Basics of Health Care Reform. What You Should Know

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1 Basics of Health Care Reform What You Should Know

2 The Affordable Care Act (ACA) has resulted in major across the U.S. health care system. This brochure provides an overview and timeline of the that have already been implemented and those that will be implemented in the near future. TIMELINE 2010 CHANGES Effective Date Issue Small Business Tax Credit March 23 Grandfathered Status September 23 Annual and Lifetime Benefit Limits Removed September 23 Dependent Coverage Extended to Age 26 September 23 Rescissions Prohibited September 23 Nondiscrimination Rules October 1 Preventive Health Care Coverage Required 2011 CHANGES Effective Date Issue Large- and Small-Group Definitions FSA, HRA, HSA Changes 2012 CHANGES Effective Date March 12 March 23 Before August 1 August 1 September 23 Issue W-2 Reporting Final Health Insurance Marketplace Rules (Ex) Quality Reporting Medical Loss Ratio (MLR) Women s Preventive Services Summary of Benefits and Coverage 2013 CHANGES Effective Date February 15 July 31 October 1 December 31 Issue FSA Limits Partnership Marketplace (Exchange) Deadline Patient-Centered Outcomes Research Institute (Comparative Effectiveness) Fee Health Insurance Marketplace (Exchange) Open Enrollment Electronic Health Transaction Rules 2

3 2014 CHANGES Effective Date Issue Waiting Period Limitation Rules Health Insurance Marketplace Coverage Takes Effect (Ex) Essential Health Benefits Employer Shared Responsibility Individual Shared Responsibility Health Benefit Standards Subsidies for Individuals Insurance Market Rules Rating Factor Limitations Health and Wellness Rewards Annual Health Insurance Industry Fee Single Risk Pool Requirement Risk Corridor Program Established Risk Adjustment Program and Fee Small-Group Participation in State Marketplaces (Ex) 2015 CHANGES Effective Date, , 2015 Issue Transitional Reinsurance Fee Independent Payment Advisory Board CHANGES Effective Date Issue, 2016 State Health Choice Compacts Allowed, 2017 Large-Group Participation in State Marketplaces (Ex optional) 2018 Cadillac Plan Tax Please note: This guide provides a general overview of various that have resulted from ACA regulations. You should not consider this information to be legal or compliance advice. Furthermore, the information contained in this document is subject to change. Please consult legal counsel for complete information and guidance concerning ACA regulations. You can also visit the health care reform section of our website at to view more informational flyers and FAQs. 3

4 Small-Business Tax Credit If the following hold true for an employer, he or she may be eligible for a tax credit: Has less than 25 full-time employees (Part-time employees should be counted using a specific calculation to determine eligibility for this tax credit.) Employees annual average wage is less than $50,000 Employer pays for at least 50 percent of the employee-only premiums Visit our website for a worksheet to help determine whether an employer might be eligible for the small-group tax credit. Grandfathered Status March 23 If a plan existed before March 23, 2010, it may have grandfathered status. This means it is exempt from some of the regulations resulting from the ACA. A grandfathered plan is limited in the it can make to keep grandfathered status. There are some ACA regulations that DO apply to grandfathered plans. For example, under the ACA, grandfathered plans: Cannot apply lifetime dollar limits to key health benefits Are not permitted to cancel insurance coverage as the result of an honest mistake on an insurance application Must offer dependent coverage to adult children under 26 years of age (However, grandfathered group plans do not have to offer coverage to adult dependents if they are eligible for group coverage outside their parents plan.) Visit our website for more information on grandfathered status. Annual and Lifetime Benefit Limits Removed September 23 Health plans offering group coverage are prevented from establishing lifetime or annual limits on the dollar value of essential health benefits as defined by the Health and Human Services (HHS) Secretary. Some very large annual limits are allowed for essential health benefits from 2010 to

5 Dependent Coverage Extended to Age 26 September 23 Health plans providing dependent coverage of children are required to cover an adult child until age 26. More details about this coverage are listed below: Dependent is not required to be enrolled in school to receive coverage Includes ancillary products, such as dental and vision, if enrolled in a medical plan Dependent is not required to live with parents to be covered under their plan Children of adult dependents will not be covered Visit our website for more information on dependent coverage up to age 26. Rescissions Prohibited September 23 Group and individual health plans may not rescind coverage for covered individuals except in instances of intentional misrepresentation of material fact. Nondiscrimination Rules September 23 In the past, employers who offered fully insured plans would offer more generous benefits to executive employees. ACA rules prohibit the implementation of such practices with regard to health benefits. (The IRS has prohibited self-funded plans from discriminating in favor of highly compensated employees even before the passage of the ACA.) An excise tax penalty of $100 per affected individual per day per failure will be applied to non-grandfathered group plans that don t comply. The federal government has not yet issued rules and has delayed the implementation and enforcement of this regulation for fully insured non-grandfathered plans. However, rules are expected in Preventive Health Care Coverage Required October 1 Group and individual health plans are required to cover the following preventive services: Those rated A or B by the U.S. Preventive Services Task Force Immunizations recommended by the Advisory Committee on Immunization Practices (ACIP) Preventive care for infants, children and adolescents Additional preventive care and screenings for women Visit our website for more information on preventive health care coverage. 5

6 Large- and Small-Group Definitions A large group is defined as a group health plan in connection with an employer with an average of at least 101 employees. A small group is defined as a group health plan in connection with an employer with an average of one to 100 employees. Until January 2016, states can choose to define large groups as having 51+ employees and small groups as having 1-50 employees instead of the 100-employee threshold set forth in the law. FSA, HSA, HRA Changes Distributions from health FSAs and HRAs will be allowed to reimburse the cost of overthe-counter medicines or drugs only if they are purchased with a prescription. This new rule does not apply to reimbursements for the cost of insulin, which will continue to be permitted, even if purchased without a prescription. For health savings accounts (HSAs) and Archer Medical Savings Accounts (Archer MSAs), only prescribed medicines or drugs (including over-the-counter medicines and drugs that are prescribed) and insulin (even if purchased without a prescription) will be considered qualifying medical expenses and subject to preferred tax treatment. Visit our website for more information on FSA, HSA, HRA. 6

7 W-2 Reporting Employers who filed at least 250 W-2 forms for 2011 are required to report the cost of applicable employersponsored coverage on Form W-2. This requirement will affect W-2s for calendar year 2012 and will be ongoing. The Internal Revenue Service (IRS) continues to stress that the amounts reported are not taxable. The new requirement is intended to be informational only and to provide employees with greater transparency into overall health care costs. Visit our website for more information on W-2 reporting. Final Health Insurance Marketplace Rules (Ex) March 12 The Department of Health and Human Services (HHS) released its final rule to establish Affordable Insurance Marketplaces under the Affordable Care Act (ACA). Quality Reporting March 23 HHS is required to develop standardized annual requirements for quality reporting by group health plans. These reports must address plan coverage benefits and health care provider reimbursement structures that improve health outcomes and patient safety, prevent hospital readmissions, and implement wellness and health promotion. Medical Loss Ratio (MLR) Before August 1 Health insurers (including health maintenance organizations) must pay rebates to employers and individuals if a certain percentage of the premium dollars collected by the insurer is not used to reimburse medical care. This minimum percentage is called MLR. In the individual and small-employer market, health insurers must spend at least 80 percent of premium dollars in the applicable market on medical care. In the large-employer market, health insurers must spent at least 85 percent of premium dollars on medical care. Health insurers report MLRs to the federal government by June 1 each year and must issue rebates by August 1 each year if they do not meet the required threshold in the specified market. MLR reporting will be ongoing. To find out why an employer group did or did not receive a rebate, call your Coventry account manager. Visit our website for more information on MLR. 7

8 Women s Preventive Services August 1 The following preventive care services are included without cost sharing when received in-network for all new and renewing individual and group health plans that are not grandfathered:* Well-woman visits Screening for gestational diabetes Human papillomavirus (HPV) DNA testing for women 30 years and older Sexually transmitted infection counseling Human immunodeficiency virus (HIV) screening and counseling FDA-approved contraception methods and contraceptive counseling (subject to standard medical management and formulary restrictions) Breastfeeding support, supplies and counseling Domestic violence screening and counseling * Most self-funded plans are required to offer similar coverage without cost sharing beginning on the date of the first plan year that occurs on or after August 1, Visit our website for more information on Women s Preventive Services. Summary of Benefits and Coverage (SBC) September 23 An SBC is a detailed description of a policyholder/member s health care benefits. It includes information like deductible amounts, coinsurance and copayment obligations. Because all health plans will follow the same template, SBCs will be in a standardized format, which will give people a more simple and consistent way to compare health plans. Coventry prepares SBCs and employer groups distribute them to participants and beneficiaries. Coventry delivers SBCs to employer groups with quotes for new and renewing policies. If off-renewal plan affect SBC information, notification must be provided to members no later than 60 days before the take effect. While Coventry prepares SBCs, employer groups will be responsible for distributing them to employees, as outlined in the Employer Acknowledgment. Visit our website for more information on SBCs. 8

9 FSA Limits A $2,500 limit is imposed on employee contributions to health FSAs with adjustments for inflation in future years (limit does not include employer contributions). Partnership Marketplace (Exchange) Deadline February 15 States must inform HHS if they have chosen to establish health insurance marketplaces in partnership with the federal government. Other options are for the states to establish their own marketplaces or to leave it to the federal government to establish one in that state. Patient-Centered Outcomes Research Institute (Comparative Effectiveness) Fee July 31 Health plan sponsors (e.g., self-funded groups) and issuers of individual and group health insurance policies (e.g., Coventry Health Care) are required to pay a new fee to help fund the Patient-Centered Outcomes Research Institute (PCORI). The PCORI was authorized by the U.S. Congress to provide evidence-based research that will help people make informed health care decisions. During its first year, the fee will amount to $1 per covered life, per year, or about $0.08 per member, per month (PMPM). During its second year, the fee will be $2 per covered life, per year, or about $0.17 PMPM. In following years, it will be indexed to national health expenditures until the fee ends in For more information on how Coventry Health Care will process ACA fees and taxes, contact your Coventry account manager. Visit our website for more information on Patient-Centered Outcomes Research Institute fee. Health Insurance Marketplace (Exchange) Open Enrollment October 1 Open enrollment for individuals and small businesses to buy insurance through states health insurance marketplaces begins October 1, 2013, and will run through March 31, In following years, the health insurance marketplace open enrollment will run from October 15 through December 7. Coventry will provide updates as they are available. Electronic Health Transaction Rules December 31 A single set of operating rules for electronic health transactions (e.g., eligibility verification, claims status) will be developed by the HHS Secretary. Health plans are required to file a statement with HHS certifying that data and information systems are in compliance with standards and operating rules for: Electronic funds transfers Health plan eligibility Health claim status Health care payment and remittance advice 9

10 Waiting Period Limitation Rules Waiting periods for coverage offered by employers are limited to no more than 90 days. Health Insurance Marketplace Coverage Takes Effect (Ex) Individuals and small groups may be able to purchase health plans through these marketplaces. A health insurance marketplace is where individuals and small businesses can buy health benefit plans. Marketplaces will offer a choice of health plans that meet certain benefits and cost standards. Creates four benefit categories of plans Bronze, Silver, Gold, Platinum plus a Catastrophic Plan available to those under age 30 and to certain other individuals. Requires the Office of Personnel Management to contract with insurers to offer at least two multi-state plans in each marketplace with at least one plan offered by a nonprofit entity. Requires all individual and small-group plans (inside and outside the marketplace except grandfathered plans) to cover essential health benefits. Coventry will keep you informed of our marketplace initiative. Essential Health Benefits The ACA requires non-grandfathered small-group and individual plans both inside and outside health insurance marketplaces for plan years beginning on or after January 1, 2014, to cover a set of health services and benefits called the Essential Health Benefits Package. These include: 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 and wellness services and chronic disease management Pediatric services, including oral and vision care Visit our website for more information on essential health benefits. Employer Shared Responsibility 10 Large employers (i.e., those who have at least 50 full-time employees) will have a responsibility to offer health care coverage that meets certain minimum standards to their full-time employees and their dependents. Associated with this ACA requirement is a potential penalty that would be assessable by the Internal Revenue Service (IRS) to employers who do not comply. Continued on next page "

11 Employer Shared Responsibility continued from previous page It s important for employer groups to understand that part-time employees figure into the equation of meeting the 50 full-time employee eligibility. Employer groups should contact their Coventry account manager for help in calculating whether they have the equivalent to 50 full-time employees. Visit our website for more information on the employer shared responsibility. Individual Shared Responsibility January 2014 Most individuals must have health insurance or face a potential penalty. Individuals will be required to have minimum essential coverage for themselves and their dependents. Some will be exempt from this mandate or penalty. Others may receive financial assistance to help pay the cost of health insurance. Health Benefit Standards Out-of-pocket costs for most health plans are capped at the limits under HSAs (estimated: $6,400/individual and $12,800/family in 2014). Non-network and noncovered services are not included in these amounts. Subsidies for Individuals Subsidies in the form of advanced premium tax credits are available to individuals who enroll in a qualified health plan on the individual health insurance marketplace if: a) Their income is less than 400 percent of the federal poverty limit AND b) They do not have access to minimum value employer coverage Insurance Market Rules In conjunction with the start of health insurance marketplaces, new insurance rules are imposed on health insurance issuers in the small-group and individual markets: Annual and lifetime limits may not be imposed on the dollar value of coverage. Plans may apply annual or lifetime per-beneficiary limits to nonessential health benefits. Rescissions of coverage may not be made except in cases of fraud. Health insurance issuers will generally be prohibited from denying coverage to people because of pre-existing conditions or other factors. In general, people will need to purchase coverage during open enrollment periods. Also, individuals will have special enrollment opportunities in the individual market when they experience certain losses of other coverage. Health insurance issuers are prohibited from refusing to renew coverage because an individual or employee becomes sick or has a pre-existing condition. Rating Factor Limitations The rates for non-grandfathered plans and policies sold in the small-group and individual markets may vary based on the following factors: Continued on next page " 11

12 Rating Factor Limitations continued from previous page Whether coverage is for an individual or family Geographic rating area Age The rate must not vary by more than 3:1 for like individuals of different age who are 21 years and older. The variation in rate must be actuarially justified for individuals under age 21, consistent with a uniform age rating curve. A state may use a narrower ratio with approval by CMS. A person s age for rating purposes is their age at time of the policy s effective or renewal date. Tobacco use Rates based on tobacco use may not vary by more than 1.5:1 for similar individuals who vary in tobacco usage. A state may use a narrower ratio with approval by CMS. Rates for tobacco users can vary up to the 1.5:1 ratio. In other words, younger smokers may have lower tobacco rating factors (e.g., 1.25) than older smokers (e.g., 1.5). The tobacco rate may be applied to individuals who may legally use tobacco under federal and state law. Visit our website for more information on rating factor limitations. Health and Wellness Rewards The incentives that employers may offer to reward employees who participate in wellness programs to achieve health status targets rises to 30 percent of the cost of coverage from 20 percent. Under HIPAA, incentives were previously limited to 20 percent of the cost of coverage. Annual Health Insurance Industry Fee Health insurance issuers (e.g., Coventry health plans) will be assessed an annual fee to fund some of the provisions of the ACA. The total amount collected from the fee will be $8 billion in 2014 and will increase to $14.3 billion in After 2018, the amount will be determined by the annual rate of premium growth. Based on estimates from Oliver Wyman, a national consulting group, the fee could increase premiums by percent in 2014 and by 3-4 percent in later years. Health insurance issuers will be responsible for paying this fee. The fee applies to Coventry health plans fully insured, Medicare, Medicaid and dental business. It also applies to both grandfathered and non-grandfathered fully insured plans. For more information on how Coventry Health Care will process ACA fees and taxes, contact your Coventry account manager. 12 Visit our website for more information on ACA fees and taxes.

13 Single Risk Pool Requirement Health insurers are required to consider all enrollees in all health plans offered in the small-group market in a state (other than grandfathered health plans) to be a single risk pool. Risk Corridor Program Established This applies to qualified health plans in the individual and small-group market segment between 2014 and Government payments will be provided to plans if allowable costs exceed 103 percent of the target amount. Payments equal: 50 percent of costs above 103 percent but less than 108 percent of target 80 percent of costs above 108 percent of target Plans must pay the government if total allowable costs are below 97 percent of the target amount. Payments equal: 50 percent of costs below 97 percent but above 92 percent of target 2.5 percent of target plus 80 percent of costs below 92 percent of target Risk Adjustment Program and Fee The ACA creates a new risk adjustment program to spread the financial risk borne by health insurance issuers in the individual and small-group markets. In turn, HHS anticipates the program will stabilize premiums and provide issuers the ability to offer a variety of plans to meet the needs of a diverse population. Under the risk adjustment program, issuers will be required to pay a fee to offset the cost of operating the program. Coventry estimates that the risk adjustment fee will cost fully insured plans that participate in the individual and small-group markets in a given state about $0.08 PMPM. The fee does not apply to large-group plans or selffunded plans, nor does it apply to any grandfathered plans. For more information on how Coventry Health Care will process ACA fees and taxes, contact your Coventry account manager. Visit our website for more information on ACA fees and taxes. Small-Group Participation in State Marketplaces (Ex) States are directed to create a Small Business Health Options Program (SHOP) to assist small-group employers in facilitating the purchase of and enrollment in qualified health plans. In 2014 and 2015, small businesses with less than 50 employees may participate in the SHOP. In 2016, small businesses with up to 100 employees may purchase coverage through the SHOP. States can decide to expand the SHOP to businesses with up to 100 employees before Marketplaces will be Web-based organizations. 13

14 Transitional Reinsurance Fee The ACA establishes a transitional reinsurance program to help stabilize premiums for coverage in the individual market during calendar years 2014 through All health insurance issuers and third-party administrators on behalf of self-insured group health plans will pay into the program to fund payments to individual market issuers covering high-cost individuals. HHS proposes that the annual assessment will cost $63 (plus a possible small administration fee) per individual enrolled under a plan/policy in HHS will require plan administrators to submit enrollment counts by November 15, The agency will send out assessment bills by December 15, Payments will be due 30 days later. Health insurance issuers (e.g., Coventry health plans) and self-funded health plans will be responsible for paying this fee. This fee applies to both grandfathered and nongrandfathered plans. Quarterly collections by the government will begin in January 2015 when the initial payments are due. This fee will be phased out after calendar year For more information on how Coventry Health Care will process ACA fees and taxes, contact your Coventry account manager. Visit our website for more information on ACA fees and taxes. Independent Payment Advisory Board 5 An Independent Payment Advisory Board will be created to submit recommendations to Congress to slow growth in national health expenditures (and recommendations to reduce Medicare spending one year earlier). 14

15 State Health Choice Compacts Allowed, 2016 States are permitted to form health care choice compacts and allow insurers to sell policies in any state participating in the compact. Large-Group Participation in State Health Insurance Marketplaces, 2017 States may allow large employers (those with more than 100 employees) to purchase coverage through the marketplace. Cadillac Plan Tax 2018 plan year A 40 percent excise tax is imposed on Cadillac health plans when the value of coverage exceeds $10,200 for individuals and $27,500 for families. The Cadillac Plan Tax could have a significant impact on some group health plans. Coventry offers products and services to help find options to avoid such taxes. Contact your Coventry broker or account manager for more information. Visit our website for more information on ACA fees and taxes. 15

16 This brochure provides a general overview of various regulations resulting from the Affordable Care Act (ACA). You should not consider this information to be legal or compliance advice. Furthermore, the information contained in this document is subject to change. Please consult legal counsel for complete information and guidance concerning the ACA Coventry Health Care. All rights reserved. HCR.BOOK.0413

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