Health Care Reform: Health Plans Overview. Presented by: Brian Lenzo, Preferred Benefits Services

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1 Health Care Reform: Health Plans Overview Presented by: Brian Lenzo, Preferred Benefits Services

2 Agenda What is the legal status of the law? Which plans must comply? Grandfathered plans Reforms currently in place compliance deadlines Future compliance deadlines Questions

3 Legal Status of Health Care Reform Law

4 What Will Be Next? Implementation of health care reform law continues as scheduled for now Changes to law may come from Congress Some changes already made Democrats will oppose any major changes, and President Obama has promised to veto However, changes to law possible in connection with fiscal cliff bargain Courts will address other aspects of the law For example, courts have ruled on the law s contraceptive coverage mandate, with mixed results on whether employers must comply

5 Which Plans Must Comply?

6 Plans Subject to Health Care Reform Health care reform s health plan rules generally apply to group health plan coverage Exceptions Excepted benefits Retiree-only plans Group health plans covering fewer than 2 employees Excepted Benefits Accident or disability income coverage Separate dental and vision plans Liability insurance Some FSAs

7 Grandfathered Plans Grandfathered plan: group health plan or health insurance coverage in which an individual was enrolled on March 23, 2010 Certain health care reform provisions don t apply to grandfathered plans, even if coverage is later renewed A plan can lose grandfathered status by making too many changes to benefits or costs Plans will have to analyze status and changes at each renewal

8 Reforms Currently in Place

9 Provisions Already Effective Small employer tax credit Dependent coverage up to age 26 No lifetime limits/restrictions on annual limits No rescissions No pre-existing condition exclusions for children No cost-sharing for preventive care services (non-gf plans) Appeals process changes (non-gf plans) No reimbursement for OTC medicine or drugs (without a prescription) Medical loss ratio rules

10 Compliance Deadlines

11 W-2 Reporting Employers must report aggregate cost of group health plan coverage on each employee s Form W-2 Does not change the tax rules for health coverage coverage is still not taxable

12 Effective Date for W-2 Reporting Reporting optional for all employers in 2011 Mandatory for 2012 tax year (W-2 Forms provided in January 2013) For small employers (filed fewer than 250 W-2 Forms last year), reporting requirement is delayed until further guidance issued Covered employers need to be compiling data

13 Summary of Benefits and Coverage Simple and concise explanation of benefits Applies to GF and non-gf plans Model template and guidance available Instructions Sample language Uniform glossary of terms Final guidance specifies compliance deadlines Original deadline was March 23, 2012

14 Providing the SBC to Health Plans Issuers must provide SBC to health plans: Upon application Before the first day of coverage (if there have been changes to the SBC) When a policy is renewed or reissued Upon request

15 Providing the SBC to Enrollees Plans must provide SBC to enrollees: For each benefit package offered or which they are eligible Annually at renewal (or 30 days before new plan year if automatic renewal) With enrollment application materials (if no written enrollment materials, when the participant is first eligible to enroll) Before the first day of coverage (if there have been changes to the SBC) To special enrollees within SPD timeframe Upon request

16 60-Day Notice Rule Material modifications not in connection with renewal must be described in a summary of material modifications (SMM) or an updated SBC Material modification: Enhancement of covered benefits or services Material reduction in covered benefits or services More stringent requirements for receipt of benefits Must be provided at least 60 days BEFORE modification becomes effective

17 Preventive Care for Women New guidelines for preventive care for women on Aug. 1, 2011 Must provide coverage for women s preventive health services without any cost-sharing Applies to non-gf plans No deductible, copayment or coinsurance Effective for plan years beginning on or after Aug. 1, 2012

18 Increased Medicare Tax Medicare tax rate to increase for high-earners 0.9 percent increase (from 1.45 percent to 2.35 percent) High-earner threshold Single: $200,000 Married : $250,000 Employer responsibilities Withhold additional amounts from wages in excess of $200,000 No requirement to match additional tax No requirement to notify employees

19 Health FSA Limits Current limits No limit on salary reductions Many employers impose limit Beginning in 2013, limit is $2500/year Limit is indexed for CPI for later years Applies to plan years beginning on or after 1/1/13 This is a change from initial effective date Does not apply to dependent care FSAs

20 Comparative Effectiveness Research Fees Patient-Centered Outcomes Research Institute Created to improve informed health decisions Research funded by a fee paid by insurers and plan sponsors of self-funded plans Effective date Plan years ending after Sept. 30, 2012 Do not apply for plan years ending after Sept. 30, 2019 For calendar year plans apply for plan years Amount of fee: $1 per covered life Increases to $2 Indexed for CPI

21 Notice of Exchange Employers must notify new and current employees of exchange information Effective Date TBD Notice must include information about 2014 changes: Existence of health benefit exchange and services provided Potential eligibility for subsidy under exchange if employer s share of benefit cost is less than 60 percent Risk of losing employer contribution if employee buys coverage through an exchange More guidance and model notice expected

22 2014 Compliance Deadlines

23 Individual Mandate Jan. 1, 2014: Individuals must enroll in coverage or pay a penalty Penalty amount: Greater of $ amount or a % of income 2014 = $95 or 1% 2015 = $325 or 2% 2016 = $695 or 2.5% Family penalty capped at 300% of the adult flat dollar penalty or bronze level premium

24 Are You a Large Employer Only large employers are subject to potential penalties Large employer is an employer with average of 50 FT employees & FT equivalents in prior calendar year = # FT employees (30+ hours), + # FT equivalents Add all hours for those under 30 hours and divide by 120 Count on a controlled and affiliated service group basis But pay on individual entity basis With 30 free employees for $2,000 penalty ratably divided 5% margin for error also on individual entity basis Predecessors count (no guidance)

25 Are You a Large Employer All common law employees count But partners, sole proprietors, 2% S Corp. SHs do not How do you count average Ees? Look back to prior calendar year, and for each month Count # of FT employees and aggregate hours of FT equivalents/120 Add totals of all months Divide by 12 Round up to whole number Transition rule for 2014: May select any period of at least 6 consecutive months in 2013 calendar year to determine if large ER in 2014

26 Are You a Large Employer Special rule for seasonal workers of 120 days or less You can disregard seasonal workers and avoid large employer status if Seasonal workers stay fewer than 120 days, and Their hours result in average FT equivalents for year being above 50 when you would not have been otherwise, and You are only above 50 in 4 or fewer months

27 Health Insurance Exchanges Health insurance exchanges will be established in each state (by the state or the federal government) Individuals and small employers can purchase coverage through an exchange (Qualified Health Plans) In 2017, states can allow employers of any size to purchase coverage through exchange Individuals can be eligible for tax credits Limits on income and government program eligibility Employer plan is unaffordable or not of minimum value

28 Employer Responsibility Large employers subject to Pay or Play rule Offer coverage of a certain quality or possibly pay a penalty Applies to employers with 50 or more full-time equivalent employees in prior calendar year FT employee: employed for an average of at least 30 hours of service per week Penalties apply if: Employer does not provide coverage to all FT employees and any FT employee gets subsidized coverage through exchange OR Employer does provide coverage and any FT employee still gets subsidized coverage through exchange

29 Exchange Premium Assistance Employee eligibility will trigger employer penalties Employees who are not offered coverage Not eligible for government programs (like Medicaid) Meet income requirements (less than 400% of FPL) Employees who are offered coverage Not enrolled in employer s plan Not eligible for government programs (like Medicaid) Meet income requirements (less than 400% of FPL) Employer s coverage is unaffordable (greater than 9.5% of income) or not of minimum value (covers less than 60% of cost of benefits)

30 Employer Penalty Amounts Employers that do not offer coverage to all full-time employees: $2,000 per full-time employee Excludes first 30 employees Employers that offer coverage: $3,000 for each employee that receives subsidized coverage through an exchange Capped at $2,000 per full-time employee (excluding first 30 employees)

31 Safe Harbors Employer penalties: who is a full-time employee? Ongoing employees New full-time employees New seasonal and variable hour employees Affordability safe harbor Use W-2 income Waiting periods Cannot exceed 90 days No penalty for employees in waiting period Employers can rely on safe harbors through 2014

32 Employer Reporting Employers will have to report certain information about health coverage to the government and individuals Applies to: Applicable large employers Offering employers employers that provide coverage if employee cost exceeds 8% of income Applies to coverage offered after Jan. 1, 2014 First returns to be filed in 2015

33 Information Required Employer identifying information Whether employer offers health coverage to FT employees and dependents Number of FT employees for each month Length of any waiting period Monthly premium for lowest-cost option in each enrollment category Employer s share of cost of benefits Names and contact info of employees and months covered by employer s health plan

34 More 2014 Changes No pre-existing condition exclusions or limitations Wellness program changes - maximum reward increases to 30% Limits on out-of-pocket expenses and cost-sharing No waiting periods over 90 days Coverage of clinical trial participation Guaranteed issue and renewal No annual limits on essential health benefits Insurance premium rating restrictions

35 Future Compliance Deadlines

36 2018 Cadillac Plan Tax 40 percent excise tax on high-cost health plans Based on value of employer-provided health coverage over certain limits $10,200 for single coverage $27,500 for family coverage To be paid by coverage providers Fully insured plans = health insurer HSA/Archer MSA = employer Self-insured plans/fsas = plan administrator More guidance expected

37 Nondiscrimination Rules Coming for Fully-Insured Plans Will apply to non-grandfathered plans Discriminating in favor of highly-compensated employees (HCEs) will be prohibited Eligibility test Benefits test HCEs 5 highest paid officers More than 10% shareholder Highest paid 25% of all employees Effective date delayed for regulations

38 Automatic Enrollment Rules Will apply to large employers that offer health benefits Applies to GF and non-gf plans Large employer = more than 200 employees Must automatically enroll new employees and reenroll current participants Adequate notice and opt-out option required DOL: Regulations will not be ready to take effect by 2014 Employers not required to comply until regulations issued and applicable

39 Pay or Play The Mechanics of Determining Whom You need to Cover Can look at each month real time to determine who is 30+ hours or Choose measurement period to determine if average 30+ hours, then give coverage for stability period Shorter measurement periods allowed and might be used by employers with workers whose hours vary widely

40 Pay or Play How Do You Count Hours? Hours = time for which paid or entitled to payment for services or time off due to vacation, illness, or leave of absence (same rule as for 401(k) plans) Hourly employees: Must count actual hours Salaried employees: 3 Choices: 1. Actual hours (need to create system to tract part-time salaried workers!) 2. Assume 8 hour per day any work is performed 3. Assume 40 hours per week any work is performed Can use different methods for reasonable classifications of Ees May change methods each year Anti-abuse rule

41 Pay or Play How Do You Count Hours? Use best judgment on commissioned employees, transportation, and other employees paid per day or with legal hour limits. Hours counting rule for Ees returning from special unpaid leave (i.e., unpaid leave subject to FMLA or USERRA or on account of jury duty): Determine average hours/week during the measurement period excluding the unpaid leave period and use that average as the average for the entire measurement period Could also choose to treat employees who take unpaid leave for these purposes as having taken paid leave Special rule for Ees of educational organizations: If work 30+ hours on average during active portions of academic year, then must be considered to average 30+ hours during employment break periods (i.e. summer vacation)

42 Pay or Play Measurement and Administration Definitions and special rules current employees: (w/o regard to 2014 transition) Standard Measurement Period: 3-12 mo. Period when you track EE hours for Ees hired prior to period start Shorter measurement periods might be used by Ers w/workers whose hours vary widely Admin Period: Up to 90 days to identify and enroll 30+ employees Standard Stability Period: 6-12 month period when those who met standards during measurement period must be covered (or, the 3-12 month period when those who did not meet the standards during the measurement period may be excluded), regardless of hours worked

43 Pay or Play Measurement and Administration 2014 Transition Rules for Employers Must have a 6-month measurement period beginning before 7/1/2013 Note: look-back only applies to employees hired before measurement period begins Example with Calendar Plan Years Select 6-month measurement period (4/15/13 to 10/14/13) 2+ partial-month administrative period to analyze who you have to cover and offer enrollment (10/15/13 to 12/31/13) 12-month stability period (1/1/14 to 12/31/14) Might adjust dates slightly each year to start/stop on payroll periods

44 Pay or Play Measurement and Administration Fiscal plan year beginning on 7/1/14 10 month transition standard measurement period 6/15/13 to 4/14/14 applies to those hired before it begins Regs. require 2013 measurement start no later than 7/1/2013 and starts earlier here to provide for slightly longer admin. Period 2+ partial-month admin. Period (4/15/14 to 6/30/14) 12-month stability period (7/1/14 to 6/30/15) This employer would use 4/15/2014 4/14/2015 as next measurement period to determine who to coverage in 2015 plan year that begins 7/1/2015

45 Pay or Play Measurement and Administration Optional Special Enrollment Period for Fiscal Year Plans Plans with fiscal plan years may want to have a special enrollment period in late 2013 (to enroll 1/1/2014) to: Allow employees to drop employer coverage so that they can purchase coverage through an Exchange and/or Allow employees to purchase employer coverage so that they can avoid individual mandate tax effective 1/1/14 Will require amendment to health and cafeteria plans

46 Pay or Play What About New Hires? New hires expected to average 30+ hours per week (either because hired into position with set hours or hours vary and 30 is the average # of hours expected to be worked over a measurement period) Must be offered coverage to be effective by 90 th day from first day of work (generally first day of second month after hire) Must be eligible for coverage until completion of a full standard measurement period Example: hired 10/17/2013; enroll by 1/14/2014 and must stay in until end of 2015 calendar plan year, because was not employed for entire 10/15/ /14/2014 measurement period Transition rule for 2014: must be eligible within 90 days of hire or 1 st day of 2014 plan year, if later. Example for calendar year plan: EE hired May 2, 2013, must be eligible by January 1, 2014 If hired December 2, 2013, must be eligible by March 1, 2014 or enrolled mid-month (April 1 too late) Neither can be dropped by ER before end of 2014 stability period (12/31/2014)

47 Pay or Play What About New Hires? New hires whose hours you do not reasonably expect to average near 30/week (for example: hours are schedule at 30 and EE not free to take other shifts, etc.) = a non-full-time employee Can leave out of plan until/unless they have more than 30 on average during some future measurement period Does not appear that a change in status during a year mandates coverage (but stay tuned for refinements) However, you must keep data in case you have to justify not offering coverage Variable Hour new hires and seasonal employees If (and only if) cannot determine whether their hours will average to 30 (due to contingencies like amount of work, amount they will agree to work, etc.), then new hire is classified as variable hour with some special rules Seasonal employees subject to same special rules Seasonal employee not yet defined; reasonable good faith interpretation required

48 Pay or Play Special Variable Hour and Seasonal New Hire Rules May use initial measurement period/look-back method if using look-back method for ongoing employees But different rules give employees benefit of the doubt in these cases: Material change in employment position or status can trigger sooner enrollment

49 Questions?

50 Thank you! This presentation is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Please contact legal counsel for legal advice on specific situations. This presentation may not be duplicated or redistributed without permission Zywave, Inc. All rights reserved.

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