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1 The Employer s Guide to Health Care Reform What you need to know now to: Consider your choices Decide what s best for you Follow the rules

2 Health care reform is the law of the land. Some don t like it. Most don t get it. And many of its rules are still being refined, defined or delayed. But the Patient Protection and Affordable Care Act (ACA) better known as health care reform is the law. And many of its most sweeping and major rules go into effect January 1, Most Americans, especially those under age 65, count on their employer for health insurance. 1 As an employer, you play a big role in carrying out health care reform. You have a lot to know, much to think about, and many choices to make. Only by understanding your choices can you decide what s best for your workers and your business. This guide will help you understand the health care reform rules that affect you. Keep in mind that the law is complex (more than 2,000 pages) and the rules are still changing. At the back of this guide you ll find more resources; be sure to check them regularly for updates. TABLE OF CONTENTS PART I Health Care Reform and Your Business...3 PART II Health Plan Benefits and Costs...6 PART III Medical Loss Ratios and Rebates...9 PART IV Choices and Considerations for Employers...10 Health Care Reform and Your Business New Rules: Plan requirements On January 1, 2014, every American must have a certain amount of health insurance coverage or pay a tax. While the ACA does not make employers offer coverage, it: Offers tax credits to small businesses that offer health benefits. Has penalties for large businesses that do not offer insurance at a price a person can pay for insurance. Has penalties for large businesses that offer coverage below certain standards. For businesses that do offer health insurance, the ACA says plans must cover a certain level of benefits and costs. For new plans and plans renewing on and after January 1, 2014: All nongrandfathered small business health plans must cover essential health benefits. These include ambulatory patient services, stays in the hospital overnight or longer, emergency services, maternity and newborn care, pediatric care, lab services, mental health and substance use disorder services, preventive and wellness services, long-term disease management, rehabilitative and habilitative services and devices, and prescription drugs. All nongrandfathered small business health plans must cover at least 60% of the cost of benefits paid by the plan (minimum value). Self-insured and large business plans do not have to cover essential health benefits or meet minimum value rules. But, employers can avoid possible penalties by offering plans that do meet minimum value. Also, plans offered by all employers: PART I Must have certain out-of-pocket dollar limits on essential health benefits. (Large business, self-funded and grandfathered plans can have frequency or visit limits.) Cannot have yearly or lifetime dollar limits on essential health benefits. Must be at a price a person can pay, with the worker s part of the premium for a self-only plan no more than 9.5% of that worker s income. The government offers financial help through tax credits, cost-sharing subsidies and/or Medicaid. To qualify, individuals and families must meet certain income rules and not have a chance to get affordable health insurance with minimum coverage standards from an employer or a government program. 2 3

3 As defined by the ACA and as used in this guide: Small businesses are those with 49 or fewer full-time equivalent workers. Large businesses are those with 50 or more full-time equivalent workers. Small business will be redefined as workers in States may delay this change until Workers are considered full-time if they work 30 or more hours per week. The ACA has a formula for figuring out full-time equivalent workers. Here s an example In 2013, a company has 20 full-time workers working an average of 30 hours per week each month. It also has 40 part-time workers who work 90 hours per month, and no seasonal workers. 1. Count the number of workers working at least 30 hours per week, per month = Count the number of workers who are equivalent to full-time based on the formula by adding the number of hours worked by all part-time workers (as well as seasonal) and dividing by 120. Part-time workers: 40 x 90 hours per month = 3600 divided by 120 = Add = 50 That means this company must offer coverage to full-time workers in 2014 because its average number of workers in 2013 is 50. Remember, calculating the number of workers for these situations can be complicated. You should always speak with your attorney or tax adviser for help. A New Marketplace: Health Insurance Exchanges To help make coverage easier to find and easier to pay for, individuals and small businesses can shop for coverage in a new Health Insurance Marketplace. This is also known as an insurance exchange. Coverage for plans bought through marketplaces will start on January 1, Large businesses are likely to have access to Health Insurance Marketplace plans beginning in The small business marketplace called the Small Business Health Options Program (SHOP) will help make it easier for small businesses to find and compare health plans from private insurance companies. Unlike the individual marketplace, there is no open-enrollment period for businesses. A business can join when it s time to renew its current policy, or whenever it chooses. To help you compare plans with similar benefits and premiums, plans are arranged in tiers by the percentage of total average costs they cover for specific benefits (called actuarial value). These tiers are also called metal levels and can vary plus or minus 2%. TIER TOTAL AVERAGE BENEFIT COSTS COVERED Platinum 90% (+/-2% = 88%-92%) Gold 80% (+/-2% = 78%-82%) Silver 70% (+/-2% = 68%-72%) Bronze 60% (+/-2% = 58%-62%) 60% IS THE MINIMUM COST COVERAGE ALLOWED. Rules delayed or on hold Employee Choice for Small Businesses ACA at first called for SHOP exchanges to give employers an employee choice beginning in Employers could choose a benefit tier (bronze, silver, gold or platinum) and workers could select any qualified health plan, from any insurance company, from that tier on the SHOP. The exchange would send one bill to the business for all workers, and the exchange would pay the different insurance companies for each worker they cover. Now, exchanges may delay offering the employee choice until Automatic Enrollment for Large Businesses The ACA said that starting in 2014, employers with more than 200 full-time workers would have to automatically enroll new full-time workers in one of their health plans. The U.S. Department of Labor has put off the date and has not said when automatic enrollment will be required. 4 5

4 PART II Health Plan Benefits and Costs Health care reform legislation was enacted in 2010, and its rules have been implemented little by little ever since. No year will see bigger changes than Not only is access to health plans changing the benefits of those plans are changing as well. And new fees and taxes on plan issuers and sponsors will help fund the increase in benefits and government subsidies. New Benefits: More coverage, fewer limitations Here s an overview of the most important changes to plan benefits: Small business and individual plans must include essential health benefits, as described on Page 3. Out-of-pocket maximum limits (added together for all coverage). Plans cannot exclude people with pre-existing conditions, no matter what their age. Plans cannot have a waiting period for coverage more than 90 days. Businesses with 50 or more full-time equivalent workers must offer coverage with minimum value (60% coverage of costs), or pay a penalty. Routine care costs must be covered for patients who have life-threatening illnesses and take part in clinical trials. Deductibles for individual and small business plans are limited to $2,000 (individual) and $4,000 (family). HIPAA nondiscrimination rules apply to wellness programs. The maximum incentive on wellness programs goes up to 30%, and up to 50% for programs to prevent or lower tobacco use. Health coverage is guaranteed to all Americans. In a nutshell, complete health benefits must be offered for all Americans, no matter their age or health condition. Plans must have limited deductibles and out-of-pocket costs, and no yearly or lifetime dollar limits to the essential health benefits. These changes to plan benefits are likely to change premiums as well. Guaranteed access to coverage for people with pre-existing conditions may raise average premiums, as people with higher health costs come into the insurance system. 2 Also, premiums could change as the burden is shared among all enrollees. Rates can vary only by age (within limits), tobacco use, geography and the number of family members covered. 3 The highest premium cannot be more than three times the lowest premium for the same plan. Most changes to rates in 2014 due to health care reform will be for individuals and small businesses. This is where rating limits, product rules, new benefit mandates and new taxes will have the biggest impact. The impact will likely vary a lot between each individual and each small business. New Taxes and Fees: Funding the changes Here s an overview of the new taxes and fees starting or changing in 2014: ACA Insurer Fee Purpose: Health care reform calls for issuers of fully funded plans (including dental and vision plans) to pay a yearly fee to fund premium subsidies and expand Medicaid. Effective Date: The fee starts on January 1, 2014, not as plans renew. It can be prorated for plans beginning or renewing on or after February Amount: The ACA Insurer Fee will be approximately 2.46% of premium (before state tax gross-up).* The Internal Revenue Service bases the fee on the insurer s market share of net premiums written for the year before. The total fee amount is to be collected across all insurers. It starts at $8 billion in 2014 and goes up to $14.3 billion in After 2018, the fee will go up each year based on premium growth. 6 7

5 ACA Reinsurance Fee Purpose: Fully funded and self-insured plans pay this fee to help support the transitional reinsurance program. This program aims to stabilize premiums in the individual market. The fees will be used to make reinsurance payments to health insurance issuers that cover high-cost people in nongrandfathered individual market plans. Effective Date: The fee starts on January 1, 2014, not as plans renew. It can be prorated for fully insured plans beginning or renewing on or after February Amount: In 2014, the fee is estimated to be $5.25 per member per month.* The fee is part of a short-term program. The fee will go down over three years and then be removed. Comparative Effectiveness Research Plan Fee Medical Loss Ratios and Rebates PART III Health care reform calls for health insurers to report medical loss ratios. Medical loss ratio is the percentage of premiums that insurers spend on health care, including claims and services that make health care better. Health insurers must spend at least 85% on health care in the fully insured large business market and 80% in the fully insured small business and individual markets. If the insurance company does not meet the medical loss ratio, any subscriber who had an active, fully insured health insurance policy during the calendar year can get a rebate. Rebate amounts are based on rules from the federal government. Rebate checks for any calendar year should be received by August 1 of the next year. Purpose: This fee helps support the Patient-Centered Outcomes Research Institute, a nonprofit, nongovernmental group, to explore how well health treatments work and their risks and benefits. Fees are paid by issuers of fully insured plans and sponsors of self-funded plans. Effective Date: Fees are to be collected for plan years and policy years that end after September 30, 2012 and before October 1, Amount: $1 multiplied by the average number of covered members for plan years that end October 1, 2012, through September 30, The fee goes up to $2 multiplied by the average number of covered members for plan years that end October 1, 2013, through September 30, The cost will then be adjusted for medical inflation. * This is an estimation and may be subject to change. Rebate Examples Rebate calculations are very difficult. Most of the time, insurers divide the amount they pay for medical care and quality improvement programs by the amount they earn in premiums, minus state and local taxes. That amount is distributed proportionately to all people in the specific plan in a state. SMALL BUSINESS In the small business market insurers must spend at least 80% of premium on health care costs and quality improvement programs. LARGE BUSINESS In the large business market insurers must spend at least 85% of premium on health care costs and quality improvement programs. 8 9

6 PART IV Choices and Considerations for Employers As 2014 comes closer, you have many choices to make. Let s review your choices and considerations: Small Businesses If you are an employer with 49 or fewer workers, you do not have to offer health insurance. You have many choices in 2014, including: Offer a fully insured plan through either: A Small Business Health Options Program (SHOP) exchange The off-exchange market Offer a self-insured plan, if allowed by state law If you self-insure, rules about which benefits to provide don t apply Stop offering coverage and let workers buy through the Individual market Offer non-affordable coverage to some workers They may buy coverage from the health insurance marketplace Large Businesses Like small businesses, you do not have to provide health coverage for your workers. But, starting in 2015: If minimum coverage is not offered to full-time employees, and at least one worker gets a subsidy or tax credit to buy a plan from the health insurance marketplace, then you must pay a $2,000 penalty for each full-time worker (after the first 30). If minimum coverage is offered to full-time employees but it is not affordable for an employee, and that worker gets a subsidy or tax credit to buy a plan from the health insurance marketplace, then you must pay a $3,000 penalty for each full-time worker getting subsidized coverage. Beginning in 2013, small and large businesses must tell workers about the new Health Insurance Marketplace (exchange), including subsidies and tax credits. Definitions Minimum coverage, whether through a fully insured or self insured plan, must include medical insurance that isn t limited to specific benefits such as vision or dental only. The plans also must cover at least 60% of the total cost of the benefits for the year. YOU MAY GET A TAX CREDIT for offering coverage. Through tax year 2013, there is a tax credit for businesses with 25 or fewer full-time equivalent workers who are paid an average yearly salary of less than $50,000. Qualifying employers can get a tax credit of up to 35% of premium costs (25% for non-profits). Starting in 2014, the tax credit goes up to 50% (35% for nonprofits) until 2016 if you offer coverage through a SHOP. The U.S. Department of Health and Human Services and the Internal Revenue Service have developed a minimum value calculator to help you find out if a plan meets the definition. Download and access the calculator from the Center for Consumer Information and Insurance Oversight at Regulations-and-Guidance/Downloads/mv-calculator-final xlsm Affordable coverage means that the worker s share of the premium (to cover one person) cannot be more than 9.5% of his or her earnings. You must figure out each worker s share. You can figure this out using the wages showing in box 1 of the employee s W-2. Or, you can use the federal poverty level for a single person. For example, in 2013 that amount is $11,490, and 9.5% of that is $1, So, the worker s yearly cost for one-person coverage must be less than $1, to be considered affordable. You don t have to offer health insurance to your workers. But, you have many good reasons to do so plus incentives included in health care reform legislation. People who are insured are more likely to get needed health care, so workers with health insurance are more likely to be healthy and useful workers. Health insurance is good for your workers and your business

7 To learn more, please contact your broker or agent. Or contact your Anthem representative. 1 Economic Policy Institute, A decade of declines in employer-sponsored health insurance coverage ; Elise Gould, February 23, 2012; employer-sponsored-health-insurance/, accessed 5/10/ Henry J. Kaiser Family Foundation, accessed 5/10/13 3 National Association of Insurance Commissioners & The Center for Insurance Policy & Research, accessed 5/11/13 Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.

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