Nevada Health Exchange - ACA Employers Need to Know Presentation
Nevada Health Link Exchange Summit:What Employers Need to Know About HealthCare ReformKatherine L. Georger
Disclaimer This is an overview.– There is no substitute for reading the statute, rules andagency guidance.– Check the rules when it is time to comply (see last slidefor link).– Contact your attorney, accountant, tax and/or financialplanner to address questions about your uniquebusiness and circumstances. Many of the rules are provisional. Additional rules andguidance are issued frequently and current provisionalrules and interpretations of the ACA may change. This does not establish an attorney-client relationship. This does not constitute legal advice.
ACA: Key Provisions Individual Mandate Expansion of Medicaid Employer Responsibility Provisions– Penalties—covered employer may face penalties forfailure to provide any or inadequate coverage to eligibleemployees.– Reporting Requirements—Form W-2s; Exchanges; Affordable Insurance Exchange—creates state-based, joint federal-state, or federally runexchanges– Essential Health Benefit Benchmark– Small Business Health Option Program (SHOP)
Constitutional Challenge Individual Mandate– Requires vast majority of Americans to obtain “minimumessential” health insurance coverage– Penalties—individual fails to comply with individualmandate, will have to pay “shared responsibilitypayment” (penalty) payable with the individual’s taxes; Upheld under Congress’s constitutional power to tax Medicaid Expansion– ACA provided additional Medicaid funds, but requiredStates to cover all individuals up to 138% FPL or risklosing all Medicaid funding Struck down as unconstitutional use of federal power to attachpenalty of loss of all Medicaid funding for opting out of increase
Unanticipated Consequencesfor Large Employers? States that decline the Medicaid expansioncomponent of ACA could expand potential liabilityof large employers– Exchange-eligible employees are full-time employees(FTE) with household incomes between 138% and400% FPL Medicaid expansion would have covered nearly allpersons with household income up to 138% FPL If states reject expansion, FTE with householdincome of 100% to 138% FPL eligible for theexchange and eligible to get a subsidy or tax credit
Employer-Related Issues– Employer Responsibility Provisions Penalties: large employers’ failure to provide ANY coverage orINADEQUATE coverage to full-time employees (and theirdependents) Reporting Requirements: large employer must file returncertifying it offers full-timers(and their dependents) opportunityto enroll in minimum essential coverage and report number offull-timers.– Tax Related Issues Form W2s: cost of coverage (250+ employees) Small Business Tax Credits: less than 25 full-timers, avg.income < $50,000.– Exchanges Employer Reporting Requirements: Coverage & COBRAelections
Employer ResponsibilityProvisions Applicable “large employer” may be subject to an“assessable payment” (penalty) if:– It fails to offer its “full-time employees” (and their“dependents”) the opportunity to enroll in a “minimumessential coverage” employer-sponsored plan; OR– The full-time employee’s contribution for “self-onlycoverage” exceeds 9.5% of the employee’s“household income;” OR– The employer-sponsored plan fails to give the full-timeemployee “minimum value” Penalty ONLY triggered if a full-time employee applies forand receives a premium subsidy or tax credit*
Employer ResponsibilityProvisions: Covered Employers Beginning Jan. 1, 2014— “large employers” mayface penalties for not offering health coverage orfor failing to offer adequate coverage– Large employers are employers with at least 50 full-timeequivalent employees Hours of part-timers (those working less than 30 hours perweek) are included in calculation of “large employer”;HOWEVER, part-timers are not eligible to receive tax credit Hours of seasonal workers may count– Only large employers who have at least one full-timeemployee (FTE) receiving premium subsidy or tax creditthrough an exchange and employ at least 30 full-timeworkers may pay penalty
Potential Employer Penalties:No Coverage Large employer’s failure to provide any coverage– If covered employer does not offer coverage full-timersand at least one of its full-timers receives a “premiumtax credit” or “cost sharing subsidy,” then employer isassessed penalty of $2,000 per full-time employeebeyond company’s first 30 full-time employee.– Assessed on monthly basis– Example: Company A has 100 full-timers but no full-timers receive credits. Penalty? No—because employer penalty only triggered upon full-timeemployee’s receipt of tax credit
Employer Penalties: NoCoverage (cont.) Example: Company B has 30 full-timers and 100part-timers. Penalties?– No—employer is considered “large employer” with 80full-time equivalent workers; however, penalty is onlyassessed against number of full-time employeesbeyond the first 30 full-timers. Example: Company C has 50 full-timer and onefull-timer files for tax credit. Penalties?– Yes, employer will have to pay (50-30)X$2,000=$40,000 annual assessment.
Potential Employer Penalties:Inadequate Coverage Large employer’s failure to provide “affordable” oradequate coverage may face penalties if:– Cost of self-only enrollment is more than 9.5% of thefull-timer’s family income OR– Employer’s plan covers less than minimum value orless than 60% of the health care expenses for a typicalpopulation. Penalty only triggered if full-timer applies for taxcredit and obtains coverage on an Exchange.– Employer assessed annual penalty of $3,000 for eachfull-timer receiving a tax credit **BUT cannot exceedpenalty for offering NO coverage.
Employer Penalties: InadequateCoverage (cont.) Example: Firm A has 50 full-timers, 10 of whichmust pay more than 9.5% of family income andapply for and receive premium credits– Employer will be assessed annual penalty of ($3,000 X10) = $30,000 Example: firm has 50 full-timers, but coverage isunaffordable for 20 who receive premium credits.– Employer would be assessed annual penalty of ($3,000X 20) = $60,000– HOWEVER, because that penalty exceeds the penaltyof offering no coverage at all, the penalty cannot exceed$2,000 X (50-30) = $40,000
ACA Employer AssessablePayment FlowchartEmployer50 or more full-time equivalents(FTEs)EmployerofferscoverageTax credit obtained byat least one full-timerbecause coverage is“unaffordable” or doesnot meet “minimumvalueAnnual penalty of$3,000 per full-timer who receivesthe creditTax credit notobtained by any full-timerEmployeeElects PlanNo employerpenaltyEmployeerejects PlanEmployee buysown planNo employerpenaltyEmployee opts toforgo insuranceand pay individualassessmentNo employerpenaltyEmployerdoes not offercoverageTax credit obtained byat least one full-timerAnnual penalty of$2,000 X full-timers (after thefirst 30*)Tax credit not obtainedby any full-timerNo employerpenaltyLess than 50 full-time equivalents(FTEs)No employerpenalty
IRS Guidance: Definitions Employer– Controlled group– Affiliated service group Employee:“common law” definition– Excludes: leased employee, sole proprietor, partner, 2%Sub S Shareholder Full-time employee– 130 hours per calendar month as monthly equivalent Hours of Service– Paid for work, vacation, holiday, illness, incapacity,layoff, jury duty, military duty or leave of absence
IRS Guidance: Definitions Large Employer: Means employer employs anaverage of 50 full-time equivalent employees Full-time equivalent (FTE): all employees(including part-time, variable, seasonal) who workless than 30 hours per week are included incalculating the employer’s FTEs for a given month Seasonal Worker Exception: if sum of employer’sfull-time employees & FTEs is 50 for 120 days (4months) or less during the preceding calendaryear, not a large employer– The four calendar months and 120 days are notrequired to be consecutive
Large Employer New Businesses: Employers not in existence in preceding calendar year arecounted as applicable large employers for current calendar year if they“reasonably expected to employ” an avg of 50+ full-time/FTEs during currentyear and actually do Aggregate Rules– All company units (control group & affiliated service groups as definedunder section 414(b), (c), (m) & (o)) count for: Determining large employer status (50 full-time equivalents) and thus,whether penalties apply Determining 30 first full-time employee reduction in no-coveragepenalty formula (each member gets pro rata share)– Subsidiaries do NOT count for Determining whether an employer is subject to an assessable paymentand amount of that penalty IRS has said liability is assessed on a individual member basis
Large Employer DeterminationCorporation P(no full-timers)Corporation S(40 full-timers)Corporation T(60 full-timers)Which corporations are “large employers”?Which are large employer “members”?
Large Employer AssessmentCorporation A(40 full-timers)Corporation B(35 full-timers)•Corp A does notsponsor a planduring 2015•Corp A receivesa “certification”that at least oneof its full-timersobtained apremium taxcredit for 2015•How much isCorp A’sassessment?•How much isCorp B’sassessment?
Calculating FTEs Full-time: At least 30 hours per week or 130 hoursper month– Clarifies that ALL periods of paid leave considered Full-time equivalent: take aggregate hours ofservice for all non-full-timers (less than 30 hours ofservice per wk) in given month /120 = FTE month Calculating hours:– Hourly: ACTUAL hours worked (time cards)– Non-hourly: 3 options; BUT cannot use to understate Actual Hours Worked Days Worked Equivalency: 8 hours per day Weeks Worked Equivalency: 40 hours per week
Calculating FTEs (cont.) Foreign Workers: hours worked outside U.S.(outsourced) not calculated for large employerdetermination Educators: full-time employees (paid time off) Adjunct faculty, Pilots, Transportation,Commission: IRS seeking comments– “Reasonable method” to calculate for now– Expect future rules
Dependents ACA requires large employers to offer “all full-time employees andtheir dependents” Dependent: IRS has interpreted to this to mean ONLY an employee’schildren who are under 26 years and not spouse or domestic partner– Transitional Relief Safe-harbor: Employer begins to “take steps”during the 2014 plan year toward offering dependent coverage tofull-timers (where it did not formerly offer such coverage), nopenalty. ONLY applies for the 2014 plan year. For purposes of determining “affordability” only need to look at cost ofcoverage of self-only coverage that cannot exceed 9.5% of wages.– Dependent coverage and coverage of related individuals is deemed to be affordablebased on self-only coverage even if family coverage exceeds 9.5% of theemployee’s household income.– If a related individual (e.g., spouse or dependents) is eligible for minimum essentialcoverage under the employer-sponsored plan, then they are ineligible for subsidizedcoverage from a public exchange if the employee premium cost for self-onlycoverage (not family) does not exceed 9.5% of household income.
Determining Full-Timers New Employee: any employee who has been employed less than onecompleted standard measurement period, including new “Break in Service”rules.– Employee may be treated as new employee for purposes of determiningfull-time employee status if time of no credited hours of service exceeds 26weeks.– Rule of parity: periods with no credited hours of service (of less than 26weeks) is at least four weeks long and longer than employee’s period ofemployment immediately preceding that period with no credited hours ofservice. New Variable Employees: facts and circumstances of start date, “reasonablylikely” to be full-time must be given coverage– Employer cannot take into account the likelihood that it will terminateemployee before the end of the initial measurement period– High turnover position—have to measure because you hired them withexpectation they would be full-time
Short Term & Seasonal Workers New Short-term Employees: no penalties if employmentperiod less than 3 months Temp Agencies: Anti-abuse rule– No use of temp agencies to evade penalty provisions. Seasonal Workers—performs work on a seasonal basis asdefined by the Secretary of Labor, including (but not limitedto) workers covered by 29 CFR 500.20(s)(1) (agricultural)and retail workers employed exclusively during Holidayseasons.– Employers may apply a “reasonable, good faithinterpretation” of the term “seasonal worker”– Expect future rules & guidance on seasonal workers
Temporary Employees IRS: will take into account the factual nature of the common lawanalysis in determining who is the common law employer of theworkers providing the services. IRS: “It is anticipated that many new employees of temporary staffingagencies will be variable hour employees” based on the facts andcircumstances– Example: individual hired by temp agency as its “common lawemployee” can be expected to be offered more than one or moreassignments with different clients each lasting no more than 2-3months, clients have different requests with respect to hours andgaps between assignments, then employees would be a variablehour employee. May be instances where employee is full-timer (i.e.technical/professional workers) IRS has requested further comments
Employer ResponsibilityProvision Safe-Harbors Large Employer Determination (2014 only)– Employer look-back to any 6 consecutive month periodin 2013 to determine if employed avg. of 50 FTEs No Coverage– 95% Compliance: large employer deemed compliant ifoffers coverage to all but 5% or if greater, 5 full-timers Affordability: Self-Only Coverage– Form W2: employee’s annual wages (Box 1)– Rate of Pay: hourly rate X 130 hours X 9.5%– Federal Poverty Line: self-only coverage < 9.5% of FPL Minimum Value– Minimum Value Calculator (HHS rolled out Feb. 2013)
Form W-2 SafeHarbor Employee A is full-timer of Corp. Z from Jan. 1,2015 through Dec. 31, 2015. Z offers minimumessential coverage during that period that meetsthe minimum value requirements. A’s contribution is $100 per month. A’s Form W-2 wages for 2015 are $24,000 Affordable?– Yes. Monthly premium ($100) x 12 months to get theemployee’s contribution cost ($1,200)– Next take the employee’s contribution cost and divideby his W-2 annual wage amount ($1,200/$24,000) toget the percentage of the employee contribution (5%)
Form W-2 SafeHarbor Employee B is full-timer employed by Corp. Yfrom Jan 1, 2015 through Sept. 30, 2015. Y offers B and her dependents minimum essentialcoverage during that period that meets minimumvalue requirements. B’s contribution is $100 per month. B’s Form W-2 wages are $18,000 Affordable?– Yes. $100 X 9 months (# months employed & offeredcoverage)= $900/$18,000=5% of employee’s wages.
Form W-2 SafeHarbor Employee C is full-timer employed by Corp. X fromMay 15, 2015 through Dec. 31, 2015. X offers C coverage on Aug. 1, 2015 (90 daywaiting period). Employee contribution for self-only coverage is$100 per calendar month. C’s Form W-2 wages are $15,000 Affordable?– Yes. Take wages ($15,000) and multiple by 5/8 (theproportionate share of covered months over employedmonths during the year)= $9,375; multiply that figure bythe employee’s contribution cost ($500)=5.33%of wages
Rate of Pay SafeHarbor Co. employs D full-time from Jan. 1, 2015 throughDec. 31, 2015. Co. offers D and his dependentsminimum essential coverage during the period thatmeets the minimum value requirements. Employee contribution is $85 per month D is paid a rate of $7.25 per hour for the entire year. Take 130 hours (monthly) service X $7.25= $942.50 Compare $85 figure to assumed income $942.50 Affordable?– Yes. $85/$942.50=9.01% of employee’s income per month
Rate of Pay SafeHarbor E employed by V from May 15, 2015 through Dec.31, 2015. V offers E coverage from Aug. 1-Dec. 31, 2015 Employee contribution for self-only coverage is$100 per month. May 15-Oct. 31, 2015, E paid $10 per hour Nov. 1-Dec. 31, 2015, E paid $12 per hour Affordable?– Yes. V may assume that E earned $1,300 per month(130 hours of service X lowest hourly rate of pay forcalendar year); $100/$1,300=7.69% of income permonth
FPL SafeHarbor F is employed by W from Jan. 1, 2015 through Dec. 31, 2015. W offers coverage providing minimum essential coverage duringthe period that meets minimum value. W uses a “look-back measurement” method, under which F istreated as a full-timer the entire year. W is credited with 35 hours per week, but only works 20 hoursin March and 15 hours in August FPL for individual is $11,170. W determines monthlycontribution of 9.5% X $11,170 = $1,061. 15/12=$88.42 monthlycontribution Affordable?– Yes. Because regardless of F’s actual wages for any calendar month(like March and August when F has lower wages b/c of lower hours ofservice), coverage is treated as affordable under the FPL Safeharbor
HHS Final Rule: Minimum Value February 25, 2013: HHS issued final rules onMinimum Value and described several options fordetermining MV.– Use the Minimum Value Calculator– Safe Harbors developed by HHS or IRS– Non-standard plans: Actuarial certification from amember of the American Academy of Actuaries– Small group plan: provides bronze level plan.
MV Calculator Allows employers to determine if their employersponsored plan covers no less than 60% of totalallowed costs Based on 2009 data where enrollees continuouslyenrolled for 12 months Denominator: avg allowed cost of all services forthe standard population in the year Numerator: share of avg allowed cost covered bythe plan, using the cost-sharing parametersspecified
MV Calculator Select user inputs for plan parameters– Integrated (applies to both medical & Rx) or Separatedeductible, maximum out-of-pocket, and/or coinsurancespending limits– Grandfathered Plan Option—user may enter cost-sharing for preventive services (cannot select this optionfor other plans)– HSA/HRA Employer Contribution Option– Blended Network/Point of Service (POS) Plan MV Calculator available at:cciio.cms.gov/resources/files/mv-calculator-final-2-20-2013.xlsmhttp://cciio.cms.gov/resources/regulations/index.ht
MV: IRS Proposed Regulations May 3, 2013: IRS Proposed Regulations—purposeto clarify the health benefits considered indetermining the “share of benefit costs paid by aplan.”– HSAs: employer contributions for current plan yearconsidered in determining plan’s share of costs for MV.– HRAs integrated into group health plan: employer’scurrent year contributions considered in plan’s share ofcost only for cost-sharing– Wellness programs: reduction in cost-sharing throughwellness programs may count toward MV only if everyindividual satisfies the terms of a non-discriminatoryprogram aimed at tobacco prevention/reduction.
MV Safeharbors IRS proposed rule has three safe harbors fordetermining MV– Plan with a $3,500 integrated medical & drugdeductible, 80% cost sharing and $5,000 max out ofpocket limit.– Plan with $4,500 integrated deductible; 70% costsharing, $6,400 max out of pocket limit, $500 employercontribution to HAS.– Plan with $3,500, $0 drug deductible, 60% medical costsharing, $10/$20/$50 copay tiered drug plan and 75%coinsurance for specialty drugs.– IRS has request suggestions for other common plansthat would satisfy MV.
IRS MV Regulations: OtherIssues Clarifies that former employees eligible for retireecoverage are excluded from eligibility for premiumtax credits only if they enroll in such coverage Active employees eligible for COBRA coverageb/c of reduced hours will have eligibility forpremium tax credit determined applying the sameMV rules that apply to other active employees. Employer penalty & FLSA violation if:– Employer that fails to offer MV but requires employeesto accept a sub-MV plan (DQ’ing the employee fromreceiving a premium tax credit b/c he/she is enrolled inemployer coverage).
IRS Proposed Regulations:Affordability Affordability: employer HSA contributions &contributions to HRAs integrated into group healthplan (cost-sharing only) can be considered toincrease the affordability of employee coverage.– Wellness incentives that reduce premium will NOT beconsidered to increase affordability except for premiumscharged to tobacco users who complete a non-discriminatory wellness program related to tobacco use.– 2014: if employee receives premium tax credit becauseplan unaffordable, employer not subject to employermandate penalty if: Coverage would have been affordable had employee satisfiedrequirements of the non-discriminatory wellness program ineffect at the time of the publication of the rule.
Process & Appeals1. Employee seeks coverage through the Exchangeand seeks subsidies for coverage.2. If not eligible for Medicaid, Exchange will make adetermination on eligibility for subsidies based oninformation provided by employee (employeesupposed to provide all relevant informationregarding plans available from employer(s))3. Notice of Eligibility provided to employee andemployer– Small employers may receive these – this does not mean there is liabilityfor penalties.
Process & Appeals4. If employee denied tax credit/cost sharingsubsidy, has 90 days to appeal to the Exchange30 days to appeal to HHS, judicial review5. If employee is held eligible for tax credit/costsharing subsidy, employer has 90 days from thedate of the determination letter to request anappeal to the Exchange– Appeal can be requested by telephone, mail, in personwhere available, or by Internet.– Employee notified of appeal and both opportunity tosubmit additional information to the Exchange (i.e.Employer may want to show that individual is not an“employee” or that it meets a safeharbor
Process & Appeals5. Appeal must be of determination that employer– Does not offer coverage;– Offers coverage that is not affordable; or– Offers coverage that does not meet the minimum valuestandards Review by one or more impartial officialswho have not been directly involved in the employeeeligibility determination.6. Exchange/appeal agency must provide writtenappeal decision within 90 days of the date theappeal request is received.– Unlike individual appeal, employer has no right toappeal to HHS in the event Exchange rulesunfavorably upon the appeal
Process & Appeals Employer may contest tax penalties throughseparate IRS tax appeal procedures. Unclear how Exchanges, HHS & IRS willcoordinate information that arises from thesevarious procedures HHS currently working on standardized templatefor employers to use to gather, submit anddisseminate information about their coverageoptions to allow an Exchange to verify whether anemployee has access to employer-basedinsurance coverage and/or the value of thatcoverage
Employer ResponsibilityProvision Checklist Step 1: Large Employer– Most will be clear, but for those close to 50 FTEs, needto consider Aggregate Rules & Methods of Calculation Step 2: Determine full-timers– Look-Back Period (standard measurement period) Step 3: Determine affordability– W2 Form, Rate of Pay, FPL Step 4: Determine minimum value– Minimum Value Calculator Step 5: Certification, Process & Appeal– HHS working on standardized template for employers touse to gather, submit and disseminate info about plans
Employer ReportingRequirements: 2013 January 2013: Beginning with the 2012 taxableyear, employers with 250+ are required to reportthe value of the employer-sponsored group healthplan benefits on employees’ annual Form W-2– Mandatory reporting for ALL large employers 2015
Employer ReportingRequirements: 2013 March 2013: Employers must provide writtennotice to all new hires and current employees of:– Existence of an exchange– Employee’s potential eligibility for tax credit and subsidy– Employee’s potential loss of employer contribution ifemployee purchases plan through exchange Small employers should provide notice too DOL has extended Exchange notice deadline to“late Summer or early Fall 2013”
DOL: Temporary Guidance &Model Notice Applicable employers?– Section 18B of the FLSA: (1) one or more employees;(2) interstate commerce; (3) generally at least $500,000in annual volume of business; (4) hospitals, nursinghomes, schools Who gets notice?– All employees regardless of plan enrollment status orpart-time/full-time status Content?– Must inform employees (1) of the Exchange; (2)eligibility to qualify for tax credit; (3) loss of employercontribution & that all or some of the contribution maybe excludable from income for income tax purposes.
DOL: Temporary Guidance &Model Notice Timing?– New Hires: Must provide notice to new employees atthe time of hiring beginning on October 1, 2013; 2014: DOL considers notice timely if provided within 14 days ofemployee’s start date– Current Employees: Must provide notice not later thanOctober 1, 2013; Manner?– Notice must be automatic and free of charge toemployees & must be provided in writing either: Via first-class mail OR electronically pursuant to 29 CFR2520.104b-1.
DOL: Model Notices One model for employers who do not offer healthpan One model for employers who offer a health planto some or all of its employees Employers may use, these models or a modifiedversion, provided the notice meets the contentrequirements. COBRA Model Notice: revised to make qualifiedbeneficiaries aware of other coverage optionsavailable on the Exchange. http://www.dol.gov/ebsa/healthreform/
Whistle blower Provisions DOL: No employer shall discharge or discriminate against“any employee with respect to his or her compensation,terms, conditions, or other privileges of employment”because employee has “received” credit or subsidy.– Employee’s hours or pay may not be reduced for havingreceived a subsidy– Leaves open whether courts will view whistleblowerprovisions as applicable to the reduction of anemployee’s hours so that employee would not havecoverage and also not be full-time an ineligible forsubsidy (triggering event to employer penalties) Complainant must show that protected activity was a“contributing factor” leading to the adverse employmentaction
Whistleblower Provisions IRS interprets whistleblower provisions to closeloophole:– Mandatory enrollment in unaffordable plans will beviewed the same as not supplying any benefits and theemployer will be penalized as though it did not offer anycoverage at all (i.e. $2,000 X (# full-timers-30)). IRS’s interpretation means that employee does notactually need to receive the premiumsubsidy/credit in order for the ACA whistleblowerprotection to apply.
Small Business Health OptionProgram Small Business Health Option Program: Eligibleemployees may receive subsidies for coverageobtained through SHOP exchange (if makebetween 133%-400% FPL)– April 1, 2013: Obama administration announced delay in33 federally-run SHOP exchanges Benefit of offering coverage: premiums are taxdeductible for the employer (lose out on taxdeduction if stop offering coverage)
Small Business Tax Credits Small businesses (up to 25 FTEs with averageannual salary of less than $50,000) can get up to50% tax credit for 2014 and 2015 if they purchasecoverage from a SHOP
Want more? Contact: Katherine L. Georger– firstname.lastname@example.org For more information about health care topics,including the ACA, and for a schedule of ourupcoming health law events please visit Holland &Hart’s Health Law Blog– www.hhhealthlawblog.com
Resources For general ACA information and recentregulations, including the IRS’s ProposedEmployer Responsibility Provision rules visit– http://www.cms.gov/cciio/index.html The Center for Consumer Information & InsuranceOversight– http://www.cms.gov/cciio/resources/regulations-and-guidance/index.html Dep’t of Labor—Notice Requirements– http://www.dol.gov/ebsa/healthreform/