Health care reform: Past, present and future. Manufacturer & Business Association September 25, 2013

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1 Health care reform: Past, present and future Manufacturer & Business Association September 25, 2013

2 Agenda Health Care Reform - The Past - The Present - Coverage - Exchanges - The Future Questions 1

3 The Past: Background on Health Care Reform Patient Protection and Affordable Care Act (PPACA) Signed into law on March 23, 2010 Health Care and Education Tax Credit Reconciliation Act of 2010 Signed into law on March 30, 2010 Guidance and regulations issued almost every week since then: 2

4 The Past: Background on Health Care Reform Basic elements: Market Reform Individual Responsibility Insurance Exchanges Employer Responsibility Financing 3

5 The Past: Background on Health Care Reform Effective First Plan Year Six Months After Enactment Approximately January 1, 2011 No lifetime or annual limits Prohibition on rescission No pre-existing conditions on dependents below age 19 Development and utilization of uniform explanation of coverage and standard definitions Extension of dependent coverage for married and unmarried, adult children to age 26 Medical loss ratio (MLR) requirements (85 large employer/80 small employer and individual) and rebates 4

6 Uniform summary of benefits and coverage (SBC) - effective for open enrollment periods beginning on/after September 23, 2012 Form W-2 reporting of health coverage for 2012 tax year begins Self-funded plans must have external appeal contracts with 3 or more independent review organizations ERRP funds exhausted Plans may begin to receive medical loss ratio (MLR) rebates Health care reform timeline for employer group health plans Health Care FSA contributions capped at $2,500 Retiree drug subsidy deduction ends Additional preventive services for women must be covered at 100% Comparative effectiveness research tax fees must be paid Medicare Hospital Insurance tax increased for high income filers Medicare tax applies to investment income of high income filers Excise tax on medical device manufacturers Employer notice of state insurance exchanges and premium credits 60-day advance notice of mid-year changes (Notice of Material Modification) required Selected provisions for calendar-year plans note effective dates may vary for non-calendar year plans 40% excise tax on high-cost insurance (Cadillac tax) established Employer reporting of health insurance coverage Annual dollar limits prohibited on essential health benefits Pre-existing condition exclusions prohibited for all enrollees Child coverage to 26 even if eligible for other coverage Waiting periods over 90 days no longer permitted Coverage of routine patient costs in connection with clinical trials Limitations on out of pocket limits Plans may not discriminate against providers with respect to plan participation Auto enrollment required (effective date delayed) Individual/employer shared responsibility provisions effective State health insurance exchanges established Low income premium subsidy available for Exchange coverage HIPAA wellness incentives limits increased to 30% (up to 50% for smoking cessation) Transitional Reinsurance Program States may open insurance exchanges to large employers Part D donut hole filled Provisions in blue italics only apply to new plans or plans that have lost grandfathered status. For information regarding 2010 and 2011 Health Care Reform provisions see Buck Consultants timeline. Note that plans losing grandfathered status will need to satisfy some of these provisions. 5

7 To do list: The Present

8 The Present: Short-term to do list 2012 Form W-2 reporting issued in early 2013* Health FSA limit of $2,500 effective January 1, 2013 (amend plan document December 31, 2014) 2012 comparative effectiveness fee paid by July 31* Exchange notice due to current employees by October 1 (temporary guidance released earlier this summer) 7

9 The Present: Marketplace Notice Model Marketplace notices provided by DOL Marketplace notices must be provided by plan sponsors Existing employees by October 1, 2013 New employees within 14 days of the employee s start date Notice provided by first class mail Electronic distribution must satisfy DOL Electronic Safe Harbor New model COBRA notice also provided Prepare notices and distribution method Coordinate with COBRA administrator 8

10 The Present: Update SBCs 2014 SBCs largely unchanged from 2013 No changes to instructions and model language No changes to coverage examples Include two new statements: Does coverage provide minimum essential coverage? Does this coverage meet the minimum value standard? SBC transition relief extended into 2014 Determine if minimum value and minimum essential coverage Update SBCs for any 2014 plan design changes 9

11 The Present: Essential Health Benefits (EHB) In 2014 individual and small group plans must cover EHBs State benchmark plans have been finalized Used to design scope and limits on EHB in Exchange plans Large group/self-funded plans not required to cover EHB Can t have annual or lifetime dollar limits on EHB Must select definition of EHB Review any dollar limits in plans o Chiropractic, infertility, autism, DME, hearing aids, etc. Review all annual and lifetime dollar limits in plan Select benchmark EHB plan 10

12 The Present: Cost Sharing Requirements Limits on enrollee cost sharing Maximum OOP limits based on HDHP/HSA plans o 2014 limits of $6,350/$12,700 OOP maximums includes: In-network deductibles, coinsurance and copayments OOP maximums do not apply to: Grandfathered plans Transition rule for carve-out plans Review for non-grandfathered plans 11

13 The Present: Waiting Periods No waiting periods in excess of 90 days Appears to apply to all options in a plan Applies to part-time employee benefits Other eligibility standards may be allowed Completion of 1200 hours of service HIPAA certificates of creditable coverage not required after 2014 Review waiting periods 12

14 The Present: Wellness Programs Increases 20% HIPAA incentive to 30% (50% tobacco) Two broad types of programs: Participatory Health-contingent Regulations significantly impact heath-contingent programs Effective for plan years beginning on/after January 1, 2014 No transition relief Review wellness programs 13

15 The Present: Retiree HRAs and EAPs Retiree-only HRAs can be continued in 2014 However, retiree would be ineligible for Exchange subsidies Consider offering retirees the option to enroll in HRA EAPs can be considered excepted benefits Not subject to ACA requirements o Minimum essential coverage and SBCs Safe harbor option for employers Review retiree and EAP programs 14

16 The Present: Employer Reporting Requirements Delayed to 2015 Information reported to: Employees Treasury Information used to: Enforce employer mandate Enforce individual mandate Significant reporting requirements 15

17 The Present: Other 2014 Requirements All Plans No waiting periods in excess of 90 days No pre-existing condition limits Cover all adult children up to age 26 Reinsurance contribution tax Health insurer tax Auto enrollment (delayed) Non-grandfathered Plans Coverage of routine patient cots of clinical trials Provider non-discrimination Nondiscrimination requirements for insured plans (delayed) Review grandfathered status 16

18 Employer shared responsibility

19 Employer Shared Responsibility 2014 Individual mandate goes into effect Play and pay penalty - $3,000 (indexed) penalty for each full-time employee who opts to elect coverage through an Exchange if the employee s contribution for single coverage under the plan exceeds 9.5% of his or her W-2 income or plan does not meet the 60% actuarial value (awaiting additional guidance) Pay or play penalty - $2,000 (indexed) penalty for each full-time employee (excluding the first 30) for not offering coverage if at least one employee receives a subsidy in an Exchange Eligibility and Enrollment Issues - Full-time employee is defined as working 30 or more hours per week - 90 day waiting period 18

20 Eligibility Look Back Period 2014 Standard measurement period: time period used to determine employee status Stability period: time period where employee is eligible or ineligible for benefits based on standard measurement results Administrative period: time period between standard measurement and stability periods used to determine eligibility and enrollment Potential employment status - New full-time employee (Benefit eligible) - New part-time employee, with fewer than 30 hours expected (Do not have to provide benefits) - New employee, uncertain long-term status, but expect to work 30 hours (Benefit eligible) 19

21 Look-Back Method for Ongoing Employees Administrative Period Up to 90 Days Period used to determine employee eligibility and enroll employees Standard Measurement Period 3 to12 Calendar Month Period Period used to determine employee status as a full-time employee. Employee is considered fulltime if averaged at least 30 hours per week during this period Stability Period Period during which the employee status determined in the Standard Measurement Period is fixed regardless of hours worked during the stability period 20

22 Exchanges

23 Exchanges Types of Plans Public Medicaid / CHIP Bronze, Silver, Gold, and Platinum Plans Other state programs Low income subsidies Private Standard plans similar to Bronze, Silver, Gold, and Platinum Plans Customized Plans Developers Primary Buyers State-based (18 states) State-partnership (7 states) Federally facilitated (25 states) CO-OPs - varies Low-income non-medicare individuals who access subsidized coverage Small group employers (<101) Health plans Provider organizations Business groups Consulting / brokerage firms Independent exchanges Mid- to large group employers Varies by private exchange developer focus and contracts 22

24 Public Exchanges Most states have yet to establish exchanges or pass enabling legislation Not all states will create exchanges Federal government will establish exchange if state doesn t Will the exchanges be viable in 2014? Federal assistance available for all individuals with low incomes 23

25 States get time for health exchange decisions Declaration Letter 11/16/2012 Deadline for blueprint 12/14/2012 Deadline for partnership exchange blueprint All exchanges must be ready to enroll All exchanges must be fully operational 2/15/ /01/ /01/

26 Sample metal level designs Provision Platinum Gold Silver Bronze Individual Deductible $200 $600 $2,000 $4,500 Coinsurance after Deductible 80% 80% 80% 80% Out-of-pocket Limit $1,500 $5,000 $5,000 $6,400 PCP Office Visit $10 $25 80% 80% Specialist $10 $50 80% 80% Generic Rx $10 $15 80% 80% Formulary Brand $20 $30 80% 80% Non-formulary Brand $20 $50 80% 80% Actuarial Value 90% 80% 70% 60% 25

27 The Future: The horizon for Health Care Reform: What s ahead: possible confusion when state exchanges are actively promoted for sign-ups (mailings, TV, newspapers, radio, bus signs, billboards and more!) What we re seeing: for many, reactive communication until now Most large employers plan no major 2014 changes; communication has been reactive while awaiting guidance on ACA and wellness Proactive employers are beginning to educate on highlights of ACA What you should consider: Compliance aspects If staying the course for 2014, say so and reduce potential future confusion If expecting an ACA-related cost shift, shape your message on the rationale Prepare management to understand the shifting sands as guidance is released and marketplace offerings evolve Clarify the role of health/wellness in your employee value proposition 26

28 Align communication strategy with your objectives Assuming you plan to play (at least for 2014), decide what employees need to know And what level of engagement do you seek, for 2014 or over the longer-term future? Minimize confusion Steer employees Engage employees in health and wellness OR exit or move to a private exchange 27

29 Questions? 28

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