Sandy Wood, CEBS (Certified Employee Benefit Specialist) Healthcare Consultant

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2 Sandy Wood, CEBS (Certified Employee Benefit Specialist) Healthcare Consultant

3 Terms you need to know Required Notices 2014 Plan Requirements The Grandfathered Plan Taxes and Fees Employer Size Penalties FSA / HRA Rules 3

4 FSA Flexible Spending Account HRA Health Reimbursement Arrangement COBRA Consolidated Omnibus Reconciliation Act CHIP Children s Health Insurance Program FTE Full-Time Equivalent NGF Non-Grandfathered GF Grandfathered SBC Summary of Benefits & Coverage QHP Qualified Health Plan EHB Essential Health Benefits PCORI Patient Centered Outcome Research Institute

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6 In 2014, employers that don t offer medical coverage don t need to do anything under healthcare reform. 6

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8 All employers must provide Regardless of size Regardless of whether offer group-based medical All employees must receive Full-time and part-time Remember seasonal employees, temps, and COBRA participants Must be provided either First Class mail Electronically, if allowable 8

9 COBRA Changed to include Marketplace information Both the General Notice and the Election Notice CHIP Updated state availability Make sure has (expires 10/31/2016) on your version 9

10 Wellness Plan Disclosure in all communications If require individual to meet a standard related to a health factor in order to obtain a reward (e.g. cholesterol below 200) And if it is part of a group health plan (such as premium differentials) Must disclose the availability of a reasonable alternative standard (or waiver) (checklist) 10

11 Examples where disclosure needed: If pass 3 of 5 biometric tests, will have a lower plan deductible If walk 10,000 steps 20 days each month, will pay lower premiums If nonsmoker, will receive lower premiums Examples where disclosure NOT needed: If complete biometric screening will have lower plan rates If pass 3 of 5 biometric tests will receive a $50 gift card If sign up for the FIT program at work will get $100 in HRA dollars If nonsmokers, or go through smoking cessation program, will receive lower premiums (additional requirements..) 11

12 Similar to a plan summary Must be in format provided by government Goal is to make plans comparable side-by-side

13 Which All medical plans Health Reimbursement Arrangements When Open enrollment (remember your COBRA members!) New hires Upon request How Culturally and linguistically appropriate Can provide electronically, but limitations Rules if 10%+ do not speak English as a first language See: FAQs/Downloads/2013-clas-data.pdf In WA Adams, Chelan, Douglas, Franklin, Grant, Yakima (Spanish) 13

14 See: 14

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16 Some medical plans are still being allowed to include preexisting condition waiting periods. 16

17 AS PLANS RENEW in 2014 Eliminate pre-existing condition waiting periods Remove all annual dollar limits on Essential Health Benefits Follow Wellness Plan rules if offering any incentives Allow dependent child coverage to age 26 even if the dependent has access to other group-sponsored healthcare (new for GF) Be careful if part of a Trust program, may not apply until the TRUST renews in

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19 Plan changes (after 9/30/2010) dictate non-grandfathered status Increase employee coinsurance Decrease or eliminate a plan benefit Increase any of the following by > medical inflation + 15% Copays ($5 max allowed) Deductibles Out of pocket maximums Lower employer contribution for employees by > 5% Must disclose GF status Use model notice wording Must retain all plan documents to prove GF status 19

20 Keep your medical plan Grandfathered as long as possible to skirt the majority of healthcare reform plan change requirements. 20

21 Only 9 provisions you can still skirt If GF, you don t have to: 1. Provide coverage for preventive care without cost-sharing (contraception) 2. Follow non-discrimination rules if fully-insured (regs not finalized) 3. Cover out-of-network emergency department services like in-network 4. Expand claims and appeals requirements 5. Provide right to choose a primary care designation 6. Allow OB/GYN access without a referral 7. Report to HHS on quality of care (delayed indefinitely) 8. Add coverage for routine costs associated with clinical trials 9. Cover health care providers acting within the scope of their license or certification under applicable state law 21

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23 To develop evidence-based health guidelines Applies to Fully insured and self-funded plans Small and large plans Plans affected Medical Health Reimbursement Arrangements Some FSAs You ll pay more than once if: Your medical plan is fully insured and you also have an HRA/FSA Your self-funded medical plan and HRA/FSA have different year-end 23

24 Plan Year End Amount to Pay By When 2012 Oct / Nov / Dec $1/member/year 7/31/ Jan Sept $1/member/year 7/31/ Oct / Nov / Dec $2/member/year 7/31/ Jan Sept $2/member/year 7/31/ Oct / Nov / Dec TBD 7/31/ Jan Sept TBD 7/31/2016 Who Pays? Fully-insured: Insurance carrier pays Self-funded: Employer pays HRA/FSA: Employer pays 24

25 The Cadillac tax will require high-cost medical plans to pay a 40% excise tax on all medical premiums beginning in

26 Annual Excise Tax 40% of the amount of excess benefits Charged on high value health benefits $10,200 for single coverage; $27,500 for family coverage Higher for retirees and those in high risk professions May be higher for special workforce demographics Includes Full medical plan premiums, gap coverage, disease coverage Employee and employer contributions to HSAs, FSAs, HRAs Who pays Self-funded = employer Fully insured = insurance company

27 To fund various provisions of the ACA Applies to Fully insured plans only Small and large plans Insurers with $25+ million in net annual premiums Plans Affected Medical, vision, and dental Medicare Advantage and Part D plans Retiree health insurance Current 2014 estimate is 1.9% to 3.0% of premiums $8 billion to be collected in 2014 (will increase annually) 27

28 Called the 3R Fees Permanent Risk Adjustment Program ongoing Protects against adverse selection in individual and small group markets Applies to non-grandfathered individual and small group plans Both inside and outside the Exchange Temporary Risk Corridor Program Protects against inaccurate rate setting in individual and small group markets Applies to all individual and small group plans Both inside and outside the Exchange Transitional Reinsurance Program Ensures stabilization of individual market 28

29 Transitional Reinsurance Program Ensures stabilization of individual market Temporary reinsurance for individual plans for 2014, 2015, 2016 Fee applies to all fully-insured and self-funded health plans $63.00 per enrollee per year for 2014 (or $5.25 PMPM) $44.04 per enrollee per year for 2015 (or $3.67 PMPM) $27.72 per enrollee per year for 2016 (or $2.31 PMPM) - estimate Includes retirees and COBRA members Does not count those where Medicare is primary $12 billion to be collected in FAQs/Downloads/Reinsurance-contributions-process-FAQ pdf 29

30 Under the Affordable Care Act, eventually all employers will have to offer medical coverage to their full-time employees, or else pay a penalty. 30

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32 Include all full-time Defined as 30+ hours per week OR 130+ hours per month Include all your part-time as Full Time Equivalents Count up each person s hours Cap at 120 hours per month Divide by 120 (you can round to nearest 1/100 DO NOT include Contractors Seasonal employees working < 120 days per year 2015 TRANSITION RELIEF: do not include if work < 6 months per year Federal (or state) work study students Unpaid interns and externs Member of a religious order who has taken a vow of poverty

33 Each hour a Salaried employee is paid due to: Vacation Holiday Illness Disability Layoff Jury duty Military duty Leave of absence Each hour an Hourly employee is paid due to: Actual hours of service Hours for which payment is made or due

34 Does your company have common ownership with another? You may have to combine employees from all groups IRS has a 108 page primer Talk to your CPA, tax attorney, or corporate attorney 34

35 Quickie Calculator Excel Go to Choose Resources, then Helpful Links Click on Employer ACA Size Calculator

36 Due to transition rules under pay or play, employers with full-time equivalent won t have to worry about this until

37 Can you pass all the requirements? Average employees in 2014 Cannot reduce # of employees between 2/9/14-12/31/14 in order to move under 100 Keep employer contribution either: At same % of premiums as you were before 2/9/14, or At least 95% of the dollar amount you were before 2/9/14 Cannot eliminate coverage for classes covered before 2/9/14 Cannot change your plan year after 2/9/14 to renew on a later month in the calendar year Have to provide certification to the government that you qualify

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39 As long as you offer a Qualified Health Plan to at least 95% of your full-time equivalent employees, you won t have to pay any penalties under the pay or play rules. 39

40 Penalty amounts for 2015 only. Will be adjusted annually. a Employer does not offer coverage OR Employer plan is not offered to substantially all full-time employees. You ll have to offer to 95% or more of your FT employees 2015 TRANSITION: 70% Penalty $2000 per FT employee Minus first 30 employees 2015 TRANSITION: 80 (groups 100+) b Employer plan does not meet minimum value and/or is unaffordable. Also applies to the percentage of FT employees not offered coverage. Penalty $3000 for each FT employee receiving a subsidy Not to exceed Penalty a

41 Minimum value Plan must pay at least 60% coverage actuarially HSA deposits included Integrated HRA deposits included Unaffordable If employee pays > 9.5% of household income For employee-only medical coverage Employer Safe Harbors W-2 wages (Box 1 of Form W-2) Monthly wage (take hourly wage times 130 hours) Federal Poverty Level (for a single individual)

42 The IRS has threatened employers with a $36,500 penalty per employee, per year. 42

43 43

44 Applies to individual plan premiums Past pre-tax options outlawed Premium Only Plan Flexible Spending Account Health Reimbursement Arrangement If employer pays with pre-tax dollars $100 per member per day penalty Over the year, that s 365 days $36,500 penalty 44

45 Flexible Spending Accounts You can only provide to employees if ELIGIBLE for a group-based qualified health plan (QHP) Election waiting period would need to be same or longer than QHP Minimum hours would need to be same or higher than QHP Example: Medical plan = 30+ hours, 1 st following 60 days FSA = 20+ hours NOT ALLOWED FSA = 1 st following 30 days NOT ALLOWED FSA = 30+ hours, 1 st following 60 days ALLOWED FSA = 35+ hours, 1 st following 120 days ALLOWED 45

46 Health Reimbursement Programs You can only provide to employees if ENROLLED on a group-based qualified health plan (QHP) You can provide to those enrolled on a different employer s QHP but you need to ensure that the other plan is in fact a QHP Example: HRA = $100/mo for those not eligible for medical plan NOT ALLOWED HRA = $50/mo if waive the group medical plan NOT ALLOWED SAME..but requires OTHER group medical ALLOWED HRA = $20/mo if waive the group dental plan ALLOWED 46

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