Employer Health Insurance Forum. Presentation by the South Dakota Division of Insurance

Transcription

1 Employer Health Insurance Forum Presentation by the South Dakota Division of Insurance

2 Employer Assistance Program Zaniya Task Force Recommendation HB1027 allows agents/insurers to provide insurance related services to employers Employer assistance webpage on Division of Insurance website Employer Forums

3 Employer Assistance Effective 7/1/09 insurers and agents allowed to provide insurance related assistance in the ( administration form of services (e.g. COBRA Employer assistance webpage Tips and information on health insurance for employers

4 Small employers have right to purchase health insurance Small employers (2-50 employees) can purchase group health insurance regardless of health status etc. Rate bands prevent insurers from pricing small employers out of the market max rating differential is.75 to 1.25 with age and gender outside band Insurers can require minimum participation ( 50% (normally 75%) and participation (often

5 Availability of Group Insurers Plenty of choice in insurance companies ( ) 15 Small group 12 Large group Variety of choices in plan design Literally thousands of different options in deciding what plan to choose South Dakota has some mandates but fewer than most other states With small group, insurers must offer all plans to all small employers

6 Samples of cost saving options Deductibles and coinsurance Disease management (limitations on how it's ( regs structured due to federal HIPAA Defined contribution Network restrictions Wellness programs

7 Three types of continuation available in South Dakota COBRA/mini COBRA COBRA for 20+ employees (federal) Mini COBRA under 20 employees (state) Both apply when employees leave employment/dependent with qualifying event Continuation when employer ceases operations (state) Employee pays premiums and applies for coverage directly to insurer Only 12 months coverage

8 COBRA and mini COBRA COBRA Applies to employers who have 20 or more employees Continuation coverage for covered employees, spouses, and dependent children upon qualifying events. 60 days to elect COBRA continuation Mini COBRA Applies to employers with less than 20 employees Generally mirrors COBRA

9 Qualifying Events for Employees Voluntary or involuntary termination of employment for reasons other than gross misconduct Reduction in the number of hours of employment

10 Qualifying Events for Spouses Voluntary or involuntary termination of the covered employee's employment for any reason other than gross misconduct Reduction in the hours worked by the covered employee Covered employee's becoming entitled to Medicare Divorce or legal separation of the covered employee Death of the covered employee

11 Qualifying Events for Dependent Children Loss of dependent child status under the plan rules Voluntary or involuntary termination of the covered employee's employment for any reason other than gross misconduct Reduction in the hours worked by the covered employee Covered employee's becoming entitled to Medicare Divorce or legal separation of the covered employee Death of the covered employee

12 Early Termination of continuation coverage Group health Plan may terminate continuation coverage early for: Premiums are not paid in full in a timely basis The employer ceases to maintain any group health plan A qualified beneficiary begins coverage under another group health plan after electing continuation coverage (as long as that plan doesn t impose any exclusion or limitation with respect to any preexisting condition of the qualified beneficiary) A qualified beneficiary becomes entitled to Medicare benefits after electing continuation coverage; The notice must be given as soon as practicable after the decision is made, and it must describe the date coverage will terminate, the reason for termination, and any rights the qualified beneficiary may have under the plan or applicable law.

13 Longer Periods of Continuation Disability can extend the 18 month period of continuation coverage for a qualifying event that is a termination of employment or reduction of hours. To qualify for additional months of COBRA continuation coverage, the qualified beneficiary must: Have a ruling from the Social Security Administration that he or she became disabled within the first 60 days of COBRA continuation coverage. Send the plan a copy of the Social Security ruling letter within 60 days of receipt, but prior to expiration of the 18-month period of coverage. If these requirements are met, the entire family qualifies for an additional 11 months of COBRA continuation coverage. Plans can charge 150% of the premium cost for the extended period of coverage. A second Qualifying Event may also extend COBRA continuation coverage to 18 months giving a total of 36 months of continuation coverage. If a second qualifying event does occur, you will need to notify the plan. A description of the notification process should be described in your plan document

14 Options to Decrease Benefits Any insurer offering continuation coverage, whether the continuation is pursuant to COBRA or mini COBRA, shall offer to all beneficiaries who are eligible the option to decrease benefits. The options shall include, at a minimum, those coverage options that would have been otherwise available to employees or dependents who initially enrolled into the coverage if the options decrease coverage or a carrier may offer a standardized plan to all those eligible for continuation that contains similar benefits to the beneficiaries prior coverage but at a higher deductible or other reduced benefit features. If a person does not elect the option to decrease benefits and continues the group plan with no change in benefits, that person does not have the right to a reduction in benefits at a later date even if it is an open enrollment period under the group plan. Reduced coverage option applies to second chance continuation options under ARRA

15 American Recovery & Reinvestment Act ARRA -New opportunities to elect continuation of group health insurance

16 Plans subject to the premium reduction provisions All group health plans sponsored by private-sector employers or employee organizations (unions) subject to the COBRA rules under the Employee Retirement Income Security Act of 1974 (ERISA). Also apply to plans sponsored by State or local governments subject to the continuation provisions under the Public Health Service Act, and plans in the Federal Employee Health Benefits Program (FEHBP). The premium reduction is also available under state continuation (mini COBRA).

17 Who is eligible to receive the COBRA premium reduction? "assistance eligible individuals." COBRA qualified beneficiary who meets the following requirements: Is eligible for COBRA continuation coverage at any time during the period from September 1, 2008 through December 31, 2009; Elects COBRA coverage (when first offered or during the additional election period provided by ARRA); and The COBRA election opportunity relates to an involuntary termination of employment that occurred at some time from September 1, 2008 through December 31, If the individual is eligible for other group health coverage (such as through a new employer s plan or a spouse's plan) or Medicare he/she is not eligible for the premium reduction.

18 Second Election Opportunity Qualified beneficiaries whose qualifying event was an involuntary termination of employment during the period from September 1, 2008 through February 16, 2009 who did not elect COBRA when it was first offered OR who did elect COBRA but are no longer enrolled (for example, those who dropped COBRA coverage because they were unable to continue paying the premium) have a new, second election opportunity. This is also true of those individuals who did not elect State Continuation (minicobra). This was made possible through emergency rule 120:06:40:19 through 120:06:40:22. Individuals eligible for the extended COBRA election period must receive a notice informing them of this opportunity. This notice must be provided by April 18, 2009 and individuals have 60 days after the notice is provided to elect COBRA. However, this special election period does not extend the period of COBRA continuation coverage beyond the original maximum period (generally 18 months from the employee's involuntary termination). COBRA coverage elected in this special election period begins with the first period of coverage beginning on or after February 17, 2009.

19 Pre-existing condition exclusions The period beginning on the original qualifying event date and ending on the first day of the first COBRA coverage period beginning after the date of the enactment of the ARRA is disregarded when determining if the individual had a 63 day break in coverage for purposes of applying pre-existing condition exclusions.

20 Premium Reimbursement The employer (or other responsible entity) may recover the subsidy provided to Assistance Eligible Individuals by taking the subsidy amount as a credit on its IRS Form 941 quarterly employment tax return. For more information on the Form 941 credit and the tax provisions in ARRA, visit the IRS web site.

21 Notice Requirements Plans and issuers are required to notify qualified beneficiaries regarding the premium reduction and other information about their rights under ARRA as follows: A general notice to all qualified beneficiaries, whether they are currently enrolled in COBRA coverage or not, who have a qualifying event during the period from September 1, 2008 through December 31, This notice may be provided separately or with the COBRA election notice following a COBRA qualifying event. A notice of the extended COBRA election period to any Assistance Eligible Individual (or any individual who would be an Assistance Eligible Individual if a COBRA continuation coverage election were in effect); who had a qualifying event at any time from September 1, 2008 through February 16, 2009; and who either did not elect COBRA continuation coverage or who elected but subsequently discontinued COBRA. This notice must be provided within 60 days following February 17, Unless specifically modified by ARRA, the existing COBRA notice manner and timing requirements continue to apply. The issuer of the group health plan must provide the notice to qualified beneficiaries with the information on how to apply for the premium reduction. The Department of Labor has developed model notices that are available.

22 Continuation of coverage for full time students If a group plan is providing coverage for dependent children, there is a statutory right to continue coverage until age 30 Only if a full time student at an accredited institution of higher learning Not retroactive, if break in coverage then no continuation right exists

23 CHIPRA special enrollment for SCHIP New federal legislation requires plans to have a special enrollment if a dependent loses eligibility for SCHIP or Medicaid Also special enrollment if qualifying for Medicaid or SCHIP Special enrollment (must be within 60 days) means that participant/dependent can elect to enroll in the plan as if the employee were a new hire can't be treated as late enrollee Required even if plan documents not updated

24 2009 Legislation

25 SB 29 ~ Group life changes Allow for continuity of coverage for employees when switching group life carriers If employee disabled can choose to continue coverage by prior carrier If not, presumed actively at work unless gone on unapproved absence Additional notice provisions for employers/employees

26 SB 19 An Act to revise the grounds for which continuation or conversion is not required for group health policies. This bill deletes the continuation requirement when an insurance company cancels for reasons of failure to meet participation requirements or other eligibility requirements. The bill also allows affected employees and dependents who do not have another source of health insurance to get into the risk pool. It does so by waiving the 12 months of prior creditable coverage requirement for these employees and dependents.

27 SB 109 An Act to revise the provisions for the risk pool to allow uninsurable children to enroll and provide for additional funding This legislation will allow uninsurable children to join the risk pool based on certain enrollment criteria Only category of individuals eligible without prior qualifying coverage

28 Implementation of SB 109 July 1, 2009 effective date Enrollees must: Under the Age of 19 South Dakota resident Citizen of the United States Been rejected or offered coverage conditioned upon exclusionary riders by at least two carriers No comprehensive major medical coverage or other creditable coverage within the past 6 months Not covered or eligible for any other creditable coverage Subject to six month waiting period unless applying during the open enrollment

29 SB 109 ~ Open Enrollment July 1, days Without Creditable Coverage for at least 12 months Enrollee not subject to a pre-existing waiting period if enrolling during this open enrollment

30 South Dakota Risk Pool Bureau of Personnel South Dakota Risk Pool Capitol Building 500 East Capitol Avenue Pierre, SD fax

31 Future? Obama's plan Require insurers to cover preexisting conditions National health insurance exchange that sells plans directly to individuals without access to group plans Large employer play or pay Small business health tax credit Cover catastrophic losses in return for lower employee premiums

32 Division of Insurance Website

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36 DOI Website Highlights Tips for Shopping for Insurance Coverage Licensed Insurance Companies Verify Licensure COBRA Information

37 Questions? 445 E Capitol Avenue Pierre, SD insurance@state.sd.us