Health Care Reform Alert: Important Deadlines for Employers

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1 T HE J AECKLE A LERT HEALTH CARE AND EMPLOYEE BENEFITS PRACTICE GROUPS ATTORNEY ADVERTISING Health Care Reform Alert: Important Deadlines for Employers Although many important reforms under the Patient Protection and Affordable Care Act are already in place, many of the most fundamental changes will take effect on January 1, 2014, and other important new requirements will become effective over the next year. In this Alert we will summarize key requirements that have recently become effective or that will come into effect over the next several months, and preview the fundamental changes that will apply beginning on January 1, Appeals Procedures and External Review Requirements New Requirement: Claims and appeals procedures under group health plans and health insurance policies must comply with new regulations issued by the Departments of Health and Human Services ( HHS ), the Treasury and Labor (we will refer to these three Federal agencies as the "Health Care Reform Agencies"). Key Dates: These requirements were effective for plan years beginning on or after September 23, 2010; however, HHS established an "enforcement grace period", during which it will not seek to enforce the new rules, until January 1, What Group Health Plan Sponsors Must Do: Group health plans must establish or amend their claims and appeals procedures including both internal appeals and external review to comply with the new requirements under the Affordable Care Act and the implementing regulations. For most New York insured health plans, compliance with the rules under the New York State Insurance Law (as amended in 2011) will satisfy the federal requirements. Self-insured plans, in New York State and elsewhere, must comply with the new Federal requirements. Medical Loss Ratio Requirements and Treatment of Rebates New Requirement: Health insurers must spend at least a specified percentage of their premium revenues on medical care (rather than overhead), and issue rebates to consumers if they fail to meet the "loss ratio" target. The minimum loss ratio is 85% in the large group market and 80% in the small group market. Key Dates: The medical loss ratio requirements went into effect for policy years beginning on or after January 1, The first rebate checks were payable as of August 1, 2012.

2 Page 2 What Group Health Plan Sponsors Must Do: Sponsors of insured plans should consider how any rebates paid to the plan will be handled, taking into account whether the rebates will be ERISA plan assets. If rebates constitute ERISA plan assets, there may be restrictions on how the rebates can be used. Health plan sponsors should consider whether to amend their health plan documents to clarify how any such rebates will be handled. Summary of Benefits and Coverage (SBC) New Requirement: Group health plan sponsors and health insurers must provide a summary of benefits and coverage under the plan or policy to all plan participants each year. Note that this new requirement is separate from the existing employer duty (under ERISA) to furnish a summary plan descriptions (SPDs) to health plan participants. For insured health plans, both the insurance company or HMO and the employer/plan sponsor are responsible for preparing and distributing the SBC. For self-insured plans, the sponsor or administrator alone is responsible. Key Dates: The SBC requirements are effective for plan or policy years beginning on or after September 23, What Group Health Plan Sponsors Must Do: Sponsors of insured plans should work with the insurer to make sure the required coverage summary is provided to participants. Sponsors of self-insured plans must prepare and distribute the required summary, or make arrangements with a third party administrator or other vendor to do this. Note: HHS has issued model summaries and templates that can be used by insurers and sponsors to fulfill this disclosure obligation. Prior Notice of Plan Changes New Requirement: As part of the new SBC requirement (see the preceding paragraph), group health plans must provide 60 days advance notice of any material change to the plan or insurance coverage that is adopted outside of the annual enrollment period. Key Dates: The SBC rules, including the requirement to furnish advance notice of certain plan changes, are effective for plan or policy years beginning on or after September 23, What Group Health Plan Sponsors Must Do: Group health plan sponsors must be sure to provide the required advance notice if they adopt any material plan amendments outside of the annual enrollment period. PCORI (Comparative Effectiveness Research) Fee New Requirement: Insurers and sponsors of self-insured health plans must pay a fee to fund the Patient-Centered Outcomes Research Institute, which was established pursuant to the Affordable Care Act to conduct comparative effectiveness research that is, to evaluate the relative effectiveness, risks and benefits of medical treatments and services. The fee is $1.00 for each covered life for the 2012 policy or plan year, $2.00 for the 2013 policy or plan year, and an increased amount each year thereafter.

3 Page 3 Key Dates: The fees generally apply to policy and plan years ending on or after October 1, 2012 and before October 1, What Group Health Plan Sponsors Must Do: For sponsors of insured health plans, the insurer will report and pay the fee. Sponsors of self-insured plan sponsors must report and pay the fee; the first filing due date is July 31, Insurers and plan sponsors must report and pay these fees annually on IRS Form 720, which will be due by July 31 of each year. The IRS has issued guidance on how the fee is calculated. W-2 Reporting of the Cost of Employer Health Coverage New Requirement: Beginning with the 2012 tax year, large employers (those who filed 250 or more W-2s in 2011) must report the cost of employer-sponsored health coverage on employees W-2s. Key Dates: For large employers, the first W-2s are due in January 2013, for the 2012 tax year. For small employers those who filed fewer than 250 W-2 in 2011 the reporting requirement will be effective, at the earliest, for the 2013 tax year (for which the Form W-2s would be due in January 2014). What Group Health Plan Sponsors Must Do: Large employers must be prepared to issue the Form W-2s by January 13, Small employers have a reprieve until next year. Note that the IRS has issued detailed guidance on how the cost of employer provided coverage is determined for reporting purposes Flexible Spending Arrangements $2,500 Cap New Requirement: Employee salary reduction contributions to health flexible spending arrangements (FSAs) are limited to $2,500 per year beginning with the 2013 tax year. The limit will be adjusted for inflation in subsequent years. Key Dates: The $2,500 cap is effective as of January 1, Cafeteria plan documents do not have to be amended to reflect this new limit until December 31, What Group Health Plan Sponsors Must Do: Health plan sponsors or administrators must implement the new contribution cap beginning January 1, 2013, and adopt an appropriate plan amendment by December 31, FICA Tax Increase New Requirement: The hospital insurance or Medicare portion of FICA tax will increase by 0.9 percentage points on wages over $200,000 for an individual or $250,000 for married couples filing jointly. The additional Medicare tax also applies to earned income that is subject to the Self-Employment Contributions Act (SECA). Key Dates: The FICA/SECA tax increase is effective as of January 1, 2013.

4 Page 4 What Employers Should Do: Employers should consider the impact of the FICA tax increase on its employee benefit plans, including deferred compensation plans. Employee Elections Under Fiscal Year Cafeteria Plans New Transition Rule: Under the proposed regulations on the shared responsibility penalty, issued on January 2, 2013, employers that sponsor cafeteria plans with fiscal (noncalendar) plan years, can permit employees to make one election change during the plan year that begins in 2013, to either drop or elect health insurance coverage, without regard to whether such an election change would otherwise be permitted under the qualified status change rules. Key Dates: Employers must adopt an appropriate amendment no later than December 31, 2014, which must be effective retroactively to the first day of the 2013 plan year of the cafeteria plan. What Employers Should Do: Employers with cafeteria plans that operate on a fiscal plan year should consider permitting participants to make these special election changes. Employee Notice Regarding Health Insurance Exchanges New Requirement: Employers must provide a written notice to all employees about Health Insurance Exchanges, eligibility for premium tax credits and the effect of purchasing coverage under an Exchange health plan. Key Dates: The original deadline was March 1, 2013, but recent Department of Labor guidance indicates the notice will not be required until late summer or fall of 2013, which will coordinate with the open enrollment period for Exchanges. What Employers Should Do: Employers should be prepared to deliver the required notice after the final guidance is issued, later this year Employer Shared Responsibility Penalty ( Free Rider Penalty) New Requirement: Any employer with 50 or more full-time employee equivalents (FTEs) that does not provide affordable, minimum value health coverage for its full-time employees could be subject to a substantial penalty tax. If the employer does not offer any coverage and at least one employee receives a premium tax credit for coverage under a policy obtained on one of the new health insurance Exchanges, 1 the penalty is $2,000 for each full-time employee over the first 30. If the employer offers coverage but it is unaffordable or its value is less than 60% of expected plan costs, and at least one employee receives a premium tax credit, the penalty is $3,000 for each employee who receives a premium tax credit to purchase coverage on an Exchange. This shared responsibility penalty will be explained in more detail in a future Alert. 1 See Individual Mandate and Premium Subsidies, page 5, below.

5 Page 5 Key Dates: The shared responsibility penalty is effective on January 1, The measurement periods for determining whether an employee is a full-time employee could begin as early as November 1, What Employers Should Do: Employers with more than 50 FTEs should be tracking employees hours over the next 12 months to determine what employees are full-time, and therefore must be offered coverage in order for the employer to avoid the shared responsibility penalty. Employers should also begin analyzing whether their current employee health coverage meets the affordability and minimum value requirements as to all full-time employees. See our Health Care Reform Alert, Dealing With the Employer "Shared Responsibility Penalty" for more information on this topic. Waiting Periods New Requirement: A group health plan and a health insurance issuer cannot impose a waiting period of longer than 90 days. The waiting period is defined as the period after an employee meets the eligibility requirements under the plan and before coverage becomes effective. Key Dates: The limitation on waiting periods is effective on January 1, What Employers Should Do: Employers should determine whether the waiting period rules under their health plans comply with the new limitation under the Affordable Care Act Individual Mandate and Premium Subsidies New Requirement: Most U.S. citizens who do not have acceptable health coverage will be subject to a penalty tax. The tax will be phased in during 2014 and 2015, and when fully effective in 2016, the tax will be as high as $695 per individual and $2,085 for a family. To help lower income persons obtain health insurance, premium tax credits will be available to individuals and families with income below 400% of the Federal poverty level. Key Dates: The individual mandate and premium tax credits will be effective on January 1, What Employers Should Do: Employers are not directly affected by the individual mandate but should be aware of the potential impact of the penalty on their employees if they are not eligible for employer provided coverage. Other Changes Health Insurance Exchanges: HHS issue final regulations on health insurance exchanges in June, New York State has submitted the necessary documents to HHS so that its Exchange can begin offering individual and small business health insurance policies beginning on October 1, The New York Health Insurance Exchange s website is up and running at

6 Page ? Automatic enrollment: At some point after the Department of Labor issues guidance, employers with 200 or more employees will be required to automatically enroll employees in their health plans. Employees must then be given the opportunity to opt out. The applicable guidance is not expected to be issued until 2013 at the earliest, and employers will be given substantial lead time before the requirement becomes effective, so the automatic enrollment requirement probably will not apply until January 1, 2014 at the earliest. Discrimination rules for insured health plans: At some point after the Health Care Reform Agencies issue guidance, insured health plans will be subject to rules that prohibit discrimination in favor of highly compensated employees, similar to the rules that currently apply to self-insured health plans. The applicable guidance is not expected to be issued until 2013 at the earliest, and employers will be given substantial lead time before the requirement becomes effective, so the new discrimination rules probably will not apply until January 1, 2014 at the earliest. If you have any questions about the shared responsibility penalty or any other issue under the Affordable Care Act, please contact: Robert W. Patterson rpatterson@ Michele O. Heffernan mheffernan@ Daniel J. Gocek dgocek@ This Jaeckle Alert, prepared by the attorneys at, is intended for general information purposes only and should not be considered legal advice or an opinion on specific facts. For more information on these issues, contact one of the attorneys listed above or your existing Firm contact. Prior results do not guarantee a similar outcome. The invitation to contact is not a solicitation for legal work in any jurisdiction in which the contacted attorney is not admitted to practice. Any attorney/client relationship must be confirmed in writing All Rights Reserved.. Buffalo, NY.