Health Care Reform Update. Spring 2014

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1 Health Care Reform Update Spring 2014

2 Quincy Quinlan Texas Association of Counties

3 Today s Agenda Timeline Fees/Taxes Individual Mandate Marketplace (Exchange) and Federal Subsidy Employer Mandate and Pay or Play Decision Part time vs. Full time Seasonal and Variable Hour workers Excise Tax

4

5 Health care reform: high level timeline Health Care Reform enacted Summary of Benefits and Coverage (SBC) and uniform glossary Supreme Court ruling on Health Care Reform constitutionality Individual mandate/public Exchanges open Premium and cost-sharing subsidies Medicaid not expanded in Texas gaps in coverage Additional market reforms/group health plan mandates No pre-existing condition exclusions Allow $500 carryover for health FSA Employer Mandate (50+ EEs) Sale of health insurance across state borders permitted Report value of health coverage on W-2 (over 250 EEs) Additional Medicare tax on wages $2,500 cap on employee pretax contributions to health FSAs Notice to employees of exchanged-based coverage options Public exchange development Initial open enrollment in public exchanges Adult child coverage to age 26 No lifetime dollar limits/restricted annual dollar limits on essential health benefits No pre-existing condition exclusions for enrollees under 19 First-dollar preventive care coverage No rescissions and other group health plan mandates Employer mandate (100+EEs) Auto enrollment? States may open exchanges to large employers Excise Tax Ongoing guidance, evolving interpretations, additional legislation and enforcement 5

6 Health Care Reform Fees For Employers Transitional Reinsurance 2014: the proposed national per capita contribution rate will be $63 per covered life per year (TAC paid $1,752,975 on behalf of pool members.) 2015: reduce 2014 rate by about 1/3 2016: reduce 2014 rate by about ½ Patient Centered Outcomes Research (PCORI) Fee Excise Tax a.k.a. Cadillac Tax 2012: $1 per member per year 2013: $2 per member per year 2014: For policy and plan years beginning on or after Oct. 1, 2014, and before Oct. 1, 2019, the applicable dollar amount is further adjusted to reflect inflation in National Health Expenditures, as determined by the Secretary of Health and Human Services. 2018: 40% excise tax on the amount of benefit exceeding a specific threshold annual cost greater than $10,200 for individuals and $27,500 for families

7 Individual Mandate All U.S. citizens and legal residents (with limited exceptions) will be required to maintain minimum essential coverage or pay a penalty Annual penalties for the individual vary depending on income and family status 2014: Greater of $95 per adult or 1% of household income 2015: Greater of $325 per adult or 2% of household income 2016: Greater of $695 per adult or 2.5% of household income Individuals can get coverage either from: Employer sponsored plan, Spouse s employer, Parent s employer (under age 26), A Health Insurance Marketplace, or Other coverage options that may be available, including an insurance plan outside the Health Insurance Marketplace or through Medicare and Medicaid

8 Federal Subsidy Some individuals who enroll in the Marketplace may qualify for assistance with premiums: the subsidy Qualification for a subsidy is generally based on income limits, group plan availability, and IRS dependent status Individuals who are not offered qualified employer group plan coverage (meets affordability and minimum value standards), AND whose income is within specified limits may qualify for subsidy An employeeʹs dependents who are offered coverage on the employer s qualified group plan may be eligible for subsidy IF: 1. The dependent meets the income qualifications for subsidies, AND 2. The dependent is not claimed as a personal exemption on the employee s tax return Individuals or families with incomes over 400% of the Federal Poverty Level (FPL) will not be eligible to receive a subsidy

9 Coverage options through employers and exchanges in 2014 Family Income greater than 400% of Poverty Family may purchase unsubsidized coverage in Exchange If employer coverage is available Family may choose the employer plan or unsubsidized* coverage in Exchange Family Income between 100% and 400% of FPL Family is potentially eligible for subsidy in Exchange If employer coverage is available, but either inadequate (<60% benefit) or unaffordable (premiums >9.5%) Family may choose the employer plan or subsidized coverage in Exchange If employer coverage is available and adequate and premiums are affordable Family may choose the employer plan or unsubsidized* coverage in Exchange Family Income less than Medicaid Level Family is eligible for Medicaid Family may also participate in Exchange If employer coverage is available Family may choose the employer plan or Medicaid but may fall into gap * Based on Dependent status on tax return FPL for FPL Single Individual Family of 4 100% $11,670 $23, % $15,521 $31, % $46,680 $95,400 9

10 Health Care Reform Provisions For plan years beginning on or after January 1, 2014 Summary of Benefits Coverage (SBC) Employers must provide all employees with an SBC that describes the health plan benefits. No Pre Existing Condition Waiting Period Health Plan cannot require a waiting period for treatment of a pre existing condition for new plan enrollees Maximum 90 Day Waiting Period Employers are required to enroll eligible employees in the employer sponsored health plan within 90 calendar days of their start date Comprehensive Out of Pocket (OOP) Maximum Nongrandfathered group health plans generally required to adopt a comprehensive and unified OOP maximum, with special 1 year transition for plans with multiple claim vendors; e.g., medical and prescription drugs Wellness programs Compliance with final regulations on wellness plans.

11 Grandfathered vs. Non Grandfathered Grandfathered Plans Non Grandfathered Plans Plan was in place as of 3/25/2010 and has not been significantly modified since then Not required to comply with several components of healthcare reform Majority of TAC pool counties have grandfathered plan Must provide a variety of preventive health services and screenings with no copays or deductibles are my preventive care benefits Most plans must provide women s contraceptive services with no copays or deductibles Most plans required to adopt a comprehensive and unified (medical and Rx) out of pocket maximum Must cover Essential Health Benefits Changing from a Grandfathered to Non Grandfathered Plan may cause an increase in rates Grandfathered Plan counties should be prepared to make employees aware of these differences, in the face of massive marketing campaigns by some insurance companies and brokers for new plans under the ACA

12 Ongoing variable hour/seasonal employees Standard Measurement Period Look back at hours worked by variable hour employee to determine eligibility for coverage Employer choose length from 3 to 12 months Standard Administrative Period Count hours, offer & enroll in coverage Maximum length of 90 days Cannot reduce or lengthen the measurement or stability period Overlaps with prior stability period Standard Stability Period Coverage remains available regardless of hours worked during stability period Full time employees Cannot be shorter than the standard measurement period Must be at least 6 months Non full time employees Stability period cannot be longer than the standard measurement period

13 Employer Mandate Large Employers Health Care Reform Provisions 2015 Large Employer Counties and Districts must determine whether they employ at least 100 full time equivalent employees subject to the employer mandate Classify employees who work on average at least 30 hours/week (or 130 hours/month) as full time for Affordable Care Act purposes Employees who work seasonal or variable hours may be eligible for coverage. Employers need to adopt a look back measurement period to determine eligibility If your County uses seasonal or variable hour employees, ask for help with this process.

14 Employer Mandate Health Care Reform Provisions 2015 Large Employers must: Offer minimum essential coverage (MEC) to at least 70% of full time employees and their dependents or risk paying a penalty MEC is broadly defined, but includes most forms of insured or self insured employer sponsored group health plan coverage. Determine whether the health plan coverage meets the affordability standards of Health Care Reform and is of minimum value (MV) o To be affordable, the employee only coverage under the lowest cost plan cannot be more than 9.5% of an employee s total household income o To provide minimum value, the plan must cover at least 60 percent of the total cost of covered care. Adapt payroll systems to comply with the employer data reporting requirements of Health Care Reform (beginning with 2015 coverage reported in 2016)

15 Employer Mandate Health Care Reform Provisions 2016 Large Employer definition is expanded to Counties and Districts that employ 50 or more full time equivalent employees subject to the employer mandate. If your County has less than 50 full time employees and some part time employees, ask for help with the FTE calculation. Employers with 50 or more full time equivalent employees must offer minimum essential coverage to at least 95% of full time employees and their dependents or risk paying a penalty

16 16 The employer pay or play mandate: No Employer Plan ( Pay ) Employer Shared Responsibility (ESR) payment of $2,000* x total number of full time employees 2015: Penalty (ESR) is triggered if an employer with 100 or more full time equivalent employees offers coverage to less than 70% of its full time employees, and any employee receives subsidized coverage through Marketplace 2016: Penalty (ESR) is triggered if an employer with 50 or more full time equivalent employees offers coverage to less than 95% of its full time employees, and any employee receives subsidized coverage through Marketplace Full Time employee for penalty calculation is defined as an employee who works 30 or more hours per week on average *ESR amounts will increase annually based on a statutory inflation adjustment Employer Offers Coverage ( Play ) Employer plan pays less than 60% of covered costs ( minimum value test ) OR Employee contributions for self only coverage exceed 9.5% of W 2 Box 1 or household income ( affordability test ) AND Employee household income between 133% and 400% of federal poverty level THEN Pay lesser of $3,000 for each FTE that receives a premium subsidy for a Marketplace plan, or $2,000 x total number of full time employees

17 PAY or PLAY Pros and Cons PAY (eliminate employer group plan and pay penalties) PROs Penalty costs are initially less expensive than the cost of insuring employees Employees could potentially receive subsidies to help pay for plans for themselves and their dependents Eliminates concerns about maintaining plans that are compliant with federal law CONs Leaves employees at the mercy of volatile and unpredictable marketplace Potential for additional penalties and fees that cannot be budgeted or estimated due to fluctuating regulations Loss of competitive edge in recruitment and retention of good employees PROs PLAY (keep employer group plan) Reduces stress on employees by maintaining benefits they are accustomed to and feel secure about Provides an incentive for employees to work for your county For TAC pool members, maintains fiduciary standard and ensures benefit plan compliance with federal regulations CONs Will require more attention to employee engagement in good health care consumer behavior Could necessitate benefit plan changes to avoid taxes and penalties in the future

18 Excise Tax or Cadillac Tax 2018 In 2018, if the county medical plan s total cost for employee or family exceeds a certain cost level as determined by the government County will be charged a 40% excise tax on amounts over the designated thresholds Based on current estimates, over 70% of TAC HEBP groups will exceed the cost threshold in 2018 and owe this tax 2018 cost threshold: $10,200 ($850/month) for employee only coverage, $27,500 ($2,291/month) for family coverage Thresholds to be adjusted in 2019 and thereafter

19 Management of the excise tax requires a sustainable solution % Excise Tax Cap Ceiling Improve health of plan participants Support Wellness Programs Reduce risk factors (prevention, early detection) Manage high cost claim risk (condition management) Manage cost trend by reducing claims and encouraging employees to make wise healthcare choices Plan value needs to be low enough to avoid the excise tax Plan costs need to be minimized, while still attracting and retaining employees 2014 Minimum plan of 60% actuarial value and affordable to employees Plan design needs to be high enough to avoid penalties 19

20 Roadmap for strategic decision making Pre Exchange Post Exchange Excise Tax Compliance and Opportunity Assessment Redefining the Employer Role Delayed Exit or Differentiated Play Comply with mandates and reporting Quantify impacts Examine opportunities Play, but consider changes to contribution rates, cost ROADMAP FOR sharing, and STRATEGIC plan eligibility Mitigate cost trend Optimize value DECISION MAKING Consider accelerated exit for retirees Positioning for 2014 and 2018 Play or Pay Pay and revisit total compensation package Engage in wellness and prevention programs which support employees efforts to improve health and reduce high cost claims Revisit success or failure relative to Excise Tax thresholds Re evaluate the play or pay decision Delayed exit Modify plan design and the use of exchanges/subsidy 20

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