BEST PRACTICES Health Insurance Marketplace Guidance

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1 BEST PRACTICES Health Insurance Marketplace Guidance

2 TABLE OF CONTENTS: Health Insurance Marketplace 3 Small Business Options 8 Notification of Exchanges 10 Common Pitfalls 13 Staffing Plus Solutions 14

3 CHAPTER 1: Health Insurance Marketplace Exchanges (also known as Health Insurance Marketplaces) are expected to begin operating in 2014 as an option for individuals to buy private health insurance under the Affordable Care Act (ACA). These exchanges are essentially an online shopping center for medical plans. Under this legislation, states will be allowed to provide exchanges via three options: 1. Establish one or more regional health insurance exchanges 2. Participate in a multistate exchange 3. Partner with the federal government to run an exchange A brief overview of the basics are as follows: 1. Consumers will have a choice of plans offered by different insurance carriers at different prices. 2. The exchanges will take effect by January 1, If a state chooses not to create one, the federal government will do so on its behalf. 3. Open enrollment for exchanges begins on October 1, Exchanges will open to individuals in 2014 and to small group employers (under 100 EEs) in Page 3

4 Health Insurance Marketplace Benefit Plans Individuals will have the ability to choose from a variety of plans administered by private insurance companies, which may included HMO or PPO plans, as well as highdeductible health plans. They are not required to purchase a plan that s included in an exchange. The exchanges will offer benefits in five categories: Bronze Plan Provides essential health benefits, pays for 60% of plan costs, and limits annual cost-sharing (out-of-pocket expenses) to the current Health Savings Account (HSA) maximums (subject to change each year). Silver Plan Provides essential health benefits, pays for 70 percent of plan costs, and limits annual cost-sharing to the current HSA maximums. Gold Plan Provides essential health benefits, pays for 80 percent of plan costs, and limits annual cost-sharing to the current HSA maximums. Platinum Plan Provides essential health benefits, pays for 90 percent of plan costs, and limits annual cost-sharing to the current HSA maximums. Catastrophic Plan Available to those up to the age 30 or to those who are exempt from the mandate to purchase coverage. The actuarial value and the cost of this plan will be less than the Bronze Plan. Page 4

5 Health Insurance Marketplace Who is required to participate? The notice requirement applies to employers covered by the federal Fair Labor Standards Act (FLSA). In general, the FLSA applied to employers that employ one or more employees who are engaged in, or produce goods for, interstate commerce. For most organizations, a test of not less than $500,000 in annual dollar volume of business applies. The FLSA also specifically covers certain entities such as hospitals, educational institutions, and government agencies. Page 5

6 Health Insurance Marketplace Benefits of the Marketplace Helps enhance competition in the health insurance market. Increases affordability through premium tax credits, cost sharing reductions, or public insurance programs. Ensures quality through Qualified Health Plans (QHP) that must meet basic standards, including quality standards, consumer protections, and access to an adequate range of clinicians. Makes costs clear by providing information about prices and benefits in simple terms consumers can understand, so they don t have to guess about costs. Page 6

7 CHAPTER 2: Small Business Health Options Program (SHOP) The Affordable Care Act (ACA) contains provisions that give small businesses the option of purchasing coverage through the SHOP exchange. The goal of SHOP is to enable businesses of up to 100 employees to offer workers a choice of medical options at a range of prices. It was intended that the SHOP exchange offer several health coverage options for employees of small businesses to choose from. SHOP Partially Delayed: Originally slated to be available on January 1, 2014, the employee choice option through the SHOP exchanges has been postponed until 2015 for the 33 states in which the federal government runs the exchange. Instead, employers can offer a single medical option to their workers through the SHOP exchange in Page 7

8 Health Insurance Marketplace The Employer Mandate The postponement partial delay of the SHOP exchanges does not mean that small businesses are exempt from the requirement to offer affordable medical coverage that meets certain standards. Beginning January 1, 2015, if a company doesn t comply and fails to offer coverage, and any employee even just one ends up getting coverage that is subsidized by the federal government, the company will owe a $2,000 penalty for every full-time employee on the payroll (excluding the first 30 employees). Conversely, if an employee does not qualify for a subsidy and purchases coverage in a state or federal exchange that is less expensive than the employer s coverage, the company won t pay a penalty. The penalty is triggered by the receipt of a subsidy by an employee. In the event that an employer with 50 or more employees offers coverage, but at least one fulltime employee receive a premium tax credit, the employer will pay the lesser of $3,000 for each employee receiving a premium credit or $2,000 for each full-time employee, excluding the first 30 employees. The ACA employer mandate means that companies with at least 50 full-timeequivalent employees must provide workers with medical insurance starting in Page 8

9 CHAPTER 3: Notification of Exchanges The Patient Protection and Affordable Care Act (PPACA) created a new Fair Labor Standards Act (FLSA) section that requires employers to provide notice to employees of coverage options available through the Health Insurance Marketplace. In May 2013, the Department of Labor (DOL) issued guidance about the notices that employers are required to provide to employees. Page 10

10 Health Insurance Marketplace The exchange notices must contain the following: 1. A description of the services provided by the state health exchange. 2. Contact information for customer assistance. 3. The circumstances under which an employee who buys coverage may be eligible for a premium tax credit or subsidy. 4. A statement explaining that participating in an exchange may cause an employee to lose employer contributions for their employer-sponsored group health coverage (if any) and the effect on the individual s income taxes. The employer also must include the company name, address, and employee identification number (EIN). The notice must contain the name of a company contact and that person s phone number and address. Timing & Distribution 1. Notification about the exchanges must be sent no later than October 1, 2013 to all current employees, including parttime staffers and those not enrolled in a companysponsored medical plan. 2. Anyone hired after October 1, 2013 must receive the notice within 14 days of their start. 3. The notice must be provided in writing in a manner easily understood by the average employee. It may be provided by first-class mail. Alternatively, it may be provided electronically if the requirements of the Department of Labor s electronic disclosure safe harbor are met. Page 11

11 Health Insurance Marketplace Sample Exchange Notifications The Department of Labor (DOL) has provided two sample notices employers may use to comply with the Health Insurance Exchange Notice. The law requires that specific information be included in each notice. Exchange Letter Templates 1. Model Notice for Employers that offer a health plan to some or all employees. 2. Model Notice for Employers that do not offer a health plan. CLICK HERE Model COBRA Notices In addition to the model notices for the exchanges, the EBSA released a modified COBRA notice. It includes information telling qualified beneficiaries about the availability of coverage through the exchanges. Page 12

12 CHAPTER 4: Common Pitfalls As with any new process of such an allencompassing nature, the possibility for confusion will continue to exist. We have outlined some of the anticipated confusion below: My insurance provider is taking care of the notice requirement for me. Be careful! Employers are required to send the notice to all employees. You should work with your provider to make sure all employees, not just plan participants, receive the notice. I just looked at the DOL model notice, and we don t have time to fill out individualized information for every employee. The individualized information requested on page 3 of the DOL model notice for employers who offer health coverage is optional. I m sure this requirement doesn t apply to my small company. As detailed above, the requirement applies to nearly all employers, large or small. An employer that fails to distribute the notice would violate the FLSA and the PPACA, and may be subject to investigation and penalties. Page 13

13 CHAPTER 5: Staffing Plus Solutions Staffing Plus offers personalized HR services that will help control cost, lower risk and minimize the financial impact to your organization. We will provide you with the HR expertise and resources you need, so that you can stay focused on your strategic business and financial goals. Many Americans are still unclear about Health Care Reform. Let us help answer those questions. For further guidance on Healthcare Reform and other HR related areas, please contact our HR Outsourcing experts at (610) or via at Page 14

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