What the Health Care Reform Bill Means to Employers

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1 What the Health Care Reform Bill Means to Employers No doubt you have heard the news that on Tuesday, March 23, 2010, President Obama signed into law sweeping health care overhaul legislation. This followed a Sunday night vote in which the House of Representatives, by a margin of , approved the health care reform bill which had previously been approved by the Senate on Christmas Eve. Although the legislation is over 900 pages long, we wanted to reference some of the key provisions that will be of interest to our clients. However, keep in mind that the law will be implemented in waves, and many of the provisions below will not become effective until Also, the provisions below are all taken from the actual health care reform law, and some of them are likely to be amended if and when the budget reconciliation bill is passed (see further below for an explanation of the budget reconciliation bill). Here are some of the key provisions: 1. Health coverage will be extended to an additional 32 million Americans. This will be accomplished through expansions to Medicaid, a mandate that most individuals have health insurance, and government subsidies to help lower wage earners afford health insurance. 2. Individuals will be required to have health insurance coverage. Those who do not have health insurance will be penalized up to the greater amount of either $750 per year or 2% of their taxable income. However, exceptions to this mandate will be granted in certain situations, including financial hardship, religious objections, undocumented immigrants, etc. Effective date: 3. Employers with over 50 employees will be required to offer health insurance coverage or pay a penalty. Employers not offering health coverage to all full-time employees will be required to pay annual penalties of $750 or more for each full-time employee not offered coverage. Employers whose health plans have waiting periods will also have to pay penalties of between $400 and $600 for each employee subject to a waiting period of 30 to 90 days. Effective date: 4. Significant expansion of the government s Medicaid health coverage for the poor. Medicaid will be expanded to cover all individuals (including children, families, adults without children, etc.) with incomes up to 133% of the federal poverty level (FPL). Effective date: 5. Government provided premium subsidies will help individuals pay for health insurance. Those with incomes between 100% and 400% of the FPL will receive government subsidies on a sliding scale to help them pay for their coverage (note that 400% of the FPL would be $88,200 for a family of four). These subsidies will only be available to U.S. citizens and legal U.S. residents, and the subsidies will generally not be available to those individuals who have access to employer provided coverage. Additionally, employers may have to offer free choice vouchers to employees earning less than 400% of the FPL who chose to enroll in an individual policy through the Exchange, but only if the employee meets financial hardship requirements. Note that tax credits will also be available to qualifying small employers to help them provide coverage. Effective date:

2 6. Insurance market forms create numerous new mandates for individual and group plans, including prohibitions of past insurance practices, such as refusing to cover people with pre-existing medical conditions and charging higher premiums for those with health problems. Although there are numerous insurance market reforms, some of the key mandates impacting both individual and group policies include that they: 1) be guarantee issue and guarantee renewable, 2) eliminate all pre-existing condition exclusions of any kind, 3) eliminate all annual and lifetime benefit limits or caps, 4) provide coverage to dependent children up to age 26 regardless of student status, and 5) require that premium variations for individual and group policies be based only on age (limited to 3 to 1 ratio), coverage tier, geographic region, and tobacco use (limited to 1.5 to 1). This means that individuals with severe health problems will now be able to get the same health insurance coverage at the same cost as a similarly situated individual in good health. Effective dates: Creation of state-based Exchanges where individuals can compare and shop for insurance plans. These exchanges will be largely internet based, and like an internet travel site but for health insurance, it will enable individuals to purchase health insurance online by receiving real time price quotes from a number of insurance carriers. These exchanges will be regulated by the state, will be required to provide detailed educational tools, and will require insurers to offer at least four mandated insurance plans (referred to as the bronze, silver, gold and platinum plans) so that individuals can compare plans on an apples to apples basis. These exchanges will also be available to employers with under 100 employees (and may later be expanded to larger employers). Effective date: 8. Tax on Cadillac health plans. A penalty tax of 40% of the premium will be charged to the insurance company or health plan when the annual premium is over $8,500 for individuals or $23,000 for families (higher threshold amounts apply to retirees and high risk professions). Effective date: Increase the Medicare payroll tax for the wealthy. The Medicare payroll tax will increase from 2.9% to 3.8% for wages and self-employment income for those earning over $200,000, or $250,000 if married. This payroll tax increase will only apply to wages earned above the $200,000 or $250,000 threshold limit, and will be shared between the employee and employer. Effective date: Wellness plans and Consumer Directed Health Plans are vital components of health care reform. Employers may increase workplace wellness incentives under HIPAA from 20% of the total premium cost to 50% of the total premium cost. Additionally, HSA and HRA based plans are still permitted, and will be a core component of many of the plans offered in the Exchanges. Effective date: Health Care Reform: What's Next? After approving the health care reform bill, the House approved a budget reconciliation bill which included a number of revisions to the health care reform bill. Since the budget reconciliation bill had not yet been approved by the Senate, it is now on the Senate floor where debates are ongoing and a vote is scheduled for this Friday. However, if Republicans succeed in getting parts of the budget reconciliation bill thrown out, then it may be a few weeks before the budget reconciliation bill is passed into law. So although comprehensive health care reform legislation has been officially signed into law, we still do not know for sure what the end product will look like since the bill that was signed into law is likely to be modified slightly if and when the budget reconciliation bill is passed. What is the Budget Reconciliation Bill? You may be asking why the House approved a budget reconciliation bill, rather than just amending the health care reform bill directly. Well the reason is political in nature, and has to do with the fact that the House could not make any amendments to the health care reform bill since doing so would require it to go back to the Senate for another vote. And this was no longer an option for the Democrats after they

3 lost a seat in the Massachusetts run off, since they no longer had the 60 votes needed to defeat a Republican filibuster and approve the bill. Instead, the Democrats game plan was to approve the health care reform bill as is, and then amend it via a budget reconciliation bill which would then go to the Senate for approval. The Senate Democrats have promised the House Democrats that they would approve their budget reconciliation bill and accept the changes the House democrats demanded. And due to the budget reconciliation bill procedural rules, filibusters are not permitted so the Democrats should be able to approve the bill with a mere simple majority vote, which they should have no trouble attaining. However, as mentioned above the Senate Republicans are not going to roll over. Instead, they have vowed to challenge various provisions in the budget reconciliation bill. Many of these challenges will be under the Byrd Rule (after the West Virginia Senator of the same name), which can be used to strike provisions from budget reconciliation bills that do not adequately pertain to the budget deficit or surplus. If the Republicans succeed in striking various provisions from the budget reconciliation bill, this may require the budget reconciliation bill to have to go back to the House for another vote, and may lead to some conflicts amongst Democrats if provisions of the budget reconciliation bill which were vital to House Democrats are deleted. Note that if for some reason the budget reconciliation bill were to not pass, which is unlikely, then that would simply mean that the health care reform legislation that was signed into law would take effect unmodified. What do Employers need to be Aware of Now? As mentioned above, the health care reform law will be implemented in waves. Although the majority of the provisions will be taking effect in 2014, some requirements will become effective within six months of the law s enactment (and some even sooner). However, some of these provisions will be modified by the budget reconciliation bill, assuming it is passed. In addition to attending the Leaders Forum and the upcoming Webinar (see sidebar) to learn more about the new health care reform laws, Associated Financial Group will be providing updates and support for our clients as details continue to unfold and clarity emerges. We look forward to providing you with more concrete action steps once the legislative process is completed. Future Timeline 2010 (many of the below provisions take effect in six months) Tax credits for qualifying small businesses who provide health coverage to employees, and who have less than 25 employees with an average wage of less than $50,000 Unmarried dependent children must be permitted to stay on their parents' insurance policies until their 26th birthday, regardless of student status (effective six months following enactment). Individual and group insurance plans are prohibited from doing the following: 1) denying coverage to children with pre-existing illness, 2) having lifetime limits, or 3) having annual limits on essential benefits (as defined by DHHS). Additionally, fully-insured plans (but not self-funded plans) must offer 100% coverage for specified preventative care treatments. Provides temporary reinsurance program for employers offering retiree coverage to individuals age 55 and older who are not yet eligible for Medicare. A high-risk health insurance pool will be created to provide affordable coverage for uninsured who cannot obtain individual coverage due to preexisting conditions.

4 2011 Imposes 10% sales tax on indoor tanning. Medical Flex Spending Accounts (FSA) must cap the maximum annual election at $2500. Employers must begin reporting the value of health care benefits on employees W-2s. Over-the-counter drugs may no longer be reimbursed tax free through an HSA, HRA or FSA unless prescribed by a doctor. Elimination of the tax deduction for employers who receive Medicare Part D retiree drug subsidy payments (note this will have an immediate impact on employer s liability and income statements). Freeze payments to Medicare Advantage plans. A voluntary long-term care program will be established under which people pay premiums into system for at least five years and become eligible for support payments if they need assistance in daily living. Taxes and fees 2013 Impose $2.3 billion dollar annual fee on pharmaceutical companies, $2 billion dollar annual fee on medical device manufacturers, and impose a $2 billion dollar annual fee on insurance companies (which will increase to $10 billion by 2017). Process and funding is initiated to create non-profit member run cooperative health insurance providers to compete with private insurance companies. Employers Taxes and fees 2014 The Medicare payroll tax will increase from 2.9% to 3.8% for wages and self-employment income for those earning over $200,000, or $250,000 if married (shared between employee and employer) A penalty tax of 40% of the premium on Cadillac plans will be charged to the insurance company or health plan when the individual premium is over $8,500 for individuals or $23,000 for families (higher threshold amounts apply to retirees and high risk professions). Raises 7.5% AGI floor for personal deduction of medical expenses to 10% for those under age 65. Impose a 2.3% sales tax on certain medical devices. Create Exchanges where people without employer coverage, as well as small businesses, can shop for and purchase health coverage. Extensive requirements for individual and group health plans become effective, and will require coverage to meet certain minimum requirements involving deductibles, out-of-pocket limits, costsharing requirements, coverage mandates, actuarial based minimums, etc.

5 Extensive insurance market reforms and mandates on individual and group plans takes effect, including such things as: 1) guarantee issue and renewability, 2) elimination of preexisting condition exclusions, prohibition of premiums or underwriting being health based, etc. Employers may grandfather in their existing health plans, but will still have to comply with many of the insurance market reforms and mandates and will lose their grandfathered status if they make certain prohibited benefit cuts. Requirement begins for most people to have health insurance, and penalties take force. Requirement begins for employers with over 50 employees to provide health insurance, and penalties take force (including waiting period penalties). Subsidies begin for lower and middle-income people to help them pay for health insurance. Medicaid, the federal-state program for the poor, expands to all Americans with income up to 133% of federal poverty level. Employers must provide a notice to their employees about the Exchange, and employers must provide employees and the IRS with plan documentation. Employers with over 200 employees must auto enroll eligible employees in coverage, unless employees opt out. Employers may increase workplace wellness incentives under HIPAA from 20% of the total premium cost to 50% of the total premium cost. Taxes and fees 2017 Individuals without insurance will be penalized on a sliding scale that will increase over time to up to the greater amount of either $750 per year or 2% of their taxable income. However, exceptions to this mandate will be granted in certain situations, including financial hardship, religious objections, undocumented immigrants, etc. Employers not offering health coverage to all full-time must pay annual penalties of $750 for each full-time employee (or if greater, penalties of $3,000 for only those full-time employees not offered coverage who are receiving government premium subsidies). Employers whose health plans have waiting periods will also have to pay penalties of between $400 and $600 for each employee subject to a waiting period of 30 to 90 days. Businesses with more than 100 employees can buy coverage on insurance exchanges, if state permits it. Source: House bill; Kaiser Family Foundation; Wall Street Journal

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