Getting Ready for 2014: The Big Year for Healthcare Reform Anne Arundel County SHRM. David Johnson November 15, 2012

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1 Getting Ready for 2014: The Big Year for Healthcare Reform Anne Arundel County SHRM David Johnson November 15,

2 Topics for Discussion 1. Recap of Supreme Court Decision on Affordable Care Act (ACA) 2. Overview of Changes Coming in Individual Mandate and Subsidies 4. Health Benefit Exchanges 5. Employer Pay or Play Provisions 6. Projecting Financial Impact of Pay or Play Provisions 7. Delivery System Changes including Accountable Care Organizations 8. Employer Readiness for

3 Recap of Supreme Court Decision 2

4 Issues Supreme Court Agreed to Consider on ACA 1. Could the Court decide cases now or must it wait until 2015 after first penalty (tax) is imposed? 2. Is the individual mandate constitutional? 3. If the individual mandate is unconstitutional, could it be severed from the rest of the law, or must the entire law fall? 4. Is the expansion of Medicaid contained in the ACA constitutional? 3

5 Summary of Court s Decision 1. Individual mandate ruled constitutional in 5-4 decision 2. Severability question irrelevant and remainder of ACA allowed to stand 3. Federal government cannot require states to expand Medicaid 4. Federal government cannot deny all Medicaid funds for a state that refuses Medicaid expansion contained in ACA 5. Creates the possibility that some states will opt out of ACA Medicaid expansion 4

6 Medicaid Expansion Ruling s Impact on Employers 1. ACA expands Medicaid to any individual with income of < 138% of FPL 2. Federal government pays 100% of cost of new Medicaid eligibles through 2016 reducing to 90% by Medicaid eligibility is based on where individual lives, not where the employer is located 4. A number of states have already adopted expanded eligibility 138% of FPL by Household Size 1 $15,028 2 $20,300 3 $25,571 4 $30,843 5 $36,115 6 $41,386 5

7 Health Insurance Premium Payment Program (HIPP) 1. State can enroll Medicaid recipient in his or her employer plan under HIPP 2. Medicaid expansion will result in more low income active employees qualifying for Medicaid, increasing possibility that state will enroll those recipients in employer plans 3. Impact on employers will vary from state to state a. Depending on how many low income employees the employer has and current participation rate b. Greatest possible impact = Employer with large number of low income employees eligible for insurance and low participation rate in states with expanded eligibility c. Least impact = Employer with few low income employees or in state with limited Medicaid eligibility 6

8 Overview of Changes Coming in

9 Major Changes Coming in Individual health coverage mandate 2. Federal premium subsidies for low- and middle-income individuals 3. Health Benefit Exchanges and insurance market reforms 4. Employer play or pay penalties 5. Employer health coverage reporting 6. Automatic enrollment (implementation date unclear) 7. Various plan design changes Elimination of annual limits Cost-Sharing Limitations No waiting period > 90 days Wellness incentives increasing to 30% Coverage for clinical trials 8

10 Individual Mandate and Subsidies 9

11 Individual Mandate Beginning in 2014 individuals must have health insurance or pay an excise tax Qualified plans must be minimum essential coverage and could be from a variety of sources: Individual health insurance Health plan offered by an employer Medicare or Medicaid Children s Health Insurance Program (CHIP) TRICARE or Veteran s health plan 10

12 Individual Mandate Annual excise tax = greater of: 2014: $95/adult, $47.50/child (max $285/family) or 1% of income 2015: $325/adult, $162.50/child (max $975/family) or 2% of income 2016 and later: $695/adult, $347.50/child (max $2,085/family) or 2.5% of income Tax is capped at the national average of the cost of a bronze level health insurance plan, for the applicable family size 11

13 Subsidies Subsidies (premium tax credits & cost sharing reductions) for individuals purchasing health insurance through an exchange Premium tax credit available to individuals with household income up to 400% of Federal Poverty Level (FPL) No subsidy to individuals eligible for affordable employer coverage Affordable =» Employee s required contribution for employee only coverage is less than 9.5% of household income 12

14 Health Benefit Exchanges 13

15 Exchange Overview from Healthcare.gov Affordable Insurance Exchanges are designed to make buying health coverage easier and more affordable. Starting in 2014, Exchanges will allow individuals and small businesses to compare health plans, get answers to questions, find out if they are eligible for tax credits for private insurance or health programs like the Children s Health Insurance Program (CHIP), and enroll in a health plan that meets their needs. An Exchange Can Help Individuals: Look for and compare private health plans Get answers to questions about health coverage options Find out if individuals are eligible for health programs or tax credits that make coverage more affordable Enroll in a health plan 14

16 Overview of Exchange Rules If state does not set up an exchange the federal government will operate an exchange in that state Subsidies for low and middle income individuals purchasing individual health insurance administered by the Exchange Debate if subsidies will be provided through the federal exchange IRS has taken position that subsidies are available through federal exchange Each state Exchange is also required to create a Small Business Health Options Program ( SHOP ) 15

17 Maryland Health Connection Maryland s Benefit Exchange 16

18 Maryland Health Connection - History Maryland General Assembly gave initial approval to the Health Benefit Exchange Act of 2012 on March 26, 2012 The Exchange will allow individuals and small employers to compare rates, benefits, and quality among plans to help find an insurance product that best suits their needs The Exchange will also be the entity that calculates and provides tax credits to eligible small employers and advances tax credits for individuals below 400 percent of the federal poverty level Private insurers will compete in this open marketplace, with the goals of creating an even playing field and providing transparent and accurate information 17

19 Expected Enrollment Projections from the State of Maryland Enrollment through Maryland Health Connection is scheduled to begin in October 2013, with insurance coverage beginning January 1, 2014 As many as 150,000 individuals are expected to enroll in qualified health plans (QHPs) during the first year, increasing to approximately 275,000 by 2020 Medicaid enrollment is expected to increase by 101,000 in the first year, growing to 187,275 by

20 Employer Pay or Play Provisions 19

21 Employer Penalties (apply only to employers with 50+ FTE) #1: ER coverage is unaffordable If employee contribution for single coverage exceeds 9.5% of employee s wages, the employer will be liable for a $250/month penalty for each employee that purchases subsidized individual health insurance through an exchange #2: ER fails to offer minimum essential coverage to all full time EEs ER will pay $ per month times all full time employees 20

22 Unaffordable Coverage Penalty This penalty applies if the employer offers its FTEs (and their dependents) the opportunity to enroll in Minimum Essential Coverage under an eligible employer-sponsored plan, and at least one FTE enrolls in health coverage purchased through a state exchange and a premium tax credit or cost sharing reduction is allowed or paid to the employee because the employer s coverage is considered to be unaffordable. 1. Monthly Penalty: # FTEs (who receive premium tax credit or cost sharing reduction) x 1/12th of $ However, the penalty is capped and will never be more than the penalty imposed on an employer that does not offer coverage. 3. Monthly Penalty: 1/12TH $2,000 X (FTE 30). Employer-provided coverage is deemed unaffordable if an employee s contribution for the lowest cost, self-only coverage exceeds 9.5% of the employee s income. 21

23 No Coverage Penalty This penalty is imposed if a covered employer fails to offer its FTEs and their dependents the opportunity to enroll in Minimum Essential Coverage and at least one of its FTEs enrolls in health coverage purchased through a state exchange with respect to which a premium tax credit or cost sharing reduction is allowed or paid to the employee. 1. Monthly Penalty: Employed FTEs during the month x 1/12th of $ However, the number of FTEs is first reduced by Monthly Penalty: 1/12TH $2,000 X (FTE 30). In addition, for purpose of the penalty calculation, FTEs include only employees employed on average at least 30 hours per week and does not include any FTE equivalent employees. As a general rule, employees qualify for a premium subsidy or reduced cost sharing if they meet certain income requirements for assistance (generally, they must have household income between % of the Federal Poverty Level). 22

24 Projecting Financial Impact of Pay or Play Provisions 23

25 Key Employer Questions 1. If health reform were in full effect today what would be the impact on my current plans? 2. What would happen if I changed my plan design or employer contributions? 3. What would be my expected costs if I do not offer employer sponsored health insurance to all my full time employees? 24

26 Important Variables in Financial Projections 1. Impact will vary significantly from employer to employer based on employee demographics, plan details and employer contributions 2. No one size fits all answer 3. Analysis will need to address four areas: Financial impact of newly eligible employees Risk of employer penalty due to unaffordable coverage Impact of employers plan of Medicaid expansion Different employer costs involved if employer does not provide benefits to all fulltime employees (FTEs) 25

27 Case Study One 500 employee company offers coverage to all FTEs Premium: Employee only =$550 Employer contribution: Employee only = $300 Employee contribution: Employee only = $ employees qualify for subsidy & purchase coverage through exchange (10 were on plan) Component Calculation Result Employer Monthly Penalty $250 X 25 $6,250 Savings from employees leaving plan Net monthly cost to employer $300 x 10 ($3,000) $3,250 26

28 Case Study Two Firm with 180 full-time EEs who is considering dropping coverage 127 employees with household incomes < 400% FPL 3 employees will be Medicaid eligible $1200 Deductible, $2400 Max OOP Premium Single Coverage = $629 Employer contribution = $512 Employee contribution = $117 Current Eligibility = 35 hours per week Question: Employer decides to stop providing coverage to all employees; is the cost just the employer penalty? 27

29 Case Study Two (continued) Cost Impact of Not Offering Coverage to all FTEs Employer Penalty $ 300, Additional Compensation $ 706, Employer payroll tax on additional compensation $ 49, Tax impact of penalty not being tax deductible $ 30, $1,200,000 $1,000,000 $942,140 $1,056,074 $800,000 $600,000 $400,000 Current Employer Cost Additional Compensation $200,000 Penalty $0 Current Plan Cost Penalty Additional Comp Payroll Tax Employer Tax 28

30 Delivery System Changes 29

31 Accountable Care Organizations CMS Description Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients Medicare offers several ACO programs: 1. Medicare Shared Savings Program a program that helps a Medicare fee-for-service program providers become an ACO 2. Advance Payment Initiative a supplementary incentive program for selected participants in the Shared Savings Program. 3. Pioneer ACO Model a program designed for early adopters of coordinated care. CMS is no longer accepting applications. 30

32 CMS ACO Participants as of April 1,

33 Illustrative ACO Movement in Maryland - GBMC In order for GBMC to maintain its status as a provider of the highest quality medical care to our community, in the context of an evolving national healthcare system, we must transform our philosophy and organizational structure, and develop a model system for delivering patient-centered care. As part of GBMC Healthcare, the Greater Baltimore Health Alliance is chartered to integrate the delivery of the full spectrum of clinical services through collaboration of employed and community-based physicians and the hospital with the goal of improving access for patients and providers, maximizing quality and reducing the cost of care We will use the principles of an Accountable Care Organization to assure that we focus on maximizing quality and removing waste from the system. 32

34 Additional Delivery System Changes Tied to ACA The CMS Innovation Center was created by ACA to test new models of health care delivery and payment. The Center also offers technical support to providers to improve the coordination of care and share lessons learned and best practices throughout the health care system. ACA created the Prevention and Public Health Fund to address emerging health threats and the persistent chronic disease rates. The Fund is intended to ensure a coordinated, comprehensive, sustainable, and accountable approach to improving health outcomes through the most effective prevention and public health programs. The Fund will invest $12.5 billion over the next ten years (FY2013-FY2022). In response to ACA, the State of MD has created a Health Care Delivery Reform Subcommittee and launched Health Care Innovations in Maryland (www.dhmh.maryland.gov/innovations) to identify and share best practices in improving health care quality in the State. 33

35 Quality Improvement Initiatives for Maryland Hospitals The Maryland Health Services Cost Review Commission (HSCRC), which sets hospital rates for all payers, has created several key initiatives linking payment with quality 1. Quality Based Reimbursement (QBR) Initiative 2. Maryland Hospital Acquired Conditions (MHAC) Initiative 3. Admission-Readmission Revenue Hospital Payment Constraint Program 4. Total Patient Revenue Initiative 34

36 Multi-Payor Patient Centered Medical Home Program (PCMH) Established during the 2010 legislative session, program is designed to improve patient health and elevate the role of the primary care provider Program features two types of enhanced reimbursement Practices will receive a per patient per month (PPPM) payment for attributed patients to offset expenses associated with providing PCMH services Practices will also be eligible to share in cost savings from reductions in emergency department and hospital utilization each year Aetna, CareFirst BlueCross BlueShield, CIGNA, United Healthcare and Coventry are required to participate Program has accepted applications from primary care providers family practice, internal medicine, geriatric and pediatric physicians, and nurse practitioners throughout the State Maryland Health Care Commission (MHCC) has worked with participating providers to design outreach materials for engaging patients in the Program Letter informs patient of their right to opt-out of Program 35

37 CareFirst Patient-Centered Medical Home Program (PCMH) CareFirst s PCMH program is designed to provide PCPs with a more complete view of their patients' needs and services they receive from other providers Objective is to help PCPs better manage patients individual risks, keep them in better health and produce better outcomes PCMH is entirely voluntary and providers who participate can earn reimbursement increases of three types: 12 percentage point increase added to current fee schedule New fees for developing care plans for select patients with certain chronic or multiple conditions that put them at risk and for monitoring progress against those plans Additional fee schedule increases (including an 80+ % increase) based on: providers engagement with their patients the quality of care delivered to their entire population of patients actual aggregate costs of care compared to expected costs 36

38 Employer Readiness for

39 Findings from Deloitte Consulting July 2012 Employer Survey When asked How well do you understand the health reform law and its requirements for health insurance coverage for employees? what percentage said they had a excellent to good understanding 58% of employers with EEs 39% for employers with EEs 73% for employers with 1,000-2,499 EEs 69% among finance companies 49% among manufacturing firms 46% among service firms 75% of executives responsible for managing health care benefits 50% of owners and CEOs 52% of CFOs 60% CHROs 30% Office managers or benefits administrators 38

40 Findings from Deloitte Consulting July 2012 Employer Survey When asked How familiar are you with the following elements of the health reform law that relate to health insurance respondents reported (where not knowing was based on response of < 8 on a 10 pt scale) 28% did NOT know ACA includes an individual mandate requiring most people to buy health insurance or pay a penalty 34% did NOT know the law will include penalties for most employers who do not offer health benefits to their workers 47% did NOT know ACA requires coverage of essential benefits by most employers offering coverage 55% did NOT know the law will set up health insurance exchanges 77% did NOT know ACA attempts to increase research-based information on the comparative effectiveness of different medical treatments 78% did NOT know ACA encourages creation of ACOs and medical homes 80% did NOT know the law introduces bundled payments/episode-based payments for hospitals and physicians 39

41 Findings from Deloitte Consulting July 2012 Employer Survey When asked how well-prepared is your company to implement or respond to the 2014 provisions of health reform law (where prepared was based on response of 8, 9 or 10 on a 10 pt scale) 24% among employers with EEs 32% among firms with EEs 38% among employers with 1,000-2,499 EEs 39% among firms with 2,500 of more EEs 33% among finance companies 24% among manufacturing firms 25% among service firms 12% among retail firms 40

42 For More Information For More Details Phone Toll Free J. David Johnson, MBA Employee Benef its Division 555 Fairmount Avenue Baltimore, MD

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