Health Care Law Implementation: What Nonprofits Need to Know WELCOME!

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1 Health Care Law Implementation: What Nonprofits Need to Know WELCOME!

2 Health Care Law Implementation: What Nonprofits Need to Know (PPACA)

3 Health Care Law Implementation: What Nonprofits Need to Know Heather Meade Senior Manager Ernst & Young Washington Council

4 Today s Agenda Overview of the Patient Protection and Affordable Care Act ( PPACA ) and Employer Requirements Regulatory Update Congress and the Courts Page 4

5 Overview

6 Key Effective Dates for Employers Immediate health insurance market reforms Medicare Part D donut hole relief begins Codification of economic substance Corporate information reporting State exchanges established Individual mandate and subsidies Employer mandate Other insurance market reforms take effect Health insurers fee 40% excise tax on high-cost health plans Coverage expansions take effect Drug manufacturers fee Reporting value of health benefits on Form W-2 Increase Medicare payroll tax by 0.9% on earned income Impose 3.8% tax on unearned income Eliminate deduction for retiree drug costs covered by Medicare Part D subsidy Excise tax on medical devices Medicare Part D donut hole closed Page 6

7 Employer Requirements Vary by Size Large Employer Small Employer Insurance Market Reforms (coverage to age 26, lifetime and annual limits, preventive coverage, etc) Minimum Essential Benefits Metal standards Access to the exchanges Employer Shared Responsibility requirements (employer mandate) Reporting requirements X 2017 X varies X X X 2014 varies Page 7

8 Definition of Large Employer Who is a large employer? Any employer with 50+ full-time equivalents Calculation: Full-time employees (30+ hrs/wk) + aggregate number of hours worked by non-full-time employees 120. Seasonal employees working 120 days or fewer not included in calculation. Measured on a control group basis (Code 414) Employees of a controlled group of corporations, partnerships or proprietorships under common control, affiliated services group or others as proscribed by Treasury. Example: A nonprofit has 23 headquarters employees (18 FT and 5 PT) and operates under common control three off-site locations with 12 full-time employees and 30 part-time employees working an average of 20 hours per week and 15 seasonal employees/interns working under 120 days. 30 full-time employees + 20 full-time equivalents (25 part-time employees x 80 hours per month / 120) = 50 full-time equivalents Page 8

9 Large Employer Requirements Beginning in 2014, large employers must offer coverage to their full-time employees that is affordable and of a minimum value or pay tax penalties for those employees who receive tax credits/subsidies for Exchange coverage. Page 9

10 Large Employer Coverage Requirements Full-time employee: Law defines as an employee who works on average 30 hours per week, per month Wait periods: Prohibits plans from including wait periods longer than 90 days before enrolling employees into employer coverage. Auto-enrollment: Employers with at least 200 employees must auto-enroll full-time employees into coverage if no election is made. Implementation delayed until regulations are issued. Affordable coverage: Employee s share of premium cannot exceed 9.5% of household income or the employee may be eligible for a premium tax credit to purchase coverage in a state insurance Exchange. Minimum value: A plan must pay 60% of the total allowed cost of benefits Grandfathered Plans: Plans that retain cost-sharing and benefit structure as of 2010 may avoid certain market reforms. Page 10

11 Calculation of Tax Penalties for Noncompliance by Large Employers Penalty for no coverage: $2,000 x the total number of full-time employees (FTEs) if at least one FTE is receiving a premium tax credit. Penalty for unaffordable coverage: The lesser of $3,000 x the number of FTEs receiving a premium tax credit or $2,000 x the total number of FTEs. Individuals are eligible for tax credits only if their income is between 133% and 400% of the Federal poverty level. No penalty for Medicaid eligible employees. To determine penalties, employers may subtract the first 30 workers. Page 11

12 Small Employer Requirements Definition of Small Employer: employers with 50 (in some states 100 for SHOP eligibility) or fewer employees SHOP Exchanges-Small Business Health Options Program Employers select level of coverage State exchange coordinates plans, employee elections, etc. Will vary by state Available for employers with up to 100 employees (or 50 depending on state) Page 12

13 Small Employer Tax Credit Small Employer tax credit The tax credit, which was passed as part of the health care reform law, is currently available to small employers with up to 25 full-time equivalents with average wages of no more than $50,000. The credit is based on a sliding scale based on employer size and average employee compensation. Tax-exempt employers are eligible for credits up to 25% of their contribution. What is the maximum credit for a tax-exempt qualified employer? For tax years 2010 through 2013, the maximum credit is 25 percent of the employer s qualified premium expenses. However, the amount of the credit cannot be more than the total amount of income and Medicare tax (i.e., hospital insurance) the employer is required to withhold from employees wages for the year and the employer share of Medicare tax on employees wages for the year. Page 13

14 Essential Health Benefits (EHB) PPACA describes EHBs as consisting of 10 benefit classes: Ambulatory patient services; Emergency services; Hospitalization; Maternity and newborn care; Mental health and substance use disorder services, including behavioral health treatment; Prescription drugs; Rehabilitative and habilitative services and devices; Laboratory services; Preventive services and wellness services and chronic disease management; Pediatric services including oral and vision care Page 14

15 Essential Health Benefits (EHB) Essential health benefit requirements apply to insurance products sold in the individual and small group markets, both inside and outside state insurance Exchanges. The EHB requirement also applies to Medicaid benchmark and benchmark equivalent plans, as well as to state Basic Health Programs. Although large group plans are not required to offer the essential health benefits package, large group plans are prohibited from imposing lifetime or annual limits on any essential health benefits that they do offer. Page 15

16 Employer Reporting Requirements PPACA establishes new plan information reporting requirements to the federal government, including: Form W-2 reporting: Beginning in 2012, employers must include the value of the benefit provided by the employer for each employee s health insurance coverage on the employee s annual Form W-2. Exchange options: PPACA amends the Fair Labor Standards Act to require employers to: Provide a written notice informing employees of the existence of an Exchange, including a description of the services provided by an Exchange, and the manner in which the employee may contact the Exchange to request assistance Inform employees that if the employer plan s share of the total allowed costs of benefits provided under the plan is less than 60% of such costs, that the employee may be eligible for a premium tax credit if the employee purchases a qualified health plan through the Exchange Inform employees that if they purchase a qualified health plan through the Exchange, they will lose the employer contribution (if any) to any health benefits plan offered by the employer and that all or a portion of such contribution may be excludable from income for Federal income tax purposes. Page 16

17 Employer Reporting Requirements (cont d.) The law also establishes new employer reporting requirements under Internal Revenue Code The new provision requires employers to report to the Internal Revenue Service: Name, date and employer identification number of the employer Certification as to whether the employer offers full-time employees and their dependents the opportunity to enroll in minimum essential coverage under an eligible employer-sponsored plan. If so, the employer must also report: Length of any wait period Months during the calendar year during which coverage was available Monthly premium for the lowest-cost option in each of the plan s enrollment categories Applicable large employer s share of the total allowed cost of benefits under the plan The number of full-time employees for each month during the calendar year The name, address, and TIN of each full-time employee during the calendar year and the months (if any) during which such employee (and dependents) were covered under any such health benefits plans Such other information as the secretary may require Page 17

18 Employer Experience Will Vary Based on State CALIFORNIA: Robust legislation and contracting process to create both Exchange and SHOP exchanges. SHOP exchange expected to permit employer with up to 50 employees to utilize exchange. FLORIDA: Returned federal dollars intended to help prepare state for 2014 and has not moved forward to prepare for exchange enrollment. Exchanges must be ready to enroll employers and individuals by fall of Page 18

19 Regulatory Update

20 Definition of Full-time Employee The Department of Treasury is considering a look-back/stability period safe harbor or a rolling-3 month new hire measurement for determining which employees would be considered full time. The length of the proposed stability period would have to be equal to or greater than the look-back period. The length of any look-back period will be capped. In situations where an employee is hired for or promoted to a position that the employer classifies as or reasonably expects to be full-time, the employee will be eligible for the employer s health plan after the applicable wait period. Guidance expected before July Page 20

21 Affordability Safe Harbor and General Rule Treasury issued an NPRM and a Request for Comment that propose an affordability safe harbor that would protect employers from penalties with respect to an employee who receives a tax credit or subsidy if the employee portion of the self-only premium for the employer s lowest cost plan that provides minimum value does not exceed 9.5 percent of the employee s current W-2 wages from the employer. Clarified that an employer must offer coverage to employees and dependents, but affordability test is based on employee contribution to self-only coverage Employers unable to utilize the safe harbor will still be able to take advantage of the general rule, which is based on 9.5% of household income. Guidance expected in Page 21

22 Estimates for Affordability Safe Harbor Estimates for Individual Eligibility for Medicaid or Tax Credits and Affordability Safe Harbor 1 Scenario Percent of federal poverty level Annual income Hourly wage 4 Affordability test safe harbor (9.5% of current wages) Estimated employee premium share for self-only coverage for affordability test safe harbor 5 Minimum wage worker 2 ~101% $11,310 $7.25 Medicaid eligible n/a eligible for Medicaid Statutory upper limit for 133% $14,856 $9.52 $1,411 $118 Medicaid eligibility Effective upper limit for 138% $15,415 $9.88 $1,464 $122 Medicaid eligibility 3 Upper limit for eligibility for tax credits 400% $44,680 $28.64 $4,245 $ The chart has been updated to reflect 2012 HHS Federal Poverty Guidelines for one person ($11,170). 2. Federal minimum wage ($7.25 per hour). Note: As of January 1, 2012, 18 states and the District of Columbia have minimum wage rates higher than the federal minimum wage. 3. PPACA 2002 (as added by HCERA 1004(e)(2)) requires states to apply an income disregard of five percent of the federal poverty level in meeting the income test, resulting in an effective income threshold of 138% of FPL for Medicaid eligibility. 4. Based on the PPACA threshold for classification as a full-time employee (average 30 hours per week) multiplied by 52 weeks % of current wages divided by 12 months Page 22

23 Minimum Value and Transition Relief To meet the minimum value an employer plan must pay 60% of the total allowed cost of benefits. Generally understood as a 60% actuarial value. Essential Health Benefits do not apply to large employer plans, but HHS may consider valuing the package as a baseline. Note if an employee is enrolled in an eligible employersponsored plan, regardless of the cost or value of the plan, such employee will be ineligible for a premium tax credit. The Administration has requested suggestions for minimum value transition relief. Guidance expected early Page 23

24 Reporting and Tax Penalties No guidance has been issued on: Employer reporting requirements or Internal Revenue Service verification, assessment and appeals processes related to employer tax penalties. Page 24

25 Congress and the Courts

26 Supreme Court The Supreme Court agreed to take up the Florida lawsuit challenging PPACA. Twenty-six states joined the lawsuit. The Court will address the following issues: Individual mandate Severability Anti-Injunction Act Expansion of Medicaid Arguments were heard March 26-28, and a decision is expected by the end June. The Court could uphold the law, strike down the individual mandate, strike down the expansion of Medicaid, strike down the entire law or punt! Page 26

27 2012 Elections and Health Care Outcome of Supreme Court case will fuel election debates. Repeal of the entire law by Congress remains exceptionally difficult. Elections will have a significant impact on: Efforts to repeal specific provisions of the law or make significant changes to the law Regulatory implementation Congressional oversight Page 27

28 Thank you! Contact us at

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