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Patient Protection and AffordableCare Act (PPACA)
The information contained in this presentation has been collected from multiple documents and presentations. It is not intended to contain any legal advise. Please consult with you legal advisors for specific information that may apply to you and your company.
Editorial Moment
Who is at fault?
Consumer
Insurance
Companies
Doctors
Agents
Lawyers
The Law
The President signed the health care legislation into law on March 23, 2010.
The regulations defining the law are being written by HHS, DOL and IRS.
IRS & OSHA have monitoring responsibility
CMS has responsibility for most of the implementation, including that of the Marketplace
You can keep your insurance
Grandfathered Plans
Grandfathered PlanBenefits of Retaining Status
◦Exemption from rating restrictions based on age variation
◦Ability to continue coverage based on class
◦Exemption from implementing Essential Health Benefits (e.g. pediatric dental)
A Grandfathered Plan
Increase Deductible up to 15%
Increase Co pays up to 15%
Increase Co insurance more than 15%
Decrease employer contributions by more than 5%
Grandfathered Plan
Most plans have lost Grandfather status. Those who have retained status must:
◦Plans must provide a statement to participant that it believes it is a “grandfathered” plan
◦Do you have your documents?
Dependents Coverage
Age 26
•Coverage for children must be available until the child reaches age 26
Do you have proof of the notice to employees? (Penalty up to $100 per day)
Minimum Loss RatioMLR
Minimum Loss Ratio MLR (2011)
The MLR is 85% for large group plans and 80% for individual and small group plans (50 and below).
Carriers will have to issue a premium rebate to individuals for plans that fail to meet the minimum MLR requirements.
Large Groups
51 or More Full Time Employees
Play or Pay
Employer Responsibility
Effective starting January 1, 2015
Employer must count all full-time employees and part-time employees – on a full-time equivalent basis in determining if they have 50 or more employees
No Coverage
If an employer fails to provide its full-time employees (and their dependents) the opportunity to enroll in “minimum essential coverage,” and
One or more full-time employees enrolls for coverage in an exchange and qualifies for a premium tax credit, then
Employer penalty = $2,000 for each of its full-time employees in the workforce◦This penalty is non-deductible◦Penalty does not offset the cost of employee coverage
Calculating Full Time Equivalent Employees
Total number of full time employees = 30Part time employees = 40Total hours worked by each part time employees in a
calendar month = 20 hrs / week X 40 = 3,200 hrs3,200 / 120 = 27 Part time equivalent employeesTotal full time and full time equivalent employees =
57Play or Pay penalties apply
Affordable Coverage
If employer offers its full-time employees (and their dependents) the opportunity to enroll in minimum essential coverage, and
One or more full-time employees enrolls for coverage in an exchange and qualifies for a premium tax credit or cost sharing reduction because
Affordable Coverage
◦The employee’s share of the premium exceed 9.5% of income, or◦The actuarial value of the coverage was less than
60%, then • Employer penalty = $3,000 for each full-time
employee who receives a tax credit or cost-sharing reduction• If the employer has many employees in this
category, the alternative penalty reverts to $2,000 per FT employee
Affordable Coverage Example
Employee hourly wage $9.50 per hour
$9.50 X 40 hours = $380.00
$380 X 9.5% = $36.10 per week
Employee cost of health insurance $156.43
Tracking Time
Start tracking part time hours now
Start tracking full time hours now
Learn about the safe harbor for seasonal employees
Miscellaneous Requirements
If employee is covered by spouses plan there is no penalty to employer unless 50+ and employer does not provide coverage or provides unaffordable coverage.
Employers are not required to cover spouses. Definition of a dependent does not include the spouse
Small Groups
1 to 50 Full Time Employees
PPACA “Metal” Plans
BronzeSilver
GoldPlatinum
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
60%70%
80%90%
Minimum Value Standards
Minimum value - actuarial value threshold of 60%
Small group plans in the bronze level of coverage meet minimum value requirements.
Beginning in 2014, summaries of benefits and coverage must indicate whether the plan meets applicable minimum value requirements
Minimum Essential Coverage
The type of coverage an individual needs to have to meet the individual responsibility requirement◦Individual market policies◦Job-based coverage◦Medicare, Medicaid, CHIP, TRICARE
The law does not specify the details of what this coverage has to be, other than it has to cover preventive care with no cost-sharing and can’t be dental-only or vision-only (limited benefit)
User Inputs for Plan ParametersUse Integrated Medical and Drug Deductible?
Apply Inpatient Copay per Day? HSA/HRA Employer Contribution? Blended Network/POS Plan?Apply Skilled Nursing Facility Copay per Day?
Use Separate OOP Maximum for Medical and Drug Spending?Grandfathered Plan?
Medical Drug Combined Medical Drug CombinedDeductible ($)
Coinsurance (%, Insurer's Cost Share)OOP Maximum ($)
OOP Maximum if Separate ($)
Click Here for Important Instructions
Type of BenefitSubject to
Deductible?Subject to
Coinsurance?Coinsurance, if
differentCopay, if separate
Subject to Deductible?
Subject to Coinsurance?
Coinsurance, if different
Copay, if separate
Tier 1
MedicalEmergency Room ServicesAll Inpatient Hospital Services (inc. MHSA)Primary Care Visit to Treat an Injury or Illness (exc. Well Baby, Preventive, and X-rays)Specialist VisitMental/Behavioral Health and Substance Abuse Disorder Outpatient ServicesImaging (CT/PET Scans, MRIs)Rehabilitative Speech Therapy
Rehabilitative Occupational and Rehabilitative Physical Therapy
Preventive Care/Screening/Immunization 100% $0.00 100% $0.00Laboratory Outpatient and Professional ServicesX-rays and Diagnostic ImagingSkilled Nursing Facility
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Outpatient Surgery Physician/Surgical ServicesDrugs
GenericsPreferred Brand DrugsNon-Preferred Brand DrugsSpecialty High-Cost DrugsOptions for Additional Benefit Design Limits:
Set a Maximum on Specialty Rx Coinsurance Payments?Specialty Rx Coinsurance Maximum:
Set a Maximum Number of Days for Charging an IP Copay?# Days (1-10):
Begin Primary Care Cost-Sharing After a Set Number of Visits?# Visits (1-10):
Begin Primary Care Deductible/Coinsurance After a Set Number of Copays?
# Copays (1-10):Output
Status/Error Messages:Minimum Value:
Service Not Covered?
HSA/HRA Options Narrow Network Options
Annual Contribution Amount:2nd Tier Utilization:1st Tier Utilization:
Tier 1 Plan Benefit Design Tier 2 Plan Benefit Design
Tier 1 Tier 2
Calculate
All
All
All
All
All
All
All
All
Minimum Value Calculator
Essential Health Benefits
The 10 categories of benefits individual and small employer plans have to provide:
◦Outpatient care◦Emergency room◦Treatment in the hospital◦Maternity◦Mental health and substance use disorder services◦Prescription drugs◦Rehabilitative and habilitative services.◦Lab tests◦Preventive services◦Pediatric dental and vision
Age Rated Plan Small Group
Censuses must provide every dependent’s date of birth and the quotes will be lined out with a rate for each belly button. So a quote might look like this on a 3-person group:
John Brown $328.95 Employee Joe Smith $358.23 Employee/Spouse/Children Jane Smith (wife) $429.29 Danny Smith (12) $158.77 Jennifer Smith (14) $167.23 Joey Smith (22) $253.97 Susie Smith (24) $260.09 Bobby Jones $598.98 Employee/Spouse Anna Jones (wife) $555.23
Health Insurance Marketplace(The Exchange)
Community Rating
Primary component of the law affected by
Age band limitations (7:1 goes to 3:1)No health underwritingCost-sharing limits (e.g. $2,000 ded)Essential health benefitsNo pre-existing conditions
Health Insurance MarketplaceThe Exchange
Smaller provider networks
Smaller hospital network
No out of network benefits on some plans
Gatekeeper plans (no open access)
Federal subsidies only available through the Exchange are based on:
◦The premium cost of the second-lowest silver Exchange plan
◦The household income of the applicant
Health Insurance Market PlaceThe Exchange
Federal Subsidies
Household Income Level (% above FPL)
Maximum Premium as Percentage of Income
Less than 133% 2.0%
At least 133% but less than 150% 3.0% - 4.0%
At least 150% but less than 200% 4.0% - 6.3%
At least 200% but less than 250% 6.3% - 8.05%
At least 250% but less than 300% 8.05% - 9.5%
At least 300% but less than 400% 9.5%
2013 Federal Poverty Level
Persons in Family
100% FPL 133% FPL 250% FPL 400% FPL
1 $11,490 $15,282 $28,725 $45,960
2 $15,510 $20,628 $38,775 $62,040
3 $19,530 $25,975 $48,825 $78,120
4 $23,550 $31,322 $58,875 $94,200
5 $27,570 $36,668 $68,925 $110,280
6 $31,590 $42,015 $78,975 $126,360
7 $35,610 $47,361 $89,025 $142,440
8 $39,630 $52,708 $99,075 $158,520
Individual Mandate Penalties
For individuals (whichever is greater)
2014 $95 or 1% of income above tax filing threshold ($9,500 in 2011)
2015 $325 or 2% of income above tax filing threshold
2016 $695 or 2.5% of income above tax filing threshold Note: Penalty for dependents under age 18 is one half of the individual amount.
For families (whichever is greater)
2014 $285 or 1% of income above tax filing threshold
2015 $975 or 2% of income above tax filing threshold
2016 $2085 or 2.5% of income above tax filing threshold
Community Rating
Real Life Examples
Family of three – 63 male, 59 female, 18 son◦Current $2500 deductible plan $819.32◦2014 $2500 deductible plan $1,397.29
Family of four – 49 male, 50 female, 14 son, 12 daughter◦Current $5,000 deductible plan $423.93◦2014 $2500 deductible plan $965.51
Small Business Marketplace (SHOP)
For a small business to qualify to purchase coverage on a SHOP they must:
Be in a SHOP service areaHave at least one common law employee (not owners)Have 50 or fewer total FTE employeesPay a consistent percentage or amount toward the premium
(at least 50%)Receive tax creditAn employer can use a defined contribution to pay for an
employee to purchase individual coverage only if that coverage is purchased through a SHOP plan.
Increasing Premiums 3% to 4%
Taxes
PCORI Tax-$2.00 per covered individual-Self Admin HRA, per employee (belly button tax)
Re insurance Tax-$63.00 per year (belly button tax) Funds large claims in the individual marker
HIT Tax- $8 B divided by premiums collected in prior year 2014. $15 B 2015, $18 B 2016- Paid by insurers to help fund health care reform
All are pass through taxes
January 1, 2013
Medicare Tax increase for high income earners an additional 0.9 to employees earning over $200,000 ($250,000 joint filers).
Miscellaneous Requirements
Government Initiative
DOL ran a contest for the best software to inform employee about their labor laws.
Award winner on November 4
$14 M effort to educate employees
1099 Independent Contractors
Many employers have said the will move employees to 1099 status.
The IRS is on to this and will be conducting audits.
An employee can contact IRS and ask about their status and you could receive an audit notice.
Engage an independent contractor for a year or more.
Be very careful with this!!!!!!!
Independent Contractor
You are not an independent contractor if you perform services that can be controlled by an employer (what will be done and how it will be done). This applies even if you are given freedom of action. What matters is that the employer has the legal right to control the details of how the services are performed.
January 1, 2014
Guarantee Issue
State Exchanges/Federal Exchange
Modified Community Rating (Groups 50 or less)
Redefines Small Group at 1-100 in 2016
Employer Mandate
Waiting Periods 90 Days Max.
Miscellaneous Requirements
Full Time Employee for health insurance purposes-30 hours per week
There is no requirement to pay the health insurance for part time employees
W-2 Reporting
Employers who issue 250, or more W-2s are required to list the value of the health insurance on the W-2.
Reporting
Employers will report employees and the hours worked each month. 2015
Exempt employees can be calculates at 8 hours per day, 40 hours per week, or actual hours worked.
Form 1095-C
Information must also be provided to each employee
Flexible Spending AccountsFSA
Flexible Spending Accounts (FSA)-Over the counter drugs are not eligible. $2,500 cap
RequiredNotices
Summary of Benefits and CoverageSBC
Uniform Explanation of Benefits◦Maximum 4 pages◦Minimum 12 point font
Penalty up to $1,000 per affected individual.
SBCDeveloped and
provided by the insurance company
Delivered during Open Enrollment
At a Qualifying Event
60 days prior to a plan change during the plan year
When an employee qualifies for coverage during the plan year
Upon request
Health Insurance Marketplace(Exchange) Notice
Employee Notice Requirement
Employers must issue a notice to employees about the Health Insurance Marketplace (Exchanges) availability and premium assistance by October 1, 2014.
No penalty
Medicare Creditable Coverage Notice
Distributed by October 15th
Distributed to all employees age 65 and older
States the company health pan has drug coverage equal to or better than Medicare Part “D”
Online verification to CMS within 60 days of renewal
Health Reimbursement Arrangement (HRA)
No stand alone, except for retirees
Possible Strategies
Will employers drop coverage to save cost?
Some will and force their employees to the Exchange.
In some cases, the penalties are lower than the cost of coverage, but what about the soft cost of competition?
Early Renewals
Keeps current plan design in place until December 1, 2014
Avoids age rates plans for all groups under 50
Avoids community rates
Avoids PPACA plan designs
Level Funded Partially Self Funding
Employer liability limited to the monthly premiums
Monthly claims reports
If plan develops a surplus the employer can receive a refund
If plan runs in a deficit, no deficit recovery
Defined Contribution
Places the insurance buying decision in the hands of the employee.
Must still comply with affordability.
Wide range of options for the employee.
Must be equal to all
Defined Contribution
Employer Allowance $300
Medical $250
Dental $25
Vision $10
Total $285
Employee $15
Summary
You will be exposed to every concept you can imagine.
Some old concepts, some new
Some will survive, and some will cause the employer bigger problems
caveat emptor (May the buyer beware)
Select a trusted advisor
Document
Document
Document
Document
Websites
DOL.gov
HHS.gov
IRS.gov
Healthcare.gov
CMS.gov-search “minimum value calculator”
EEOC.gov
e2eresources.com
Thank You
![The Patient Protection and Affordable Care Act [PPACA = ACA]](https://img.pdfslide.us/doc/110x75/56813484550346895d9b6444/the-patient-protection-and-affordable-care-act-ppaca-aca.jpg)
