Are you prepared for the ACA s employer mandate?

Transcription

1 SB SELECT BENEFITS MEC-Select Minimum Essential Coverage (MEC) Plan Administration Select Benefits Fixed-Payment Insurance Are you prepared for the ACA s employer mandate? Symetra Life Insurance Company SBM /18

2 MEC-Select MEC-Select satisfies the Affordable Care Act (ACA) mandate that employers offer a plan that provides at least minimum essential coverage. It also helps employees meet the individual mandate for this type of coverage. Employer requirements under the ACA 1 While changes are in store for the ACA s individual mandate penalty in 2019, the employer mandate remains unchanged. Employers with 50 or more full-time employees (full-time plus full-time equivalents) are still required to follow certain employee coverage rules under the ACA, or be fined. Under the ACA, employers must give employees the opportunity to enroll in a medical plan that offers at least minimum essential coverage (MEC) under an eligible employer-sponsored plan. Employers who do not offer a medical plan that provides minimum essential coverage to at least 95% of full-time employees and their dependents may be fined. For 2018, this fine is $2,320 per employee (excluding the first 30 employees). The ACA also states that even if employers offer minimum essential coverage, they may be subject to a fine for each employee that declines the MEC, purchases coverage on the exchange marketplace and receives a federal premium subsidy. In 2018, this fine equals $3,480 per employee. These fines are indexed for inflation and will increase annually. Individual requirements under the ACA 2 The individual mandate and accompanying penalty remain in effect for tax year That means individuals are required to maintain minimum essential coverage throughout the year for themselves, their spouse and dependent children under 26. Those who don t will be subject to a fee when they file their 2018 federal income tax return. 3 For tax-year 2018, the fee is the greater of: 1 2 A flat dollar amount based on the number of uninsured individuals in the household $695 per adult and $ per child under 18, up to a maximum fee of $2,085 per family % of household income, up to the national average cost of a Bronze plan as determined by the IRS. While the individual mandate itself is in place for the foreseeable future, starting in 2019 there will no longer be a financial penalty if employees do not maintain minimum essential coverage. This change was made through the 2017 Tax Cuts and Jobs Act, which was signed into law on December 22, MEC-Select

3 Employer options for meeting the ACA mandate For many employers, the challenge is finding cost-effective ways to meet ACA compliance requirements while managing their company s overall health care expenses. Groups looking for cost-effective solutions have a few options: Do nothing. Send all employees to an exchange and pay the per-employee penalty. Provide a MEC plan for preventive care services only. This type of plan must be self-funded. Supplement the MEC with fixed-payment insurance. The MEC is self-funded; the fixedpayment policies are fully insured. Despite all the requirements and regulation around employer-sponsored coverage, health insurance continues to be a core workplace benefit. To help your business stay competitive, Symetra Life Insurance Company has designed an ACA-compliant package called MEC-Select. Use this guide to learn how you can offer valuable health benefits and avoid potential fines imposed by the ACA employer mandate all while keeping your budget in check. Minimum Essential Coverage (MEC) Under the ACA, the following types of plans can provide minimum essential coverage: 5 Employer-sponsored plans Government-sponsored programs Plans in the individual market Grandfathered health plans A MEC plan must pay 100% for ACA-required preventive care services without copays, coinsurance or deductibles when participants visit an in-network provider. If employees choose an out-of-network provider, no benefits will be paid. Symetra provides comprehensive administration and claims payment services for your self-funded MEC plan when offered in conjunction with a fully insured Symetra Select Benefits fixed-payment insurance policy as part of the MEC-Select package. The list of required services falls into three categories: for all adults, for women only and for children. You can find a list of these preventive care benefits in this guide and at WHY OFFER A SELF-FUNDED MEC? Helps avoid the peremployee, per-year ACA fine. Satisfies the ACA individual mandate for minimum essential coverage. Allows you to benefit from the cost control aspects of a self-funded plan. Provides an attractive recruiting and retention tool. For a complete list of covered preventative care services, see page 8. MEC-Select 3

4 Select Benefits fixed-payment insurance What it is Our fixed-payment insurance policies can be customized to meet the needs of your full-time, part-time, temporary and seasonal workers, plus their dependents. It s not a replacement for major medical or other comprehensive coverage, but can help reduce out-of-pocket costs for services not covered by the MEC plan. Select Benefits insurance plans include some or all of the following: 7 Non-preventive doctor visits Outpatient diagnostic X-rays and labs Hospital stays Inpatient hospital admission Outpatient prescriptions Surgeries (including anesthesia) How it works A preselected, fixed dollar amount is paid for eligible services based on your unique plan design and can include things like non-preventive doctor visits, outpatient diagnostic X-rays and labs, inpatient hospital stays and outpatient prescriptions. There are no deductibles, copays or coinsurance, and benefits are paid until the calendar year maximum is met. And while participants must visit network providers to receive MEC benefits, Select Benefits fixed-payment insurance allows them to see any provider they choose, whether in-network or not. WHY OFFER FIXED-PAYMENT INSURANCE? Complements the preventive care services of your MEC plan. Offers simple-to-use coverage with no copays, coinsurance or deductible requirements. Lets employees enroll without having to go through medical underwriting. Pays benefits regardless of any other coverage participants may have. Gives you the option to enhance your plan with employee assistance and wellness programs or telehealth services. How fixed-payment insurance works with your MEC plan The example below illustrates how these two coverages work when a covered employee sees different providers for a variety of services over a period of several months. Remember, under the MEC plan employees must visit a network provider to receive benefits. With fixed-payment insurance they can see any provider they choose. Claims example for a covered participant Service type Cost of service MEC plan pays Select Benefits fixed-payment coverage pays Out-of-pocket cost Annual well-woman exam at a network provider $150 $150 $0 $0 Flu shot at a network provider $35 $35 $0 $0 Out-of-network doctor office visit for a sore throat One-day inpatient stay at an out-of-network hospital $112 $0 $80 $32 $1,000 $0 $500 $500 Total $1,297 $185 $580 $532 This claims example is for illustrative purposes only. Refer to your plan summary for coverage amounts and limits. Actual cost of services varies by provider. 4 MEC-Select

5 Why offer MEC-Select? For some employers, it may seem easier to pay the per-employee fine and let workers navigate their way through the exchanges. But how does that decision affect employee morale for retention and recruitment? As one article points out, health insurance marks an employer as an employer of choice when desirable candidates select job opportunities. 6 With MEC-Select, you have the flexibility to put together a benefits package that aligns with your company s coverage and budget goals. For example, if you have $150 per employee per month to allocate to benefits, we can design a MEC-Select package that matches that amount. Option 1 Pay the per-employee fine. Employees have no employer-sponsored coverage and may or may not go to the exchange to meet their individual mandate requirement ACA penalty # of employees (EE)* Total $2,320 per EE X 500 = $1,160,000 per year Option 2 Provide a MEC plan along with fixed-payment insurance (MEC-Select). MEC plan cost Select Benefits premium Total $70 EE only rate + $80 EE only rate X 500 enrolled X 12 months = $900,000 per year * After the first 30 employees have been excluded. Note: This premium example is for illustrative purposes only. Actual MEC plan costs and Select Benefits premium amounts will vary. Other ACA penalties may apply. MEC-Select requires minimum participation that is the greater of 50 enrolled employees or 10% of eligible employees. MEC-Select 5

6 Enrollment We want to help make your enrollment successful. Talk with your Symetra representative and then notify us, in writing, of the dates planned for your annual enrollment. We ll work with your representative on an enrollment plan and a timeline for educating employees on their new MEC-Select package and the benefits of signing up. Eligible employees can usually only enroll during the annual enrollment period. If they do not elect coverage at this time, they may have to wait until the next annual enrollment period. Anyone hired after annual enrollment has 31 days from the date of hire to elect coverage. Once this eligibility period has passed, they may have to wait until the next open enrollment period. We can provide you with materials, at no additional charge, to help encourage these newly hired employees to participate. ID cards Once we receive enrollment information, we ll send ID cards and insurance certificates for you to distribute. We can also mail ID cards directly to participants through our E-Cert program. Please contact us for more information on this service and if anyone needs to visit a provider before receiving their ID card. Filing a claim MEC claims Employees must show their ID card to the provider at the time of service. The provider must submit a claim to Symetra. In-network MEC services are paid at 100%, so employees should not have any out-of-pocket costs as long as their provider is in the network. Fixed-payment insurance claims For services covered by the fixed-payment plan, participants can show their ID card and assign their benefits to the provider, who will bill us directly. Any balance not covered by the policy is the participant s responsibility. If a participant pays the provider at the time of service, or if benefits were not assigned to the provider, an employee may file a claim with us to receive benefit payments directly. The employee must complete a claim form and return it to us along with a signed Authorization for Release of Medical Information form and an itemized bill from the provider listing dates of service, procedure codes, diagnosis codes and charges. We cannot process claims without these codes. Symetra offers aggregate stop loss protection of up to $1 million to help protect your self-funded MEC plan. For details, talk with your Symetra representative. 6 MEC-Select

7 Dependable administration Frequently asked questions All administration for MEC-Select is managed by our in-house Symetra team. This approach gives you a single point of contact, which allows for: Does the list of covered MEC preventive care services ever change? Government guidelines are periodically updated to reflect current medical and scientific advances. Unless there is a mandate for an immediate change, your plan design will stay the same throughout the year. Clear direction on when to fund the MEC claims account and how much is needed. One ID card and one claims payment address for plan participants and providers. Efficient claims processing and benefit payments we determine which claims are paid under the MEC, which are paid under the Select Benefits policies, and when to reimburse for stop loss claims, if applicable. Consolidated billing for Select Benefits policies and, if included, the aggregate stop loss policy. Why offer a MEC and fixed-payment insurance package? Employees who enroll in a MEC plan can avoid the individual penalty under the ACA. By offering Select Benefits fixedpayment insurance with that plan, you re helping employees reduce their out-of-pocket costs for non-preventive care services such as doctor visits, X-rays, lab tests and more. What does fixed-payment mean? It means a preselected, fixed dollar amount is paid for each covered service regardless of the total bill or any other medical insurance coverage. For benefits with a calendar year maximum, the plan pays the fixed amount for each covered event until the maximum is reached. MEC-Select 7

8 ACA-REQUIRED PREVENTIVE CARE BENEFITS Description of available benefits Recommended ages, frequency and populations are for example only. Coverage will be provided in accordance with current recommendations under the ACA or, if none is provided, with reasonable medical management. Unless otherwise noted, frequency will be presumed to be annual. A description of preventive services can also be found at coverage/preventive-care-benefits. Covered preventive care for all adults Wellness or office exams billed by an in-network physician for the purpose of administering the following covered services are also paid at 100%. 1. Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked 2. Alcohol misuse screening and counseling 3. Aspirin use to prevent cardiovascular disease for men and women of certain ages 4. Blood pressure screening 5. Cholesterol screening for adults of certain ages or at higher risk 6. Colorectal cancer screening for adults over Depression screening 8. Type 2 diabetes screening for adults with high blood pressure 9. Diet counseling for adults at higher risk for chronic disease 10. Hepatitis B screening for people at high risk 11. Hepatitis C screening for adults at increased risk, and one time for everyone born HIV screening for everyone ages 15-65, and other ages at increased risk 13. Immunization vaccines for adults. Doses, recommended ages and recommended populations vary. For more information on recommended immunizations, visit Diphtheria Hepatitis A Hepatitis B Herpes Zoster Human Papillomavirus (HPV) Influenza (flu shot) Measles Meningococcal Mumps Pertussis Pneumococcal Rubella Tetanus Varicella (Chickenpox) 14. Lung cancer screening for adults at high risk for lung cancer because they re heavy smokers or have quit in the past 15 years 15. Obesity screening and counseling 16. Sexually transmitted infection (STI) prevention counseling for adults at higher risk 17. Syphilis screening for all adults at higher risk 18. Tobacco use screening for all adults and cessation interventions for tobacco users 8 MEC-Select

9 Covered preventive care for women only Wellness or office exams billed by an in-network physician for the purpose of administering the following covered services are also paid at 100%. This includes an annual well-woman exam or as-needed visits for prenatal care. 1. Anemia screening on a routine basis for pregnant women 2. BRCA counseling about genetic testing for women at higher risk 3. Breast cancer chemoprevention counseling for women at higher risk 4. Breast cancer mammography screenings every 1 to 2 years for women over Breastfeeding comprehensive support and counseling from trained providers, as well as access to breastfeeding supplies for pregnant and nursing women 6. Cervical cancer screening for sexually active women 7. Chlamydia infection screening for younger women and other women at higher risk 8. Contraception*: FDA-approved contraceptive methods, sterilization procedures, patient education and counseling, not including abortifacient drugs 9. Domestic and interpersonal violence screening and counseling 10. Folic acid supplements for women who may become pregnant 11. Gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk of developing gestational diabetes 12. Gonorrhea screening for all women at higher risk 13. Hepatitis B screening for pregnant women at their first prenatal visit 14. HIV screening and counseling for sexually active women 15. Human papillomavirus (HPV) DNA test every 3 years for women with normal cytology results who are 30 or older 16. Osteoporosis screening for women over age 60, depending on risk factors 17. Rh incompatibility screening for all pregnant women, and follow-up testing for women at higher risk 18. Sexually transmitted infection (STI) counseling for sexually active women 19. Syphilis screening for all pregnant women or other women at increased risk 20. Tobacco use screening and interventions for all women, with expanded counseling for pregnant tobacco users 21. Urinary tract or other infection screening for pregnant women 22. Well-woman visits to obtain recommended preventive services for women under 65 *Does not apply to health plans sponsored by certain exempt religious employers. MEC-Select 9

10 Covered preventive care for children Wellness or office exams billed by an in-network physician for the purpose of administering the following covered services are also paid at 100%. The recommended well baby/child visit schedule is as follows: Ages 0 to 11 months Ages 1 to 4 years Ages 5 to 17 years 6 visits 7 visits Annual visits 1. Alcohol and drug use assessments for adolescents 2. Autism screening at 18 and 24 months 3. Behavioral assessments for children from birth through age Blood pressure screening for children from birth through age Cervical dysplasia screening for sexually active females 6. Depression screening for adolescents 7. Developmental screening for children under age 3 8. Dyslipidemia screening for children ages 1 through 17 who are at higher risk of lipid disorders 9. Fluoride chemoprevention supplements for children without fluoride in their water source 10. Gonorrhea preventive medication for the eyes of all newborns 11. Hearing screening for all newborns 12. Height, weight and body mass index measurements for children from birth through age Hematocrit or hemoglobin screening for children 14. Hemoglobinopathies or sickle cell screening for newborns 15. Hepatitis B screenings for adolescents at high risk 16. HIV screening for adolescents at higher risk 17. Hypothyroidism screening for newborns 18. Immunization vaccines for children from birth to age 18. Doses, recommended ages and recommended populations vary. Learn more about immunizations and see the latest vaccine schedules at vaccines/schedules. Diphtheria, tetanus, pertussis Haemophilus influenzae type B Hepatitis A Hepatitis B Human papillomavirus (HPV) Inactivated poliovirus Influenza (flu shot) Measles Meningococcal Pneumococcal Rotavirus Varicella 19. Iron supplements for children ages 6 to 12 months who are at risk for anemia 20. Lead screening for children at risk of exposure 21. Medical history for all children throughout development, from birth through age Obesity screening and counseling 23. Oral health risk assessment from birth through age Phenylketonuria (PKU) screening for newborns 25. Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk 26. Tuberculin testing from birth through age 17 for children who are at higher risk of tuberculosis 27. Vision screening for all children 10 MEC-Select

11 Health advocacy, employee assistance programs and telehealth services The following programs may be added to any MEC-Select package. Health Advocacy Personalized assistance with a full range of health care and insurance-related issues such as locating providers, explaining conditions and treatments, scheduling appointments, resolving claims and billing issues and more. NurseLine TM Round-the-clock, direct access to a registered nurse for non-urgent medical matters. Medical Bill Saver TM Access to expert negotiators who will work with providers to reduce the cost of medical and dental bills not covered under the MEC-Select package. EAP+Work/Life TM Licensed professional counselors and work/life specialists provide confidential, short-term help with personal, family and work-related issues. Wellness Coaching Unlimited access to highly trained wellness coaches by telephone, or secure web messaging. Supported by a comprehensive, secure wellness website. Telehealth Telehealth services provide quick access to a national network of U.S. board-certified doctors via telephone or video conference, with no consultation fee. Telehealth doctors can diagnose and recommend treatment for many common conditions, answer questions about symptoms and medication usage, explain a medical condition and more. Dental Savings Discounts on dental services including cleanings, fillings, root canals, crowns and orthodontics when visiting a contracting provider. Vision Savings Discounts on eyeglasses, contacts and laser surgery through a provider network that includes ophthalmologists, optometrists, independent optical centers and national chain locations. Pharmacy Benefit Management Program Convenient, cost-effective ways for employees to get their medications; includes discounts on prescriptions, home delivery, online and mobile prescription management tools, and access to pharmacists via phone to answer questions and review prescriptions. MEC-Select 11

12 Other Select Benefits coverages To help you round out your benefits package, we also offer group accident and critical illness insurance. For more information on MEC-Select, contact your Symetra representative. Symetra Life Insurance Company th Avenue NE, Suite 1200 Bellevue, WA Symetra is a registered service mark of Symetra Life Insurance Company. Fixed-payment insurance policies are designed to provide benefits at a preselected, fixed-dollar amount. They are not a replacement for major medical or other comprehensive coverage. Coverage may be subject to exclusions, limitations, reductions and termination of benefit provisions. For costs and complete details of the coverage, contact your Symetra representative. Fixed-payment insurance policies are insured by Symetra Life Insurance Company, th Avenue NE, Suite 1200, Bellevue, WA 98004, and are not available in all U.S. states or any U.S. territory. Symetra provides administrative services only for minimum essential coverage (MEC) plans. This material also describes value-add benefits and services offered through Symetra Life Insurance Company that are not available in all U.S. states or any U.S. territory. Value-add benefits and services are not insurance, are not intended to replace insurance and may have limitations, exclusions, reduction of benefits and terms under which they may be continued in force or discontinued. Health Advocacy, NurseLine TM, Medical Bill Saver TM, EAP+Work/Life TM and Wellness Coaching programs are provided by Health Advocate TM through Symetra. Health Advocate, a subsidiary of West Corporation, is not affiliated with any insurance or third-party provider. Health Advocate does not replace health insurance coverage, provide medical care or recommend treatment. Telehealth services operate subject to state regulation and may not be available in certain states. Discount Medical Benefits are NOT insurance. The discount benefits plan is not insurance coverage and does not meet the minimum creditable coverage requirements under the Affordable Care Act or Massachusetts M.G.L. c. 111M and 956 CMR It contains a 30-day cancellation period and provides discounts only at the offices of contracted health care providers, and each member is obligated to pay the discounted medical charges in full at the point of service. The range of discounts for medical or ancillary services provided under the plan will vary depending on the type of provider and medical or ancillary service received. Discount Plan Organization: New Benefits, Ltd., Attn: Compliance Department, P.O. Box , Dallas, TX , Website to obtain participating providers: MyMemberPortal.com. Not available in all states. Pharmacy Benefit Management Program is provided by Optum. Optum, Health Advocate and New Benefits are not affiliated with Symetra Life Insurance Company or its affiliates. 1 Based on IRS published guidelines retrieved Feb. 7, 2018, from 2 Source: Retrieved Nov. 17, 2017, from 3 Some individuals may qualify for an exemption. Health coverage exemptions are available for a variety of reasons: certain life events, health coverage or financial status, group membership and more Fee amounts are based on IRS published revenue procedure retrieved Feb. 7, 2018, from rp pdf 5 Source: Retrieved Nov. 17, 2017, from 6 Susan M. Heathfield, Health Insurance Is the Foundation of a Comprehensive Benefits Package. The Balance. Jul. 9, 2017, from 7 Benefits are not available in all states. Please contact your Symetra representative.