What You Need to Know About Health Care Reform

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1 What You Need to Know About Health Care Reform A Toolkit for Small Employer Group Administrators

2 What s inside Health care reform offers new choices for small businesses... 1 Why New Jersey businesses prefer Horizon BCBSNJ... 2 Introducing new health plans for small businesses New benefits. New costs Our members health care dollars pay for a lot of health care... 6 The number of employees determines how your group is affected... 7 The ACA requires essential health benefits, including comprehensive wellness and preventive services Introducing the public marketplace Count on Horizon BCBSNJ More tools and resources Introducing our new health plans Finding the new small employer health insurance plan that s right for your business Our dental plans give you something to smile about. A timeline of health care reform milestones and requirements We help you comply with requirements How to determine your number of FTEs How the ACA may affect your business in 2015

3 Health care reform offers new choices for small businesses Horizon BCBSNJ combines ACA requirements with simplified coverage and high-value provider networks The Affordable Care Act (ACA) includes tax credits for small businesses as well as penalties for individuals who do not obtain health insurance. To determine your business s eligibility for assistance and to avoid potential penalties, you ll need to understand the new law s promises and pitfalls, as well as information about the new line of health plans being introduced by New Jersey s largest health insurer, Horizon Blue Cross Blue Shield of New Jersey. The new law provides the opportunity for your business to offer employees health insurance plans that combine the required essential health benefits and preventive services with the features of Horizon Blue Cross Blue Shield of New Jersey s Exclusive Provider Organization (EPO) and Direct Access plans. We can help guide you through the changing health care landscape to select the right plan for your business and your employees. HorizonBlue.com 1

4 Why New Jersey businesses prefer Horizon BCBSNJ Horizon BCBSNJ has been serving generations of businesses and their employees for more than 80 years. Marketing surveys consistently demonstrate that we enjoy the strongest favorability ratings over our competitors among households and businesses. Here are a few of the reasons why: Provider access Our broad network of doctors, hospitals, health care professionals and pharmacies provides convenient access to the right provider or service, in the right location. Many of our new health plans offer access to out-of-state coverage through our BlueCard program. Horizon BCBSNJ offers more than twice the number of high-value providers in our network than our nearest competitor. Overall, our provider arrangement helps ensure high-quality standards that can ultimately save on premiums and the cost of covered services. Easy-to-understand plans Horizon BCBSNJ offers a simplified product line that fits the needs of small businesses. With 3.7 million members, we understand the complexities of managing health care programs for groups of every size. Our dedicated staff can guide you to help make the right decisions for your business and your employees. Value Horizon BCBSNJ health plans are priced competitively and offer a high value in terms of providers, customer service and community involvement. Horizon BCBSNJ is part of the national network of independent, community-based Blue Cross and Blue Shield Plans serving nearly 100 million people. 2 HorizonBlue.com

5 Introducing new health plans for small businesses Combining ACA requirements with the best features of Horizon BCBSNJ plans Horizon BCBSNJ s new health plans are designed to meet the requirements of the ACA and the New Jersey Department of Banking and Insurance and meet the unique needs of smaller businesses. Our new plans combine the standard essential health benefits, preventive services and other ACA requirements with the features of a Horizon Advantage EPO plan or a Horizon Advantage Direct Access plan. We offer the opportunity to customize health plans with BlueCard flexibility for better out-of-state access and coordinated care through more than twice the number of high-value provider networks offered by other insurers. Horizon Advantage EPO With Horizon Advantage EPO, members have access to all doctors, specialists and hospitals that participate in the Horizon Managed Care Network. Horizon Advantage EPO plans provide integrated medical and pharmacy benefits, including wellness and emergency care. Although members are not required to select a Primary Care Physician (PCP), there are lower out-of-pocket costs when certain care is coordinated through a selected PCP. Most Horizon Advantage EPO plans can be customized to include BlueCard for out-of-state coverage. Horizon Advantage Direct Access Horizon Advantage Direct Access plans offer the freedom for members to use any of the thousands of participating doctors, hospitals and other health care professionals in the Horizon Managed Care Network without referrals. Horizon Advantage Direct Access plans include BlueCard for out-of-state coverage. HorizonBlue.com 3

6 Dental plans Health plans purchased off of the Small Business Health Options Program (SHOP), the health insurance exchange for small businesses, must include standalone pediatric dental coverage. Pediatric oral services is an essential health benefit under the ACA. Horizon BCBSNJ can help your employees make oral health part of their overall health program. Horizon BCBSNJ offers two options: Young Grins and Young Grins Plus. Preventive services included in new benefit plans Prevention and early detection of disease are the best medicine for preserving health and reducing the overall cost of care. Under the ACA, an annual wellness visit and certain preventive services are covered in full when delivered by a network provider. New benefits. New costs. The health care reform law broadens access to benefits, expands the benefits that are covered and creates new taxes to help pay for them and other new expenses related to the law s administration. The principal factors that drive health insurance costs include: Expanding access to insurance The primary goal of health care reform is to help the uninsured access health insurance. The insured population will likely grow to include: y Those who could not afford to purchase insurance. y Those who were unable to obtain coverage due to pre-existing conditions. Expanding covered benefits Benefit plans in the individual and small group markets are required to include essential health benefits, which may be more than what an employer or consumer currently has or wants. This means that some plans that were sold in the past will no longer be sold. Some customers will see rate changes to address the cost of providing care. 4 HorizonBlue.com

7 New rating guidelines The ACA prohibits prior industry practices such as risk rating based on gender. In New Jersey, risk rating is now limited to age. And, rates for the new health plans are calculated at the member level, not the subscriber level. This means groups with employers covering larger families may pay more. Groups with healthier, younger employees previously enrolled in Horizon HMO and Horizon Advantage EPO plans may see higher rate increases. Groups with older employees previously enrolled in Horizon Direct Access may receive rate reductions. New health insurance fees The ACA introduces new fees on health insurers and health plan sponsors to help pay for many aspects of the new law. These fees include: y Annual health insurance industry fee. y Excise tax on high-cost plans beginning in 2018 (regulations pending). y Marketplace exchange user fees. y Patient-Centered Outcomes Research Institute (comparative effectiveness) fee. y Risk Adjustment Program fee. y Transitional Reinsurance Program assessment fee. HorizonBlue.com 5

8 Our members health care dollars pay for a lot of health care For years, Horizon BCBSNJ has worked to enhance care while reducing costs. The ACA shares this approach and requires health insurers to meet a federal Medical Loss Ratio (MLR). The MLR is a percentage of premium dollars that an insurance company must spend on medical services and activities to improve quality. The health care reform law requires health insurers to refund part of the premiums they receive, if they do not spend certain amounts on medical claims or activities to improve the quality of care. For the small employer market, 80 percent of premiums must be spent on medical expenses. Based on 2012 year-end data, Horizon BCBSNJ spent 88 cents, or 88 percent, of every premium dollar to pay its customers medical claims. Horizon BCBSNJ used the remaining 12 cents of each premium dollar to pay its operating expenses, which included 10 cents for administrative services and 2 cents for profit. What this means to your clients Each year, Horizon BCBSNJ must meet the MLR requirement. If it does not, it must send a rebate to its affected customers. Based on 2012 year-end data. 6 HorizonBlue.com

9 The number of employees determines how your group is affected A business s number of full-time (FT) and full-time equivalent (FTE) employees determines if it faces a penalty for not offering affordable coverage or if it qualifies for tax credits. Businesses with 50 FT and FTE employees must provide employees with affordable health coverage beginning January 1, 2015 or face a penalty. Businesses with fewer than 25 FT and FTE employees may qualify for a federal tax credit. So it is important to first determine how many FT and FTE employees a group has. Counting FTEs the new math The Affordable Care Act redefines a full-time equivalent (FTE) employee as one who works an average of 30 hours a week or more, or an average of 130 hours a month. However, part-time employees who work less than 30 hours a week may also be factored into a company s workforce, based on a total number of part-time hours worked in excess of 120 days a year. As a result, it is possible that a business that employs under 50 FT employees could move into the 50 or more category if it employs a number of part-time workers whose total hours equate to additional FTE employees. To determine how many employees your business should report, consult the page headed How to determine your number of FTEs that is included with other helpful information at the end of this kit. Or you may consult on the issue with your tax accountant. Seasonal workers who are employed less than 120 days a year are not counted if they are the only reason the employee group exceeds 49 FTE employees. HorizonBlue.com 7

10 Businesses with fewer than 50 FT and FTE employees Businesses with fewer than 50 FT and FTE employees are not required to provide health insurance. However, many employers use health benefits plans to attract and retain valued employees. Businesses with fewer than 25 FTE employees Businesses with fewer than 25 FTEs may qualify for a federal tax credit if they purchase health insurance for their employees on the Small Business Health Options Program (SHOP). Businesses that pay at least 50 percent of single coverage may be eligible for a tax credit. This credit is only available for health plans purchased through the SHOP. Tax credits toward the cost of health insurance premiums are available for small businesses on a sliding scale. Businesses with fewer than 25 FTEs, excluding owners and their family members, may qualify if their employees average annual wages are less than $50,000. This credit may reach 35 percent (25 percent for non-profits) of the cost of health benefits in 2013 and rises to 50 percent (35 percent for non-profits) in Businesses with 10 or fewer employees who earn less than $20,000 annually in 2014 are eligible for the full 50 percent tax credit (35 percent for non-profits). Credits are claimed when income taxes are filed with an IRS Form 8941 that includes FTE calculations for the credit. 8 HorizonBlue.com

11 The ACA requires essential health benefits, including comprehensive wellness and preventive services The health care reform law includes a broad expansion of required benefits, many of which are not included in the coverage many people currently choose to purchase. For policies sold or renewed for January 1, 2014 effective dates and later, individual and small employer health insurance policies must generally include essential health benefits that cover 10 categories of services: y Emergency services. y Hospitalization. y Laboratory services. y Maternity and newborn care. y Mental health and substance abuse disorder services, including behavioral health treatment. y Outpatient services. y Pediatric services, including oral and vision care. y Prescription drugs. y Preventive/wellness services and chronic disease management. y Rehabilitative and habilitative services and devices. This new requirement is intended to ensure that most Americans obtain broad and comprehensive health insurance coverage. 9 HorizonBlue.com

12 Introducing the public marketplace The ACA establishes a public marketplace for businesses with fewer than 50 employees that wish to compare health plans and purchase health insurance. This marketplace, called the Small Business Health Options Program (SHOP), can be accessed online, through a call center or through paper applications. The public marketplace for individual consumers is called the Health Insurance Marketplace. Horizon BCBSNJ offers plans on the Health Insurance Marketplace for individuals and will offer plans on the SHOP for businesses beginning November 1, 2013, when the federal government expected to launch the SHOP. The plans offered on the public marketplace will have effective dates of January 1, 2014 and later. Qualified health plans (QHPs) Only qualified health plans (QHPs) can be offered on the public marketplaces. A health plan may be certified as a QHP if the health plan meets the following certification requirements: y Ensures a sufficient choice of providers. y Includes essential community providers in its networks. y Complies with the essential health benefits package. y Is accredited on quality. y Implements a quality-improvement strategy. y Provides data on quality measures and other business practices. y Meets marketing requirements. y Uses a uniform enrollment form. y Presents plan information in a standard format. You will find that QHPs offered on and off the SHOP are priced similarly and closely matched in what they offer. This is because all new health plans offered in the Small Group market must provide coverage for essential health benefits, and must be priced within certain actuarial value ranges related to member cost sharing. HorizonBlue.com 10

13 Count on Horizon BCBSNJ We offer services and programs to help individuals and small businesses get the coverage that s right for them. We leverage the strength and resources of our national programs to benefit our members right here at home. This combination allows us to bring innovative, affordable health care coverage to benefit the individuals and businesses we are proud to serve. 11 HorizonBlue.com

14 Introducing our new health plans for groups with 50 or fewer employees Health care reform plans for your business and employees The Affordable Care Act (ACA) provides the opportunity to offer new health insurance plans that meet your needs while also meeting the standards set by the reform law. Our new plans combine the standard essential health benefits, preventive services and all ACA requirements with the features of a Horizon EPO (Exclusive Provider Organization) or Horizon Direct Access plan. Our plans are built on high-value provider networks and include coordination of care and chronic care management programs to help manage costs. Horizon Advantage EPO and Horizon Advantage Direct Access With our Horizon Advantage EPO and Horizon Advantage Direct Access plans, members have access to all doctors, specialists and hospitals that participate in the Horizon Managed Care Network. These plans provide integrated medical and pharmacy benefits, including wellness and emergency care. Although members are not required to select a PCP, there are lower out-of-pocket costs when care is coordinated through a selected PCP. Dental plans Pediatric oral services is an essential health benefit under the ACA. Horizon BCBSNJ can help your clients make oral health part of their overall health program. For more information, please contact your Horizon Blue Cross Blue Shield of New Jersey representative or visit us at HorizonBlue.com/reform. Horizon Blue Cross Blue Shield of New Jersey is an independent licensee of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. The Horizon name, symbols and Making Healthcare Work are registered marks of Horizon Blue Cross Blue Shield of New Jersey Horizon Blue Cross Blue Shield of New Jersey. Three Penn Plaza East, Newark, New Jersey (1013)

15 Finding the new small employer health insurance plan that s right for your business Horizon Blue Cross Blue Shield of New Jersey s new health insurance plans meet your business needs and include Affordable Care Act (ACA) essential health benefits and preventive services. Available for purchase directly from Horizon BCBSNJ at buy.horizonblue.com or on the Small Business Health Options Program (SHOP), Horizon BCBSNJ health plans are built on high-value provider networks and include coordination of care and chronic care management programs to help manage costs. The chart below shows how our existing small group health plans will be replaced by the new ACA-approved plans. These new plans are referred to as metallic plans because they are named after precious metals, such as platinum, gold, silver and bronze and reflect the richness of benefits offered. They are available for purchase on November 1, 2013, with effective coverage dates of January 1, 2014 and after. Existing plans Replaced by plans off SHOP Replaced by plans on SHOP Horizon Advantage Direct Access and Horizon Advantage PPO: y Horizon Advantage Direct Access 100/70 y Horizon Advantage Direct Access 100/90/70 y Horizon Advantage Direct Access 100/80/60 $20/$40 y Horizon Advantage Direct Access 100/80/60 $30/$50 y Horizon Advantage PPO 100/80/60 Horizon Advantage Direct Access Platinum 100/70 BlueCard Horizon Advantage Direct Access Gold 100/80/60 BlueCard N/A Horizon Advantage Direct Access Gold 100/80/60 BlueCard For more information, please contact your Horizon Blue Cross Blue Shield of New Jersey representative or visit us at HorizonBlue.com/reform. Horizon Blue Cross Blue Shield of New Jersey is an independent licensee of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. The Horizon name, symbols and Making Healthcare e Work are registered marks of Horizon Blue Cross Blue Shield of New Jersey Horizon Blue Cross Blue Shield of New Jersey. Three Penn Plaza East, Newark, New Jersey

16 Existing plans Replaced by plans off SHOP Replaced by plans on SHOP Horizon Advantage EPO: y Horizon Advantage EPO 100 $25/$50 no BlueCard y Horizon Advantage EPO 100 $30/$50 with BlueCard y Horizon Advantage EPO 100 $20/$40 no BlueCard y Horizon Advantage EPO 100/80 $20/$40 no BlueCard y Horizon Advantage EPO 100/80 $30/$50 no BlueCard y Horizon Advantage EPO 100/70 $20/$40 with BlueCard y Horizon Advantage EPO 100/50 $30/$50 no Blue Card y Horizon HSA Compatible Direct Access 100/80/60 $20/$40 y Horizon HSA Compatible Direct Access 100/80/60 $30/$50 y Horizon MyWay HSA Direct Access 100/80/60 $20/$40 y Horizon MyWay HSA Direct Access 100/80/60 $30/$50 y HSA Horizon Advantage EPO 100 $30/$50 no Blue Card Horizon Advantage EPO Gold 100 $30/$50 BlueCard is an option Horizon Advantage EPO Gold 100 $20/$40 BlueCard is an option Horizon Advantage EPO Gold 100/80 BlueCard is an option Horizon Advantage EPO Silver 100/70 BlueCard is an option Horizon Advantage EPO Silver 100/70 BlueCard is an option Horizon Advantage EPO Silver 100/50 BlueCard is an option Consumer-Directed Health Plans: HSA Horizon Advantage Direct Access Silver 100/80/60 BlueCard HSA Horizon Advantage EPO Bronze 100 $30/$50 BlueCard is an option N/A Horizon Advantage EPO Gold 100 $20/$40 no BlueCard Horizon Advantage EPO Gold 100/80 no BlueCard Horizon Advantage EPO Silver 100/70 no BlueCard N/A N/A N/A HSA Horizon Advantage EPO Bronze 100 $30/$50 no BlueCard For more information, please contact your Horizon Blue Cross Blue Shield of New Jersey representative or visit us at HorizonBlue.com/reform. Horizon Blue Cross Blue Shield of New Jersey is an independent licensee of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. The Horizon name, symbols and Making Healthcare e Work are registered marks of Horizon Blue Cross Blue Shield of New Jersey Horizon Blue Cross Blue Shield of New Jersey. Three Penn Plaza East, Newark, New Jersey Small Group (1013)

17 When it comes to dental care and prevention, our plans give everyone something to smile about Everyone likes a good smile and our dental plans are enough to make everyone smile because they satisfy a variety of needs and circumstances. When it comes to dental care for adults and children, our plans emphasize preventive care and come in a wide choice of coverage options. Our extensive dental network makes it easy for employees to maximize their reimbursement. Dental plans for adults Flexible designs and a range of cost-sharing options Horizon Dental Companion Plan y The Horizon Dental Companion Plan is available when it is purchased together with a Horizon Blue Cross Blue Shield of New Jersey medical plan. y The Horizon Dental Companion Plan covers frequently needed, eligible preventive and diagnostic services, such as exams, cleanings, X-rays, amalgam (silver) fillings and space maintainers, at 100 percent when received in network. There are out-of-network benefits for certain eligible dental services. In some cases, there are no out-of-network benefits at all. For more information, please contact your Horizon Blue Cross Blue Shield of New Jersey representative or visit us at HorizonBlue.com/reform.

18 Horizon Dental Option Plans The Horizon Dental Option Plans offer the freedom to receive dental services from any dentist, while employees save money and maximize benefits by choosing dentists within our extensive, nationwide network of 136,000 dentists. y y y Discounts between 10 and 30 percent with in-network dentists. Preventive dental services cover 100 percent of allowed charges. Deductibles and coinsurance may apply to the out-of-network option. Horizon Dental Option Plans offer flexibility with three benefit levels. y Horizon Dental Option Plan 100/80/50 y Horizon Dental Option Plan 100/80/60 y Horizon Dental Option Plan 100/100/50 Horizon Dental PPO Access Plans The Horizon Dental PPO Access Plans are available for employers with 10 or more employees and cover 100 percent of the most common dental services. For other major or specialty services, employees pay a reduced Horizon Dental PPO Plan allowance. For out-of-network care, employees pay higher out-of-pocket costs for certain eligible dental services and may be asked to pay dentists at the time of service and then submit a claim for reimbursement. In some cases, there are no out-of-network benefits. y Horizon Dental PPO Access 1050 Plan. This option offers employees a reduced fee to participating dentists for major or specialty services, including root canals, crowns and bridges. y Horizon Dental PPO Access Plan. This option requires employees to pay for any fees above the Horizon Dental PPO Plan allowance for major or specialty services, including root canals, crowns and bridges. Employees also may be asked to pay at the time of service and submit a reimbursement claim. HorizonBlue.com

19 Horizon Dental PPO Plans Horizon Dental PPO Plans offer the lowest fees available to employees through our Horizon Dental PPO Network of dentists. Employees have a choice of visiting out-of-network dentists, and in turn paying extra costs. The plans offer: y y Discounts between 10 and 30 percent with in-network dentists. Preventive dental services covered 100% of allowed charges, with In-network dentists. Horizon Dental PPO Plans are offered with three benefit levels. y Horizon Dental PPO Plan 100/80/50 y Horizon Dental PPO Plan 100/80/60 y Horizon Dental PPO Plan 100/100/50 Dental plans for children under 19 Pediatric oral health plans emphasize prevention Pediatric dental benefits are an important part of overall health. Beginning in January 2014, all individual and small group health plans, including those offered outside the Small Business Health Options Program (SHOP), must provide pediatric oral health services as part of the required essential health benefits package. While medical plans have the option of providing a bundled benefit that includes pediatric dental coverage through the SHOP, dental benefits may continue to be offered in a plan separate from other health care benefits. HorizonBlue.com

20 Horizon Pediatric Dental Plans Available for children under 19 years of age, these pediatric plans emphasize routine screenings, risk assessment and early intervention. Employers may choose from two plans: Employers can choose a plan that offers in-network benefits only or one with both in- and out-of-network benefits. y Horizon Young Grins. This plan requires that dental services be obtained from an in-network provider. There is no reimbursement for out-of-network care. y Horizon Young Grins Plus. This plan offers a higher reimbursement level when an in-network dentist provides care. It also offers a lower-level out-of-network benefit when care is obtained from a non-participating provider. Horizon BCBSNJ adult and pediatric dental plans help employees make oral health part of their overall health program and give them something to smile about. For more information, please contact your Horizon Blue Cross Blue Shield of New Jersey representative or visit us at HorizonBlue.com/reform. Horizon Blue Cross Blue Shield of New Jersey is an independent licensee of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. The Horizon name, symbols and Making Healthcare Work are registered marks of Horizon Blue Cross Blue Shield of New Jersey Horizon Blue Cross Blue Shield of New Jersey. Three Penn Plaza East, Newark, New Jersey (0913) HorizonBlue.com

21 A timeline of health care reform milestones and requirements When What* How this may affect you Dependent coverage Medical loss ratio (MLR) rebates Patient-centered outcomes research tax Expanded women s preventive care services Summary of benefits & coverage (SBC) Flexible spending account (FSA) annual limit HIPAA certification Medicare tax on wages & unearned income Employee notice of exchange Public exchanges open The individual mandate begins Annual dollar limits, waiting periods & pre-existing conditions Insurance carrier industry tax New individual and small group health plans become effective Wellness incentives Employer mandate and reporting requirements Excise tax on high cost (aka Cadillac ) plans Dependent children up to age 26 years must be allowed to remain on their parents group health plan. If an employer receives an MLR rebate from its insurer, it must return a proportional share to each enrollee or use the rebate to enhance plan benefits. A federal tax of $1 per covered person is charged for plan years ending in 2012 to help fund the Patient-Centered Outcomes Research Institute. The fee must be paid by July 31, This fee increases to $2 per covered person for plan years ending in 2013 and in subsequent years is indexed to medical inflation. Beginning August 2012, expanded preventive services for women are covered with no cost-sharing. Beginning September 2012, employees must be provided with SBCs during the enrollment period. Beginning January 1, 2013, a $2,500 limit applies to employee health care FSA contributions. Employer group health plans must certify that the plan s data and information systems are in compliance with Department of Health and Human Services (HHS) rules for certain electronic transactions. Medicare tax on wages increases by.9%. This applies to those earning $200,000, if filing single, $250,000 if married filing jointly, and $125,000 if married filing separately. Employers must provide employees with information about the Health Insurance Marketplace beginning October 1, 2013, when the Marketplace opens and at the date of hire thereafter. The Health Insurance Marketplace for individuals, and the Small Business Health Options Program (SHOP) open, allowing individuals and small businesses to purchase health insurance and determine eligibility for tax credits and cost-sharing subsidies. Almost all U.S. citizens are required to have health insurance coverage or pay a minimum fine. This fine is the higher of $95 or 1% of income in 2014; $325 or 2% of income in 2015, $695 or 2.5% of income in 2016 and increases annually by the cost of living thereafter. All of the fines are per person per year. Families have a cap on the total fine of $2,250 and the fine amount for children is half of the adult fine. Individual and employer health plans may not impose annual dollar limits on essential health benefits, waiting periods of longer than 90 days, or pre-existing condition exclusions. A new tax is placed on fully insured plans to fund the subsidies provided by the insurance exchanges. Non-grandfathered, high-deductible plans are replaced with new health plans with essential health benefits, plan design limits, limits on out-of-pocket medical expenses and changes in the prior rating methodology. Permitted wellness incentives increase from 20% of cost of coverage to 30%. If the wellness program is established to promote tobacco use prevention or reduction, the incentive increases to 50%. Employers with 50 or more full-time employees or full-time equivalents must offer affordable health insurance that provides minimum value to employees and their children up to age 26 years or face penalties. In addition, they are required to report information to the IRS about the coverage and verify that it provides minimum value. Employers become subject to a 40% excise tax if their group health coverage exceeds certain thresholds. The anticipated cost limits for 2018 are $10,200 for individual coverage and $27,500 for family coverage. * The mandates are generally applicable to group health plans and health insurance. Not all requirements may uniformly apply. For more information, please contact your Horizon Blue Cross Blue Shield of New Jersey representative or visit us at HorizonBlue.com/reform. Horizon Blue Cross Blue Shield of New Jersey is an independent licensee of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. The Horizon name, symbols and Making Healthcare Work are registered marks of Horizon Blue Cross Blue Shield of New Jersey Horizon Blue Cross Blue Shield of New Jersey. Three Penn Plaza East, Newark, New Jersey (0913)

22 We help you comply with requirements January 2013: Limits on health FSA contributions take effect. October 2013: Employers must provide employees with information about the Health Insurance Marketplace, benefit plans and tax credits Enrollment: Employers must coordinate with Horizon BCBSNJ to distribute a Summary of Benefits and Coverage (SBC) to employees. January 2015: Large employers must provide coverage and minimum value reporting. January 2015: W-2 reporting requirement (on 2014 income) begins for groups with more than 250 full-time equivalent (FTE) employees. For more information, please contact your Horizon Blue Cross Blue Shield of New Jersey representative or visit us at HorizonBlue.com/reform.

23 Pre-tax salary-reduction contribution takes effect in 2013 Beginning in January 2013, employee pre-tax salary-reduction contributions to a health Flexible Spending Account (FSA) must be limited to $2,500, indexed for cost-of-living adjustments beginning in The plan sponsor also has the option of placing an even lower limit on these programs. The $2,500 limit does not apply to employer contributions to the health FSA and it does not impact contributions under other employer-provided coverage. For example, employee salary reduction contributions to an FSA for dependent care assistance or adoption care assistance are not affected by the $2,500 health FSA limit. What you must do y Determine whether your clients health FSA programs place the prescribed limit on employee annual pre-tax FSA contributions. y Adjust the prescribed limit according to the cost-of-living index each year, beginning in Inform employees of health insurance marketplace, plan options and subsidies Beginning in the fall of 2013, employers must provide employees with written information about their health insurance, the Health Insurance Marketplace and that they may be eligible for premium tax credits. Existing employees must be notified no later than October 1, New hires must receive this written notice within 14 days of their start date. The notice must: y Inform employees about the Health Insurance Marketplace and the services it provides. y Explain how employees may be eligible for a premium tax credit or a cost-sharing reduction if the employer s plan does not meet certain requirements. HorizonBlue.com

24 y Inform employees that if they purchase coverage through the Marketplace, they may lose any employer contribution toward the cost of employer-provided coverage, and that all or a portion of this employer contribution may be excludable for federal income tax purposes; and y Include contact information for the Marketplace and an explanation of appeal rights. The notice may be provided electronically if the requirements of the United States Department of Labor s (DOL s) electronic disclosure safe harbor are met. Otherwise, it must be sent by first-class mail. A model notice is available through the DOL s website, dol.gov. Employers may customize the model notice or develop their own, provided they meet the content requirements. What you must do y Obtain a model notice and tailor it for your company. y Schedule its distribution to employees prior to October 1, y Institute a Human Resources policy to ensure new hires are notified within 14 days of their start date. Provide employees with a Summary of Benefits and Coverage The Summary of Benefits and Coverage (SBC) is a document that provides information about health plan benefits and coverage. In accordance with Affordable Care Act requirements, Horizon BCBSNJ will provide an SBC to the plan sponsor for plan participants and beneficiaries. Plans and issuers must provide the SBC to participants and beneficiaries who enroll or re-enroll during an open enrollment period. The SBC also must be provided to participants and beneficiaries who enroll at other times, such as new hires and special enrollees. What you must do y Determine the type of coverage for which an SBC must be provided. y Confirm with Horizon BCBSNJ when you will receive an SBC and coordinate who will send it to participants and beneficiaries in accordance with distribution rules. HorizonBlue.com

25 Provide employees with the value of their benefits on their W-2 forms Employers must report the value of the benefits on each employee s annual W-2 form beginning with the calendar year 2012 forms. This reporting requirement is already in place for most employers that issue more than 250 W-2 forms in a calendar year. Some employers are exempt from this requirement until the IRS issues further regulations. Exempt employers include employers filing fewer than 250 W-2 forms in the prior calendar year, multi-employer plans, HRA plans and self-insured plans not subject to COBRA rules. Provide coverage and minimum value reporting to the IRS Beginning with tax year 2015, large employers that provide minimum essential coverage are expected to be required to report information to the Internal Revenue Service (IRS) about the coverage offered to full-time employees. Similarly, information must be supplied whether the coverage provides minimum value. Applicable large employers with at least 50 full-time and full-time equivalent employees must annually file additional information on employer responsibilities beginning in The IRS is expected to release final rules on this process in the future. For more information, please contact your Horizon Blue Cross Blue Shield of New Jersey representative or visit us at HorizonBlue.com/reform. Horizon Blue Cross Blue Shield of New Jersey is an independent licensee of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. The Horizon name, symbols and Making Healthcare Work are registered marks of Horizon Blue Cross Blue Shield of New Jersey Horizon Blue Cross Blue Shield of New Jersey. Three Penn Plaza East, Newark, New Jersey (0913) HorizonBlue.com

26 How to determine your number of FTEs For purposes of testing employer mandate applicability only The Affordable Care Act (ACA) impacts businesses differently, based on their number of full time-equivalent employees (FTEs). The number of FTEs determines whether a business must provide health coverage in 2015 (for businesses with 50 or more employees) or comply with the W-2 reporting requirement (for businesses with 250 or more employees). STEP 1 Total full-time employees Calculate the number of full-time employees for each calendar month in the previous year, and then total for the year. January July February August March September April October May November June December Full-time employees The ACA defines a full-time employee as one who works an average of at least 30 hours per week. Note: Employees who work for 120 days or less during a calendar year do not count toward the full-time employee total. STEP 2 STEP 3 Total part-time employees Calculate the number of hours your part-time employees worked each month (not to exceed 120 hours per month per employee), and then total the number of hours for the year. January July February August March September April October Divide the total number of hours worked by part-time employees by 120 to calculate the full-time equivalent. X 120 = full-time equivalent May Add total full-time employees to total part-time employees. November June TOTAL December TOTAL TOTAL EMPLOYEES Part-time employees Part-time employees (those working less than 30 hours a week) count toward employer size. Note: You can use employee information from any six consecutive months in 2013 to determine your projected group size in An employer is not considered to exceed 50 full-time employees if the number of employees is a result of seasonal employees who work for 120 days or less during a calendar year. Seasonal employees Seasonal employees who work less than 120 days a year are not counted. STEP 4 TOTAL EMPLOYEES Divide the total by 12 and round down. TOTAL EQUIVALENT EMPLOYEES (Round down) This information is provided to serve as a conceptual guide to calculating your number of FTEs and is not an official document. To ensure certainty, employers are advised to consult their tax accountants for final determination of FTEs they employ. For more information, please contact your broker or your Horizon Blue Cross Blue Shield of New Jersey representative or visit us at HorizonBlue.com/reform. Horizon Blue Cross Blue Shield of New Jersey is an independent licensee of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. The Horizon name, symbols and Making Healthcare Work are registered marks of Horizon Blue Cross Blue Shield of New Jersey Horizon Blue Cross Blue Shield of New Jersey. Three Penn Plaza East, Newark, New Jersey (0913)

27 How the ACA may affect your business in 2015 Under the Affordable Care Act (ACA), large employers may face penalties in 2015 if they don't make affordable coverage available to employees. Use this chart to find out how your business may be affected. Start here Does the employer have at least 50 full-time equivalent employees? No Penalties do not apply to Small Employers. (See 1 below) Yes Does the employer group offer coverage to its full-time employees? No Did at least one employee receive a premium tax credit or cost-sharing subsidy on the Health Insurance Marketplace? Yes The employer must pay a penalty for not offering coverage. (See 2 below) Yes Does the insurance pay for at least 60% of covered health care expenses for a typical population? No Did at least one employee receive a premium tax credit or cost-sharing subsidy on the Health Insurance Marketplace? Yes The employer must pay a penalty for not offering affordable coverage. (See 3 below) Yes Do any employees have to pay more than 9.5% of household income for the employer coverage? Yes These employees can choose to buy coverage on the Health Insurance Marketplace and receive a premium tax credit. There is no penalty payment required of the employer, since it offers affordable coverage. No 1 If the employer group has 25 or fewer employees and average wages that don t exceed $50,000, it may be eligible for a health-insurance tax credit. 2 The penalty is $2,000 annually times the number of full-time employees, beginning with the 31st employee (the first 30 employees are excluded). 3 The penalty is $3,000 annually for each full-time employee receiving a tax credit, up to a maximum of $2,000 times the number of full-time employees, minus the first 30 employees. The penalty is increased each year by the growth in insurance premiums. For more information, please contact your broker or your Horizon Blue Cross Blue Shield of New Jersey representative or visit us at HorizonBlue.com/reform. Horizon Blue Cross Blue Shield of New Jersey is an independent licensee of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. The Horizon name, symbols and Making Healthcare Work are registered marks of Horizon Blue Cross Blue Shield of New Jersey Horizon Blue Cross Blue Shield of New Jersey. Three Penn Plaza East, Newark, New Jersey (0913)

28 Horizon Blue Cross Blue Shield of New Jersey is an independent licensee of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. The Horizon name, symbols and Making Healthcare Work are registered marks of Horizon Blue Cross Blue Shield of New Jersey Horizon Blue Cross Blue Shield of New Jersey. Three Penn Plaza East, Newark, New Jersey (1013)

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