controls which plans are offered to eliminate/minimize the number of plans subject to excise tax  Employer contributes via a defined contribution
  • 27. Potential Action: Introduce a Private Exchange  Employees typically buy down (lower premium) when they are responsible for 100% of the cost difference among plans • The lower the contribution, the more dramatic the buy-down • Employees buy up on ancillary products (not subject to Cadillac Tax) • Direct any employer contribution savings to employees as higher wages • Employees can spend money on benefits tax-free through a Section 125 plan  Achieves our twin goals • Employer plan option decisions and employee buydown results in immediate Resetting of Premium Base employee-by-employee • Consumer-driven products incent employees to Bend the Cost Curve in their own self-interest
  • 28. Your Carrier’s Role • Form new reimbursement arrangements with providers • Pay for performance • Risk-sharing • Integrated delivery system • Specialization • Create robust performance networks • Provide transparency tools for members • Facilitate self-insurance programs and options
  • 29. Your Carrier’s Role • Aggressively identify and manage chronic conditions • Create and cover meaningful alternatives to simple care in high-cost settings • Offer effective turnkey wellness programs with demonstrable ROI • Manage pharmacy – potential near-term explosion in costs
  • 30. Transparency in Action MRI of the Brain Without Dye Facility Distance Cost Difference Good Samaritan Hospital ‐Brockton 10.6 miles $660 Brockton Hospital 6.2 miles $759 +$99 (+15%) Shields MRI – Weymouth 8.9 miles $764 +$105 (+16%) Shields MRI – Brockton  10.0 miles $764 +$105 (+16%) South Shore Hospital ‐ Weymouth 7.7 miles $1,363 +$703 (+106%)
  • 31. Conclusion  View the Cadillac Tax as a positive development • Promote meaningful dialogue with employees • Use looming deadline to act thoughtfully and decisively  Get started in the planning process now  Evaluate which combination of approaches fit with company culture and magnitude of change necessary  Continue to monitor the environment to see potential new approaches and restrictions on current ideas  And remember our twin goals . . .
  • 32. Reset the Premium Base
  • 33. Bend the Cost Curve