HEALTH CARE REFORM CHECKLIST

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1 HEALTH CARE REFORM CHECKLIST As a small employer, you need to be aware of the new regulations tied to the Affordable Care Act. Refer to this checklist to ensure you understand each one and that you re on the right track to stay compliant. Keep in mind that the Small Business Association of Michigan can help you fulfill many of the requirements you are responsible for as a company. Visit or call us at (800) for more information Health Insurance Exchange Employee Notification Starting October 1, 2013 and continuing on, all companies should have provided an Exchange Notice to all of their employees (part-time, full-time, seasonal, etc.). There are two separate notices: One version is for employers that currently offer health insurance as an employee benefit to their employees, and the other version is for employers that do not offer health insurance as an employee benefit. Going forward, new hires must receive notice within 14 days of their start date of employment. Summary of Benefits & Coverages and Summary Plan Description Employers who offer health insurance to their employees must provide a Summary of Benefits & Coverages (SBC) and a Summary Plan Description (SPD) to employees. There are multiple times that this document may need to be provided including when an employee is initially eligible, special enrollments, annual enrollment and upon the request of the employee. SBAM members enrolled in a sponsored Blue Cross Blue Shield or Blue Care Network plan automatically receive a free SPD along with a SBC. More Changes to Flexible Spending Accounts On the first day of the first plan year on or after January 1, 2013 the annual maximum contribution to a medical FSA is $2,500 per participant. More recently the IRS has granted employees more time to use their FSA dollars with an allowable rollover of unused balances up to $500 from one year to the next. To make this change your plan document will need to be amended check in with your plan administrator. Pricing Penalties, Taxes and Fees, Tax Credit Member Level Insurance Invoicing Your insurance invoice will look different beginning with your first renewal in Each covered employee will be billed a specific rate based on their age, and if covered, the ages of their spouse and dependents. In addition, some insurance plans may include a rate penalty for tobacco smokers. With every employee at a different price, think about how your company shares costs with employees and how that may need to change. Page 1 of 6

2 Individual Mandate The requirement that all U.S. citizens and legal residents have qualifying health coverage and that those without coverage are subject to a tax penalty. The penalty will be phased in according to the following schedule: Individual Penalties Sample Income Levels $9,500 $16,250 $27,800 $40,000 Year Penalty = the greater of: 2014 $95 or 1% taxable income $95 $163 $278 $ $325 or 2% taxable income $190 $325 $556 $ $695 or 2.5% taxable income $238 $406 $695 $1,000 Household Penalties Sample Income Levels $28,500 $48,750 $55,000 $83,400 Year Penalty = the greater of: 2014 $285 or 1% taxable income $285 $487.5 $550 $ $975 or 2% taxable income $570 $975 $1,100 $1, $2,085 or 2.5% taxable income $712.5 $1, $1,375 $2,085 Exemptions will be granted for financial hardship, religious objections, American Indians, those without coverage for less than three months, undocumented immigrants, incarcerated individuals, those for whom the lowest cost plan option exceeds 8% of an individual s income, and those with incomes below the tax filing threshold. Federal Subsidies Based on Income Federal government will provide refundable and advanceable premium credits to eligible individuals and families who don t have access to affordable employer-sponsored health insurance with incomes between 133% and 400% of federal poverty level. Page 2 of 6

3 Taxes and Fees In addition to the insurance premium invoices looking different due to employee level pricing, beginning January 1, 1014, you are going to pay new taxes and fees to fund the ACA that will increase your premium by approximately 4% - 6%. These taxes and fees include: Type When How Much Individual and ASC Medicare Small Group Comparative July 2013 $1 to $2 PMPY Yes Yes No Effectiveness (PCORI) Federal Tax on 2014 % of premium Yes Yes (stop loss) Yes Insurance Premiums Reinsurance Fees $5.25 PMPM Yes Yes No (phase out in 2017) Marketplace Fee % of Small Group No No premiums on marketplace only Risk Adjustment 2014 $.96 PMPY Yes No No Fee High Cost health plan (Cadillac Tax) % excise tax on premiums Yes Yes Yes, if in a Group plan Take a look at BCBSM s taxes and fees estimator tool at which now includes the State Insurance Premium Tax and the ACA federal taxes and fees. The estimator tool breaks down the taxes presented on the quote, renewal or bill and provides estimated amounts for each tax. It s important to note that the tool provides estimates, not actual amounts of taxes and fees. And, it does not apply to Medicare Advantage individual and group customers. Small Business Tax Credit (part 2) For small businesses that purchase through the Exchange and pay at least 50% of the premium, a tax credit of up to 50% of the employer s contribution to premium is available. Full credit is available to companies with 10 or fewer employees with average annual wages of less than $25,000. The credit phases out as company size and wages increase and is available for a maximum two years. Health Insurance Plan Changes Guarantee Issue & Restrictions on Insurance Carrier Rate Setting Insurers will no longer be able to set rates or exclude coverage based on preexisting conditions, and can vary premiums only by geographic location, age, and tobacco use. Insurance carriers may no longer deny coverage based on health factors. Page 3 of 6

4 Essential Health Benefits All health plans sold on the Insurance Exchange must include essential health benefit items and services in the following 10 categories: 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; and pediatric services, including oral and vision care. Group health plan annual dollar limits do not apply to essential health benefits. Deductible & Out-Of-Pocket Limits Health insurance plan deductibles are limited to $2,000 for individuals and $4,000 for families unless contributions are offered that offset deductible amounts (i.e., HRA contribution). The out-of-pocket limits for 2014 are $6,350 for an individual and $12,700 for a family. These limits apply only to innetwork levels of benefits and only apply to essential health benefits. Please refer to your plan s Summary of Benefits & Coverage for the specifics of your plan. Waiting Periods Many employers that have health plans require a new employee to work a certain period of time before the employee can enroll in the health plan. This waiting period typically applies to the employee and the employee s family. For plan years beginning on or after January 1, 2014, an employer s waiting period cannot exceed 90 calendar days. Wellness Programs Allows employers to offer employees rewards (premium discounts, etc.) or benefits for participating in a wellness programs. BCBSM and BCN offer various plans with a wellness component. Buying Health Insurance Metal Level Products Products from insurance carriers must meet the minimum value standard. Qualified Health Plans (QHPs) will be classified according to metal levels: bronze, silver, gold and platinum. The purpose is to create a level playing field a health insurance marketplace where individuals and small business owners can compare plans with similar levels of coverage and make informed decisions. The metal levels match the percentage of costs covered as follows: Bronze (60%*) Silver (70%*) Gold (80%*) Platinum (90%*) Page 4 of 6

5 *Actuarial value is the percentage of costs (claims) a health plan covers in relation to how much the enrollee is expected to pay. At the bronze level, for example, the plan would pay 60% of health care costs while the enrollee would be responsible for 40%. Bronze plans are designed with the lowest monthly premium and highest cost sharing such as deductibles, coinsurance and or copayments when health care services are utilized. Platinum plans generally have the highest monthly premium and lower cost sharing responsibility for the patient. The Affordable Care Act (ACA) sets the requirements for QHPs in terms of metal levels, out-of-pocket maximum limits, essential health benefits and more. Essential health benefits such as emergency care, maternity care, prescription drugs and other services must be covered. Medicaid Expansion The program for low-income Americans under the age of 65 would expand by increasing the income eligibility to 133% of federal poverty, or $29,327 for a family of four. In Michigan, the expansion will begin in late March or early April and Beyond Employer Mandate/Fair Share/Play or Pay Requirement Employers with 50+ fulltime equivalent employees must offer coverage or be subject to a "free rider" penalty. For the terms and definitions that you need to make this determination for your company please visit Variable Hour Employees For companies that are near the magic number of 50 Full Time Equivalent (FTE) employees, the delay on the employer penalty gives employees additional time to resolve the challenge of determining their status with regard to the Play or Pay Mandate. Visit for more information and help SHOP Exchange The Small Business Health Options Program (SHOP Exchange for small businesses with fewer than 50 employees), is scheduled to be up and running in 2015 and will offer small business and their employees several choices of insurance carriers and product options Cadillac Tax Beginning in 2018, a 40% excise tax will be imposed on the value of health insurance benefits exceeding a certain threshold. The thresholds are $10,200 for individual coverage and $27,500 for family coverage (indexed to inflation). Page 5 of 6

6 Questions? The Small Business Association of Michigan offers you SBAM s Decision Point to help you navigate the new Health Care Reform laws and regulations. This online tool compiles all the Health Care Reform information you need into one location. With a reform timeline, employee count calculator, subsidy calculator, Play or Pay information on the penalties for your customers and their employees, glossary of terms and much more. Visit to get started. Page 6 of 6

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