Transcript Document

Presented by Benefit Health Advisor and
Vantage Financial
Sponsored by Hinton Burdick
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President signed Patient Protection and
Affordable Care Act on March 23rd, 2010.
Effective dates vary – many begin with the
first plan year beginning on or after
September 23rd, 2010.
2014 is a big year in terms of changes and
many items of the law being implemented.
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Pay or Play Coverage Mandate
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Managing Employee Hours
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Minimum Essential Benefits
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Affordable Employee Contributions
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Employers with 50 or More Employees (or
Full-Time Equivalents) Must Offer Coverage
to all Full-Time Employees or Pay an Annual
$2000/Employee Penalty
◦ Full-Time employment is defined as 30 hours per
week.
◦ If an employer is subject to the Pay or Play Penalty,
the penalty does not apply to the first 30 FT
employees.
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Full-time employment is defined as 30 hours
per week.
◦ Includes all compensated time such as vacation and
sick leave.
◦ Seasonal employees working less than 120 days are
not included.
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IRS Lookback Safe Harbor
◦ Look-Back Period: The period of time an employer can use to average the
hours of variable time employees to determine if they qualify for
employer-sponsored health coverage.
 The look-back period cannot exceed 12 months.
◦ Administrative Period: A period of time between the look-back period and
the stability period that an employer uses to calculate employee eligibility
and to communicate those findings to employees.
 Cannot exceed 60 days.
◦ Stability Period: The period of time that employees can stay on the plan
once qualified.
 Must be at least 6 months and must be at least as long as the look-back
period.
 Once qualified, employees can remain on the plan during the stability period
regardless of the actual number of hours they work during the stability
period.
 Employees that do not qualify for the plan are locked out of the plan for the
duration of the stability period regardless of the number of hours worked
during the stability period.
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For an employer to be considered offering
qualified medical coverage, the medical plan
must cover at least 60% of the cost of essential
benefits as defined by the Department of Health
and Human Services.
◦ HHS has developed a calculator to help determine if plan
benefits meet the 60% threshold.
◦ States will also provide a baseline plan design that they
consider a 60% plan for comparison.
◦ Plans may also hire an actuary to make a determination
on whether a plan covers 60% of the cost of essential
benefits.
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To avoid a $3,000/year unaffordability
penalty, employers must offer a plan to their
full-time employees that covers at least 60%
of the claims cost for Minimal Essential
Benefits at employee premium contribution
rates that are less than 9.5% of their W-2
wages.
◦ 9.5% limit applies to the employee cost of the single
premium only. Family premiums can exceed that
threshold.
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This fee affects health insurers, starting in
2014 and increasing at a defined rate until
2018 at which point it will continue to
increase with premium growth.
◦ Impacted plans will be assessed approximately 2.2%
of premium in 2014. This will increase to
approximately 3-4% of premium in future years.
◦ The fee only applies to fully insured plans and the
carriers are required to pay this assessment on
behalf of the groups.
◦ Employers should expect that these costs will be
offset by carriers by additional load in their
premiums.
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Between 2012 and 2019, self-funded medical
plans will be assessed an annual fee to fund
The Patient Centered Outcomes Research
Institute (PCORI).
◦ The fee is $1 multiplied by the average number of
covered lives for policy years ending between
10/01/12 and 9/30/13.
◦ The fee increases to $2 for plan years ending after
9/30/2013 and will increase with inflation for
2014-2019.
◦ Fee must be paid by July 31 following the last day
of the applicable plan year.
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PPACA imposes an assessment to fund state
non-profit reinsurance entities for the
purpose of establishing a high-risk pool for
the individual market.
◦ Assessment is $63/year per plan participant in
2014.
◦ All group plans (both fully-insured and self-funded)
of all sizes must pay the assessment.
◦ Assessment will change in 2015 and 2016.
◦ Assessment is scheduled to end after 2016.
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Pre-Existing Conditions: Plans will be prohibited
from imposing pre-existing condition limitations
on any enrollee, regardless of age.
90-Day Waiting Period: Plans will be prohibited
from imposing waiting periods that exceed 90
days.
Automatic Enrollment: Employers with more than
200 full-time employees must automatically
enroll new full-time employees in their plan.
Employees must pro-actively opt-out of the
coverage if they do not want to be covered by the
employer’s plan.
Items of Interest
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Changes to Dependent Care Eligibility
Benefit Requirements including unlimited
lifetime/annual maximums
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Non-grandfathered plans must provide
preventive services with no employee costsharing.
Women’s Preventive Services
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Well-Woman Visits
Screening for Gestational Diabetes
HPV Testing
Counseling for Sexually-Transmitted Infections
Contraceptive Methods and Counseling
Breastfeeding Support, Supplies and Counseling
Screening and Counseling for Domestic Violence
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Adult Preventive Services Include:
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Abdominal Aortic Aneurysm
Alcohol Misuse Screening and Counseling
Aspirin (for certain ages)
Blood Pressure Screening
Cholesterol Screening
Colorectal Cancer Screening for Adults Over 50
Depression Screening
Type 2 Diabetes Screening
Diet Counseling for Adults at Higher Risk of Chronic
Disease
HIV Screening
Immunizations
Obesity Screening and Counseling
STI Prevention Counseling
Tobacco Use Screening and Certain Cessation Interventions
Syphilis Screening
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Child Preventive Services Include:
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Alcohol and Drug Use Assessments
Autism Screening
Cervical Dysplasia Screening for Sexually Active Females
Congenital Hypothyroidism Screening
Developmental Screening for Children Under 3
Dyslipidemia Screening
Fluoride Chemoprevention Supplements
Newborn Hearing Screening
Height, Weight BMI Measurements
Hematocrit or Hemoglobin Screening
Sickle Cell Screening
HIV Screening for at risk Adolescents
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Child Preventive Services Include (cont.):
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Immunizations
Iron Supplements (6 to 12 months of age)
Lead Screening
Medical History
Obesity Screening and Counseling
Oral Health Risk Assessment
PKU Screening for Newborns
STI Prevention Counseling for Adolescents
TB Testing
Vision Screening for all children
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Beginning in 2014, individuals must have health
insurance or potentially pay a penalty for
noncompliance.
◦ Individuals must maintain “Minimum Essential Coverage”
which does not necessarily include the minimum essential
benefits mandated for employer-sponsored plans.
◦ Qualified health insurance plans include: employersponsored plans, individual plans, Medicare/Medicaid,
other government plans including state-sponsored high
risk plans.
◦ 2014 Penalty: Greater of $95/person or 1% of household
income.
◦ 2015 Penalty: Greater of $325/person or 2% of household
income
◦ 2016+ Penalty: Greater of $695/person or 2.5% of
household income.
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Exchanges are online marketplaces where
consumers can go to shop for health
insurance. Exchanges also administer the
federal subsidies available to consumers.
◦ State-run exchanges: 18 States have elected to
operate their own exchange instead of relying on
the federal exchange.
◦ Federally-run exchanges
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Exchanges open 10-1-2013 for individuals
and small employers.
Employers will be required to notify their
employees of the existence of the exchanges.
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4 Benefit Levels:
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Bronze: Covers at least 60% of aggregate claims.
Silver: Covers at least 70% of aggregate claims.
Gold: Covers at least 80% of aggregate claims.
Platinum: Covers at least 90% of aggregate claims.
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2013
◦ Plan Years Beginning on or After 8/1/12
 Preventive health benefits for women paid at 100%
◦ Plan Years Beginning on or after 9/23/12
 Restricted Annual Limits of no less than $2 million.
 New Standardized Summary Explanation of Benefits
and Coverage (SBC)
 60 Day notice of material changes to SBC
◦ January 1, 2013
 Health FSA limit of $2,500
 W-2 Reporting of cost of health insurance
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2013 (Cont.)
◦ Late Summer/Fall 2013
 Employers must notify employees of Health Care Exchanges
◦ Plan years ending on or after 10/1/2013
 Patient Centered Outcome Research (PCOR) fee imposed on
plan sponsors ($1 multiplied by average number of covered
lives for prior plan year)
◦ October 1, 2013 through February 28, 2014
 Initial enrollment period for State Health Benefit Exchanges
◦ December 31, 2013
 Health plans must certify compliance with certain Electronic
Data Interchange (EDI) requirements surrounding eligibility,
claims status, electronic funds transfer and remittance
advice.
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2014
◦ January 1, 2014
 Individual coverage mandate
 Expansion of wellness incentives from 20% to 30% with an
extra 20% to prevent tobacco use.
◦ First day of plan year beginning in 2014
No annual lifetime dollar limits allowed
No pre-existing condition exclusions allowed
No waiting periods in excess of 90 for FT employees
Automatic enrollment for new employees for employers with
200+ employees
 Cover routine medical costs of clinical trial
 Allow all dependents up to age 26 coverage regardless of
other group coverage
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2014 (Cont.)
◦ Plan years ending on or after October 1, 2013 to
2019
 PCOR fee imposed on plan sponsors ($2 multiplied by
average number of covered lives for prior plan year)
 Plans must report number of covered lives for
Temporary Reinsurance Fee. Fee is estimated at $5.25
per covered life for 2014
◦ November 5, 2014
 Large health plans must obtain a Health Plan Identifier
(small plans – November 5, 2015)
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2015
◦ Employer Shared Responsibility applies (“Pay or Play
rule”) to employers with 50 or more full-time
equivalent employees.
◦ Health coverage reporting requirements to IRS and
covered individuals (awaiting guidance)
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2018
◦ Excise Tax begins for “Cadillac Plans” (awaiting
guidance)
Chris Hillier
Benefit Health Advisor
303-913-0045
[email protected]
Daniel Kemp
Vantage Financial
435-773-3681
[email protected]