Affordable Care Act Resource Guide

Transcription

1 Affordable Care Act Resource Guide for Businesses with 50 or more employees Effective January 22, 2015 Form No (02-16)

2 The information in this document is a general overview of the rules, regulations and consequences of the ACA. It may not address every aspect of the ACA that affects your health insurance and is not intended to be legal or tax advice.

3 Large Group Table of Contents Affordable Care Act Overview...2 Compliance Status Options...3 Employer Shared Responsibility...4 Calculating Group Size for Compliance...5 IRS Financial Reporting...6 Group Market Size Definitions...7 Summary of Coverage Changes...8 What s Ahead for ACA Compliance...10 Choose coverage that fits bcidaho.com 1

4 Affordable Care Act Overview Blue Cross of Idaho prepared this resource guide to help you understand how the Affordable Care Act will affect your business and impact the healthcare coverage you offer your employees. What does it mean for you? The Affordable Care Act (ACA) is the final version of healthcare reform legislation passed by Congress and signed into law on March 23, 2010 by President Obama. Some of these regulations took effect immediately, while others are being rolled out in phases over the next few years. with 50 or more full-time equivalent (FTE) employees to offer minimum essential coverage at an affordable price or pay an IRS tax penalty. In the back of this guide you will find a timeline of compliance requirements for both large and small businesses, as the ACA affects them differently. The information in this document is a general overview of the rules, regulations and consequences of the ACA. It may not address every aspect of the ACA that affects your health insurance and is not intended to be legal or tax advice. Individuals and businesses share responsibility with the government for making insurance more accessible for all. For example, the ACA requires employers Impacts of the Affordable Care Act Ensure more people have access to and get health insurance coverage Set coverage standards for health insurance benefits Lower premium and out-of-pocket costs through subsidies 2 BLUE CROSS OF IDAHO Large Group

5 Large Group Compliance Status Options As different aspects of the ACA are phased in, or in some cases postponed, businesses may have a different compliance status options depending on their group size. Grandfathered plans If your plan was effective prior to March 23, 2010 it may be grandfathered under the ACA. This option allows both large and small groups to keep offering their current coverage and avoid some of the impacts of the healthcare law, but only if no changes are made to the coverage offered. Grandmothered plans GM Small businesses with non-grandfathered plans received an extension until October 1, 2016 to offer employees a qualified health plan (QHP) that is ACAcompliant. All non-grandfathered plans were scheduled to end in 2014, but the transitional policy allows for temporary grandmothered status - however, this option is not available for large groups. Status Options G Qualified health plans QHP Qualified health plans became available to small businesses in QHPs are reviewed and certified by the Idaho health insurance exchange, called Your Health Idaho, to be fully ACA-compliant. The insurance carriers offering the plans are in good standing with the Idaho Department of Insurance. What s a PCORI? The Patient-Centered Outcomes Research Institute established by the ACA imposes a fee on health plans to evaluate and compare outcomes and clinical effectiveness of treatments, services, procedures and drugs. QHP GM Choose coverage that fits bcidaho.com 3

6 Employer Shared Responsibility The ACA requires that employers with 50 or more full-time employees offer minimum essential coverage to their workers or pay a tax penalty. Is your plan affordable with minimum coverage? The first measure is to provide minimum value coverage (MVC). To meet this requirement, your health plan must pay for at least 60 percent of covered healthcare expenses. Deciding to play or pay Large employers face the challenge of deciding to play or pay. This means choosing to comply with the new requirements or pay the penalty. Blue Cross of Idaho is here to help you navigate these decisions. The second measure is to offer affordable coverage. The cost of insurance to employees on both grandfathered and non-grandfathered plans must not exceed 9.5 percent of the employee s household income. Penalties for Noncompliance Large employers (those with 50 or more FTEs in prior year) must offer minimum essential coverage (MEC) to full-time employees and their dependent children or face a penalty. Penalties for failing to offer MEC took effect January 1, The lesser of either $3,000 for each FTE receiving assistance OR $2,000 X (FTE 80) per month in The penalty calculation changes to $2,000 X (FTE 30) per month in Employers that fail to offer MEC to full-time employees and dependents and if at least one FTE employee receives a tax credit or cost-sharing subsidy through the exchange Employers who offer coverage to full-time employees and dependents, but an employee receives a tax credit or cost-sharing reduction because the coverage is either not affordable or does not provide minimum value will pay 4 BLUE CROSS OF IDAHO Large Group

7 Large Group Calculating Group Size for Compliance Employers must calculate the number of full-time and part-time employees to determine if they are required to offer minimum essential coverage as an applicable large employer (ALE). Do you know your group size? The ACA requires that applicable large employers (those with 50 or more fulltime equivalent (FTE) employees must offer minimum essential coverage (MEC) to employees and their dependents. This insurance must be affordable and cover a certain level of healthcare expenses, or employers will pay a tax penalty. Federal FTE Counting Method Step 1 Total full-time employees Calculate the number of full-time employees for each calendar month in the previous year. January February March April May June July August September October November December Determining your group size starting in 2015 may not be obvious. Full-time and part-time employees will factor into your calculation. Full-time is defined as working more than 30 hours a week and part-time hours are combined to calculate FTEs. The federal FTE counting method applies to the employer shared responsibility mandate and the penalties for noncompliance, as well as for small business tax credits. Step 2 Total part-time employees Calculate the number of hours your part-time employees worked each month. (not to exceed 120 hours per month per employee) TOTAL January February March April May June July August September October November December (total monthly hours) 120 = (full time equivalent) TOTAL Step 3 Add total full-time employees to the full-time equivalent result in step 2 TOTAL Step 4 Divide the total by 12 and round down TOTAL Employees 12 = TOTAL Equivalent Employees Choose coverage that fits bcidaho.com 5

8 IRS Financial Reporting The Affordable Care Act includes two sections in Internal Revenue Service (IRS) code requiring insurers and applicable large employers (ALEs) to report on health insurance provided to employees. Some small companies are treated as ALEs if they are part of a related or commonly owned company that collectively meets the large group definition. These small individual employers in large multi-employer groups should consult with their tax advisors for clarification. Which reporting requirements apply? The purpose of Section 6055 is enforcement of the individual mandate. For fully insured groups, Blue Cross of Idaho will submit Form 1094-B (summary information on the employer) and Form 1095-B (information about each employee) to the IRS. We ll also send a copy of Form 1095-B to the employee. The purpose of Section 6056 reporting is enforcement of the employer mandate. Self-funded groups must file their own forms with the IRS, but Blue Cross of Idaho can assist you with the required data to submit 1094-C and 1095-C. Groups are also invited to use our tax reporting vendor to complete their reporting. Mandatory reporting in 2016 Reporting under both sections is voluntary for the 2014 plan year. The first mandated reporting will be for the 2015 plan year. Since Form 1095-B also determines employee eligibility for premium tax credits, it requires employee and dependent social security numbers, which are being collected in Blue Cross of Idaho Action Alerts on financial reporting requirements for both large and small groups, whether fully insured or self-funded, can be found at reform.bcidaho.com. 6 BLUE CROSS OF IDAHO Large Group

9 Large Group Group Market Size Definitions While the IRS identifies groups with 50 or more full-time equivalent (FTE) employees as applicable large employers for tax reporting purposes, other ACA provisions use a different counting methodology to determine group size. What does it mean to you? In Idaho, the small group definition is defined as 50 or fewer eligible employees. A large group is 51 or more employees, and the counting method also differs from the federal FTE employee calculation used to enforce the employer mandate. The Idaho Department of Insurance uses the eligible employee method of counting employees to determine whether a group is considered a small employer or a large one in terms of the insurance products available to them. In this state counting method (allowed by the federal government), part-time employees are not counted. Small group market provisions include guaranteed issue, modified community rating and essential health benefits, as well as other benefits and coverage (see pages 8 and 9 for a full list). Grandmothered small groups can retain their status until November 1, 2016 when transitional policies end. Recent legislation called the PACE Act (HR 1624) was signed by the President on Oct. 7, 2015 to allow states to keep the current small group definition at 1-50 employees instead of changing it to State Eligible Employee Counting Method OR Option 1 Employees working 30 or more hours per week on average Option 2 Employees working 20 or more hours per week on average (for groups with at least three (3) active en and by agreement between Blue Cross of and the Group) ELIGIBLE vs. ENROLLED Blue Cross of Idaho uses the state eligible employee counting method to determine group market size. In addition, we use the number of employees enrolled to rate groups. For example, 51 to 99 enrolled, eligible employees is a midsized, community-rated group according to Blue Cross policies. Groups with 100 or more enrolled employees would be experiencerated as a large group based on their actual claims. This distinction between eligible and enrolled employees does not apply to the small group market. Please see our Action Alert on this topic for specific examples. City or County Employees Only Public officers and public employees regardless of the number of hours worked. Choose coverage that fits bcidaho.com 7

10 Summary of Coverage Changes Here s a summary of coverage and plan changes for small groups resulting from the ACA. This general information provides an overview of how Blue Cross of Idaho is responding to new regulations. Effective dates refer to plan years on or after the date listed. Grandfathered plans Non-grandfathered plans Dependent age (Sept. 2010) We extended coverage for dependent adult children up to age 26, regardless of marital status, income, financial status, educational status or place of residence. Preventive health services (JAN. 2010). We cover preventive care services at 100 percent, not subject to deductible or coinsurance, when provided by an in-network provider. Preventive health services/women s health (SEPT. 2010). We cover preventive care services at 100 percent, not subject to deductible or coinsurance, when provided by an in-network provider. We also expanded covered preventive services to include additional women s health services. Lifetime Dollar limits (Sept. 2010). We removed all lifetime dollar maximum limits on essential health benefits (EHBs). Interested in a complete list of ACA-compliant Preventive Health Services? You can find them on the Blue Cross of Idaho website at com/health-and-wellness/ health-and-wellnesspreventive-care-services. page. Annual Dollar limit on ehbs (Jan. 2014) We removed annual dollar maximums from essential health benefits, including prescription drug services. Pre-existing waiting periods (Jan. 2014). We stopped requiring waiting periods for pre-existing conditions for all members, regardless of age. Summary of benefits & coverage (Sept. 2012) Blue Cross of Idaho provides individual members, employer groups and potential members access to a uniform overview of their health insurance coverage. These materials contain a short, easy-to-understand summary of benefits and coverage (SBC) and a list of definitions (called the uniform glossary) that explains terms commonly used in health insurance coverage such as deductible and copayment. 8 BLUE CROSS OF IDAHO Large Group

11 Large Group Grandfathered plans Non-grandfathered plans Wellness program incentives (Jan. 2014) The ACA allows employers who offer wellness programs to increase the maximum reward under a health-contingent wellness program from 20 to 30 percent of the cost of health coverage. Employers can further increase the reward to as much as 50 percent for programs designed to prevent or reduce tobacco use. Employee Waiting Period (Jan. 2014) Probationary periods for new employees can t exceed 90 days, beyond an official orientation period of 30 days, to meet your enrollment timeline. Beginning in 2014, Blue Cross of Idaho set a standard of the first of the month following 60 days and all groups were moved to this standard with the option to inform us of other group-specific timelines. Out-of-pocket maximums (Jan. 2014) The ACA sets a maximum amount you have to pay out of your own pocket for services. For 2015, the limits for non-grandfathered groups increase to $6,600 for individuals and $13,200 for families, including medical and pharmacy services. The ACA allows for separate OOP maximums for medical and pharmacy, and Blue Cross of Idaho s standard is to have separate maximums for most groups. Our maximum out-of-pockets are set at $5,500 medical and $1,000 pharmacy. For 2016 the limits will be $6,850 for individuals and $13,700 for families. Essential health benefits (Jan. 2014) All qualified health plans include coverage for essential health benefits in the following 10 categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including vision care. NOTE: The medical policies we currently offer do not include coverage for pediatric dental care, which is considered an EHB under the ACA. Blue Cross of Idaho offers dental products as a stand-alone plan. SBC Changes ( Sept. 2015) We updated our website so that SBCs now include a link to medical insurance contracts within the electronic document for fully insured group administrators and members. Self-funded health plans are outside the scope of this ACA requirement. Patient Protections It s important to us that you receive timely information about your health insurance and understand your rights as a Blue Cross of Idaho member. Blue Cross of Idaho will: Respond to urgent care requests for prior authorization within 72 hours of receipt. Provide members with a description of the diagnosis and treatment codes and their corresponding meanings on request. Provide unique, identifiable denial codes/reasons on all adverse benefit determinations and add a general definition of investigational and medical necessity to the explanation of benefit statements. Provide an external review process. Provide translation of some forms into Spanish, Tagalog, Chinese and Navajo Indian (Dine) on request. Choose coverage that fits bcidaho.com 9

12 What s Ahead for ACA Compliance SG LG Small employer groups SG are those with 50 or fewer eligible employees. Large employer groups LG are those with 51 or more eligible employees. May 2015 SG LG Blue Cross of Idaho reached out to groups for future financial reporting. Highlights include: Will need to capture enrollee social security numbers Contact account manager for process to request data Request a strategic impact report on effects of ACA January 2016 SG LG Non-grandfathered, mid-sized groups with 51 to 100 employees were scheduled to be reclassified as part of small group market and subject to ACA requirements. But: President Obama signed PACE Act in Oct to allow states to retain small group market as 1-50 employees Blue Cross of Idaho uses state eligible employee counting method to determine group size In addition, we use number of enrolled employees to rate groups (ie, 51 to 99 enrolled eligible employees is a midsized, community-rated group according to Blue Cross policies) January 2016 SG LG HSA plans required to have aggregate (embedded) out-ofpocket maximum: Maximum OOP costs can t exceed self-only federal limit This includes individuals enrolled in family policies Blue Cross will apply this to deductibles as well as OOP max No more HSA policies with umbrella OOP option January 2016 SG LG Employer shared responsibility reporting requirements: Blue Cross to supply data to groups by mail Group size 50 or more FTEs o We report under 6055 for fully insured groups o Self-funded groups responsible for own reporting o Tax forms 1094/1095 vary by group size and funding o All employers must provide 1095-C to FTEs Jan 2016 Jan 2016 Jan 2016 FEB 2016 HSA plans must have aggregate (not umbrella) out-of-pocket max Groups with employees remain defined as large group market ALEs must provide 1095-C to FT employees by 3/31/2016 Employers must file 1094-C and 1095-C to IRS by 5/31/2016 for paper filing 10 BLUE CROSS OF IDAHO Large Group

13 Large Group You can find links to specific regulations mentioned in this document at reform.bcidaho.com/employers Blue Cross of Idaho can create a strategic impact report to see how the ACA affects your employees and your bottom line, now and in the future. Contact your service representative or account manager to order your employee and business-specific report. February-March 2016 Applicable large employers must file 1094-C and 1095-C with IRS: LG If filing by paper, due 5/31/16 If filing electronically, due 6/30/16 November 2016 SG Grandmothered status ends: Transitional policies must move to QHPs on renewal Beginning with plan years effective 11/1/16 December 2016 SG LG New SBC formats issued for January 2017 renewals: 30 days prior to renewal OR For open enrollment period of plan January 2017 LG Large groups may be eligible to purchase on Exchange: Federal guidelines allow states to chose this option Plans must include essential health benefits However, Idaho is not extending exchange to large groups January 2020 SG LG Cadillac Tax due at group renewal date: Excise tax on employers with rich benefit plans Tax is 40% of cost above prescribed amounts Coverage amounts $10,200 individual/$27,500 family DELAYED from 2018 to 2020 by the Consolidated Appropriations Act of 2016 PLEASE NOTE: Any change in plan will require reassessment of group size using the state eligible employee counting method.blue Cross of Idaho will issue renewals for 2016 based on the plan in which the group is enrolled. Nov 2016 Dec 2016 Jan 2017 Jan 2018 GM status ends - must move to QHP on renewal, beginning 11/1/2016 New SBC formats issued 30 days prior to renewal or for open enrollment Large groups buy on exchange in some states (not ID) Federal excise tax of 40% imposed on employers with rich benefit plans Choose coverage that fits bcidaho.com 11

14 Notes 12 BLUE CROSS OF IDAHO Large Group

15 The information in this document is a general overview of the rules, regulations and consequences of the ACA. It may not address every aspect of the ACA that affects your health insurance and is not intended to be legal or tax advice.

16 P.O. Box 7408 Boise, ID bcidaho.com Meridian Street Address 3000 E. Pine Avenue Meridian, ID Mailing Address P.O. Box 7408 Boise, ID Claims Inquiries Coeur d Alene Idaho Falls Lewiston Pocatello Twin Falls 1450 NW Blvd., Suite 106 Coeur d Alene, ID Channing Way Idaho Falls, ID S. 5th Ave., Suite 150 Pocatello, ID Blue Lakes Blvd. N. Twin Falls, ID by Blue Cross of Idaho, an Independent Licensee of the Blue Cross and Blue Shield Association