WASBO Federal Health Care Reform Patient Protection and Affordable Care Act

Transcription

1 WASBO Federal Health Care Reform Patient Protection and Affordable Care Act What and Employer Needs to Know for 2015 & 2016 May 15, 2015 David A. Grunke Sr. Director, Sales Operations WPS Health Insurance

2 How did we get here? The Federal Government and Health Care Financing In the beginning A Chicken for Services s Health Insurance from Employment s Taft Hartley Act s Medicare & Medicaid s Federal fostering of HMOs s HIPPA s Consumer Directed Benefits, H.S.A PPACA

3 Why Are We Here? A Simplified View of a Complex Problem and a Complex Solution that Leads to Actionable Items that can be Implemented Today

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5 Simple Solutions 1. Texas & California 18% 20% 25% TX 26,000,000 4,680,000 5,200,000 6,500,000 CA 38,000,000 6,840,000 7,600,000 9,500,000 Totals 64,000,000 11,520,000 12,800,000 16,000, Expand Medicaid Eligibility Wisconsin was 200% of FPL 3. Exchange 2014, 8-9 million, 7.5, 7.1, 6.7 million? State & Federal Marketplace 2015, 16.4 million, 3/16/2015 Federal HHS 26 million adults without coverage

6 What is the Solution PPACA the law March 23, ,700 pages PPACA the implementation Today Over 40,000 pages

7 The Secretary s List the Secretary shall establish the Secretary shall promulgate regulations the Secretary shall develop standards the Secretary shall periodically review as the Secretary deems are important the Secretary may develop and impose appropriate penalties the Secretary may adjust the rates if the Secretary determines necessary the Secretary has the authority the Secretary will and The President Says.

8 What Did We See?

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10 Why not take the Medicaid Money or What Money did WI Get Federal Exchange Enrollees 205,000 Receiving Federal Premium Subsidies 183,000 Average Premium Subsidy $ / month WI annual Premium Subsidy $70,052,400 Plus Deductible & Co-insurance subsidy $??? Medicaid Expansion Federal funds $345,000,000? WI State Journal

11 How Much Does the Cost Sharing (deductible & coinsurance) Subsidy Pay? A Silver Plan would pay roughly 70 percent of your total covered health care expenses.

12 What About Iowa PPACA created; Co-Opportunity Health Market area, Iowa Nebraska Federal low interest loans in 2014 $146,000,000 Premium 120,000 members x $3000 $360,000,000 total $506,000,000 Operating Loss 11/1/2014 $ (45,700,000) Cash on Hand 11/1/2014 $ 17,200,000 CMS rejected a $55,000,000 Loan Request National Co-op landscape PPACA Co-ops $3 Billion in Federal Loans ½ will fail per the Federal Government

13 2014 Age: < 18: 5% (6% all states) 18-25: 9% (11% all states) 26-34: 17% (17% all states) 35-44: 15% (17% all states) 45-54: 22% (23% all states) 55-64: 32% (25% all states) Plan Selection by Metal Level: Bronze: 20% (20% all states) Silver: 72% (65% all states) Gold 6% (9% all states) Platinum: 1% (5% all states) Catastrophic: 1% (2% all states) Enrollment by Financial Assistance Status: With financial assistance: 91% (85% all states) Without financial assistance: 9% (15% all states)

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15 The Upshot

16 What Happened

17 What Happened

18 PPACA Update Delayed or Eliminated 40+ What is OUT? 1099 reporting - spring 2011 Voucher Option - spring 2011 CLASS summer 2011 Local Co Ops - Jan 2013 (1 down) Medicaid Expansion (state by state basis)

19 PPACA Update What is/was DELAYED? Employer penalty January 1, 2015 (July 5, 2013) No Coverage $2000 Unaffordable Coverage $3000 Income Verification January 2015 (July 3, 2013) Small Employer PGSB / SHOP Full options January 2016 (2-100), January 2015 (2-50) Small Employer PGSB / SHOP single carrier November 2014

20 PPACA Update 2015 Individual Enrollment period November 15, 2014 to January 15, 2015 for a January 1, 2015 effective date (November 22, 2013) Extended to February 15, 2015 March 15, 2015 to April 30, 2015 for a May 1, 2015 effective date (February 15, 2015) 2016 Individual Enrollment period November 1, 2015 to January 31, 2016 (February 20, 2015)

21 PPACA Update Automatic Enrollment, 200+, 2014? (DOL Feb 9, 2014) 2015 Employer size Transition Relief until January 2016 (CMS February 10, 2014) Mandated Employer Reporting, Section 6055,6056, (Treasury/IRS March 6, 2014) Report in 2016 for 2015 Enrollment Elimination of Limitation on Deductibles for Employer Sponsored Health Plans, (April 4, 2014)

22 PPACA Update Affordability index increased to 9.56% from 9.5% for 2015 by IRS, August 8, 2014 HSA maximum increased to $6450 for 2015 by IRS August 2014 Out of Pocket maximum increased to $6600 by HHS for 2015 Summary of Benefits & Coverage (SBC) Rules proposed December 2014 From 4 pages to 2 pages 3 coverage examples from 2 September 1, 2015 $6450 $6600

23 PPACA Update Full Time Employee Calculator, Small Business Tax Credit estimator, (April 25, 2014) PCIP, Exchange enrollment Dec 31, 2013?, April 30,2014? Now June 30, 2014, (CMS April 26, 2014) COBRA notice update, (May 2, 2014) 2015 Exchange, Market Reform, SHOP Exchanges, Navigators, & Premium Stabilization, 436 pages (HHS May 16, 2015) Risk Corridors not budget neutral, Loss Ratio 22%,Reinsurance attachment point down to $45,000 from $70,000 (CMS May 27, 2014) Facts about the Premium Tax Credit (IRS May 29, 2014)

24 PPACA Update What was REVERSED? Reduction (2.3%) in Medicare Advantage Plan funding to a 3.3% increase (2013, April 7, 2014) What is in LIMBO? Medicare Part A and B reduction in reimbursement, the doc fix Delayed March 31, 2014, March 31, % cut in reimbursement Essential Health Benefits for large employers - IRS April March 2015 MACRA Confirmed- Individual Shared Responsibility (IRS Individual Shared Responsibility (IRS 8/27/13) What is New- Medicaid Doctor reimbursements for 2014 reduced to the 2012 level (Dec. 13, 2014 Federal Budget) 2015 Medicare Advantage reduction 3%, 160 Billion by 2022 (CBO) 2016 Released April 6, %

25 PPACA News CBO estimated fewer Americans will have to pay mandate penalties (CBO June 8, 2014) 6 million down to 4 million, $3 billion in lost revenue (tax) IRS February 15, 2015 I did not know Employer payment plans are considered to be group health plans (IRS May 13, 2014) Third party premium payments confirmed (HHS May 21, 2014) 2 million (22%) people listed different income than their IRS records (IRS May 16, 2014) IRS sends out 800,000 incorrect tax forms (20%) Citizenship questions 2016 premiums? 3 R s

26 PPACA News Emergency Room use up, ½ of ER doctors polled said they have seen more ER visits since January 1, 2014, 86% expect ER visits to rise over the next 3 years (ACEP May 21, 2014) Reinsurance contributions the form should be available no later than November 15, 2014 (CMS May 22, 2014) Poverty Guidelines 2015: Single $11,670 / $46,680 Family of 4 $23,850 / $95, : Single $11,770 / $47,080 Family of 4 $24,250 / $97,000

27 Who Is Eligible

28 Small Business Health Options Program SHOP or PGSB for ALL

29 WI School District Impact 30-40% of School Districts An Outcome Based Answer 99 or less employees based on PPACA counting Winners & Los????

30 SHOP for Business Platinum, Gold, Silver Bronze (PGSB) 1. a. The Small Business Health Options Program (SHOP) Marketplace (PGSB) was established within PPACA to help small businesses provide health coverage to their employees. Provide a Federal Tax Credit b. Mirror Coverage; PGSB Off Market Place 2. a. The SHOP Marketplace for coverage starting January 1, 2015 will be expanding via the Federal Facilitated Market Place. - May 27, 2014 HHS & WI OCI. b. For the expansion 1/1/2016 (2-49 market)

31 SHOP for Business 3. 1/1/2014 PGSB Benefits, rate compression 1/3, Male / Female equalization, no Underwriting. 4. 1/1/2015 The SHOP Marketplace is open to employers with 50 or fewer full-time equivalent employees (FTEs) using PPACA counting. 5. 1/1/2016 PGSB (2-99 market) 80-85% of businesses in WI 6. The business controls the coverage offered and how much the business pays toward employee premiums within PPACA guidelines

32 SHOP for Business 7. Employers will be able to compare health plans available in the SHOP Marketplace, within the PGSB valued plans. This will make it easier to compare and find a plan that works for each business and it s employees. 8. Businesses that enroll in SHOP coverage and have fewer than 25 employees, may qualify for the Federal Small Business Health Care Tax Credit worth up to 50% of premium costs. The tax credit is available only for plans bought through the SHOP Marketplace. 9. Starting November 15, 2014, small businesses will be able to apply, compare plans, and enroll in a SHOP plan online.

33 SHOP for Business 10. Employees will be able to enroll in the employer selected plan(s) online, making the process easier for both the employer and employee. 11. In Wisconsin, businesses will be able to offer more than one plan, increasing employee choice and allowing employees to select a health plan that works for them. 12. Premium billing and payment services will be provided to all employers in FF-SHOPS 13. Off Marketplace, current payment structure

34 As an Employer What Should I Be Doing AND Planning for?

35 1. Determine Your Size The 12 Steps Let s Review 2-25, 2-49, 50-99, 100+, CMS Calculator 2. Are you going to Play or Pay The Calculation, The Decision 3. Minimum 10 Essential Health Benefit Level 60% Bronze Level, Wellness / Preventive April 30, 2013 IRS 4. Employee Notices Notice of Exchange DOL 5. Minimum Employee Contribution 9.56% of your lowest full time wage earner 6. Tax Impact Pay, Penalties, increased employer wage. Direct. Indirect.

36 7. Eligibility for Benefits Full time, 30 hours The 12 Steps Let s Review 8. Maximum Waiting period for benefits - No more than 90 days 9. Benefit options PPACA Metal Tiers, 1/1/ PPACA Metal Tiers 10. Provider network options Narrow vs Wide 11. Grandfather Status If you like your plan ( for 2015) 12. Cadillac Tax 2018

37 Direct Taxes Effective 1/1/2014 Health Insurer Tax 2.5% of Premium 2014 Insurers 3.5% of Premium % of Premium 2016 Reinsurance Fee $5.25 PMPM 2014 Insurers & Employers $3.50 PMPM 2015 $2.25 PMPM 2016 PCORI ( $1.00) $2 PMPY Employer & Insurer Other than these factors, PPACA has somewhat limited impact on large group plans, 100+

38 Direct Taxes Pay or Play Tax ($12 billion lost revenue tax in 2014, CBO ) Pay Tax, $2000 per employee less 30 Due if member s coverage is below 60% AV or cost of coverage is too high relative to income, the tax is $3000, not to exceed $2000 (2015) Large groups need to be aware of which employees the federal government will consider to be full-time - 30 vs. 40 hours

39 Cadillac Tax 2018???? What 40% Excess Value Tax $10,200 Single, $27,500 Family Based on total cost of plan not just employer contribution FSA and HSA Employee & Employer contributions count Retirees & High Risk Professions

40 Cadillac Tax IRS Notice , Feb. 23, 2015 Seeks comments - May 15, 2015, 24 pages Change is most likely Demographic adjustment Geographic adjustment Inflation adjustment Now Benefit Adjustments HDHP

41 Individual Coverage Mandate Federal Market Plans Premium and Cost Sharing Subsidies Medicaid Expand to 138% of Federal Poverty Rate, 28 States & DC Non Federal Plans

42 Health Insurance Premium and Cost Sharing Subsidies Provides refundable and advance-able tax credits and cost sharing subsidies to eligible individuals. Premium subsidies are available to families with incomes between % of the federal poverty level to purchase insurance through the Exchanges. Cost sharing subsidies (deductible, coinsurance, copays) are available to those with incomes up to 250% of the poverty level. Implementation Update: On May 23, 2012, the IRS released final regulations related to the health insurance premium tax credits. Corrections to this regulation were published on July 17, Additionally, on January 30, 2013, IRS released a final rule on the premium tax credit test for affordability of employer-sponsored insurance.

43 The PPACA Marketplace Landscape? What Wisconsin Looked Like in 2014 & 2015 What geography will each insurer cover (OCI September 19, 2013) SHOP- 2014; 5-none, 13-one, 10-three or more 2015; 0-none, 7-one Individual 2014; 13 with one insurer 2015; 3 with one insurer How much will the mandated insurance cost (October 1, 2013) Additional benefits, value of the policy No underwriting Rate compression gender, age Taxes

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46 The PPACA Insurance Landscape Individual & Small Group (2-49) 2014, Mid group (50-99) 2016 WHAT PPACA Changed Insured Products Pool Rated, the BIG pool; Individual Small Group 2-49, (2015) Rate Compression, age 1 to 3 No male / female rating factor 16 areas in Wisconsin No Underwriting Market Reaction Self Funded/Administrative Services (ASO) Lower Group Size New Products

47 The PPACA Insurance Landscape WHERE do we find Products On Exchange / Health Insurance Marketplace Healthcare.gov, Insurers, Agents, Navigators Individuals, to get premium tax subsidy Small Group, to get premium tax credit Off Exchange / Marketplace Insurers, Agents Individual, non subsidy (PPACA Like) Small Group (2-99), non subsidy (PPACA Like) Large Group

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49 What did 2015 look like Who is in, Who is out Network, Expansion or Contraction Geography, Expansion or Contraction Benefits Compensation Delivery channel Price

50 What did 2015 look like Small Business Health Options Program (SHOP) Under 50, PPACA counting employers Wisconsin is IN May 27, 2014 HHS & WI OCI Employer Options 1. All medical plans across a single metal level and all dental plans across a single coverage OR 2. A single medical plan and a single dental plan Premium billing and payment services will be provided to all employers in FF-SHOPs

51 What will the Future Look Like 2016 Small Group, SHOP Expanded to 100 Many employers and employees will be affected by the change in the small group definition. Such a change could affect over 150,000 establishments with more than 3 million workers. Groups sized 51 to 100 will face more restrictive rating rules, which will increase relative premiums for some groups, such as those with younger and healthier populations, and reduce them for other groups, such as those with older and sicker populations. Groups sized 51 to 100 will face additional benefit and cost-sharing requirements, which could reduce benefit flexibility and increase premiums. The more restrictive rating and benefit requirements could cause more groups sized 51 to 100 to self-insure, especially among those whose premiums would increase under the new rules. If adverse selection occurs among groups sized 51 to 100, premiums for groups sized 1 to 50 could increase.

52 REPORTING REQUIREMENTS UNDER CODE SECTIONS 6055 AND B Health Coverage. Insurers and self-funded plans will provide one to each enrollee. The form provides information on the coverage provided B Transmittal of Health Coverage Information Returns. Transmittal form insurers and self-funded plans will file with IRS along with all the Forms 1095-B C Employer-Provided Health Insurance Offer and Coverage. Large employers will provide one to each enrollee. The form provides information on the coverage provided, and on to whom and when the coverage was offered C Transmittal of Employer-Provided Health Insurance Offer and Coverage Information Returns. Transmittal form insurers and self-funded plans will file with IRS along with all the Forms 1095-C A Health Insurance Marketplace Statement. Exchanges will provide to their enrollees.

53 What will the Future Look Like 2017 The perfect STORM PPACA Essential Benefits on ALL plans % of plans Reinsurance expires, 80% over $45,000 Risk Corridors expire PPACA PGSB for all

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57 Employer sponsored insurance trends CURRENT: TRADITIONAL MODEL Employer (wholesale) Employer Hands-on Limited choices Custom benefit design Defined benefit Offline Retirement and health care silos FUTURE: EXCHANGE MODEL Individual (consumer) Employer hands-off Expanded choices Standard offerings Defined contribution Online purchasing Total rewards COPYRIGHT 2014 GRUPPO MARCUCCI. REPRODUCTION PROHIBITED WITHOUT PERMISSION. 57

58 Things to Watch The Definition of Preventative Care Primary Preventive Services (section 2713) Value Based Insurance Design (VBID) University of Michigan Harvard University Medical School CVS Caremark Aetna Brigham and Woman s Hospital 5-6% increase in Premiums

59 Things to Watch Premium Subsidies In the Federal Appeals Court King v. Burwell The Supreme Court will hear the case in March 2015 Four Words established by the state Decision June States Not for Profit Hospital Charges

60 The Take A-ways The COST of health care is ultimately financed either directly or indirectly by each of us. The VOLUME of health care that we use, can be controlled by us as individuals or it will be controlled by someone else

61 The Take A-ways Don t just stand there, do something, even if it is wrong Alexander Janonis If not now, when Golda Meir / Hillel

62 Resources Internal Revenue Service United States Department of Labor Centers for Medicare & Medicaid Services U.S. Department of Health & Human Services The Henry J Kaiser Family Foundation Health Reform Source Center for Study Health System Change