Healthcare Reform: Top 10 Issues for Employers

Transcription

1 Healthcare Reform: Top 10 Issues for Employers presented by Thomas A. Walker (612)

2 Are Companies Required to Provide Health Coverage to Employees? NO requirement to provide coverage Play or Pay: starting in 2014 Excise tax (a free-rider penalty) for companies with 50 or more full-time if they don t comply

3 Is Your Plan Grandfathered or Exempt? Grandfathered plans: existing on March 23, 2010 Mandate exceptions: Nondiscrimination rules for insured plans Expanded internal and external claims review and appeals processes No employee cost for certain preventative services Women permitted to select OB-GYN

4 Is Your Plan Grandfathered or Exempt? Changes that will cause plans to lose grandfathered status: New insurance policy or group insurance carrier Any increase in employee s percentage for coinsurance Any increase in employee cost for deductible or out-of-pocket limits beyond a maximum percentage increase

5 Is Your Plan Grandfathered or Exempt? Changes that will cause plans to lose grandfathered status (continued): Any copayment increase beyond the greater of $5 (increased by medical inflation) or a total percentage of medical inflation plus 15% Over 5% decrease in employer s contribution toward cost of coverage for any class of similarly situated individuals Any decrease in or imposing of a new annual limit on dollar value of benefits under a plan

6 Is Your Plan Grandfathered or Exempt? Is Grandfathered worth it or possible? Notice requirements must be met

7 Is Your Plan Grandfathered or Exempt? Exempt Plans: Stand-alone retiree medical coverage Accident and disability insurance Limited scope dental and vision plans

8 Reimbursement for Retiree Medical Employers offering retiree health coverage (55 to 64) may qualify for temporary reimbursement Employers may obtain reimbursement for costs, premiums or cost-sharing for 80% of the costs between $15,000 and $90,000 for an individual $5 billion fund established in July to fund reimbursement Employers should apply ASAP

9 Small Employer Tax Credits Tax credit against regular or alternative minimum tax is available to certain small employers that pay at least 50% of cost for health insurance for employees Credit available for tax years

10 Small Employer Tax Credits Maximum credit 35% of employer s cost for health insurance: Full credit Employers with 10 or less full-time equivalents (FTEs) employed during tax year and average FTE wages of $25,000 eligible Minimum credit Employers with 25 FTE employed during tax year and FTE wages of $50,000

11 Nondiscrimination Requirements for Insured Health Plans Noncompliance penalties of $100 per day for each affected participant Types of arrangements affected: Providing employer-sponsored health insurance or coverage options for highly compensated employees (but not rank and file) Greater percentages of insurance paid for higher compensated groups

12 Nondiscrimination Requirements for Insured Health Plans Satisfying new rules: Passing the test Individual policy for one employee Employer payments treated as taxable income to key employees

13 The End to Reimbursements for Non-prescription Medicine No over-the-counter medicine (except insulin) purchased after December 31, 2010, will be eligible for reimbursement without doctor s prescription Applies to cafeteria plans that use the 2-1/2 month grace period for current plan year Medical aids (e.g. bandages, contact lenses, contact solutions, blood sugar monitors) still eligible for reimbursement

14 Health Coverage Changes for Children No pre-existing condition exclusions allowed for children under 19 Plans must permit health coverage for adult children until 26 th birthday Special notice and 30 day enrollment period must be given Plans with expanded definitions of children (such as grandchildren) not required to extend coverage to those children Cafeteria plans need to coordinate coverage with rules

15 Limits on Essential Health Benefits No aggregate lifetime limits and lifetime limits permitted for essential health benefits Essential health benefits yet to be defined in regulations Limits on non-essential benefits still permitted Exclusions for specific conditions still permitted Former participants who reached plan s lifetime maximum must be allowed to rejoin the plan

16 Limits on Essential Health Benefits Maximum individual limits on essential health benefits: $750,000 for next 2 plan years $1,250,000 for plan year that begins in 2012 $2,000,000 for plan year that begins in 2013 No limit after that Limits not expressed in $$ (i.e., treatment or office visits) still permitted

17 New Appeals Rules Expanded internal claims and appeals procedures Urgent care claims must be decided ASAP and no later than 24 hours Plans must provide claimants with new or additional evidence considered or relied upon by plan in connection with claim

18 New Appeals Rules New rationale for denying claim on appeal or review must be disclosed to the claimant in advance Notices may need to be provided in other language

19 New Appeals Rules Notices must provide: Information identifying claim, including diagnosis code, treatment code and corresponding meaning of codes Reasons for adverse benefit determination, including denial code and corresponding meaning Description of available internal appeals and external review processes, including how to initiate an appeal Contact information for any available consumer assistance

20 New Appeals Rules Health plans must provide continued coverage pending the outcome of the internal appeal New external appeals process applies: State external review process that meets certain requirements New federal external review process Safe harbor standards have been issued, generally require a plan (or third party administrator) to contract with at least 3 independent review organizations and rotate claims among them Non-enforcement grace period until July 1, 2011, must make good faith progress toward compliance

21 What do the Election Results Mean for Healthcare Reform?

22 THANK YOU! Thomas A. Walker (612)