What an employer should know about Health Care Reform

Transcription

1 What an employer should know about Health Presented By David L. Fear, Sr. RHU NAHU Education Foundation Sponsored by

2 PPACA - history Signed into law in March, ,700 page rough draft became the law No conference committee to rectify differences between House & Senate versions - no bi-partisan cooperation Largest piece of health related legislation since Medicare/Medicaid Many provisions went into effect immediately March, 2010 Regulations released since 2010 and more expected in the future Major portion of the law is scheduled to go into effect on 1/1/2014 2

3 PPACA history: The Supreme Court SCOTUS ruled 5-4 on 6/28/2012: Chief Justice Roberts writing for the majority: The individual mandate is legal because it is in fact a tax and Congress has the right to levy taxes Forcing the States to expand Medicaid funding by taking away all funding if they did not expand it was not legal The Chief Justice did not want the Court to be legislating and basically said that if the people don t like the law, then have Congress change it 3

4 The Future of PPACA President Obama s re-election in 2012 makes it unlikely that he will agree to a repeal, or major amendments House Republicans are unlikely to hold any more repeal votes Senate would not approve repeal votes Slight chance that minor changes in the law may be made Administration is releasing regulations and guidance almost weekly The Train Has Left The Station 4

5 Prior to 2014: Some of what happened Grandfathered Status was available for plans in effect on the date of enactment Small Employer Tax Credit went into effect for eligible small businesses A Temporary Reinsurance Program began - $5 billion for retiree health plans Section 105h Non-Discrimination rules were to have gone into effect on (delayed indefinitely) A National High Risk Pool was funded for the uninsured with pre-existing conditions Federal Government website established at Lifetime benefit limits were eliminated on all health insurance policies short term exemptions issued Dependent coverage extended to age 26 Pre-Existing Condition limitations eliminated for children under age 19 5

6 Prior to 2014: Some of what happened Preventive Care Benefits were mandated with no cost-sharing (deductibles, copays) on all nongrandfathered plans The Minimum Loss Ratio rules into effect and premium rebates were issued Tax increase on non-qualified distributions from a Health Savings Account (10% to 20%) Over-The-Counter Drugs must be prescribed to be paid from an FSA/HRA/HAS A Public Long Term Care program (CLASS Act) was to have gone into effect, but was delayed The 1099 Reporting Requirement was repealed A fee of $1-$2 per employee to fund the new Patient Centered Outcomes Research Institute (PCORI) W-2 Reporting of Health Insurance cost for large employers (delayed 1 year for small employers) 6

7 Prior to 2014: Some of what happened Increase in Medicare Part D (drug) premium for those earning more than $85k/$170k A tax on Medical Devices and on the Pharmaceutical Industry goes into effect Requirement for a standardized Summary of Benefits and Coverage went into effect The Medicare Tax was increased from 2.9% to 3.8% for those earning more than $200k/$250k This 3.8% tax is also imposed on certain unearned income for those same individuals with AGI of $200k/$250k A $2,500 Cap on Employer Contributions into a Flexible Spending Account was enacted Employer Notice to Employees of existence of a Health Insurance Exchange (delayed) The Deduction Threshold for Unreimbursed Medical Expenses increased from 7.5% to 10% States are to begin enrollment into Health Insurance Exchanges by October 2013 or the Federal Government will do it for them 7

8 2014: When Things Get Interesting The Individual Mandate takes effect All coverage becomes guaranteed issue Premium Subsidies available through an Exchange Employer Play or Pay Mandate takes effect Benefit mandate for non-grandfathered plans Community rating for insured plans New taxes and fees 8

9 2014: The Individual Mandate All American citizens and legal residents will be required to purchase essential health insurance coverage or pay a fine ( tax ) Exceptions will be allowed for: Religious objectors Incarcerated individuals Hardship waivers, individuals with income less than 100% of FPL Members of Indian Tribes People with no income tax liability Individuals not lawfully present Those who were not covered for a period of less than three months during the year 9

10 2014: The Individual Mandate Mandate applies to employed and unemployed persons: If their employer does not provide an essential benefit plan, they must still comply and pay penalty if they fail to obtain essential coverage The penalty for non-compliance of the individual mandate is the higher of: A percentage of gross household income equal to: 1% in % in % in 2016 Capped at the value of the average bronze-level insurance premium (60% actuarial value), or A flat amount equal to: $95 per person in 2014 $325 per person in 2015 $696 per person in

11 2014: Insurance Market Reforms All health insurance coverage will be guaranteed issue and guaranteed renewable in all markets (Individual, Small Group, Large Group) Self Insurance is still permitted after 2014 Pre-existing condition exclusions will be prohibited in all markets Full prohibition on any annual or lifetime benefit limits in all plans Benefit plans will become more standardized with the introduction of Metallic Plans and essential benefit categories in the small employer & individual markets: Platinum (90% Actuarial Value) Gold (80% Actuarial Value) Silver (70% Actuarial Value) Bronze (60% Actuarial Value) Expect that premium rates will increase as these new benefit designs replace current plans 11

12 2014: Insurance Market Reforms Redefines the small group market as employees California has elected to keep 1-50 definition until 2016 All fully insured individual and group policies up to 100 lives must abide by strict community rating standards: Premium variations only allowed for: Age (3:1 price ratio compressed from 7:1) Tobacco use (1.5:1 price ratio) Family composition (EO, ES, EC, EF) Geography (California will have 19 regions) Experience rating will be prohibited Wellness discounts are allowed for group plans under very specific circumstances 12

13 2014: Federal Premium Subsidy A Federal health insurance premium subsidy becomes available to qualified individuals: It is a sliding-scale refundable tax credit paid to the health plan for individuals or families with incomes of between 133% and 400% of Federal Poverty Level (family of 4 = $29,000 to $90,000) Subsidy only available through an Exchange Not available to employees (or their dependents) of employers who offer affordable and the minimum value coverage to their employees Amount of subsidy based on the Silver level benefit in the exchange rating area where the person resides and is higher for families than for individuals *Subsidy can be changed in 2019 if total subsidy payments exceed.504% of Gross Domestic Product 13

14 2014: Health Insurance Exchanges PPACA mandates that an Exchange will be available in all States in 2014 For Individuals and for Small Employers (SHOP) Large Employers can join in 2017 Exchange will handle the administrative tasks including: Negotiate rates, benefits and services with health plans Educate the public on health care reform Determine eligibility for premium subsidy, tax credits Bill, collect, remit premium for health plans Transmit data to Feds to comply with individual mandate California established its own exchange with about $1.5 billion in grants from Feds ( Covered California ) Developing plans, rates and services for 10/1/2013 kick off date for 1/1/2014 effective date Will feature both an Individual and Small Employer exchange Will employ more than 1,000 state workers Will contract with over 20,000 Navigators, Assisters and Insurance Agents to enroll individuals and small employer groups Likely to feature 30+ participating carriers 14

15 2014: Employer questions Am I considered a Large Employer or a Small Employer under the law? 50+ Full Time Equivalent employees is the break point Will my premium costs go up? Depends on your current benefits and age of your group. There are several new taxes and fees that will go into effect and will have an impact on your cost Will the coverage I provide now meet the requirements of the law in 2014? Probably, if you provide an HMO or PPO plan, not so if you provide a limited benefit plan What penalty will I pay if I don t comply? The lesser of $2000 x EEs 30 or $3000 x EE s with an Exchange subisidy Will I have to provide coverage to my Part Time or Seasonal employees? Not unless they average 30+ hours per week Can I drop my coverage? If you are a small employer you can without penalty; If you are a large employer you can but will pay a penalty based on your size Can I participate in the Exchange? Exchange will be open to Individuals and Small employers initially, large employers in 2017 Can I still work with my insurance agent? Yes, for both Exchange and non-exchange plans they must be certified with the Exchange 15

16 2014: The Employer Mandate A Shared Responsibility or Play or Pay mandate applies to Applicable Large Employers with 50+ Full Time Equivalent employees (*see following example) They are to offer coverage to Full-Time employees who work an average of 30 hours per week or 130 hours per month The coverage must meet a minimum value standard The coverage must be affordable The penalty for failure to do this the lesser of: $2,000 x no. of Full-Time employees less the first 30 employees, or $3,000 x no. of Full-Time employees who receive an exchange premium subsidy Employers are NOT required to provide coverage to Part Time employees or to Seasonal employees Recent safe harbor regulations allow for employer to do a look back on variable hour employees to determine their full time status (*see following example) 16

17 2014: Other Issues A national health insurance premium tax will begin on all fully insured plans Est. cost initially about $500 per family/year Increases annually ($8 billion up to $11+ billion) A national reinsurance fee will be charged to all fully insured and self funded health plans of $63 per person per year Limits employee waiting periods to 90 days Inclusive of first of the month entry Can be based on number of hours worked Applies only when employee becomes eligible Expect the Section 105(h) non-discrimination requirements to be enforced ($100/day penalty) Auto-Enrollment for groups of 200+ to be enforced Employees will be able to opt-out with other coverage HIPAA workplace wellness rules will change incentive values increase from 30% to 50% 17

18 After 2014: More to come 1/1/ implementation of a 40% excise tax on insurers of employer sponsored health plans with aggregate values that exceed $10,200* for singles and $27,500* for families (*adjusted for inflation annually): Transition relief would be provided for 17 identified high-cost states; The above values include reimbursements from F.S.A. s, H.R.A. s and employer contributions to H.S.A. s; Stand-alone dental and vision are excluded from the calculation; Premium values are indexed to the CPI; Plans will be allowed to take into consideration age, gender and certain other factors that impact premium costs. 18

19 Concluding thoughts PPACA is a huge compliance issue for both individuals and employers Individual and Employer Mandate Standardized rates, benefits and services New rules apply that employers and individuals must comply with in 2014 Regulations are being released weekly and clarifying a number of issues Some transitional relief will be offered Businesses will need to re-think their employee benefit strategy going forward: Plan design issues including non-discrimination and funding Employee contribution issues Use of the exchange as an employer or individual most exchanges will not be able to handle employer issues (will use agents) Private exchange viable alternative? Continue to offer coverage, or let employees do their own thing Individual employees / consumers will need more help especially when it comes to premium subsidy, plan choice, provider access 19

20 For a copy of this presentation David L. Fear, Sr. RHU , ext 13 davidfearsr@fearcorp.com 20