PPACA/Healthcare Reform CHANGES

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1 PPACA/Healthcare Reform CHANGES beginning in 2014 for small employers A guide to understanding the administrative provisions, benefit changes, new taxes and credits, market reforms and purchasing options available inside and outside the Marketplace for small employers beginning in Prepared By: Jeffrey Ingalls Stratford Financial Group, Inc. Stratford Employer Services, LLC 122 Parish Drive, Wayne, New Jersey Phone: (866) ext

2 Excessive Waiting Periods Effective on plan years beginning on or after January 1, 2014, employees cannot be made to satisfy a waiting period of longer than an exact 90 days. Employers that do not adhere to this provision may be subject to penalties of $100 per day, per violation, per person (potentially in addition to claim liability). This will immediately apply to those new employees in the existing waiting period upon the plan renewal date. In addition to updating the waiting period with your medical plan, employers should consider altering the waiting period on other lines of coverage dental, vision, life insurance) for consistent and streamlined administration. Lastly, employers should review their Section 125 plan documents and Summary Plan Descriptions (SPDs) to insure the language has properly updated to reflect any changes. Summary of Benefits and Coverage The Summary of Benefits and Coverage (or SBC) is required to be linguistically appropriate, made available in paper form, and provided 30 days before the plan renewal, 7 days after enrollment, plan change or date of request, within 90 days of a special enrollment or 60 days prior to a material modification. Employers that do not adhere to this provision may be subject to penalties of $100 per day, per violation, per person (in addition to a $1,000 penalty for willful neglect). Additionally, effective on plan years beginning on or after January 1, 2014, the standardized Summary of Benefits and Coverage (SBC) needs to updated to include a statement as to whether or not the plan provides minimum value (maintains an actuarial value of 60%, the value of a Bronze plan, or greater).

3 Notice of Employee Marketplace Coverage Options This provision began with a requirement to provide current employees with a notice by October 1, 2013 and continues with new employees being provided a notice within 14 days of their hire date. The notice serves to explain coverage options and potential subsidies available in the Marketplace. The notice also provides employer plan details such as eligibility, coverage and affordability (Page 1+2 required). The notice is most safely provided via first class mail or electronically (DOL safe harbor); however, some alternate methods of distribution may also be deemed acceptable. COBRA-eligible employers also need to confirm their COBRA Qualifying Event Notice is updated with similar information relative to the Marketplace coverage options, etc. Public Marketplace (SHOP) and Private Exchanges Effective on or after January 1, 2014, small employers will have the option to purchase coverage through a variety of pathways: inside the Marketplace through the Small Health Options Program (SHOP), outside the Marketplace in the standard small employer health market (SEH) or through a private exchange such as the Bright Choice Exchange offered by Liazon and sponsored by Benefit Advisors Network of which The Stratford Financial Group is a member organization. In its initial year of operation, employers purchasing coverage through the SHOP will be limited to one carrier and one plan choice. Employers purchasing outside the Marketplace will have the option of offering multiple plans depending on each carriers underwriting guidelines. The Bright Choices Exchange provides employers the option of offering robust prebuilt suites of plans from participating carriers, most often incorporating a defined contribution approach.

4 Small Employer Plan Designs Effective January 1, 2014, (upon renewal for existing plans) each small employer plan offered inside or outside the Marketplace (SHOP) must include all ten Essential Health Benefits, comply with the proper cost-sharing limitations and meet the actuarial value of one of the metal plans listed above (+ or - 2%). Essential Health Benefits 1) Ambulatory Patient Services 2) Emergency Services; 3) Hospitalization 4) Maternity and Newborn Care 5) Mental Health/Substance Use Disorder Services, including behavioral health treatment 6) Prescription Drugs 7) Rehabilitative (and habilitative) Services and Devices 8) Laboratory Services 9) Preventive and Wellness Services and Chronic Disease Management 10) Pediatric services, including oral (dental) and vision care. Effective on plan years beginning on or after January 1, 2014, small employer healthcare plans must include all ten Essential Health Benefits (EHBs). Additionally, coverage standards (such as per day annual benefit limitations) must adhere to the minimums found in the New Jersey State Benchmark plan. Essential Health Benefits may not be subject to a monetary annual or lifetime benefit. Coverage for pediatric dental may be purchased as an embedded benefit in the healthcare plan or on a stand-alone basis (Most current stand-alone dental plans do not provide the appropriate level of benefit.) The pediatric dental benefit will include medically necessary orthodontia and will be provided to children up to their 19th birthday.

5 Cost Sharing Limitations Effective on plan years beginning on or after January 1, 2014, small employer plans are prohibited from including an annual deductible greater than $2,000/employee and $4,000/employee and dependent(s) (repealed retroactively). Carriers may be permitted to utilize a higher deductible if a higher deductible is required to achieve a particular metal level of coverage. Additionally, maximum out-of-pocket costs need to include all Essential Health Benefits, including prescriptions drugs (although some transitional relief may apply) and are limited to (in 2014) $6,350/employee and $11,700/employee and dependent(s). A Health Reimbursement Arrangement (HRA) may be utilized to comply with the maximum out-of-pocket element of the provision only. Rating Methodology: Member Level Pricing (NJ) Effective on plan years beginning on or after January 1, 2014, small employer plans will be rated differently than prior to Healthcare Reform. While plan choice, company headquarters and effective date will still be utilized, each employee will be rated on a member-level, which will represent a change from the current composite rating method. Gender will no longer be utilized and while permissible under PPACA, tobacco use will also not be utilized. Each employee will be rated utilizing a 2 to 1 pricing ratio and one rate band for children ages 0 to 20, single year rate bands for adults ages and one rate band for adults age 64 and older. It is important to note that Medicare carve-out rates will no longer be permissible and only the three oldest children, under age 20, will be included. For Example: a 30 year old employee married to a 34 year old spouse with one child, age 5 would be rated as follows: Adult 30 Rate + Adult 34 Rate + Child 0-20 Rate = Family Premium

6 Minimum Value and Affordability Employer sponsored healthcare plans calculated to maintain an actuarial value of 60% or greater (a Bronze level plan or better) are considered to be of minimum value. In order to determine if an employer sponsored healthcare plan is deemed to be affordable, the annual employee contribution for employee-only coverage in the lowest cost plan providing minimum value must be 9.5% or less of the employee s Box 1 W-2 income. (Please Note: The employer may elect to utilize one of two other permissible safe harbor for affordability calculations.) Individual Marketplace Subsidies Individuals and (their) dependents with a modified adjusted gross household income between 138%-400% of the Federal Poverty Level who are not eligible for affordable, minimum value employer sponsored coverage may enroll as individuals in the Marketplace and can potentially be eligible to receive the available subsidies. (Please Note: The current Federal Poverty Level is approximately $11,000 for individuals and $23,000 for a family of four.) The Premium Assistance subsidy (an advance tax credit) sets the premium for a Silver Plan at a percentage of household income, based on a sliding scale. The Cost Sharing Assistance Subsidy increases the actuarial value of the Silver Plan and reduces the plan s maximum out-of-pocket, also based on a siding scale according to household income.

7 The Premium Assistance Subsidy The Cost-Sharing Assistance Subsidy

8 The Small Business Tax Credit Beginning in 2014, small employers who elect to purchase coverage through the Marketplace (SHOP) may be eligible for a tax credit of up to 50% of the amount of the annual employer contribution (based on the sliding scale found below). The small employer must meet three criteria: employ fewer than 25 full-time equivalent employees, maintain an average employee annual income of less than $50,000 and make a uniform employer premium contribution of at least 50% or greater for all tiers of coverage. The Small Business Tax Credit is reduced to a maximum of 35% for tax-exempt companies. Additionally, the tax credit can be claimed for a maximum of two consecutive years.

9 PPACA/Healthcare Reform Taxes and Fees Beginning in or before 2014, small employers offering employer sponsored group coverage will be subject to three new taxes and fees which will equate to higher premiums directly attributable to PPACA/Healthcare Reform. Patient Centered Outcome Research Fees This tax provision will equate to $2 per member annually and will be utilized to fund the not-for-profit corporation designed to research and report upon patient outcome research as it relates to controlling healthcare costs. Reinsurance Fees This tax provision will equate to approximately $63 per member annually and the funds collected will be used to stabilize the individual marketplace and the risk associated with the influx of new, potentially high-risk enrollees. The Health Insurance or HIT Tax This tax provision will equate to a 2%-3.5% increase in premiums and the funds collected will be used to fund the individual subsidies being provided to eligible enrollees purchasing individual coverage in the Marketplace beginning January 1, 2014.

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