Health Care Reform: A Guide for Self-Funded Plans. Key steps to prepare for 2014 Preparing for the future Snapshot of reform ( )

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1 Health Care Reform: A Guide for Self-Funded Plans Key steps to prepare for 2014 Preparing for the future Snapshot of reform ( )

2 Table of Contents Health Care Reform is Here: Are you ready? 3 Key steps to prepare for 2014 Grandfathered Plans Plan Design and Benefits 5 Employee Notifications and Communications 6 Health Insurance Marketplace Employee Notifications Summary of Benefits and Coverage (SBC) Fees for Group Health Plans 8 Patient Centered Outcomes Research Institute (PCORI) Fee Reinsurance Fee Prepare for the Future 2015 and Beyond 11 Employer Shared Responsibility Employer Reporting Requirements Excise Tax on High Cost Plans AmeriHealth Administrators is Here to Help 14 Resources 15 Snapshot of Reform ( ) ACA Benefit and Coverage Changes 2010 through 2013 Action Items Checklist This guide has been prepared by AmeriHealth Administrators as a general reference source for you to use. The guide is not intended to provide legal and or tax advice. 2

3 Health Care Reform is Here: Are you ready? In 2010, the Patient Protection and Affordable Care Act (PPACA or ACA) was signed into law and has promised to transform the way health care is delivered, managed, and paid for in the United States. Although some of its components and provisions have been implemented to date, the most significant changes take effect in 2013, 2014, and As an employer and sponsor of a self-funded health plan, you have responsibilities under health care reform and becoming informed of what they are, when they are effective, and how they may affect your group health plan will help you prepare for health care reform. Key steps to prepare for 2014 We have developed this guide to provide you with information that may help you make important decisions about the health coverage you provide to your employees and to develop strategies to become and remain compliant with health care reform. Here are some key components: Plan design/benefits. What benefits should your plan include? What are the limits and requirements for coverage? Notifications/communications. What do you need to tell your employees about health care reform? What can you do to help them make good decisions about their health care coverage? Fees. Do you know what fees you are obligated to pay and how to minimize their financial effect on your company? Looking ahead to 2015 and beyond. The Employer Shared Responsibility Provision: Are you going to Pay or Play? What about reporting requirements? What else is on the horizon? A Snapshot of Reform: For a look back to 2010 and a look forward to 2019, see page 16. Just as a solid business plan gives you specific steps to successfully reach your business goal, having a plan to comply with health care reform will help you meet your obligations and avoid or minimize potential penalties. AmeriHealth Administrators is here to help with your plan design compliance with health care reform and provide your employees and their families with access to high-quality health care. One of the key provisions of the ACA The Employer Shared Responsibility ( Pay or Play ) provision is scheduled to take effect on January 1, This provision requires that employers with 50 or more full-time equivalent employees offer health care coverage to their employees or pay a penalty instead. On July 2, 2013, the reporting and penalty provisions of Pay or Play were delayed until Please see page 11 for more information on Employer Shared Responsibility. 3

4 Grandfathered Plans Grandfathered plans are exempt from some of the provisions of the ACA. Non-grandfathered plans are subject to all provisions of the ACA. A group health plan that was in existence on or before March 23, 2010, and covered more than one individual on that date is considered grandfathered provided the plan follows the regulations documented in the ACA. Plans may lose their grandfathered status if they make certain changes that reduce benefits or increase costs to plan members. The following is a list of provisions which grandfathered health plans do not have to comply with; however, they may choose to include one or more of these provisions: Preventive Care Women s Preventive Services Internal Appeal and External Review Process Choice of a Primary Care Provider Referral for OB/GYN Services Emergency Services Dependent Coverage for adult children up to age 26, if dependent is eligible for employer-sponsored coverage. Effective for plan years beginning on or after January 1, 2014, ALL plans including grandfathered plans must cover dependents up to age 26 even if the dependent is eligible for employer-sponsored coverage. Group health plans must also include a statement in plan materials to participants, beneficiaries, or primary subscribers describing the benefits provided in the plan and explaining why they believe the plan is grandfathered as defined by the ACA. Contact information for questions and complaints must also be included. The Department of Labor has developed model language for this statement. 4

5 PLAN DESIGN AND BENEFITS As a result of the ACA, several benefit and coverage changes became effective beginning in 2010 through 2013 (see page 18). Below is a description of specific benefit changes/plan provisions that are effective for plan years beginning on or after January 1, ACA Provision Description Plans GF NGF Annual limits No annual limits on essential health benefits Pre-existing condition exclusions No pre-existing exclusions are permitted, regardless of age Dependent coverage for children up to age 26 Coverage required, even if dependent qualifies under another employer s plan Waiting period Plan sponsors of group health plans cannot have a waiting period to receive benefits that exceeds 90 days Cost-sharing limitation* Out-of-pocket maximum expenses, including deductibles, copays, and coinsurance must not exceed a specified dollar amount for essential health benefits (for 2014, the maximum is $6,350/$12,700 for single/family coverage) Approved clinical trials Routine patient costs for clinical trials must be covered Wellness programs Plan sponsors can offer incentives up to 30% of the cost of coverage to an employee who enrolls in wellness programs or up to 50% with a tobacco reduction or cessation program Wellness programs and minimum value Plan sponsors cannot use the reduction in cost-sharing from participating in a wellness program to calculate minimum value with the exception of tobacco cessation programs Action Items *There is a safe harbor for plans that use separate service providers to administer different elements of their health benefits program for GF - Grandfathered NGF - Non-grandfathered 1. Modify plan design as required. 2. Review earlier benefit and coverage changes to ensure your plan is compliant, if required (see page 18). 5

6 EMPLOYEE NOTIFICATIONS AND COMMUNICATIONS Taking steps to educate your plan members about health care reform is worthwhile. It will not only help them better understand their benefits so they can make more informed decisions, it will also give you the opportunity to show them the value of having a group health plan. AmeriHealth Administrators has developed a guide Health Care Reform Law & You to help individuals understand more about the Affordable Care Act and what it means to them. As an employer, you are also required to provide some specific notifications to your employees as outlined below. Health Insurance Marketplace Employee Notifications The Health Insurance Marketplace (the Marketplace) also called the Exchange is a public website where individuals can compare and purchase health insurance plans. Employee Notification Under the ACA, employers are required to provide written notification to all current employees, no later than October 1, 2013, about the existence of the new Health Insurance Marketplace. Employees hired on or after October 1, 2013, must be given notice within 14 days of their date of hire. The written notification must inform current and new employees of the following: the existence of the Marketplace; the employee s potential eligibility for federal premium assistance and cost-sharing reduction if your plan s share of the cost of the benefits is less than 60 percent; the potential loss of the plan sponsor s contribution toward the employee s coverage, along with the associated tax advantages, if the employee chooses to purchase insurance from the Marketplace. The Department of Labor has provided plan sponsors, who currently offer health coverage, an employee notification model notice, for use in their employee notification. The model notice is just a sample and the plan sponsor can modify the format as long as it provides the required information outlined above. The model notice contains three pages. Part A is required. Part B contains additional information that may be provided at the discretion of the plan sponsor. COBRA Notification The ACA does not affect the plan sponsor s responsibilities required under Consolidated Omnibus Budget Reconciliation Act (COBRA). However, the ACA has modified the content of the COBRA election notice to include information about the existence of The Marketplace and the potential to receive subsidies, if qualified. The Department of Labor (DOL) has a COBRA model claims notice that plans may use to satisfy both the COBRA election notice and the ACA employee notification requirements. A redline version is available on the DOL s website to help plan sponsors identify what changes were made to the original content. For more information on COBRA continuation coverage, download a copy of our complimentary COBRA white paper. 6

7 Summary of Benefits and Coverage (SBC) Many employers are already familiar with the SBC. The SBC is a standard, plain language summary of benefits and coverage designed to help plan members better understand their health care coverage options and to make better informed decisions. The summary is intended to give plan members and newly-eligible individuals clear, accurate, and consistent information to help them compare health plans. Changes to the SBC On April 23, 2013, the Department of Labor issued FAQs that require SBCs to include information on a plan s Minimum Essential Coverage (MEC) and Minimum Value (MV). An updated SBC template and sample completed SBC have been released by the DOL. A 60-day notice is required for any off-renewal date plan changes that affect the SBC. The two specific questions, below, are required to be added to the SBC exactly as written. Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as minimum essential coverage. This plan or policy [does/does not] provide Minimum Essential Coverage. Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a Minimum Value standard of benefits of a health plan. The Minimum Value standard is 60 percent (actuarial value). This health coverage [does/does not] meet the minimum value standard for the benefits it provides. When does the updated SBC format take effect? The updated SBC format applies to the second year of applicability plan years beginning on or after January 1, 2014, and before January 1, For a plan year beginning on January 1, 2014, the updated SBC format with the Minimum Essential Coverage and Minimum Value information should be made available during open enrollment period, typically, in the fall of Action Items 1. Distribute health insurance marketplace notifications to employees. 2. Update COBRA notification. 3. Update SBC. 7

8 Fees for Group Health Plans There are two fees that plan sponsors will be responsible to pay: the Patient-Centered Outcomes Research Institute (PCORI) fee and the Transitional Reinsurance fee. Patient-Centered Outcomes Research Institute Fee The ACA established a private, non-profit, non-governmental organization called the Patient-Centered Outcomes Research Institute (PCORI). The Institute is an independent organization whose role is to fund and produce reliable, evidence-based research guided by patients, caregivers, and the health care community to determine the comparative clinical effectiveness of medical treatments. The PCORI fee is based on the average number of lives covered under the health insurance policy or self-funded plan ( covered lives include plan participants and covered dependents/beneficiaries), multiplied by the applicable dollar amount for that plan year. Here is an easy way to help determine your applicable dollar amount and payment due date: If your plan ends Applicable Dollar Amount Payment Due Date on or after October 1, 2012 and before January 1, 2013 on or after January 1, 2013 and before October 1, 2013 on or after October 1, 2013 and before January 1, 2014 on or after January 1, 2014 and before October 1, 2014 $1 per life covered July 31, 2013 $1 per life covered July 31, 2014 $2 per life covered July 31, 2014 $2 per life covered July 31, 2015 on or after October 1, 2014 and before October 1, 2019 To be determined July 31 of the year following the plan s end date 8

9 Calculating the covered lives and fees The PCORI fee is calculated by multiplying the average number of covered lives for the plan year by the applicable dollar amount for the plan year. To determine the average number of lives covered under a self-funded plan during a plan year, a plan sponsor is permitted to use any one of these methods: Actual count method. The plan would count the total covered lives for each day of the plan year and divide that number by the total number of days in the plan year. Snapshot methods Snapshot count method. The plan would count the number of covered lives on at least one date in each quarter of the plan year and divide by the number of dates chosen. (The date(s) in the 2nd, 3rd and 4th quarters must correspond to date(s) in the 1st quarter). Snapshot factor method. Similar to the Snapshot count method, except that covered lives, on any date, would be equal to the sum of a) the number of employees with single coverage, plus b) the number of employees with coverage other than single coverage multiplied by This method may be advantageous for employers with a high member-to-employee ratio for employees enrolled in coverage other than single coverage. Form 5500 method. For self-only coverage, determine the average number of covered lives by combining the total number of participants at the beginning of the plan year with the total number of participants at the end of the plan year (each as reported on the Form 5500) and divide by two. In the case of plans with selfonly and other coverage, the average number of total lives is the sum of total participants covered at the beginning and the end of the plan year, as reported on the Form There is no single method that yields the best calculation for all organizations. There are several scenarios that can be analyzed using a variety of permitted methods and dates to determine the lowest fee calculation. Reporting and paying the fee AmeriHealth Administrators offers a PCORI Fee analysis service to help find the most advantageous way to calculate the PCORI Fee based on your specific plan membership. AHA does not provide legal or tax advice. The results of the analysis should be reviewed by your legal and/or tax advisor. It is the responsibility of the sponsor of the group health plan to report and remit payment of the PCORI fee. The group health plan must pay the PCORI fee annually and report it on the IRS Form 720 (Quarterly Federal Excise Tax Return). The fee is due each year by July 31, beginning in The location to report the number of covered lives and fee total is located under Part II, of IRS line number 133. View the complete filing instructions for more information. For more information, see our ACA Implementation Alert on the PCORI Fee. 9

10 Reinsurance Fee The reinsurance fee is a transitional fee assessed on health insurers and sponsors of self-funded plans to help stabilize insurance premiums in the individual health insurance marketplace in anticipation of a large influx of high-risk individuals. The fee goes into effect January 1, 2014, and is planned to be levied for three years 2014 through The reinsurance fee is $63 per covered life for However, there may be an adjustment in the per-covered-life fee in subsequent years. AmeriHealth Administrators offers a Reinsurance Fee analysis service to help find the most advantageous way to calculate the Reinsurance Fee based on your specific plan membership. AHA does not provide legal or tax advice. The results of the analysis should be reviewed by your legal and/ or tax advisor. Calculating the covered lives and fees The payment is based on the average number of covered lives (including plan participants and covered dependents/ beneficiaries) for the calendar year. To determine the average number of lives covered under a self-funded plan during a plan year, a plan sponsor is permitted to use any of the counting methods employed to calculate the PCORI fee (see page 9). There is no single method that yields the best calculation for all organizations. There are several scenarios that can be analyzed using a variety of permitted methods and dates to determine the lowest fee calculation. Reporting and paying the fee Plan sponsors of self-funded plans and health insurers are required to report the average number of covered lives to Health and Human Services (HHS) by November 15 of each year (2014, 2015, and 2016). HHS will calculate the fee based on the reported number of covered lives and notify the plan sponsor or health insurer of its liability within 15 days of receiving the report, or by December 15, whichever is later. The plan sponsor or health insurer is required to remit payment within 30 days of receiving the notification. For more information, see our ACA Implementation Alert on the Reinsurance Fee. The IRS has issued Frequently Asked Questions on the reinsurance fee. Action Items 1. Ensure PCORI fee has been filed and paid. 2. Prepare for reinsurance fee. 10

11 PREPARE FOR THE FUTURE 2015 AND BEYOND Health care reform will continue to evolve as various provisions of the ACA become effective over the next few years. Looking ahead, the reporting and penalty provisions of the Employer Shared Responsibility or Pay or Play provision have been delayed until The transition relief provided for information reporting and the penalty provisions is intended to provide additional time for employers to adapt their health coverage and reporting systems. Final guidance on other provisions such as the excise tax on high-cost health plans and automatic enrollment has not been released, but it s important to be aware that the provisions will become effective at a future date. Here s a look at the provisions: Employer Shared Responsibility One of the biggest decisions a large employer will have to make is whether to offer health care coverage to their employers or pay a penalty instead. This provision only applies to large employers, so your first step is to determine whether the size of your organization makes you subject to the Employer Shared Responsibility requirement. The government has provided transitional relief for the reporting requirements and the Employer Shared Responsibility provision until The transition relief is intended to provide employers time to adapt their health coverage and reporting systems. IRS notice encourages employers to voluntarily comply in 2014 with the information reporting provisions (once the reporting rules have been issued) and to maintain or expand health coverage in However, plan sponsors would not be penalized for non-compliance in By the numbers According to the ACA, employers with 50 or more full-time equivalent (FTE) employees are subject to provisions of the Employer Shared Responsibility. In general terms, a full-time employee is defined as someone who averages at least 30 hours of work per week. All employees, including part-time and seasonal employees, are taken into account when calculating the number of FTE employees. There are several counting methods which include Safe Harbor rules. For more detailed rules and information on the large employer calculation and calculating FTEs, see the Federal Register article on Shared Responsibility for Employers Regarding Health Coverage. Meeting the criteria To meet the requirements of the Employer Shared Responsibility provision, large employers must offer health care coverage that meets certain guidelines under the ACA. Generally, large employers must offer coverage that provides minimum value and is affordable to substantially all of their active, full-time employees. If the coverage does not meet the criteria and at least one of their full-time employees receives a subsidy for purchasing individual coverage from the new Health Insurance Marketplace, the employer may pay a penalty. 11

12 If a large employer offers health coverage, it must meet all three criteria to be considered in compliance: Minimum value standard. The plan pays 60 percent or more, on average, of total allowed costs of benefits provided under a group health plan or health insurance plan. The Department of Health Human Services (HHS) provides an online tool to help calculate whether or not a plan meets the Minimum Value standard. There are also instructions for using the calculator tool. Affordability. The employee s contribution to the plan s cost for self-only coverage cannot exceed 9.5 percent of employee household income. Safe Harbor: Since most employers do not know an employee s household income, the IRS has created three Safe Harbors for determining affordability. In each Safe Harbor test outlined below, the employee s contribution for the lowest-cost, self-only coverage cannot exceed 9.5 percent of: the employee s W-2 income as reported in Box 1; the employee s hourly rate multiplied by 130 or monthly income for salaried employees; the Federal Poverty Level (FPL). AmeriHealth Administrators offers a health care reform tax penalty consultation service that will analyze your existing plan(s) against the Employer Shared Responsibility requirements. AmeriHealth Administrators does not provide legal or tax advice. The results of the consultation should be reviewed by your legal and/ or tax advisor. Offer coverage for substantially all full-time active employees. Substantially all has been defined as 95 percent or more of full-time active employees in In 2015, coverage must be offered to employees and dependents (children). A full-time employee is defined as someone who averages at least 30 hours of work per week or 130 hours per month. If the coverage offered does not meet these requirements or if the employer chooses not to offer any health coverage, they may be subject to penalties. We will provide more information about penalties when future guidance is released. 12

13 Employer Reporting Requirements Under the ACA, employers will have significant new reporting responsibilities in connection with the health care coverage they provide. Proposed rules for information reporting are expected to be published in Automatic enrollment The effective date of this provision has not been published, although final regulations are expected to be released in Under this provision, employers with more than 200 employees are required to automatically enroll new full-time employees into their group health plan after the applicable waiting period, which cannot exceed 90 days. The employer must also provide advance notice of the automatic enrollment feature and the opportunity for employees to opt out. Excise Tax on High-Cost Plans In the proposed regulation beginning in 2018, health insurers and sponsors of self-funded plans must pay a 40 percent tax on the excess value of any plan whose premium exceeds the annual limit set by Health and Human Services. This fee will apply if the annual value of a medical plan is higher than $10,200 for single coverage; $27,500 for other than single coverage. The limits will be adjusted in future years. The tax is payable per covered employee. The purpose of the excise tax is to help offset the costs of health care reform and encourage employers to provide cost-effective plans. Action Items 1. Prepare for Employer Shared Responsibility provision. 2. Look for information about new requirements in

14 AMERIHEALTH ADMINISTRATORS IS HERE TO HELP AmeriHealth Administrators is a national third-party administrator of comprehensive, self-funded health plans, representing over $1 billion in health benefits. With 25 years experience helping organizations design, implement, and manage cost-effective health plans, we are constantly working to help clients and their plan members navigate the regulatory changes in the industry. In addition to this Health Care Reform Employer Guide, AmeriHealth Administrators offers additional resources, including: Educational Resources As Reform Takes Form a bi-monthly e-news series Health Care Reform Law & You a plan member s guide to health care reform ACA Implementation Alerts information on key ACA provisions Consultation Services PCORI fee Reinsurance fee Employer Shared Responsibility Summary of Benefits and Coverage (SBCs) are provided to clients at no charge Action Items 1. Contact your AmeriHealth Administrators account representative, broker, or benefits consultant for additional information. 2. Take a deep breath and relax. We ll keep you updated on any new developments. 14

15 Resources Snapshot of Reform ( ) ACA Benefit and Coverage Changes 2010 through 2013 Action Items Checklist Sources for this guide include: cms.gov dol.gov federalregister.gov irs.gov

16 SNAPSHOT OF REFORM Grandfathering 100 percent coverage for preventive care Internal appeals and external reviews Choice of PCP or pediatrician 2010 Extension of coverage for dependents to age 26 Elimination of lifetime maximums and restrictions on annual limits Coverage for emergency services Prohibition of pre-existing condition exclusions for children under 19 Tax changes to health care savings and spending accounts 2011 Flexible Spending Account (FSA) restrictions Medicare payroll tax W-2 disclosure of health plan value PCORI fee assessment begins 2012 Summary of Benefits and Coverage (SBC) Women s preventive services Flexible spending account (FSA) limits Medical device sales tax 2013 Employee notification of Health Insurance Marketplace PCORI fee payable The intent of this timeline is to provide a snapshot of the major provisions for self-funded plans, therefore it should not be viewed as all encompassing. 16

17 SNAPSHOT OF REFORM Mandatory insurance for individuals Prohibition of pre-existing conditions exclusion, regardless of age Cost-sharing limitation 2014 Reinsurance fees for employers SBC update Employers cannot have a waiting period to receive benefits that exceeds 90 days Large employers are required to provide health coverage. Reporting and penalty provisions have been deferred until Penalty increases for individuals who do not purchase insurance 2015 Penalty increases for individuals who do not purchase insurance 2016 Coverage across state lines Reinsurance fee phased out Excise tax on high-cost health plans PCORI fee last assessment The intent of this timeline is to provide a snapshot of the major provisions for self-funded plans, therefore it should not be viewed as all encompassing. 17

18 ACA BENEFIT AND COVERAGE CHANGES 2010 THROUGH 2013 ACA Provision Description Plans Effective Date GF NGF Preventive care In-network preventive care must be covered with no cost sharing Plans on or after September 23, 2010 Choice of primary care provider Members can choose any participating primary care provider as their doctor or participating pediatrician as their child s doctor Plans on or after September 23, 2010 OB/GYN services No referral or preauthorization is required to see a participating OB/GYN specialist Plans on or after September 23, 2010 Emergency services No prior authorization is required before seeking emergency services from non-network providers and must be covered at in-network cost sharing. Minimum standards for reimbursement of out-of-network providers. Plans on or after September 23, 2010 Internal appeals and external review process An internal appeals and external review process must be implemented that meets ACA requirements Plans on or after September 23, 2010 Annual Limits* (increased in 2011 and 2012; eliminated in 2014) $750,000 annual limit on essential health benefits Plans on or after September 23, 2010 $1,250,000 annual limit on essential health benefits Plans on or after September 23, 2011 $2,000,000 annual limit on essential health benefits Plans on or after September 23, 2012 Lifetime Limits No lifetime limits on essential health benefits Plans on or after September 23, 2010 Pre-existing condition exclusions* No pre-existing exclusions for children under age 19 Plans on or after September 23, 2010 Flexible Spending Account (FSA) Women s Preventive Services Dependent coverage for children under age 26* Flexible Spending Account (FSA) FSA dollars can only be used for Insulin and over the counter drugs if the plan member has a prescription In-network Women s preventive services must be covered with no cost sharing Coverage required regardless of marital or student status, financial support, etc. Not required to offer dependents eligible for coverage under another employer s plan The annual contribution limit for a health limit for an FSA is $2,500 in 2013, and indexed to cost-of-living adjustment for subsequent years January 1, 2011 Plans on or after August 1, 2012 Plans on or after September 23, 2010 January 1, 2013 *Provision changes in 2014 (see page 5) GF - Grandfathered NGF - Non-grandfathered 18

19 ACTION ITEMS CHECKLIST Review ACA benefit and coverage changes through January 1, Modify plan design to meet ACA benefit and coverage changes, if necessary. Distribute Health Insurance Marketplace notifications to employees by October 1, Update COBRA notifications. Update Summary of Benefits and Coverage (SBC) with Minimum Essential Coverage and Minimum Essential Value language. Ensure PCORI fee has been filed and paid for Prepare for Reinsurance fee beginning in Prepare for Employer Shared Responsibility provision in Questions? Contact your AmeriHealth Administrators account management team. 19

20 This guide has been prepared by AmeriHealth Administrators as a general reference source for you to use. The guide is not intended to provide legal and or tax advice AmeriHealth Administrators, Inc.

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