The Large Business Guide to Health Care Law

Transcription

1 The Large Business Guide to Health Care Law How the new changes in health care law will affect you and your employees

2 Table of contents Introduction 3 Part I: A general overview of the health care law 5 Responsibilities of employers, employees and individuals Part II: Knowing your group size is the first step 8 Group size is a key factor How do I determine group size Part III: Will I have to pay penalties? 11 Large groups may incur penalties Part IV: Grandfathered status 14 Part V: Other important provisions 15 Part VI: Additional taxes and fees 17 Part VII: Take action now Checklist for large employers 19 Introduction As an employer or benefits manager, health insurance is one of the most important things you can provide for your employees and their families. That fact isn t changing. But many things about health insurance are changing as part of the new health care law officially called the Patient Protection and Affordable Care Act. The health care law affects employers differently. In fact, most employers have already felt some of the law s effects. The impacts on your business depend on the size of your company, how much your employees are paid, the type of coverage you currently provide, and whether your plan qualifies for grandfathered status. In general, many small businesses will need to make changes to their current plans to comply with the law. Larger businesses will see less impact to products and rates. But larger businesses will see new penalties for not offering the right level of coverage, or if the coverage offered isn t affordable based on an employee s pay scale (effective in 2015). Independence Blue Cross (IBC) created The Large Business Guide to Health Care Law to help you understand how the health care law affects the way you provide health care benefits to your employees. This guide highlights some of the critical impact areas facing businesses, including what your legal requirements are under the health care law, the penalties you may incur for non-compliance, and key decisions you will need to make. It also contains information and tools that will help you and your business prepare for the changes ahead as more key provisions of the law are implemented. Part VIII: What Independence Blue Cross is doing to help 20 Complying with the law Finding solutions Part IX: Glossary of common health care terms 23 3

3 Here s a brief outline of what you ll find in this guide: A quick overview of the health care law Information about the penalties you may incur as a large business Step-by-step instructions for determining eligible employees A description of key provisions of the health care law that affect large businesses A checklist to help you comply with the law and make important decisions about the health care benefits your company offers A description of what Independence Blue Cross is doing to help A glossary that explains common health care terms IBC is your partner in providing quality, cost-effective health care coverage. We re here to help you navigate the changing health care environment, comply with the law, and make the best health care coverage choices for your business and employees. Part I: A general overview of the health care law The health care law affects virtually everyone individuals, families, and businesses of all sizes. The law s provisions are being implemented in phases over a 10-year period from 2010 to Some provisions of the law are already in effect. They include the following: All group health plans that offer dependent coverage must cover dependents until they reach the age of 26. Plans must cover certain preventive health care services at 100 percent for in-network providers, and an individual will have no financial responsibility for those preventive services. (Grandfathered plans are exempt from this requirement.) Plans cannot deny coverage to people under the age of 19 who have pre-existing health conditions. Plans cannot impose lifetime maximum dollar limits on essential health benefits and annual limits of these benefits are restricted; there will be no annual dollar limits beginning on January 1, Plans must have internal and external appeals processes that members can use to appeal coverage decisions. (Grandfathered plans are exempt from this requirement.) Members can designate any participating primary care physician or pediatrician (for a child) as their primary care physician. In addition, women can see OB/GYN physicians without a referral. (Grandfathered plans are exempt from this requirement.) 5

4 Other major changes are scheduled for implementation in Although some of these provisions do not apply to large employers directly, they may affect decisions you make about the health care benefits you offer your employees. Some of the changes scheduled to take effect in 2014 include: Everyone is required to have health insurance. No one can be denied coverage because of his or her health status. Annual dollar limits on essential benefits are eliminated. Employees who work at least 30 hours per week are to be considered full-time and should be offered health coverage if the employer has 50 or more FTEs. Coverage waiting periods of greater than 90 days are eliminated for group health plans. Many single people and working families who purchase coverage on their own may get tax credits/subsides from the government to help pay their health care coverage costs. This includes many people who the government does not currently help. Individuals and small businesses will have a new way to buy health insurance. They can compare and evaluate health plans through an online portal called the Health Insurance Marketplace. The law encourages states to expand eligibility for their Medical Assistance programs, also known as Medicaid, to those under age 65 whose incomes are below 133% of the federal poverty level. Many states are expanding their Medical Assistance programs and offering health plans to more people who are uninsured. Some states began phasing in coverage of these individuals in To find out more about Medicaid eligibility in each state, visit: The employer reporting provision requires you to submit annual reports to the U.S. Department of Health and Human Services on the terms and conditions of health care coverage provided to your full-time employees. The employer mandate penalties and reporting requirements, which were scheduled for implementation in January 2014, will now go into effect on January 1, Responsibilities of employers, employees, and individuals As of January 1, 2014, most individuals will need to enroll in a health care plan or face government penalties. This provision is known as the individual mandate. One of the ways an individual can obtain health coverage is through a group health plan provided by an employer. However, the individual mandate applies to individuals even if their employer does not offer health insurance. Effective January 1, 2014, groups with fewer than 50 full-time employees do not have to offer health care coverage, and there is no penalty if they do not offer coverage. Small businesses that offer coverage may be eligible for tax credits if they offer health insurance. If a small business offers health care coverage, it must provide certain benefits and cost-sharing levels. Large groups of more than 50 full-time or full-time-equivalent employees must offer health care coverage to all full-time employees or incur a penalty starting in (See explanation of group size on page 8.) 2014 sample penalty for individuals without a health plan The federal government made some important decisions about some of the key provisions that affect large businesses. The employer mandate, or employer shared responsibilities provision, goes into effect in January However the government has delayed implementation of the penalties that apply to employers who do not comply and the employer reporting requirements. Under the employer mandate, you could incur penalties if you do not provide your employees with health care coverage, the right level of coverage, or coverage that is considered affordable. $300 $150 $15,000 $30,000 Taxable Income $600 $60,000 7

5 Part II: Knowing your group size is the first step Group size is a key factor The size of your business determines how your benefits or rates are constructed, and whether or not you will be penalized for not offering coverage. The health care law includes precise guidelines about calculating group size. In 2014, the federal government will define full-time workers as those who work 30 hours per week or more. Part-time employees will be counted as part of the total employee count. The health care law defines small groups as those with a total of full-time and full-time-equivalent (FTE) employees. But the law allows states to modify the FTE number for small businesses for 2014 and Most states are choosing that option and will classify small business as those with up to 50 FTEs. Groups with 51 or more total employees are classified as large groups. Starting in 2016, businesses in every state with employees will be classified as small businesses. How do I determine group size? To determine your group size, you first need to calculate the number of hours worked by your full-time and full-time-equivalent employees (see page 10). Determine your full-time employees by identifying all employees who work 30 or more hours per week. To that amount, add the number of your full-timeequivalent employees. You must also account for part-time workers, by calculating full-time-equivalents as follows: 1 2 Add the total hours worked by part-time employees per month and divide that number by 120. Add this number to your total number of full-time employees. This will give you your group size. Seasonal workers may also contribute to your overall group size. For more details on how to determine your group s size, please refer to the Internal Revenue Service website and/or consult your legal or accounting professional for assistance. Definition of hours of service An employee s hours of service include each hour for which she or he is paid, or entitled to payment, during the tax year. You must also add each hour of paid leave, but no more than 160 hours of paid leave service per year are required to be counted for an employee. 9

6 Ways to determine hours of service per employee: Determine actual hours of service from records of hours worked and hours for which payment of wages is made or due, including hours for paid leave; or Use a days-worked equivalency which credits the employee with 8 hours of service for each day payment of wages is made or due, including days of paid leave; or Use a weeks-worked equivalency which credits the employee with 40 hours of service for each week payment of wages is made or due, including weeks of paid leave. How to calculate your group size Once you have determined each employee s accurate hours of service, add the total hours of service you pay wages to your employees during the year (but not more than 2,080 hours for any employee). Divide by 2,080. If the result is not a whole number, round it to the next lowest whole number. If the result is less than one, round up to one. Seasonal workers are generally not covered unless they work more than 120 days per year. However, premiums you pay on behalf of seasonal employees may be counted to determine the amount of your credit. Part III: Will I have to pay penalties? Large groups may incur penalties As a large employer with 50 or more employees, you are required to offer health insurance coverage in Starting in 2015, you may incur penalties under the employer mandate or employer shared responsibilities provision if you do not provide your employees with health insurance coverage, or the minimum level of health insurance coverage, or if the health insurance coverage you offer is considered unaffordable to some of your employees. You also must submit annual reports to the government about the coverage you provide to your full-time employees. This provision is scheduled for implementation in January But the federal government delayed implementation of the penalties and reporting requirements for a year. They will now go into effect in Penalties incurred in 2015 will be payable in Although implementation of the employer penalties and reporting requirements has been delayed, the Internal Revenue Service encourages large employers to voluntarily maintain or expand health coverage and to comply with information reporting requirements in You can avoid penalties that the federal government will start imposing in 2015 by providing your employees with a health plan that meets the coverage and affordability requirements established by the new health care law. 11

7 As a large group, your plan must meet certain coverage requirements: The minimum value of your health plan must be 60 percent or greater of the total cost. This means that the cost-sharing associated with the plan must on average result in the plan paying 60 percent of associated costs and the member paying no more than 40 percent. The federal government has issued a calculator that you can use to test the cost-sharing of your plan to determine whether or not it meets minimum value requirements. 60% 40% Employer must pay at least 60% of plan value You are not required to offer essential health benefits. But if you do offer any of the 10 essential health benefits identified by the health care law, you cannot impose any lifetime or annual dollar maximums on those services. The annual out-of-pocket maximum (OPM) for essential health benefits cannot exceed the OPM for health savings account compatible high deductible health plans. These amounts will be indexed annually. For 2014, the OPM is $6,350 for individual coverage and $12,700 for family coverage, and only needs to include major medical. In 2015, the OPM must include major medical and ancillaries. How do I pay? Your business could incur two types of penalties one for not providing health insurance coverage, and one for not providing the minimal level of health insurance coverage or affordable health insurance coverage. The amount of the penalties will increase over time. For 2015, the penalties that will be assessed are: A $2,000 penalty if you do not offer group health insurance coverage. This penalty is based on the total number of full-time employees your business employs (the first 30 employees are not included in this calculation). At least one employee has to purchase subsidized coverage on the new Health Insurance Marketplace for this penalty to apply. If you choose not to offer any coverage, and one employee goes to the individual Marketplace and receives a subsidy, you will be penalized $2,000 per full-time employee after the first 30. A $3,000 qualification penalty if you fail to offer a qualifying plan (minimum and/or affordable) to any employee. The penalty applies if any of those employees purchase subsidized coverage through the Marketplace. This penalty is assessed based on the number of employees who are not offered qualifying coverage and subsequently purchase subsidized coverage through the Marketplace. Starting in 2015, you may incur penalties if you do not offer health coverage to all full-time employees who work 30 hours a week and if you have 50 or more FTEs, and you must begin reporting to the government. You also must offer coverage to their dependent children (not spouses), although you are not required to pay for those dependents. Your health plan also must be affordable: Affordability is determined by the single employee contribution amount for the lowest-cost plan offered. If the contribution towards a single premium exceeds 9.5 percent of an employee s W2 wages, the plan is unaffordable for that employee. There are other safe-harbor measures available to groups to determine affordability of health plans they offer. $2,000 penalty if you do not offer group health insurance $3,000 qualification penalty if you fail to offer a qualifying plan (minimum and/or affordable) to any employee 13

8 Part IV: Grandfathered status If your plan has been granted grandfathered status, your health plan has to comply with some but not all provisions of the health care law. Grandfathered status applies only to plans that were in effect on March 23, 2010 and that continue to meet specific guidelines to maintain that status. Some requirements your grandfathered plan may not have to meet, include: Covering 100 percent of certain preventive services if the services were received from an in-network provider. Allowing female employees to see OB/GYN physicians without a referral. Allowing members to designate any participating primary care physician or pediatrician (for children) as their primary doctor. Implementing an internal and external appeals process. Eliminating prior authorization for hospital emergency services for participating and out-of-network providers. Prohibiting discrimination that favors highly compensated individuals (fully insured plans only). Even if your plan has grandfathered status, you must comply with many provisions of the health care law including the following: You must provide coverage to children under age 19 with pre-existing health conditions. Starting in 2014, you cannot deny coverage to anyone because of existing health conditions. You cannot impose lifetime dollar limits on essential health benefits. The health care law limits annual dollar limits on essential health benefits through 2013, and eliminates them in Part V: Other important provisions As a large employer, other provisions in the health care law will affect your business and your health plan in the months and years ahead, including: Notification requirements 2013 You are required to notify all employees in writing by early fall of 2013 and all new hires who start working for your company after that time. The Marketplace is an online shopping tool administered by the federal government. Beginning no later than October 1, 2013, employers must provide the Marketplace notice to each new employee at the time of hiring. For 2014, the government will consider a notice to have been timely delivered if it is provided within 14 days of an employee s start date. With respect to current workers, employers are required to provide the notice by October 1. The notice must be provided automatically, free of charge, and written in language that the average employee can understand. Specifically, you must: Provide a description of the services the Marketplace offers, Provide instructions about how to contact the Marketplace and request assistance, Let employees know that they may be eligible for premium tax credits if the plan you offer pays less than 60 percent of the costs of covered services, Explain that if employees purchase a qualified health plan through the Marketplace, they may lose any employer contribution to any health plan offered by the employer and all or a portion of the contribution may be excluded from income for federal income tax purposes. If your plan covers dependent children, you must extend coverage to dependent children until age 26. Keep in mind that you can lose grandfathered status if you make significant changes to the health plan, such as the benefits it includes or the amounts employees pay in cost-sharing fees (deductibles, premiums, and copayments). 15

9 Guaranteed issue and renewability 2014 In 2014, the health care law requires insurers to offer all insurance products in the individual and group market to everyone in the state. This means that employees are guaranteed coverage regardless of their health status or other factors. In addition, all group health insurance plans must have guaranteed renewability. That means insurers cannot refuse to renew coverage when people are sick. Wellness provisions 2014 The Department of Health and Human Services has issued rules to increase the incentives you can offer employees who participate in wellness programs. Here s how the rules would affect the two types of wellness programs offered to employees. Participatory wellness programs These programs are generally available to everyone, regardless of their health status. Examples of participatory wellness programs include: reimbursement for gym memberships, rewards for attending no-cost health education seminars, or completing a health risk assessment without requiring any further action. The proposed rules do not alter the incentives available for these programs. Health-contingent wellness programs These programs generally require individuals to meet specific standards to obtain rewards. For example, employees may receive rewards if they do not use tobacco or if they decrease the use of tobacco products; or, they may receive awards if they achieve a specified cholesterol level or weight. The final rules would allow you to increase the rewards you offer for these programs from 20 to 30 percent of the cost of health coverage (total premium). The maximum reward could increase to as much as 50 percent for programs that prevent or reduce tobacco use. The final rules would require health-contingent wellness programs to meet certain requirements. To qualify, you must offer rewards for programs designed to promote health or prevent diseases, offer rewards to all similarly situated individuals (the program should have provisions for those whose medical conditions make it inadvisable or difficult to participate), and notify employees about their opportunity to qualify for the rewards. New reporting requirements 2015 Large employers will have to submit annual reports to the U.S. Department of Health and Human Services on the terms and conditions of health care coverage provided to full-time employees. The report should include: duration of waiting period, the monthly premium for the lowest-cost option offered to employees, employer s premium share, and a list of employees. This provision was scheduled for implementation in Although the federal government delayed implementation until January 2015, the Internal Revenue Service encourages large employers to voluntarily submit these reports in Large groups may be allowed on the marketplace 2017 States will have the option of allowing large companies with more than 100 employees to buy health insurance through state-based health insurance marketplaces. Initially, only individuals who buy their own insurance and small businesses will be able to use these online portals when they open in the fall of The marketplaces will make it easier for those purchasing health insurance to compare products and prices. Part VI: Additional taxes and fees Cadillac tax 2018 HEALTH CARE ANNUAL REPORT 2015 The health care law imposes a 40-percent tax on high-value health plans starting in The tax applies to an amount above established dollar thresholds and is levied on insurers for fully-insured plans, employers for health savings account (HSA) contributions, and plan sponsors for self-insured plans. Taxes are imposed when employee health plan costs exceed $10,200 for single person plans and $27,500 for other plans, such as family plans. This limit is subject to annual adjustments. Higher benefit limits are allowed for retirees age 55 and older who are not eligible for Medicare and for people in high-risk jobs. The health plan costs are defined by the total cost of premiums, including employer and worker contributions to flexible spending accounts or HSAs. Stand-alone vision, dental, accident, disability, and long-term care benefits are not included in the limits under the cadillac tax rule. 17

10 New taxes and fees The health care law includes mandated taxes and fees from nearly all health insurers to build a pool of funds for several initiatives. These funds will be used to help stabilize premiums for people who are newly insured, and develop best practices to improve the quality of medical outcomes. After basic medical rates are calculated, health insurers will add the following fees to employer plans: Patient-centered outcomes research trust fund fee This fee funds research to help patients and health care providers make more informed decisions. The fee started in 2011 at $1 per enrollee and doubled to $2 per enrollee in This fee will continue through Health insurance companies collect this fee for fully-insured employers. The plan sponsor is responsible for paying the fee for self-funded groups. Reinsurance program contribution This fee will be used to fund state-based transitional reinsurance programs. The fee, which will be collected from 2014 to 2016, will be based on the number of enrollees. The contributions will be set each year by the Department of Health and Human Services. It is estimated that the amount assessed in 2014 will be from $ per enrollee. Health insurance provider tax/fee This tax helps fund the health care law. Health insurers must pay an annual non-deductible tax/fee to the Internal Revenue Service. The amount assessed is calculated by market share based on premiums written. Part VII: Take action now Checklist for large groups Here are some of the things that are already required, or that you may need to do in the future to comply with the new health care law: Determine your group size Determine whether your health plan continues to qualify for grandfathered status. Address new administrative duties Perform discrimination testing (new for non-grandfathered, fully insured groups) Implement higher Medicare Part A payroll taxes for high-wage earners Implementation Date Delayed (New date not set yet) 2013 Issue notice of Marketplace to employees 2013 Implement health flexible spending account maximum 2013 Include the aggregate value of health coverage on employees W2 forms Create and submit health care coverage annual report to the Department of Health & Human Services Manage new taxes and fees Discontinue any tax deduction for Medicare Part D subsidy amounts Implementation Date 2013 Calculate and pay patient-centered outcomes fee (self-funded plans only) Calculate and pay reinsurance contribution (self-funded plans only) Assess your current offerings Implementation Date Does your business meet new waiting period requirements? 2014 Does it meet the health care law s actuarial value and affordability requirements? Identify changes you need to make and implement remedies as needed Ongoing 19

11 Part VIII: What Independence Blue Cross is doing to help Complying with the law At IBC, we re following implementation of the health care law closely. We have made major changes to our health plans, and will be making additional changes to make sure your plans comply with the law. We have met many requirements of the health care law, and adopted other provisions prior to when they took effect. For example, no changes needed to be made to your coverage in the following areas because IBC already included these provisions in its health plans: Coverage for in-network emergency room visits The ability to select a pediatrician as a primary care physician Direct access to OB/GYN physicians No preexisting-condition exclusions for children Here are some of the changes we ve made to comply with the health care law. All IBC plans now include these benefits: Coverage of employees dependents to age percent coverage for designated preventive care services No lifetime dollar maximums on essential health benefits (this eliminates limits, such as $1 million lifetime maximums for out-of-network care) We ll also incorporate other key provisions of the health care law into many of our plans. For 2014, we will: Eliminate pre-existing condition exclusions for adults Add new maximum out-of-pocket limits for non-grandfathered plans (these limits in 2014 will be $6,350 for individual plans and $12,700 for family coverage) Finding solutions IBC is working on your behalf to find innovative solutions that address cost and quality issues for employers. Some steps we re taking include: Joining a national effort to improve service at lower costs for multi-state customers; Offering innovative workplace wellness programs to employers; Using technology to more effectively serve our customers and help them to improve their health. We also think it s our responsibility to be part of the solutions that will help make our community healthier, and to provide access to quality health care coverage in a way that s efficient and cost effective. The health insurers that will thrive in this fast-paced and rapidly changing environment will be those with a clear plan and powerful focus on finding fresh and innovative ways to deliver real value to consumers. So we ve set a bold vision to lead the way regionally and nationally in transforming the delivery of health care by lowering costs and helping to raise the quality of health care. No annual dollar maximums on essential benefits (this eliminates limits, such as the $2,500 annual limit for durable medical equipment) No rescission (cancellation) of coverage except in cases of fraud, intentional misrepresentation of material facts, or nonpayment of premiums No preexisting condition exclusions for children under 19 Enhanced internal appeals and external review processes 21

12 Here are some of the specific things we re doing to help improve the health care system for us all: Strengthening partnerships We believe that collaboration and partnership are the answers to most problems that face our health care system. We are, and have been, working closely with other Blue Cross and Blue Shield plans, affiliates, physicians, and hospitals, and with more than a dozen health care systems to find solutions that work. IBC is helping create groundbreaking new models of cost-effective care that use new and different methods and practices, experimenting with options, launching new pilots, and finding the best ways to keep people healthy. For example, we re funding a large pilot program in the United States for a relatively new health-care model called the patient-centered medical home that is revolutionizing primary care. Developing incentive programs We started talking several years ago with doctors and hospitals about new ways to work together to manage costs and improve quality of care. And we developed incentive programs that reward high-quality, cost-effective care. Planning for the future We re helping create a new center for health care innovation where innovators can incubate and develop ideas, harness technology, and create new products, services, and marketing approaches. IBC is committed to delivering the health care coverage we believe Americans truly need Part IX: Glossary of common health care terms Here are simple definitions of some of the health insurance terms in this guide. Employer shared responsibility A provision of health care law that requires groups with 50 or more fulltime or full-time-equivalent employees to provide affordable and minimum value health coverage to their employees. If this level of health care coverage is not provided and a group member obtains a subsidy from the individual Marketplace, the group will be subject to a government penalty. Group size The number of full-time and full-time-equivalent employees employed by a company. In 2014, the definition of a full-time employee is someone who works at least 30 hours per week. Health care law A short way to refer to the Patient Protection and Affordable Care Act. President Obama signed this bill into law in Many key parts of the law go into effect in This law is sometimes referred to as Obamacare. Health insurance marketplace A new online state marketplace where consumers and small businesses can shop for health insurance, comparing products and prices. It also is known as an Exchange and the Small Business Health Options Program (SHOP). States will have the option of allowing large companies with more than 100 employees to buy health insurance through these marketplaces starting in Encouragement to stay well Superb care when they are ill A coordinated health care system that rewards those who provide the safest, most effective care Individual mandate A provision of health care law that requires individuals to have health care coverage by 2014 or the individual may be subject to government penalties. Minimum value Minimum value is the average share of total health spending on essential health benefits paid for by the plan. Tax credits/subsidies Subsidies that will lower the costs of health care for many people based on their income level. Some people may be eligible for health plans with $0 or low-cost premiums. Others will be eligible for tax credits that help lower their monthly premiums and also give them a break on their out-of-pocket health care costs (a deductible, copayments, and co-insurance amounts). 23

13 (9/13) Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association.