Health Care Reform Patient Protection Affordable Care Act (PPACA) Overview Key Principles
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1 Health Care Refrm Patient Prtectin Affrdable Care Act (PPACA) Overview Key Principles DESCRIPTION: Healthcare Refrm/Patient Prtectin & Affrdable Care Act (PPACA) were passed int law March Hwever, the prvisins were spread ut ver the years fllwing the passing f the law. The fllwing timeline prvide a brief verview f the highlights f the bill. What fllws is a brief summary f several PPACA / Recnciliatin Act prvisins t shw the timeline impact Healthcare Refrm will have n emplyers/insured. Fr mre specifics, see (this link gives yu access t details and access t the full text f the law. It is recmmended that legal cunsel be sught fr any implementatin purpses. DETERMINING GRANDFATHERED VS NON-GRANDFATHERED: Grandfathered Health Plans Under the Patient Prtectin and Affrdable Care Act (PPACA), prvisin was made t allw peple already cvered by health insurance t keep that cverage. The term grandfathered plan was created t describe thse plans that were in existence n March 23, Grandfathered plans are exempt frm much f the new insurance refrms f the PPACA, as lng as they retain their grandfathered status. What PPACA Requirements Apply t a Grandfathered Plan? Fr ur grandfathered grup plans, effective January 1, 2011, the fllwing changes apply: A child f the insured wh is nt eligible fr emplyer-spnsred health benefits n his r her wn (cannt be eligible fr wn cverage requirement ends 1/1/2014) can be cvered under the parent s cverage t age 26, Can be married and still be eligible Lifetime benefit limits n essential health benefits are prhibited. Rescissin f cverage is prhibited except in the case f fraud r intentinal misrepresentatin f material fact. Preexisting cnditin exclusins cannt be applied t persns under the age f 19. Annual limits n the dllar value f essential health benefits are restricted. An internal and external appeals prcedure must be prvided. What Changes Cause a Plan t lse Grandfathered Plan Status? Examples f changes that will cause a plan t lse grandfathered status are: Increasing an emplyee s premium cntributin rate by mre than 5%. Eliminating benefits fr a particular cnditin. Increasing an insured s cinsurance percentage by any amunt. Increasing a fixed deductible amunt r an ut f pcket limit by mre than the rate f medical inflatin plus 15%. Increasing a fixed amunt cpayment by mre than the lesser f $5 plus medical inflatin r medical inflatin plus 15%. Eliminating a plan ptin. (Disclaimer): This infrmatin is an verview nly; it is nt all encmpassing and it is nt intended t cver all the law s details and is nt be used a legal recmmendatin fr any implementatin prcesses. It is advised that legal advice be sught regarding any specifics f this law.
2 Health Care Refrm Patient Prtectin Affrdable Care Act (PPACA) Overview Key Principles What Benefit Changes Will Nt Cause a Plan t Lse Grandfathered Plan Status? Adjusting plan eligibility rules. Cnducting dependent eligibility audits t ensure nly eligible dependents are cvered by the plan. Adding emplyees and dependents t the plan. Making changes t cmply with state and federal law. Vluntarily changing benefits t cmply with health refrm. Adding benefits. Making changes t dental & visin prgrams. Making changes t the PPO netwrks. Changing insurance carriers, s lng as the structure f the cverage desn t vilate ne f the ther rules fr maintaining grandfathered plan status (amended 11/17/2010). Nn-Grandfathered Health Plans Under the Patient Prtectin and Affrdable Care Act (PPACA), a nn-grandfathered plan is a plan that came int existence n r after March 23, 2010, r a previusly grandfathered plan that made changes that were significant enugh t cause it t lse its grandfathered status. Nn-grandfathered plans are subject t all f the new insurance refrms f the PPACA. What PPACA Requirements Apply t a Nn-Grandfathered Plan? As f September 23, 2010, new nn-grandfathered plans must: Allw a child f the insured t be cvered under the parent s cverage t age 26, even if married. Prvide unlimited lifetime benefits fr essential health benefits. Only allw rescissin f cverage in the case f fraud r intentinal misrepresentatin f material fact. Remve preexisting cnditin exclusins fr persns under the age f 19. Prvide essential health benefits. PPACA TIMELINE: 2010 N Pre x children -Eliminate pre-existing cnditin clauses fr enrllees under the age f 19 Eliminate annual benefit maximum-eliminate lifetime and annual benefit maximums Dependent eligibility -dependents eligible up t age 26 Dependent child can be married, and des nt have t rely n parent fr supprt If plan grandfathered, dependent child cannt be eligible fr emplyer spnsred insurance n their wn (until year 2014) Wellness: Cver specific preventive care services with n cst- sharing and cver emergency services at the in- netwrk level regardless f prvider Grandfathered plans insurance cmpany definitin f wellness applies Nn Grandfathered plans Gvernment definitin f wellness applies See Primary Care MD- Allw enrllees t designate any in- netwrk dctr as their primary care physician Allw access t care by a participating primary care physician t include certain types f physicians (i.e., pediatrician and OB/GYN), (Disclaimer): This infrmatin is an verview nly; it is nt all encmpassing and it is nt intended t cver all the law s details and is nt be used a legal recmmendatin fr any implementatin prcesses. It is advised that legal advice be sught regarding any specifics f this law.
3 Health Care Refrm Patient Prtectin Affrdable Care Act (PPACA) Overview Key Principles ER Access-Must permit access t emergency services withut requiring prir authrizatin Autmatic Enrllment in Health Plans by emplyers with mre than 200 full-time emplyees 2011 Benefit disclsure -Disclse Value f benefits prvided by emplyer n annual W-2 frms Standardizes Definitin f Qualified Medical Expenses fr HSAs, FSAs, and HRAs t the definitin used fr the itemized deductin. Preventative Services: New plans required t cver preventive services with little t n cst sharing Specific Language: Cmply with Dept. Health & Human Services (DHHS) guidance n specific language that is required t be included in plan dcuments and summaries (subject t fines fr nncmpliance used fr the itemized deductin). Medical Lss Rati (MLR)-Health insurers must prvide cnsumer rebates where less than 80 t 85 percent f dllars are used fr benefits Health insurers must annually reprt n the share f premium $$ spent n medical care versus prfits and/r administratin H.S.A. (health savings accunts) & FSA (Flex Spending Accunts) n lnger eligible fr OTC (ver the cunter) medicatins. HHS grup plan analysis HHS must review the grup plan market, determinging if new refrms are likely t result in adverse selectin in the large grup market, r encurage self insurance in smaller grups SBC-Prvide emplyees with Pre-Enrllment/Re-Enrllment Summary f Benefits SBC Must be prvided at enrllment, re-enrllment, when plicy is delivered, r when material change is made Effectiveness Fee Fee impsed n individual & grup plans t fund cmparative effectiveness research - $1 per participant thrugh year 2013, then $2 per participant thru 2019) Implement Internal Claim Appeals Prcess Self fund MLR: Self-Funded Plans must reprt /medical lss rati annually t HHS n percentage f premiums used t pay medical claims vs plan administrative expenses t assist DHHS annual study f self funded plans. Self Fund financial respnsibility-dhhs t determine if an emplyer is financially sund enugh t ffer a self fund plan and if they find they are nt, they can rder them t g fully insured Cntraceptive cverage mandate (8/2012)- nn grandfathered plans nly 2013 Health inf exchange: Health plans must adpt and implement unifrm standards and business rules fr the electrnic exchange f health infrmatin t reduce paperwrk and administrative burdens and csts. FSA cntributins: limits Health Flexible Savings Accunt Cntributins t $2,500 per year (indexed by CPI fr subsequent years. Remval Rx subsidy: Eliminates deductin fr emplyers subsidy f Rx drug plans fr their Medicare Part D eligible retirees. (Disclaimer): This infrmatin is an verview nly; it is nt all encmpassing and it is nt intended t cver all the law s details and is nt be used a legal recmmendatin fr any implementatin prcesses. It is advised that legal advice be sught regarding any specifics f this law.
4 Health Care Refrm Patient Prtectin Affrdable Care Act (PPACA) Overview Key Principles Annual Fee fr patient-centered utcmes research becmes effective n insured and self-insured plans t fund the patient-centered utcmes research trust fund. $1 per participant in 2013; $2 per in 2014; $2 increased by annual medical inflatin fr FYs 2015 thrugh Tax penalty tax penalty distributins frm H.S.A accunts fr nn qualified medical expenses increased frm 10% t 20% 2014 Cverage mandate: Requires mst individuals t btain acceptable health insurance cverage r pay a penalty f $95 fr 2014 (r 1% taxable incme), $325 fr 2015(r 2% taxable incme), $695 fr 2016 (r, up t 2.5 percent f incme in 2016); after 2016 amunts based n adjustments fr inflatin. Emplyer Respnsibility Requirement impsed n large emplyers nt ffering affrdable health insurance cverage will require paying a mnthly penalty f $ per full-time emplyee beynd the first 30, as lng as the emplyer has at least ne emplyee wh receives subsidized cverage in the lcal health insurance exchange. The penalty amunt will be adjusted annually after 2014 t reflect the natinal increase in insurance premium csts. N penalty applies t part-time wrkers (thse wrking less than 30 hurs a week) wh are nt ffered cverage. Small emplyers (thse with fewer than 50 FTEs) are exempt frm the emplyer respnsibility requirement. (affrdable cverage defined = cvering at least 60% f medical csts and nt extracting an emplyee cntributin twards the price f that cverage in excess f 9.5% f that emplyees husehld incme) Emplyers with 50 r mre FTEs will pay a penalty f $250/mnth ($3,000 a year) fr each fulltime wrker wh is ffered emplyer cverage but instead receives a premium credit t buy cverage in the exchange. The ttal amunt that an emplyer will have t pay with respect t such emplyees will be capped at an amunt equal t $2,000 times the ttal number f fulltime wrkers in excess f 30 that the firm emplys. These dllar amunts will be adjusted annually after 2014 by the grwth in health insurance premiums. Will need t cunt emplyees wh d nt wrk full time (i.e.-part time emplyees) by dividing the aggregate # wrk hurs wrked fr 1 mnth by 120; Will need t cnsider cntrlled grup rules, as members f a cntrlled grup will be treated as a single emplyer, and all emplyees will be treated as emplyed by a single emplyer; and Will nt be cnsidered t have emplyed mre than 50 full time emplyees if the emplyer s wrkfrce exceeds 50 full time emplyees fr 120 days r fewer during the calendar year and the emplyees in excess f the 50 during the 120 day perid were seasnal wrkers Sample: In preceding year; ABC Manufacturing emplys 35 emplyees wrking year rund. They emply 40 seasnal emplyees fr 90 days. This is nt a large emplyer, as they exceeded 50 emplyees fr less than 120 days (if grup exceeded 50+ fr 120 days including seasnal emplyees, they wuld be cnsidered a large emplyer) N Pre-x: Health plans can n lnger exclude cverage fr treatments based n pre-existing health cnditins (applies t all ages) Guaranteed issue: Insurance carriers must accept every persn and emplyer wh applies fr cverage (als see rating restrictins belw) Rating restrictins: Insurance cmpanies restricted frm charging higher rates due t heath status, gender, r ther factrs. Premiums can vary nly n age (n mre than 3:1), gegraphy, family size, and tbacc use. N annual limits -prhibits all emplyer plans frm impsing annual limits n amunt f cverage individual may receive (des nt apply t grandfathered plans) Cst Share limits-implement $5,950 Cst-sharing limits fr individual cverage and $11,900 fr family cverage (Disclaimer): This infrmatin is an verview nly; it is nt all encmpassing and it is nt intended t cver all the law s details and is nt be used a legal recmmendatin fr any implementatin prcesses. It is advised that legal advice be sught regarding any specifics f this law.
5 Health Care Refrm Patient Prtectin Affrdable Care Act (PPACA) Overview Key Principles Essential benefit levels-implement new levels f essential benefit cverage, e.g., prescriptin drugs, disease management. ambulatry, emergency, mental nervus, substance use disrder, rehabilitative, labratry, preventive, wellness, and pediatric services, hspitalizatin, maternity and newbrn care, etc. SF reprting: Begin reprting self-insurance cverage t IRS Waiting perid maximum: maximum waiting =90 days Maximum deductible: Limit the maximum deductible t $2,000 fr individual cverage and $4,000 fr family cverage Opens Health Insurance Exchanges (HIE). This new ptin allws peple t shp fr standard health packages. It enables enrllment and administers tax credits, purpse is fr peple f all incme ranges can btain affrdable cverage. Multistate Natinal Plans will be ffered t individuals and small emplyers thrugh state exchanges Health insurance exchanges will be established at the state level fr individuals and small emplyers (generally <100 emplyees). The exchanges may include large emplyers January 1, Large emplyer: Federal definitin f a large emplyer is an emplyer with 101 r mre emplyees (small emplyer = emplyees). Hwever, the states can elect t change this large emplyer definitin t 51 r mre emplyees and small 1-50 emplyees (until 1/1/2016) Health Care Premium Tax Credits Available thrugh the HIE t ensure peple can btain affrdable cverage. Credits are available fr peple with incmes abve Medicaid eligibility and belw 400 percent f pverty ($88,000 fr a family f fur) wh are nt eligible fr r ffered ther acceptable cverage. Premium subsidies will be available fr individuals and families with incmes between 133 percent and 400 percent f the pverty level, r $14,404 t $43,320 fr individuals and $29,326 t $88,200 fr a family f fur. Prvides fr health care premium subsidies n sliding scale (fr example, a family f 4 earning 150 percent f the pverty level, r $33,075 a year, will have t pay 4 percent f its incme, r $1,323, n premiums. A family with incme f 400 percent f the pverty level will have t pay 9.5 percent, r $8,379. HIPAA requirements fr Wellness: Wellness Plans must satisfy current HIPAA rules regarding wellness prgrams, with an increase in the limit applicable t wellness incentives frm 20 percent t 30 percent. This means that generally the reward fr satisfying the wellness prgram, tgether with the reward fr ther wellness prgrams available under the plan, may nt exceed 30 percent f the cst f emplyee-nly cverage under the plan Exchange eligibility: Wrkers wh qualify fr an affrdability exemptin t the individual respnsibility plicy but d nt qualify fr tax credits can take their emplyer cntributin and jin an Exchange plan. Free chice vuchers: Emplyers must ffer free-chice vuchers t emplyees whse share f the premium fr emplyer-spnsred cverage wuld be between 8 and 9.5 percent f their incme. The amunt f an emplyee s vucher wuld equal the cntributin the emplyer wuld make t its wn health plan n behalf f the emplyee, and the emplyee culd use the vucher t purchase insurance in the exchange. Reinsurance; A temprary reinsurance prgram will be set up fr individual market and funded by grup and individual health plan assessments (Disclaimer): This infrmatin is an verview nly; it is nt all encmpassing and it is nt intended t cver all the law s details and is nt be used a legal recmmendatin fr any implementatin prcesses. It is advised that legal advice be sught regarding any specifics f this law.
6 Health Care Refrm Patient Prtectin Affrdable Care Act (PPACA) Overview Key Principles 2018 Merged Markets: States can merge the individual and grup markets New Tax: Excise tax n high cst emplyer-prvided health plans takes effect. EMPLOYER GUIDANCE Cadillac health plans tax-. 40% fr amunt > $10,200 fr individuals and $27,500 fr family plans paid by insurance cmpanies and administratrs. EMPLOYER REQUIREMENTS/PENALTIES: COVERAGE MANDATE: In Year 2014, if the large emplyers with 50 r > emplyees elect nt t ffer cverage (r ffer cverage that is nt affrdable), they will have t pay an assessment fee. The 50 emplyee cunt des include full and part time emplyees (based n full time equivalency rules). Emplyer with less than 50 emplyees are exempt frm cverage requirements. (affrdable cverage defined = cvering at least 60% f medical csts and nt extracting an emplyee cntributin twards the price f that cverage in excess f 9.5% f that emplyees husehld incme) Emplyers (with 50 r mre ttal emplyees) that d nt ffer minimum essential cverage will be subject t a penalty. Penalty fee $2,000 fr each emplyee ver the first 30 emplyees if ne f their emplyees gets a tax subsidy t purchase cverage thru an exchange Emplyers (with 50 r mre emplyees) that des ffer minimum essential cverage, but still has at least 1 emplyee receiving subsidized cverage thru an exchange, will pay the lesser amunt: $3,000 per emplyee getting a premium credit, r $2,000 fr each full time emplyee. SBC (Summary Benefit Descriptin) distributin t emplyees prir t enrllment r at re-enrllment (September 2012) Must be prvided at enrllment, re-enrllment, when plicy is delivered, r when material change is made What is a ft emplyee under the mandate? emplyees that wrk at least 30 hurs a week fr at least 1 week per mnth EMPLOYER REPORTING: Emplyers mandated t disclse the value f health care benefits n each emplyees annual W-2 Emplyee ntificatin- emplyer must ntify emplyees f: Exchange availability new emplyees at hire time, current emplyees by 3/1/2013 Pssibility f eligibility fr subsidy under an exchange if the emplyers cntributin t the plan is less than 60% f ttal allwed csts If emplyee pts t take exchange, he/she will lse emplyer premium cntributin 2014-large emplyers will be subject t expand 5500 reprting t include infrmatin n health insurance cverage f their emplyees TAX CREDITS (SMALL BUSINESS ONLY): In Year 2010, small businesses (less than 25 emplyees) and average wages less than $50,000 can get a tax credit fr their cntributins tward their health insurance cntributins fr their emplyees. Credits start at 35% & increase t 50% in 2014 when exchanges kick in. (Disclaimer): This infrmatin is an verview nly; it is nt all encmpassing and it is nt intended t cver all the law s details and is nt be used a legal recmmendatin fr any implementatin prcesses. It is advised that legal advice be sught regarding any specifics f this law.
7 Health Care Refrm Patient Prtectin Affrdable Care Act (PPACA) Overview Key Principles MEDICARE- MEDICAID IMPACT: PART D Rx Dnut Hle: % brand discunt n drugs in dnut hle gap. Generic drugs in the dnut hle gap will experience a reductin t; dnut hle will be eliminated by year 2020 Retiree Drug Subsidy 2013: emplyers may n lnger deduct the retiree drug subsidy when ffering qualified cverage under Medicare Part D Medicaid 2014: States are required t prvide premium assistance and wrap arund benefits t any Medicaid beneficiary wh is ffered emplyer spnsred cverage, if cst effective. Medigap NAIC will create new mdel plans fr benefit packages C & F t prvide nminal cst sharing t be available in year 2015 (Disclaimer): This infrmatin is an verview nly; it is nt all encmpassing and it is nt intended t cver all the law s details and is nt be used a legal recmmendatin fr any implementatin prcesses. It is advised that legal advice be sught regarding any specifics f this law.
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