Healthcare Reform in Texas. How the Affordable Care Act Will Impact Small Employer Health Insurance. UTD Healthcare Management.

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1 Healthcare Reform in Texas How the Affordable Care Act Will Impact Small Employer Health Insurance UTD Healthcare Management June 11, 2013

2 Rising Health Care Costs - The Familiar Challenge Employer sponsored health plans are the leading source of insurance today, covering 150+ million workers in America. These employers are constantly searching for ways to balance the health care needs of the workforce with the realities of a challenging business economy. - U.S. health care spending doubled from 1996 to The U.S. currently spends 17.6% of its GDP on health care and that is expected to rise to 25% by The U.S. pays 50% to 60% more per unit of health care than any other industrialized country...and approximately $700 billion on unnecessary tests and services. - Health care costs add between $1,500 and $2,000 to the sticker price of every General Motors vehicle, more than the cost for steel. - Employer sponsored health insurance premiums have more than doubled in the last 9 years, a rate 3 times faster than cumulative wage earnings. 2

3 Affordable Care Act: Daunting Challenges For the foreseeable future, stakeholders will deal with the unintended consequences of the Affordable Care Act. Near-term concerns include: Funding and Operating the Exchanges Since federal grants/money for State Exchanges will be prohibited after 2014, how will the state exchanges and the Small Business Health Option Program programs be funded? Time Restraints Can the vast, supporting infrastructure for the Affordable Care Act be developed and implemented by October 2013? (Enrollment and eligibility systems, employer readiness, enforcement mechanisms, expanded provider networks, qualified health plans, etc.) Cost-Shifting While the ACA strives to make insurance more affordable for older/sicker consumers, costs are predicted to increase significantly for young/healthy individuals and for small groups. 3

4 Affordable Care Act: Key Provisions for 2014 and Beyond Minimum Essential Coverage: All U.S. citizens are required to maintain minimum essential health coverage each month or pay a penalty. Employers with an average of at least 50 full-time employees in the prior year must offer minimum essential coverage to employees. Guaranteed Issue: All carriers in the individual and small group markets will be required to offer coverage to any individual or group that applies, and plans/policies are guaranteed renewable. Public Exchanges: Individual and small group health insurance exchanges will become operational. For states that do not establish an exchange, a federal exchange will be operated in their state. Employer Tax Credits: The Affordable Care Act increases the small business tax credit to 50% of employer cost for providing employee health coverage (35% for tax-exempt employers). Credits will only be available on plans offered through health insurance exchanges. 4

5 Affordable Care Act: Key Provisions for 2014 and Beyond Coverage for Clinical Trials: If a qualified individual is in an approved clinical trial, the plan cannot deny coverage for related services. Essential Benefits: No more lifetime or annual dollar limits are allowed on essential health benefits. Waiting Periods: Waiting periods cannot be longer than 90 days. Pre-existing Conditions: No exclusions of some or all benefits allowed due to pre-existing conditions. Provider Non-discrimination: Health care providers will not be prevented from participation in an insurer s provider network if willing to abide by the terms and conditions for participation and are acting within the limits of their medical license or certification. 5

6 Essential Health Benefits Defined 1. Ambulatory patient services 2. Hospitalization 3. Emergency services 4. Maternity and newborn care 5. Mental health & substance use disorder services, including behavioral health treatment 6. Prescription drugs 7. Rehabilitative services and devices 8. Laboratory services 9. Preventive and wellness services and chronic disease management 10. Pediatric services, including oral and vision care 6

7 Insurance Reforms: 2013 Preparation Individual/small group policies (2-50 employees, EXCLUDES self-insured plans): - Benefits Must cover essential health benefits Must satisfy specified deductibles/out-of-pocket limits Must satisfy actuarial value (AV) requirements. Metallic plans (bronze, silver, gold, platinum) designate the percentage of total average costs covered by each plan from 60 90% coverage. 3 Proposed Approaches: Employer customizes plans, employer selects a Metallic Level, or employer gives employees a specific dollar contribution - Premiums Rates are adjusted only for age, tobacco use, and geography. Rates are determined based on the specified risk pools (individual or small-group). 7

8 Employer Free Rider Penalties: 2014 and Beyond Affects employers with 50 or more full-time employee equivalents. Two possible penalties: - The A penalty - If employer does not offer coverage (and one FTE receives a tax credit on an Exchange), penalty is $2,000 (annualized) times the total number of FTEs (minus the first 30 FTEs). - The B penalty - If employer does offer coverage (and one FTE receives a tax credit on an Exchange), penalty is $3,000 (annualized) times the number of FTEs receiving a tax credit on an Exchange (not to exceed the A penalty). NOTE: The B penalty applies only if the coverage is inadequate (less than 60% minimum value) or unaffordable (individual coverage costs more than 9.5% of W-2 income). Numerous Safe Harbor approaches are under development to help minimize/avoid the impact of these penalties. Now, more than ever, businesses need to seek the counsel of a well-versed benefit advisor to keep them out of harm s way. 8

9 2013 Checklist for Large Employers 50 FTEs or More Determine company s status as a large employer by counting the number of full-time employees and adding the number of full-time equivalents employed during If the number is 50 FTEs or more, the business will be subject to the ACA penalties in For 2014, ensure that employee premiums cost no more than 9.5% of the employee s W-2 income. (Is the coverage affordable?) Design the 2014 benefit plan to ensure it provides minimum value, which generally means the plan pays at least 60% of the cost of the benefits. (Is the coverage adequate?) Amend group health plans to reflect the mandates effective in 2014, limiting waiting periods to no more than 90 days and removing all pre-existing condition exclusions. Eliminate mini-med or limited benefit plans that cannot comply with the prohibition on lifetime and annual limits on essential health benefits. 9

10 Self-Funding: Increased Small Business Interest Nearly 20 million Americans work in businesses with employees. Over 70% of these businesses offer health benefits to their employees. In 2012, only 15% of companies with fewer than 200 employees were self-insured compared with 81% of larger firms. (Kaiser Family Foundation Study) To minimize the costs incurred with ACA compliance, carriers are now offering innovative options for companies with as few as 25 employees. Self-Funding Basics: 1) Establish a fund to pay claims, 2) Control and customize plan design, 3) Acquire Stop Loss protection for large, costly claims, 4) Utilize the claims data to identify and manage employee needs. Self-funding is not suitable for every company. Businesses should work with knowledgeable benefit advisors who understand the pros/cons. 10

11 Potential Advantages of Self-Funding for Small Businesses Predictability, Flexibility, Control and Transparency Avoid/minimize PPACA s mandated benefits and pricing rules Potential for near-term savings and sustainable cost control Greater flexibility in health benefits options and plan design Improved cash flow management Lower administrative costs Access to claims data ability to identify and cater to employee needs Unique cost and utilization controls (i.e., Incentive and Wellness Programs) 11

12 Wellness and Prevention: Employer Best Practice Prevention should be a priority for businesses today. Companies are increasingly taking advantage of carrier sponsored wellness programs from weight loss and smoking cessation programs to discounted gym memberships, nutrition classes, wellness newsletters and more. -Renewed focus on awareness. Unhealthy lifestyle choices drive increases in diabetes, heart disease and cancer. -Introduce biometric screenings weight, cholesterol, blood pressure. -Encourage utilization of no-cost preventive services. -Implement Carrot or Stick employer incentives. -Focus on activities, not just outcomes. 12

13 Employee Lifestyle Risks 13

14 Employee Clinical Risks 14

15 Why Wellness? Why Now? The Overall Health of any Employee Group is Ever-changing. Employees and their dependents will: Improve their own health Stay the same Become a greater liability because unaddressed health risks have intensified Studies show that without an effective wellness program, it is likely that a group s health will worsen. The number of employees in the low-risk group will decrease while the number of employees in the moderate and high-risk groups will increase. Benefits of a Best Practice Wellness Program: Improve employee health Reduce absenteeism Reduce healthcare costs Improve morale and productivity Position company as an employer of choice 15

16 Contact Us Joyce Gaines Senior Consultant Phone: , Ext. 105 Alkali Benefits 2301 Ohio Dr. Suite 260 Plano, TX

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