4/8/2013. Health Care Reform and the. NYS Exchange. Dr. Arthur Vercillo, MD Regional President April 8, Health Care Reform and the NYS Exchange

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1 Health Care Reform and the NYS Exchange Presentation to the Health Planning Council Advisory Board April 8, 2013, Ithaca NY By Dr. Arthur Vercillo, MD Additional resources on next to last slide. Health Care Reform and the NYS Exchange Dr. Arthur Vercillo, MD Regional President April 8, 2013 The Health Planning Council is a program of the Human Services Coalition. For information about the Health Planning Council: or contact the Director, Betty Falcao, at or Agenda Overview and the Individual Mandate Health Care Exchanges Employer Impacts Health Care Reform Funding and Taxes Post 2014 Timeline How can we help you? References and Resources Overview Health Care Reform and the Individual Mandate 3 4 Brief Overview Health Care Reform Legislation Health Care Reform legislation signed into law in March 2010 Focus on coverage expansion and insurance market reform Some provisions were effective immediately Major reforms in 2014 Health Care Reform is known as many different terms, you will hear it referred to as Affordable Care Act, PPACA, ACA, HCR, Obama Care. All of these terms are referring to the same law that was signed into effect in March Some provisions were effective in 2010 including such things as Preventive Services Covered in Full, dependent to age 26, no pre-existing for children and annual and lifetime limits. The major reforms including individual penalty, exchanges and employer requirements take effect in Executive order signed by NYS Governor Cuomo 5 6 1

2 What does this mean for individuals? Keep or obtain coverage through Employer sponsored health plan Medicaid, Family Health Plus or Child Health Plus Medicare, Medicare Advantage plans Coverage through spouse Individuals offered COBRA may choose to go to the exchange Obtain coverage direct from health insurance carrier or through new Health Care Exchange If you do not obtain health insurance coverage, you will pay the penalty each year through annual income tax filing U.S. Citizens are required to have health insurance as of 1/1/2014 or pay a tax penalty. As of 1/1/14, you need to either keep coverage or obtain qualified coverage: Government programs (Medicaid, Family Health Plus, Child Health Plus) Medicare, Medicare Advantage Plans Employer Sponsored Coverage Direct coverage through insurance companies or through exchanges Spouse coverage counts Coverage via the exchange If individuals do not have coverage, they will pay a tax penalty, up to 3 people per household The last Pre Question: Will there be a comparison tool for products on the exchange vs products off the exchange? Answer: Carriers may develop tools for comparison on products, but not aware of any tool that will compare across carriers for on and off exchange 7 8 Tax Penalty Amt Per Person Flat amount or No Health Insurance Tax Penalty when filing income tax $95 $325 $695 $695 + adjustment for inflation % of income 1% 2% 2.5% 2.5% (whichever is greater) Penalties are paid annually Amount is prorated based on the number of months with no coverage Penalties for not having coverage will occur through annual IRS tax filing. New box on tax filing to show if you have coverage or not. Penalties as shown in box. (numbers are estimates and subject to change) Year One: $95.00 or 1% of income (whichever greater) Year Two: $ or 2% of income (whichever greater) Year 3: $695 or 2.5% of income (whichever greater) Year 4: $695 plus adjustment for inflation or 2.5% of income (whichever greater) There is potential that young, healthy will pay the penalty rather than get coverage. Amount is prorated on a per month basis (if you have coverage for part of the year) NOTE: Even if you pay the penalty, you are still responsible for all medical costs incurred 9 10 What is an Exchange? Health Insurance Exchanges provide people a place to research, compare and purchase health plans Health Care Exchanges Most commonly an online marketplace think Expedia Exchanges have four primary roles Establish web portal for shopping and enrollment Manage eligibility and assistance for those applying for coverage Approve health insurance plans for participation Assist in outreach and education to consumers

3 Status of Exchange Functions/Timeline Conditional approval to be a State Based Exchange Several grants already received and studies completed to determine exchange structure and market rules Regional Advisory, CEO and technical meetings are underway RFA in process for Exchange Navigators Health plan submission as Qualified Health Plan due by April 2013 (includes network & quality standards) Approval of health plans anticipated by 7/15/13 Coverage begins 1/1/14 SHOP = Small Business Health Options Program delayed at federal level but moving forward in NYS. The final set of rules is still pending Health Care Exchanges Open For Enrollment October 1, 2013 Who is eligible to purchase through an exchange? NYS Health Benefit Exchange Open 10/1/2013 For 1/1/14 Coverage Effective Date Individuals Small Businesses An individual must: Be a citizen, national, or non-citizen lawfully present in the United States; Not be incarcerated, except pending the disposition of charges; and, Be a resident of the state that established the exchange. Small Businesses with <50 employees Annual Enrollment Period for Exchanges First annual enrollment period begins Coverage effective for anyone purchasing before 12/15/2013 Exchanges close for the initial annual enrollment. After 3/1/14, only able to purchase before next open enrollment if there is a qualifying event Annual enrollment opens for Exchanges for 1/1/15 effective date Annual enrollment closes for Exchanges for 2015 The initial open enrollment period begins October 1, 2013 and extends through March 31, Next year the federally-defined open enrollment will be Oct 2014 through Dec However, states will have the option to create additional open enrollment periods within their own borders Qualifying events: An individual or dependent loses minimum essential coverage. Marriage, birth, adoption or placement for adoption. An individual who was not previously a citizen becomes one. An individual s enrollment or non-enrollment in a plan is the result of an error of an agent of the exchange. An enrollee s plan violated a material provision of its contract. An individual has a change in financial eligibility. An enrollee gains access to new qualified health plans as a result of a permanent move

4 How to Enroll through an Exchange Through the web NYS Exchange website, link from health plan web site Community Agencies may apply to receive funding to be assistors or navigators. Navigators cannot be a broker or insurance carrier. However, NYS may allow for the Small group exchange (SHOP). Web Phone In-person Health Insurance Companies Broker/Agent Community Agency Pre question on whether preference would be given to the uninsured: Answer: There is no system to prioritize 1 person over another Individuals Receive Assistance Based on Income 100% Medicaid 138% Single Person Annual Income 200% 300% Assistance available through Exchanges Family of Four Annual Income 400% No assistance available 500+%+ % of Income Required to Pay Toward Premium Notes to previous page Prior to ACA, eligibility for Medicaid was below 100% except for certain populations. With ACA, eligibility will move to 133% of federal poverty level. 100% $11,170 $23,050 None Qualify for Medicaid 139% $16,000 $32,575 Required to pay 3.36% 200% $23,000 $46,850 Required to pay 6.30% 300% $34,500 $70,500 Required to pay 9.50% 400% 46,000 $93,600 Required to pay 9.50% Two Types of Assistance Available If Enroll Through Exchange Premium assistance (called Premium Tax Credit) or Cost-sharing assistance Available to those under 200% Federal Poverty Level Qualify for reduced deductibles, coinsurance and copays Premium credits are refundable tax credits available to citizens and legal immigrants with incomes up to 400% of the who are not eligible for other coverage. premium credits limit what people will be required to pay to a % of income, ranging from 3% of income for people with incomes at 133% of the federal poverty level to 9.5% of income for people with incomes between 300 and 400% of the. People apply for credits when they file taxes. However, because low income people may need upfront assistance, the law allows advance payment to eligible individuals. In this case, once an individual enrolls in a plan, advance payments are made directly to the insurer. The enrollee pays the remaining share of the premium to the insurer. Paid monthly directly to insurer Lump sum through income tax Occurs when selecting a plan on the Exchange A Basic Health Program (BHP) is another alternative for low-income individuals who are not eligible for Medicaid. States have the option to implement the BHP. Criteria for Determining Eligibility for BHP include state residency, <65 yrs, income levels between 133% and 200% of. NYS will NOT be offering a BHP in

5 Premium Tax Credits: Scenario 1 Age: Household Size: Annual Income: Percent : Annual Household Income $40,000 Required Premium Percentage X 4.95% Expected Annual Contribution $1, $40, % Estimated Plan Premium $11,010 Expected Contribution - $1,982 Premium Tax Credit $9,028 (annual) for silver plan Based on using subsidy calculator from Kaiser Family Foundation. Available for use at Kaiser.org For those who choose to claim the credit when they file their taxes, the credit will be applied against any taxes they owe or will be refunded for taxpayers who do not owe any taxes. Conversely, if they have received advanced payments based on presumed income but find their income was higher than anticipated, they will be required to refund the advanced payments. Source: Kaiser Family Foundation Health Reform Subsidy Calculator Premium Tax Credits: Scenario 2 Annual Household Income Age: Household Size: Annual Income: Percent : $40,000 Required Premium Percentage X 9.5% Expected Annual Contribution $3, $40, % Estimated Plan Premium $3,913 Expected Contribution - $3,800 Premium tax credit for $113 silver-plan Example of a single person household. Age 34, household size 1, income is $40,000, therefore Federal Poverty Level is 378% Required to pay 9.5% of their income for the premium, based on second lowest silver plan. Expected annual contribution is $3,800 per year. If the estimated plan premium (for the second lowest silver plan) is $3,913 and the customer is required to pay $3,800, they would receive $113 in tax credits. Able to receive credits in advance direct to carrier to pay toward premium or receive annually on annual tax filing. Can buy up or buy down but subsidy amount does not change. 27 Source: Kaiser Family Foundation Health Reform Subsidy Calculator 28 Exchange products must meet specific requirements Essential Health Benefits: Effective upon 2014 policy renewal Plans on and off exchange for small groups must cover Essential Health Benefits NYS choose Oxford EPO small group as the benefits to follow Any annual dollar limits for these services will need to be removed Out-of-pocket maximum applies, may not exceed IRS HSA limit for that year HSA max for 2013, $6,400 single/$12,800 family Large groups not required to offer Essential Health Benefits, however if it is offered it must meet the same standard as the Oxford Plan Coverage for clinical trials. Continue to lack definition and requirements Coverage for obesity related services. Effective date and details still unknown New employees can not wait more than 90 days to start coverage

6 Essential Health Benefits Essential benefits: Emergency room, Hospitalization, Maternity and newborn care, Mental health and substance abuse disorders, Prescription drugs, Rehabilitative services and devices, Lab services, Preventive and wellness services and chronic disease management, Pediatric services, including oral and vision care 31 Source: America s Health Insurance Plans (AHIP), December 13, Exchange products must meet specific requirements, continued Plans must offer four coverage tiers for individual and small group Platinum, gold, silver and bronze Called the metal levels NYS requiring one standard plan with set benefit levels within each metal level Carriers can have up to 2 additional non-standard plans per level A catastrophic policy is also required Plans must offer at least one plan in each metal level. NYS chose Oxford Small Group EPO product as the product all plans must follow Catastrophic Health Plans - The ACA stipulates that in addition to the metal levels, health plans must offer a Catastrophic Health Plan. Eligibility is restricted to either (1) young adults under age 30 prior to the start of the plan year or (2) individuals who have been deemed exempt from the individual mandate; The plan provides the essential health benefits defined under 1302(a) after the insured has met a deductible which must be equal to the maximum annual out-of-pocket limit for High-Deductible Health Plans (HDHP) as defined by the IRS for the given plan year; The deductible does not apply to at least three primary care visits Actuarial Values for Exchange Health Insurance Products For individuals: % of premium required to pay is based on second lowest silver plan offered by any insurer on the exchange Insurer 90%, customer 10% Insurer 80%, customer 20% Insurer 70%, customer 30% Assistance based on silver level Insurer 60%, customer 40% 36 Metal Level Coverage: For example: Platinum Insurer is expect to return roughly 90c of every dollar for medical care. The customer would expect to pay the remaining 10% in some mix of deductibles, coinsurance and copays For individual coverage, when they are purchasing on exchange, the amount required to pay is based on buying the second lowest silver level plan. If they qualify for tax credit or subsidy, it would cover the remaining premium cost to that silver plan. They can then buy up or down. Maximum out-of-pocket costs may also be capped on a sliding scale. The current limits in health savings account products are $5,950 for an individual and $11,900 for a family although they will be adjusted over time. 6

7 How Exchanges Work American Health Benefit Exchange Small Business Health Options Program (SHOP) Exchange Purchaser Tax Credit/ Subsidy Individuals Members below 400% Small groups Employers below 25 EEs Employer Impacts Product Levels Catas- Platinum Gold Silver Bronze trophic Member Selects Platinum Gold Silver Bronze Employer Selects Carriers Carrier A Carrier B Carrier C Carrier D Carrier A Carrier B Carrier E Carrier F Member Selects Member Selects New Formula to Determine the Size of the Group Under Health Care Reform Step 1: Choose 6- month continuous period from 2013 data Choose Time Period Step 2: For each months, count # of full-time employees (anyone who worked 30 hours or more per week) Count Full-Time Employees 1/1/2013-6/30/2013 Jan: 30 employees Feb: 31 employees March: 30 employees April: 31 employees May: 31 employees June: 31 employees Step 3: For each month, count total # of hours worked by non full-time employees and divide sum by 120. Determine Full-Time Equivalent Employees Jan: 200 hours worked /120 Feb: 210 hours worked/120 March: 195 hours worked/120 April: 199 hours worked/120 May: 204 hours worked/120 June: 202 hours worked/120 Step 4: Add full-time + fulltime equivalents for each month. Then add monthly totals and divide by # of months from Step 1. If you average 50 or more employees, considered a large group. Open question as to whether HHS is enforcing the rule to count part-time employees for 2014 and Exception may apply for employers with seasonal employees. Common Ownership may impact the size calculation and penalties Small Group Implications No penalties apply to small groups that have <50 employees under the HCR formula Small groups can continue to purchase coverage as they do today Ability to buy through small group Exchange (SHOP) beginning 10/1/13 for effective date of 1/1/2014 (new info delayed at Fed level) Sole proprietors are considered individuals in 2014 and must buy individual coverage Tax credit available if purchase coverage from Exchange for groups with: <25 full-time equivalent employees Average salary <$50,000 At least 50% employer contribution to premium Tax credit sunsets in 2016 No Penalties apply to small group. Average salary of <$50,000 At least 50% employer contribution to premium

8 Large Group Implications Employer Shared Responsibility Rules apply to groups with 50 employees Rule #1* Must offer coverage to full-time employees or may pay a penalty Rule #2 Must offer minimum coverage or may pay a penalty Rule #3 Must offer affordable coverage or may pay a penalty *Rule applies that 95% of full-time employees must have coverage per draft regulations released 12/28/12 Rule 1: Full time is anyone who works an average of 30 or more hours a week. Rule 2 (minimum coverage): Must offer at least one plan that covers 60% of the cost. Rule 3 (Affordability): Must offer affordable coverage Employee individual premium contribution for lowest single policy must be <9.5% of employee income Penalty if Coverage is NOT Offered $2,000 per full time employee, first 30 employees are exempt Penalty if Coverage Offered but Does Not Meet Minimum Affordable Coverage $3,000 for each full time employee purchasing subsidized exchange coverage, OR Capped at $2000 per full time employee (first 30 exempt) Penalty paid if at least 1 employee purchases coverage on exchange and receives tax credit in lieu of employer coverage (see Safe Harbor regs) Employer notified when employee applies, and has ability to appeal Examples of Employer Penalties 100 full-time employees Employer Not Offering Affordable, Minimum Coverage 100 full-time employees Employer Chooses NOT To Offer Coverage First 30 employees 10 employees not offered affordable or minimum coverage & they receive tax credit on exchange 70 employees 10 employees $2,000 per fulltime employee $3,000 per employee $140,000 penalty $30,000 penalty Employer Reporting Requirements Requirement Description Applies To New W-2 reporting Employers required to notify employees of Exchanges Employer reporting requirements in 2015 for calendar year 2014 Employee W-2s must include cost of health care. New format required. See IRS for more information Template letter to be made available by DOL. Issue to all employees in 2013 then ongoing to new employees. Rules pending Two separate reports to the IRS January 2013: groups >250 W-2s TBD: groups filing <250 W-2s; anticipate 2014 All size groups TBD: Delayed from initial 3/1/13 deadline TBD based on final rules 48 Employers have the burden of reporting income info. Large employers may be assessed a penalty if employees are awarded premium tax credits through the exchange. Employees qualify for tax credits based on household income, but since that is not known to the employer, safe harbor measures have been proposed. If the employer meets one of the affordability safe harbor measures they would not be liable for a Shared Responsibility payment. Employers must 1) determine whether employer-sponsored health coverage qualifies as affordable under the ACA under one or more of the affordability safe harbor tests, and 2) keep appropriate records of the results. An example of a safe harbor measure: Affordability will be based on whether an employee s premium contribution for the lowest-cost, self-only coverage that provides minimum value exceeds 9.5% of the employee s unadjusted wages as reported on Form W-2 Box 1 for the calendar yr. In practice, this could mean that employees earning the same amount with the same healthcare premiums could have different results under this test depending on the amount of their respective pretax deductions, such as 401(k) or other retirement plan contributions and Section 125 (cafeteria plan) elections. Additional safe harbor regs are being considered. Also, details are available for Employees Who Were Not Full Time for the Entire Year 8

9 Health Care Reform Taxes Paid by Amount Due Health Care Reform Funding and Taxes Patient-Centered Outcomes Research Tax Transitional Reinsurance Program Fee Insurer for insured groups Employer/Plan Sponsor for self-funded Stand alone HRAs considered separate plan and must be paid by employer/plan sponsor FSA considered a separate plan only if they are not considered an excepted benefit under HIPAA Insurer for insured groups Employer/Plan Sponsor for self-funded $1 per covered life for policy and plan years ending between 10/1/12 and 09/30/13 $2 for policy and plan years that end between 10/1/13 and 09/30/2014 To be determined for policy and plan years ending after October 1, 2014, based on the projected health care inflation rate Estimated fee for 2014 is $5.25 per enrollee per month (dollar amount has not been finalized. Applicable from Beginning 11/15/2014, report the number of enrollees to HHS. HHS will notify total amount due for payment First payment due 7/31/2013 for plans. Payment due each year on 7/31 through December 15 th of the applicable plan year, or 30 days after notification from HHS (whichever later) The first payment is due December 15, 2014 The final payment is due December 15, HRA = Health Reimbursement Arrangement FSA = Flexible Spending Account Cadillac Tax Health Insurance Excise Tax Health Care Reform Taxes Paid by Amount Due Employer for plans with premiums that exceed $10,200 individual, $27,500 annually Thresholds may be adjusted upward before tax takes affect Health Insurance providers Self-funded plans are exempt 40% on annual value of costs that exceed the threshold More details to be available with future guidance. The amount of the tax is determined by the percent of the health plan s market share, based on net premiums, reported to the IRS. Total Amount of Annual Tax, to be divided among insurers 2014: $8 billion 2015: $11.3 billion 2016: $11.3 billion 2018 Annually, by September 30 of the applicable year Future Health Care Reform Changes 2015 Coverage requirements not only for employee but also employee dependents except for spouse (need to show good faith in 2014) 2016 Groups of shift to community rating 2017 States can choose to open the exchange to large groups 2018 Cadillac Tax for plans with excessive premiums How Can We Help You? HCR section on Excellus web site, Go to Employers, Health Care Reform Information includes overview, specific provisions, timeline and resources Links available to other web sites under Resources tab

10 References and Resources NYS: US Dept of Health and Human Srvcs: HCR section on Excellus web site (click on for employers, then on Health Care Reform ): BlueCross BlueShield Association reference guide: Essential Benefits, Behavioral and Mental Health info: America s Health Insurance Plans (AHIP): Kaiser Family Foundation: Thank you

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