FLORIDA HEALTH CARE COALITION

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2 FLORIDA HEALTH CARE COALITION Orlando-based 501c3 non-profit, established 29 years ago Provide education, research and program development support to our members Focus on quality improvement, first and foremost, then value and affordability Demonstration and research projects that test innovative benefit design, care coordination and management, and payment

3 OUR MISSION AND VISION FHCC is a community catalyst that uses its collective employer power to effect change in healthcare delivery. The national issue of healthcare reform will be solved at the community level. We work collaboratively with our community partners to improve the quality of healthcare in Florida and to keep healthcare affordable and sustainable.

4 UNDERSTANDING PPACA (PPACA = Patient Protection and Affordable Care Act) Our healthcare system is very complicated, so no surprise that reform is complex. Simply put, though, PPACA requires individuals to obtain health insurance and employees to offer it. The law is over 2700 pages long and that doesn t begin to include the thousands more pages of definitions and guidance documents that are still being issued. Regulations began in 2010 and go through There is a lot to keep up with! Focus of this presentation is on the key components that directly affect employers in the next two years.

5 PPACA DOES NOT APPLY TO EVERY EMPLOYER Small employers with fewer than 50 full time equivalent (FTE) employees are not subject to the penalty portion of the bill. If there are parent, brother, sister companies, they all come together to count as one employer. If small businesses do offer coverage, they must comply with the new regulations. Some small employers are eligible for incentives to implement health coverage and grants to add a wellness program to their new plan or existing plan if they have one. Tax credits to small employers who cover at least 50% of employee premiums.

6 2012 PPACA RULES EFFECTIVE IN 2012 AND 2013 Uniform benefit summary distributed during open enrollment Reporting the cost of coverage on W-2 s Self funded employers paying $1 fee per covered life for the Patient Centered Outcomes Research Institute 2013 $2,500 limit for Health FSA s (flexible spending accounts) Increased FICA (Medicare) withholding Notice of health insurance exchanges Loss of deduction for retiree drug subsidy

7 PPACA RULES EFFECTIVE IN 2014 Essential health benefits (defined by each state) covered Health insurance exchanges operational Individual coverage mandate Low income premium subsidy in the exchange Employee free choice vouchers for the exchange Annual dollar coverage limits prohibited No pre-existing condition limits (all ages) No waiting period for coverage over 90 days Doubling of fees to Patient Centered Outcomes Research Institute

8 PPACA REGULATES THREE THINGS 1. Plan eligibility 2. Plan benefits 3. Plan contributions PPACA provides some flexibility for employers to customize their plans. Most experts estimate that about 80% of health plans are already compliant with all key requirements of PPACA.

9 PLAN ELIGIBILITY PPACA requires that all plans offer coverage to employees who regularly work 30 hours a week or more. Mandates a maximum wait period for coverage of 90 days. There is an exemption for seasonal workers.

10 PLAN BENEFITS Does not allow employers to offer different (i.e. better) coverage to highly compensated employees Defines a minimum credible coverage plan design (identified as BRONZE ) pays at least 60% of the estimated medical charges. Equates to about $2000 in deductibles with $6000 out of pocket per year Requires free routine services such as a broad spectrum of screenings and immunizations Unlimited lifetime maximums Elimination of pre-existing condition limitations Requires standard plan formats summary of benefits and coverage

11 HEALTH INSURANCE EXCHANGES The most significant change for employers is the establishment of health insurance exchanges, run either by their own state government or the federal government. Exchanges are virtual marketplaces which allow consumers and small businesses to comparison shop for health insurance. Within the exchanges, there will be additional buy up plans (SILVER, GOLD, PLATINUM) that pay a higher percentage of charges for a higher premium. Exchanges are the only way to get premium subsidies. Significant delays in progress to establish these exchanges due to uncertainties with the Supreme Court decision and election results.

12 FLORIDA AND THE EXCHANGE 17 states plus Washington DC have been conditionally approved to operate their own exchanges in Florida decided not to build a PPACA style exchange. We have until February 15 th to notify the federal government if we would like to partner with them, overseeing certain aspects of the new exchanges, or just leave it all to the federal government. Just lost the opportunity to have a CO-OP (consumer operated and oriented plan) due to fiscal cliff negotiations. Uncertainties with Medicaid expansion in Florida. Concern that the federal government might not have the capacity to set up and run exchanges for dozens of states by January 1, 2014.

13 PLAN CONTRIBUTION Plans must be affordable must limit the employee s cost share for individual coverage to 9.5% of their family income. If not in compliance, there are three choices: 1. Enhance their current plan to meet the minimum requirements 2. Keep their plan in place and pay a penalty 3. Eliminate the plan and pay $2000 penalty per year per employee

14 EMPLOYER MANDATE PENALTIES How Much Are The Penalties? If a business does not provide insurance and if at least one employee receives federal insurance subsidies in the exchange, the business will pay $2,000 per employee (minus the first 30). Example: a business with 50 employees, two of whom are subsidized, would pay $40,000 = $2,000 x (50 30). To qualify for subsidies, an employee must meet two criteria, described below. If a business does provide insurance, and if at least one employee receives insurance subsidies, the business will pay $3,000 per subsidized employee OR $2,000 per employee (minus the first 30) whichever is less. So a providing business with two subsidized employees would be fined $6,000. With 14 or more subsidized employees (above the tipping point for the formula), the penalty for a 50-employee firm would be $40,000. SOURCE: NFIB Research Foundation

15 WHAT DETERMINES ELIGIBILITY FOR SUBSIDIES? To qualify for subsidies, an employee must meet two criteria. First, his or her household income must be less than 400% of the federal poverty level (about $92,000 for a family of four in ). Second, the employee s portion of the insurance premium must exceed 9.5% of household income.

16 MUCH TO CONSIDER Do the math to determine best course of action. Premiums are deductible and penalties are not. Increases penalty cost by 25% to 40%. Crossing the line in the sand 50 FTE s How to stay on top of data collection on family financial situation/changes in coverage to avoid penalties. What will competitors do? Traditionally it is benefits that attract and retain talented workers.

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