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2013-04-23 Healthcare Reform
1. Health Care
Reform: Health
Plans Overview
Matthew Roberts, Account Executive
April 23, 2013
Thrive. Grow. Achieve.
2. AGENDA
WHICH PLANS MUST COMPLY
REFORMS CURRENTLY IN PLACE
2012-2013 COMPLIANCE DEADLINES
2014 COMPLIANCE DEADLINES
WE HAVE YOU COVERED
QUESTIONS
Health Care Reform 2
4. WHICH PLANS MUST COMPLY
Rules generally apply to group health plan coverage
Exceptions
Excepted Benefits
Retiree-only plans
Excepted Benefits
Accident or disability income coverage
Separate dental and vision plans
Liability insurance
Some FSA’s
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5. GRANDFATHERED PLANS
Grandfathered plan: Group health plan or health
insurance coverage in which an individual was enrolled on
March 23, 2010
Certain health care reform provisions don’t apply to
grandfathered plans, even if coverage is later renewed
A plan can lose grandfathered status by making too many
changes to benefits or costs
– Plans will have to analyze status and changes at each
renewal
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6. WHICH RULES DON’T APPLY TO
GRANDFATHERED PLANS?
Patient Protections
No cost-sharing for preventive services
Non-discrimination rules for fully-insured plans
New appeals process
Quality of care reporting
Insurance premium restrictions
Guaranteed issue and renewal of coverage
Non-discrimination based on health status
Comprehensive health insurance coverage
Limits on cost-sharing
Coverage for clinical trials
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7. WHICH RULES DO APPLY TO
GRANDFATHERED PLANS?
Extension of dependent coverage
Elimination of lifetime and annual limits
Elimination of pre-existing condition exclusions
Limits on rescissions
Limits on waiting periods
Summary of benefits and coverage
Reporting medical loss ratio
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9. REFORMS CURRENTLY IN PLACE
Small employer tax credit
Dependent coverage up to age 26
No lifetime limits/restrictions on annual limits
No rescissions
No pre-existing condition exclusions for children
No cost-sharing for preventive care services (non-GF
plans)
Appeals process changes (non-GF plans)
No reimbursement for OTC medicine or drugs (without a
prescription)
Medical loss ratio rules
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11. W-2 REPORTING
Employer must report
aggregate cost of group health
plan coverage on each
employee’s Form W-2.
Does not change the tax rules
for health coverage – still not
taxable.
Reporting optional for all
employers in 2011.
Mandatory for 2012 tax year
(W-2 Forms provided in
January 2013).
For small employers (filed
fewer than 250 W-2 Forms last
year), reporting requirement is
delayed until further guidance
issued.
Covered employers need to be
compiling data.
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12. W-2 REPORTING
Report coverage under employer-sponsored group health
plans
Does not include excepted benefits/plans that don’t provide
health coverage
Aggregate cost must be reported
Include both employer- and employee- paid portions
Determined under rules similar for determining “applicable
premium” under COBRA
Not required for:
Employees who terminate during the year and request a W-2
before the end of the year
Employees who would not otherwise receive a W-2
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13. SUMMARY OF BENEFITS AND COVERAGE
Simple and concise explanation of benefits
Applies to GF and non-GF plans
Model template and guidance available
Instructions
Sample language
Uniform glossary of terms
Final guidance specifies compliance deadlines
Original deadline was March 23, 2012
Issuers to health plans: Sept. 23, 2012
Must be provided 30 days prior to new plan year or within
7 days of renewal acceptance
No duplication required: if issuer provides to enrollees,
plan doesn’t have to
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14. 60-DAY NOTICE RULE
Material modifications not in connection with renewal
must be described in a summary of material modifications
(SMM) or an updated SBC
Material modification:
Enhancement of covered benefits or services
Material reduction in covered benefits or services
More stringent requirements for receipt of benefits
Must be provided at least 60 days BEFORE modification
becomes effective.
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15. PREVENTIVE CARE FOR WOMEN
Must provide coverage for women’s preventive health
services without any cost-sharing
Applies to non-GF plans
No deductible, copayment or coinsurance
Effective for plan years beginning on or after August 1,
2012
Covered Health Services
Well-women visits
Gestational diabetes screening
HPV DNA testing
Sexually transmitted infection counseling
HIV screenings and counseling
Breastfeeding support, supplies and counseling
Domestic violence screening and counseling
Contraceptives and contraceptive counseling
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16. INCREASED MEDICARE TAX
Medicare tax rate to increase for high-earners
0.9 percent increase (from 1.45 percent to 2.35 percent)
High-earner threshold
Single: $200,000
Married : $250,000
Employer responsibilities
Withhold additional amounts from wages in excess
of $200,000
No requirement to match additional tax
No requirement to notify employees
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17. HEALTH FSA LIMITS
Current limits
No limit on salary reductions
Many employers impose limit
Beginning in 2013, the limit is
$2500/year
Limit is indexed for CPI for later
years
Applies to plan years beginning
on or after 1/1/13
This is a change from initial
effective date
Does not apply to dependent
care FSAs
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18. COMPARATIVE EFFECTIVENESS
RESEARCH FEES
Patient-Centered Outcomes Research Institute
Created to improve informed health decisions
Research funded by a fee paid by insurers and plan
sponsors of self-funded plans
Effective date
Plan years ending after Sept. 30, 2012
Do not apply for plan years ending after Sept. 30, 2019
For calendar year plans – apply for 2012-2018 plan years
Amount of fee:
$1 per covered life per month
Increases to $2
Indexed for CPI
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19. NOTICE OF EXCHANGE
Employers must notify new and current employees of
exchange information
Original deadline was March 1, 2013, but this has been
delayed pending more guidance from the DOL
Notice must include information about 2014 changes:
Existence of health benefit exchange and services provided
Potential eligibility for subsidy under exchange if employer’s
share of benefit cost is less than 60 percent
Risk of losing employer contribution if employee buys
coverage through an exchange
More guidance and model notice expected
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21. INDIVIDUAL MANDATE
Jan. 1, 2014: Individuals must enroll in coverage or
pay a penalty
Penalty amount: Greater of $ amount or a % of
income
2014 = $95 or 1%
2015 = $325 or 2%
2016 = $695 or 2.5%
Family penalty capped at 300% of the adult flat
dollar penalty or “bronze” level premium
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22. HEALTH INSURANCE EXCHANGES
Health insurance exchanges will be established in
each state (by the state or federal government)
Enrollment starts October 1, 2013; coverage begins
January 1, 2014
Individuals and small employers can purchase
coverage through and exchange (Qualified Health
Plans)
In 2017, states can allow employers of any size to
purchase coverage through exchange
Individuals can be eligible for tax credits
Limits on income and government program eligibility
Employer plan is unaffordable or not of minimum value
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23. LOCAL HEALTH INSURANCE
EXCHANGES – SMALL GROUP
Maryland – state-based exchange
Virginia – federal exchange
District of Columbia – state-based exchange
Exchange Board’s focus is mandating individuals and
employers to purchase insurance through the exchange
This will initially be for employers with less than 50
employees but will inevitably encompass employers with
up to 100 employees
Will be done on a transitional basis, with employers with
existing plans required to buy from the exchange at the
2015 renewal
City Council will be voting on a bill, including the
“consolidation” of the current market, next month
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24. HEALTH INSURANCE EXCHANGES
Migration to “metal” plans
Platinum – 90%
Gold – 80%
Silver – 70%
Bronze – 60%
Rates are the same whether offered in or outside the
exchange
Carrier selection
Changes to underwriting
Age-band compression
Health status
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25. CALCULATING EMPLOYER
RESPONSIBILITY
Dual calculation
First – calculate if an employer is “large”
Second – if an employer is “large”, then determine possible
penalties for full-time employees
Employer size calculation
Full-time – counted as one employee
Full-time equivalent – total hours worked by part-time
employees in a month divided by 130
Seasonal – counted if working more than 120 days
Penalty calculation
FT employee: employed for an average of at least 30 hours
of service per week over employer designated measurement
period (not less than 3 or greater than 12 months)
Seasonal employee: subject to same calculation
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26. EMPLOYER PENALTY AMOUNTS
Employers that do not offer coverage to all full-time
employees:
$2,000 per full-time employee
Excludes first 30 employees
Employers that offer coverage:
$3,000 for each employee that receives subsidized
coverage through an exchange
Capped at $2,000 per full-time employee (excluding first
30 employees)
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27. EXCHANGE PREMIUM ASSISTANCE
Employee eligibility will trigger employer penalties
Employees who are not offered coverage
Not eligible for government programs (like Medicaid)
Meet income requirements (less than 400% of FPL)
Employees who are offered coverage
Not enrolled in employer’s plan
Not eligible for government programs (like Medicaid)
Meet income requirements (less than 400% of FPL)
Employer’s coverage is unaffordable (greater than 9.5% of
income) or not of minimum value (covers less than 60% of
cost of benefits)
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28. SAFE HARBORS
Employer penalties: who is a full-time employee?
Ongoing employees
New full-time employees
New seasonal and variable hour employees
Affordability safe harbors
Three different safe harbors for determining affordability –
W-2 income, rate of pay and federal poverty line
Waiting periods
Cannot exceed 90 days
No penalty for employees in waiting period
Employers can rely on safe harbors through 2014
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29. EMPLOYER REPORTING
Large employers will have to report certain
information about health coverage to the government
and individuals
Applies to coverage offered after January 1, 2014
First returns to be filed in 2015
Information required
Employer identifying information
Whether employer offers health coverage to FT
employees and dependents
Number of FT employees for each month
Length of any waiting period
Monthly premium for lowest-cost option in each
enrollment category
Employer’s share of cost of benefits
Names and contact info of employees and months
covered by employer’s health plan
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30. MORE 2014 CHANGES
No pre-existing condition exclusions or limitations
Wellness program changes - maximum reward
increases to 30%
Limits on out-of-pocket expenses and cost-sharing
No waiting periods over 90 days
Coverage of clinical trial participation
Guaranteed issue and renewal
No annual limits on essential health benefits
Insurance premium rating restrictions
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32. WE HAVE YOU COVERED
With the changes brought on by health care reform,
you may be feeling overwhelmed by additional
questions from your clients. Take a deep breath – we
can help.
We have all the resources you need to successfully
navigate health care reform including:
Compliance checklists and timelines
Health care reform legislative updates and guides
Employee education materials
Health care reform video content
Community forum
Benchmarking
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33. COMPLIANCE CHECKLIST AND
TIMELINES
It’s hard to keep track of when each change will be
taking place, so let us help. Our up-to date timelines
and checklist will keep you ahead of the curve.
Health Care Reform Timeline
Health Care Reform Timeline Chart
Health Care Reform: 2013 Compliance Checklist
2013 Open Enrollment Compliance Checklist
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34. HEALTH CARE REFORM LEGISLATIVE
UPDATES
Be the first to know
when regulations
change – our timely
legislative documents
are written and
reviewed by lawyers to
ensure accuracy.
Health Care Reform:
Potential Penalties for
Employers Under the
“Pay or Play” Rules
Health Care Reform:
Lifetime and Annual
Limits
Health Care Reform and
the Future of CDHP’s
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35. EMPLOYEE EDUCATION MATERIALS
Our educational
documents for
employees are easy to
understand, and include
everything from flyers to
payroll stuffers to help
keep your employees up
to date.
Health Care Reform:
General Questions &
Answers for Employees
Health Care Reform: The
Who, What and When
Health Care Reform: The
Supreme Court’s Decision
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36. HEALTH CARE REFORM VIDEO CONTENT
Our short, to-the-point
videos detail health
care reform and the
changes it brings. With
videos for you, and
videos for your clients,
we’ll talk you through it
all.
Health Care Reform: W-
2 Reporting
Requirements
Health Care Reform:
Summary of Benefits
and Coverage
Health Care Reform:
Patient’s Bill of Rights
Health Care Reform:
Age 26 Rule
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37. HEALTH CARE REFORM PENALTY TOOLS
The employer shared responsibility penalties are just around
the corner. Are your clients prepared? We can estimate the
potential cost of the shared responsibility penalties and help
your clients avoid them.
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38. BENCHMARKING
Find out how other employers are responding to health
care reform by reviewing our 2012 health care reform
benchmarking information.
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