The Effect of the Affordable Care Act on Your Small Business. Presented to : Greater Kansas City Chamber Business Class

Transcription

1 The Effect of the Affordable Care Act on Your Small Business Presented to : Greater Kansas City Chamber Business Class November 6, 2013

2 KHN Kaiser Health News Current Headlines October 31- November 4, 2013 Obama Seeks To Rally Health Law Support With Appearances This Week Study Finds One In Five People Who Visited Health Website Enrolled In A Plan Appeals Court Decision Is Latest Blow To Birth Control Mandate, Setting Up Possible Supreme Court Consideration For Many Workers, It s Time To Consider Insurance Options Oregon's State Exchange May Be Worse Than Healthcare.gov Figuring Out Health Law Winners And Losers Involves Trade- Offs; Triggers Anxiety, Confusion 2

3 KHN Kaiser Health News Current Headlines October 31 November 4, 2013 So You Found An Exchange Plan. But Can You Find A Provider? Doctors Treat New Condition: Questions About Health Law A Central Health Law Question: Who Is Getting Covered? Who Is Getting Canceled? Some States See Enrollment Success Even As Others, Federal Insurance Exchange Struggle Most Uninsured Signing Up On Health Website Are Going To Medicaid Obama Offers Spirited Health Law Defense, Pledges To 'See It Through' 3

4 Affordable Care Act Timeline 4

5 Today s Topics Individual Mandate Employer Shared Responsibility Obligations Reporting Obligations for Employers Small Employer Defined: Who Is Exempt From the Employer Shared Responsibility Requirement? Health Insurance Marketplaces (Exchanges) Individual Marketplace Small Business Health Options Program (SHOP) Marketplace Private Marketplace Options Local Market Overview Blue Cross/Blue Shield of KC 5

6 Individual Mandate Beginning January 1, 2014, all individuals residing in US required to maintain minimum essential health coverage (MEC) for themselves and their dependents. Transition Relief: An Individual eligible for non-calendar year employer plan will not be subject to individual shared responsibility requirement until the plan anniversary occurring on or after January 1,

7 Individual Mandate Potential Penalties for Failure to Maintain MEC Year Penalty 2014 Greater of: $95 per adult and $47.50 per child (up to $285 for a family); or 1.0% of family income 2015 Greater of: $325 per adult and $ per child (up to $975 for a family); or 2.0% of family income 2016 and Beyond Greater of: $695 per adult and $ per child (up to $2,085 for a family); or 2.5% of family income 7

8 Important Definitions Minimum Essential Coverage (MEC): Includes ERsponsored group plans, Government plans, Individual Policies, other comprehensive coverage Essential Health Benefits 1. Ambulatory patient services 6. Prescription drugs 2. Emergency services 7. Rehabilitative & habilitative 3. Hospitalization services & devices 4. Maternity & newborn care 8. Laboratory services 5. Mental health & substance use 9. Preventive & wellness services & disorder services, includes behavioral chronic disease mgmt health treatment 10. Pediatric services, includes oral & vision care 8

9 Important Definitions Affordability: Employee's required contribution <9.5% of employee s household income Minimum Value: Plan pays 60% of total allowed cost of benefits under plan (3 methods: MV calculator, safe harbor design or actuarial certification) 9

10 Employer Shared Responsibility Requirement Beginning January 1, 2014, a tax penalty could be imposed against employers who: 1. Fail to offer health coverage to full-time employees; or 2. Offer health coverage that is inadequate or unaffordable to employees qualified for premium tax credits or cost-sharing reductions. Applies to All Public and Private ERs who employ 50 FT (plus FTE) employees on business days during preceding calendar year 10

11 Employer Shared Responsibility Requirement Two separate potential excise taxes assessed: 1. No Coverage Penalty: Failure to offer MEC to FTE 30+ hours: $2,000 per full time employee 2. Inadequate or Unaffordable Penalty: Coverage fails to meet minimum value standard or is unaffordable: $3,000 per impacted employee who receives subsidy 11

12 Employer Shared Responsibility Requirement Provisions Delayed until January 1, 2015 (IRS Notice , issued July 9, 2013) Potential excise tax penalty for failure to offer adequate coverage at affordable rate IRC Code Sections 6055 and 6056 reporting requirement and related benefit statements to employees. 12

13 Marketplace Notice Obligation Who is required to provide the Marketplace Notice? All employers subject to Fair Labor Standards Act Who gets the Marketplace Notice? All employees, including FT and PT employees without regard to eligibility status for the health plan Who need not be given the Marketplace Notice? Dependents of employees Former employees including retirees Former employees on COBRA (active employees on COBRA get the notice) When must the Marketplace Notice be given? For current employees: Before October 1, 2013 New Hires: Within 14 days of hire 13

14 Other Plan Disclosure Obligations Summary of Benefits and Coverage (SBC) All group health plans, including grandfathered plans, whether insured or selffunded must provide SBCs to plan participants: 1. Upon application 2. By the first day of coverage 3. Within 90 days of enrollment be special enrollees 4. Upon contract renewal 5. Upon request For coverage beginning 1/1/14 and before 1/1/15, SBC must include a statement whether the plan does/does not meet minimum essential coverage standards and minimum value standard. Other plan disclosures SPD and SMM must be updated for changes 14

15 Other Plan Disclosure Obligations Medicare Part D Notices were due to employees by October 15 th Annual Medicare Part D open enrollment period for the 2014 year is 10/15/13 12/7/13 The Medicare Part D Notice of Creditable or Noncreditable Coverage must be provided to Medicareeligible individuals prior to October 15,

16 Group Health Plan Mandates For plan years beginning on or after January 1, 2014 all group health plans, including grandfathered and nongrandfathered plans must include these mandates: Ban on preexisting condition exclusion limitations on anyone; Extension of dependent coverage until age 26; Full implementation of ban on annual or lifetime limits for essential health services; Increased limit in outcome-based incentives/disincentives permitted in wellness programs from 20 to 30%; or, up to 50% for tobacco free programs; and Ban on waiting periods exceeding 90 days. 16

17 Group Health Plan Mandates For plan years beginning on or after January 1, 2014, non-grandfathered health plans are subject to these ACA Provisions: Fair health insurance premiums; Guaranteed availability of coverage; Guaranteed renewability of coverage; Ban on discrimination against health care providers ( any willing provider type laws); Coverage for individuals participating in approved clinical trials 17

18 Group Health Plan Mandates Inclusion of essential benefit coverage, providing a specified actuarial value, and cost-sharing limitations by insurers in small group and individual markets, and large group markets via State marketplaces. Cost Sharing Limitations: Deductible (only applicable to small insured plans offered in/outside Marketplace) $2,000 for single coverage $4,000 for coverage for more than one Out-of-pocket (applicable to insured plans offered via Marketplace, and insured and self-funded plans offered outside Marketplace) $6,350 for single coverage $12,700 for coverage for more than one 18

19 The Health Insurance Marketplace Landscape Public Marketplace Individual Marketplace can be: State Exchange State/ Federal Partnership Exchange Federal Exchange (Kansas and Missouri) Small Business Health Options Program (SHOP) can be: State Exchange State/Federal Partnership Federal Exchange (Kansas and Missouri) Private Marketplace Single-Carrier Private Exchanges Multi-Carrier Private Exchanges 19

20 Public Marketplace: Its Core Functions: Consumer Assistance: Toll-free information line; Internet comparison tool; Navigator program Plan Management: Certify and rate qualified health plans; conduct monitoring and oversight of plans Eligibility: Verify eligibility, including for premium assistance tax credits and cost sharing subsidies; connect applicants to Medicaid and CHIP if eligible Use HHS-managed data services hub to connect to federal data sources (IRS, Social Security, Homeland Security) Enrollment: Facilitate enrollment in qualified health plans Financial Management: Process premiums; ensure stabilization of premiums through reinsurance and risk adjustment 20

21 Public Marketplace: The Basic Must-Haves: A Qualified Health Plan (QHP) must be certified to be offered on the Exchange and Covers the Essential Health Benefits (EHB): Ambulatory patient services Emergency services Hospitalization Maternity and newborn care Mental health and substance abuse disorder services Prescription drugs Rehabilitative/habilitative services Laboratory services Preventive and wellness services and chronic disease management Pediatric services 21

22 Four Metal Tiers: 90% 80% 70% 60% Platinum Plan pays 90% of the cost of covered benefits Gold Plan pays 80% of the cost of covered benefits Silver Plan pays 70% of the cost of covered benefits Bronze Plan pays 60% of the cost of covered benefits 22

23 Individual Marketplace and SHOP Marketplace Must Also: Provide 60% actuarial value minimum Adhere to deductible and out-of-pocket maximum limits Participation in Individual Marketplace: Is an After-Tax Expense (Not Tax Favored) Self-employed must use Individual Marketplace (Not Considered Employers) SHOP Marketplace: Effective in 2014, only SHOP Employers are Eligible for Small Business Tax Credit (some transitional relief is available for non-calendar year plans) Enrollment in the SHOP has been delayed until November 23

24 Public Versus Private: What s the Difference? Who sponsors it? What will be offered? Who purchases it? Public Marketplace Government Entity either state or federal (if state delegates responsibility) Primarily medical, dental and /or vision insurance through multiple carriers Individuals purchasing insurance on their own and small businesses with up to 100 employees Private Marketplace Private company Medical, dental, and vision, plus, in some cases, other insurance products ranging from life, disability, critical illness, home, auto, and even pet insurance either through a single carrier or multiple carriers Active employees and retirees of the sponsoring organization, and their dependents Who pays for it? Consumer, small employer or both (federal subsidies are available to individuals with up household incomes up to 400% of federal poverty level who are not eligible for employer coverage) Consumer or employer 24

25 Small Business Tax Credit Employers with no more than 25 employees and average annual wages of less than $50,000 Tax credit of up to 35% of premiums Pay at least half the cost of coverage for employee only Arrangement must provide nonelective contribution for each enrolled employee Cannot be through salary reduction agreement Premium deduction reduced by credit amount Eligible tax exempt employers receive a credit of 25% After 2013, the credit increases to 50% for employers (35% for tax exempt), but only if coverage purchased through an insurance Marketplace (exchange), Subject to a 2 consecutive-year limit, i.e., ER can only claim credit for 2 years. The small employer does not relinquish its right to the credit by not taking it immediately. In other words, the employer could decide to claim the credit in 2017 and 2018, even though it may have qualified for the credit earlier. Aggregation Rules apply to number of employees and to annual wage limitations 25

26 New benefit & coverage rules Employer Impacts Description Small Group Fully Insured Large Group Fully Insured Self- Funded Individual 1 Essential Health Benefits (EHB) * Health Plans must provide Essential Health Benefits for individual and small group Yes No No Yes 2 OOP Max * OOP limits must comply with OOP limits for HSA plans All cost sharing (including copays) for EHB services must count toward OOPM Yes Yes Yes Yes 3 Deductible Limits * Beginning 2014 plan design deductibles may not exceed a $2,000 (self-only) or $4,000 (other than self-only) annual limitation Yes No No No 4 Metallic Levels* Four tiers of coverage for EHB packages: Bronze, Silver, Gold, and Platinum and catastrophic coverage (under 30-yearolds only) Requirement to meet actuarial value of one of four plans Requirement in and out of Exchange Yes No No Yes Pre-existing Condition Exclusion (All Ages) Beginning in 2014, pre-existing condition exclusions must be removed for all members, not just those under age 19 Yes Yes Yes Yes* * Not required for grandfathered plans For many 2014 provisions, we are awaiting further guidance. Information will be updated. 26 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

27 Carrier Marketplace Participation In KC Metropolitan area: Individual Marketplace BCBS of KC Coventry SHOP Marketplace (Small Group under 50) BCBS of KC 27

28 Carrier Variances Products and Plan Designs Network Options Rx Plan Designs Participation Requirements Impact of Age Changes on Unit Rates Pediatric Dental & Vision 28

29 The Big Picture for Small Groups: Questions you should be thinking about Can you obtain a Small Business Tax Credit if you enroll in SHOP Marketplace? What carriers are available in the SHOP Marketplace? How many plan choices do you want available to your employees? What are the offerings of the Private Marketplaces (carriers, plan options, voluntary products, etc.)? Do you continue with your current arrangement and continue to sponsor a group plan? Go self-funded (self-funded plans are exempt from some ACA mandates) 29

30 Resources Available CBIZ Health Reform site: Federal Government Health Reform Site: Center for Consumer Information and Insurance Oversight (CCIIO): Kaiser Family Foundation Site: Robert Wood Johnson Foundation: The Commonwealth Fund: Reform/Health-Reform-Resource.aspx 30

31 Questions?

32 Appendix

33 Premium Tax Assistance/Cost Sharing Available in Individual Marketplace Option Only: Table 1: Premium and Cost-Sharing Subsidies Under Health Reform [2] Income Required Premium Contribution Actuarial value of Percentage of Annual dollar Percentage of Monthly dollar coverage poverty line amount income amount Family of four % $23,550 - $31,322 2% $39 - $52 94% % $31,322 - $35, % $78 - $118 94% % $35,325 - $47, % $118 - $247 87% % $47,100 - $58, % $247 - $395 73% % $58,875 - $70, % $395 - $559 70% % $70,650 - $82, % $559 - $652 70% % $82,425 - $94, % $652 - $745 70% Individual % $11,490 - $15,282 2% $19 - $25 94% % $15,282 - $17, % $38 - $57 94% % $17,325 - $22, % $57 - $121 87% % $22,980 - $28, % $121 - $193 73% % $28,725 - $34, % $193 - $272 70% % $34,470 - $40, % $272 - $318 70% % $40,215 - $45, % $318 - $364 70% 33