MVP Insurance Agency October 2013 Newsletter - Your Health Care Reform Partner

Transcription

1 MVP Insurance October 2013 Newsletter - Your Health Care Reform Partner Are you in compliance with health care reform regulations? We can help you stay on top of health care reform to avoid penalties from legislative briefs to compliance checklists, we ve got you covered. How do you keep employees aware of changes? Our employee communications materials will help employees understand how reform affects them and their families. Do you have unanswered questions about health care reform? Gain access to a client portal where you will find answers to commonly asked health care reform questions. You will also find the forms you need to meet your everyday compliance needs Shaw Avenue, Clovis, CA , 2012 Zywave, Inc. All rights reserved.

2 Sample Documents Table of Contents Legislative Briefs Health Care Reform Timeline 3-4 Health Care Reform: 2013 Compliance Checklist 5-6 Health Care Reform: Large Employers Subject to Pay or Play Penalty 7-8 Employee Communications Health Care Reform: Who, What, When 9-10 Health Care Reform: General Q&A for Employees MyWave HR Legislative Guides 13 Video Content Employer and Employee Video Snapshots 14

3 Brought to you by MVP Premier Insurance Health Care Reform Timeline On March 23, 2010, President Obama signed the health care reform bill, or Affordable Care Act (ACA), into law. ACA makes sweeping changes to the U.S. health care system. ACA s health care reforms, which are primarily focused on reducing the uninsured population and decreasing health care costs, will be implemented over the next several years. This Legislative Brief provides a timeline of the implementation of key ACA reforms that affect employers and individuals. Please read below for more information and contact MVP Premier Insurance with any questions about how you can prepare for any of the health care reform requirements. EXPANDED INSURANCE COVERAGE 2010 Extended Coverage for Young Adults. Group health plans and health insurance issuers offering group or individual health insurance coverage that provide dependent coverage of children must make coverage available for adult children up to age 26. There is no requirement to cover the child or spouse of a dependent child. This requirement applies to grandfathered and non-grandfathered plans. However, grandfathered plans need not cover adult children who are eligible for other employer-sponsored coverage, such as coverage through their own employer, until ACA also added a new tax provision related to health insurance coverage for these adult children. Effective March 30, 2010, amounts spent on medical care for an eligible adult child can generally be excluded from taxable income. Note: A grandfathered plan is one in which an individual was enrolled on March 23, A plan will retain its grandfathered status even if covered individuals renew their coverage after March 23, 2010, family members are added to coverage or new employees (and their families) enroll for coverage. A health plan will lose its grandfathered status if there are significant cuts to benefits or increases in participants out-of-pocket spending. Grandfathered status is significant because many ACA reforms do not apply to grandfathered plans. Access to Insurance for Uninsured Individuals with Pre-Existing Conditions. The health care reform law created a temporary high-risk health insurance pool program, called the Pre-existing Condition Insurance Plan (PCIP) to provide health insurance coverage to individuals who have been uninsured for at least six months because of a pre-existing condition. The program will end in 2014, when the health insurance exchanges are scheduled to be operational. On Feb. 15, 2013, the Obama Administration issued a nationwide suspension on enrollment in the PCIP program due to limited funding. The enrollment suspension took effect immediately in 23 states where the federal government administers the program. However, state-based PCIPs may continue to accept enrollment applications through March 2, For more information, see Identifying Affordable Coverage. As required by ACA, the Department of Health and Human Services (HHS) established an Internet website - through which residents of any state may identify affordable health insurance coverage options in their state. The website also includes information for 3 3

4 Health Care Reform Timeline small businesses about available coverage options, reinsurance for early retirees, small business tax credits, and other information of interest to small businesses. So-called mini-med or limited-benefit plans are precluded from listing their policies on this website. Reinsurance for Covering Early Retirees. ACA established a temporary reinsurance program to reimburse participating employment-based plans for a portion of the cost of providing health insurance coverage to early retirees and their spouses, surviving spouses and dependents. This program was designed to end on Jan. 1, 2014, or earlier, if the $5 billion in funding was exhausted. Due to the program s popularity, it closed to new applications effective May 5, In early December 2011, HHS announced that, because the program had already provided more than $4.5 billion in reimbursements, it would not accept reimbursement requests for claims incurred after Dec. 31, HEALTH INSURANCE REFORM Eliminating Pre-Existing Condition Exclusions for Children. Group health plans and health insurance issuers may not impose pre-existing condition exclusions on coverage for children under age 19. This provision applies to all employer plans and new plans in the individual market. This provision will also apply to adults in Coverage of Preventive Health Services. Group health plans and health insurance issuers offering group or individual health insurance coverage must provide coverage for certain preventive care services without costsharing (for example, deductibles, copayments or coinsurance). Grandfathered plans are exempt from this requirement. Prohibiting Rescissions. The health care reform law prohibits rescissions, or retroactive cancellations, of coverage, except in cases of fraud or intentional misrepresentation. Also, plans and issuers must provide at least 30 days advance notice to the enrollee before coverage may be rescinded. This provision applies to all grandfathered and non-grandfathered plans. Limits on Lifetime and Annual Limits. Group health plans and health insurance issuers offering group or individual health insurance coverage may not impose lifetime limits or unreasonable annual limits on the dollar value of essential health benefits. This requirement applies to all plans, although plans were allowed to request a waiver of the annual limit requirement through HHS. The annual limit waiver program closed to applications effective Sept. 22, All annual limits will also be prohibited beginning in HEALTH PLAN ADMINISTRATION Improved Appeals Process. Group health plans and health insurance issuers offering group or individual health insurance coverage must implement an effective process for benefit claims and appeals of coverage determinations. A plan s or issuer s internal claims and appeals process must comply with the claims procedure regulation issued by the Department of Labor (DOL) in In addition, ACA requires plans and issuers to: o o o o Have an internal claims and appeals process in effect that provides claimants with a full and fair review; Provide information to claimants in a culturally and linguistically appropriate manner in some situations; Comply with additional content requirements for denial notices; and Continue to provide coverage to a claimant pending the outcome of the appeals process. This Legislative Brief is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers should contact legal counsel for legal advice Zywave, Inc. All rights reserved. 4 4

5 Brought to you by MVP Premier Insurance 2013 Compliance Checklist In light of the Supreme Court s June 28, 2012, decision to uphold the health care reform law, or Affordable Care Act (ACA), employers must continue to comply with ACA mandates that are currently in effect. Employers must also prepare to comply with ACA changes that will go into effect in the future. To prepare for upcoming changes, employers need to be aware of the ACA mandates that will go into effect in This Legislative Brief provides a compliance checklist for employers for Please contact MVP Premier Insurance for assistance or if you have questions about changes that were required in previous years. GRANDFATHERED PLAN STATUS A grandfathered plan is one that was in existence when health care reform was enacted on March 23, If you make certain changes to your plan that go beyond permitted guidelines, your plan is no longer grandfathered. Contact MVP Premier Insurance if you have questions about changes you have made, or are considering making, to your plan. If you have a grandfathered plan, determine whether it will maintain its grandfathered status for the 2013 plan year. Grandfathered plans are exempt from some of the health care reform requirements. A grandfathered plan s status will affect its compliance obligations from year-to-year. If you move to a non-grandfathered plan, confirm that the plan has all of the additional patient rights and benefits required by ACA. This includes, for example, coverage of preventive care without cost-sharing requirements. ANNUAL LIMITS Effective for plan years beginning on or after Jan. 1, 2014, health plans will be prohibited from placing annual limits on essential health benefits. Until then, however, restricted annual limits are permitted. Unless a health plan received an annual limit waiver, its annual limit on essential health benefits for the 2013 plan year cannot be less than $2 million. (This limit applies to plan years beginning on or after Sept. 23, 2012, but before Jan. 1, 2014.) SUMMARY OF BENEFITS AND COVERAGE Health plans and health insurance issuers must provide a Summary of Benefits and Coverage (SBC) to participants and beneficiaries. The SBC is a relatively short document that provides simple and consistent information about health plan benefits and coverage in plain language. A template for the SBC is available, along with instructions and examples, and a uniform glossary of terms. Plans and issuers must provide the SBC to participants and beneficiaries who enroll or re-enroll during an open enrollment period beginning with the first open enrollment period that begins on or after Sept. 23, The 5 5

6 2013 Compliance Checklist SBC also must be provided to participants and beneficiaries who enroll other than through an open enrollment period (including individuals who are newly eligible for coverage and special enrollees) effective for plan years beginning on or after Sept. 23, If your plan has an open enrollment period beginning on or after Sept. 23, 2012, confirm that the SBC is included with the open enrollment package. For participants and beneficiaries who enroll outside of the open enrollment period, confirm that the SBC will be provided to these individuals beginning with the plan year starting on or after Sept. 23, o o If you have a self-funded plan, the plan administrator is responsible for providing the SBC. If you have an insured plan, both the plan and the issuer are obligated to provide the SBC, although this obligation is satisfied for both parties if either one provides the SBC. Thus, if you have an insured plan, you should work with your health insurance issuer to determine which entity will assume responsibility for providing the SBC. Please contact MVP Premier Insurance for assistance. 60-DAY NOTICE OF PLAN CHANGES A health plan or issuer must provide 60 days advance notice of any material modifications to the plan that are not related to renewals of coverage. Notice can be provided in an updated SBC or a separate summary of material modifications. This 60-day notice requirement becomes effective when the SBC requirement goes into effect for a health plan. PREVENTIVE CARE SERVICES FOR WOMEN Effective for plan years beginning on or after Aug. 1, 2012, non-grandfathered health plans must cover specific preventive care services for women without cost-sharing requirements. The covered preventive care services for women include: well-woman visits; gestational diabetes screening; human papillomavirus (HPV) testing; sexually transmitted infection (STI) counseling; human immunodeficiency virus (HIV) screening and counseling; FDA-approved contraception methods and contraceptive counseling; breastfeeding support, supplies and counseling; and domestic violence screening and counseling. Exceptions to the contraception coverage requirement apply to certain religious employers. The preventive care guidelines for women are available at: $2,500 CONTRIBUTION LIMIT FOR HEALTH FSAS Effective for plan years beginning on or after Jan. 1, 2013, an employee s annual pre-tax salary reduction contributions to a health flexible spending account (FSA) must be limited to $2,500. (The $2,500 limit will be indexed for cost-of-living adjustments for 2014 and later years.) Health FSA plan sponsors are free to impose an annual limit that is lower than the ACA limit for employees health FSA contributions. Also, the $2,500 limit does not apply to employer contributions to the health FSA and it does not impact contributions under other employer-provided coverage. For example, employee salary reduction contributions to an FSA for dependent care assistance or adoption care assistance are not affected by the $2,500 health FSA limit. W-2 REPORTING 6 6

7 2013 Compliance Checklist Beginning with the 2012 tax year, employers that are required to issue 250 or more W-2 Forms must report the aggregate cost of employer-sponsored group health coverage on employees W-2 Forms. The cost must be reported This Legislative Brief is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers should contact legal counsel for legal advice Zywave, Inc. All rights reserved. 7

8 Brought to you by MVP Premier Insurance Large Employers Subject to Pay or Play Penalty The Affordable Care Act (ACA) imposes a penalty on large employers that do not offer minimum essential coverage to substantially all full-time employees and their dependents. Large employers that offer coverage may still be liable for a penalty if the coverage is unaffordable or does not provide minimum value. This employer mandate provision is often referred to as employer shared responsibility or pay or play rules. The employer mandate provision was set to take effect on Jan. 1, However, on July 2, 2013, the Treasury announced that the employer mandate penalties and related reporting requirements will be delayed for one year, until Therefore, these payments will not apply for The Treasury plans to issue more formal guidance on the delay shortly and additional regulations on the reporting requirements over the summer. Future guidance may also impact the rules described in this document. No other provisions of the ACA are affected by the delay. A large employer is only liable for a penalty if one or more of its full-time employees receive a premium tax credit or cost-sharing reduction for coverage under a state-based insurance Exchange. On Jan. 2, 2013, the Internal Revenue Service (IRS) released long-awaited proposed regulations on ACA s employer shared responsibility provisions. Although the proposed regulations are not final, employers may rely on them until further guidance is issued. An important first step when assessing an employer s potential liability under ACA is to determine if the employer meets the large employer threshold. Only large employers are subject to ACA s pay or play penalty. IDENTIFYING A LARGE EMPLOYER To qualify as a large employer, an employer must employ on average at least 50 full-time employees, including full-time equivalents (FTEs), on business days during the preceding calendar year. All employers that employ at least 50 full-time employees, including FTEs, are subject to ACA s pay or play rules, including for-profit, nonprofit and government employers. A full-time employee is an individual that works, on average, 30 or more hours of service each week. Hours worked by employees with fewer than 30 hours per week must be counted and then divided by 120 per month to determine the number of FTEs. The number of FTEs is then added to the actual full-time employee count. Employers will determine each year, based on their current number of employees, whether they will be considered a large employer for the next year. For example, if an employer has at least 50 full-time employees (including FTEs) for 2013, it will be considered a large employer for Transition Rule for 2014 The proposed regulations include a special rule for employers that may be close to the large employer threshold and need to know how to prepare for Rather than being required to use the full 12 months of 2013 to measure whether it has 50 full-time employees and FTEs, an employer may measure using any consecutive six-month 8 7

9 Large Employers Subject to Pay or Play Penalty period in For example, an employer could use the period from March through August 2013, and then have from September through December 2013, to analyze the results and determine whether it needs to make changes to its health coverage. It is unclear how the delay of the employer mandate penalties will impact this transition relief. Employers with Employees Working Abroad A company that employs U.S. citizens working abroad generally will be subject to the pay or play rules only if the company had at least 50 full-time employees (including FTEs), determined by taking into account only work performed in the United States. Employers with Seasonal Workers If an employer s workforce exceeds 50 full-time employees for 120 days or fewer during a calendar year, and the employees in excess of 50 who were employed during that time were seasonal workers, the employer does not qualify as a large employer. The proposed regulations allow an employer to apply either a period of four calendar months (whether or not consecutive) or a period of 120 days (whether or not consecutive) to determine if it qualifies for the seasonal worker exception. New Employers An employer not in existence during an entire preceding calendar year is a large employer for the current calendar year if it is reasonably expected to employ an average of at least 50 full-time employees (taking into account FTEs) on business days during the current calendar year. COUNTING FULL-TIME EMPLOYEES, FTES AND HOURS OF SERVICE Employers average their number of full-time employees and FTEs across the months in a year to determine if they meet the large employer threshold. The averaging method takes into account fluctuations that many employers experience in their workforce numbers each year. A common law standard applies to define the terms employee and employer. Under this standard, an employment relationship exists when the person for whom the services are performed has the right to control and direct the individual who performs the services with respect to the result to be accomplished, along with the details and means by which it is done. This is a factual determination and is not necessarily dependent on the label the employer has placed on the relationship in the past. In general, leased employees are not considered employees of the service recipient for purposes of ACA s pay or play provisions. Also, an independent contractor, a sole proprietor, a partner in a partnership and a 2-percent S corporation shareholder are not counted as employees. However, aggregation rules apply for companies under common ownership. All employees of a controlled group of businesses under Internal Revenue Code (Code) sections 414(b) or (c) or an affiliated service group under Code section 414(m) are taken into account to determine if an employer is subject to the pay or play rules. If the combined total meets the threshold, each separate member of the group is subject to the pay or play rules, even those companies that on their own do not have enough employees to meet the threshold. Full-time Employees Under ACA, a full-time employee is an employee who was employed on average at least 30 hours of service per week. The proposed regulations treat 130 hours of service in a calendar month as the monthly equivalent of 30 hours per service per wee This Legislative Brief is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers should contact legal counsel for legal advice Zywave, Inc. All rights reserved. 9 8

10 Health Care Reform: Who, What, When Timeline of health care changes Here is a look at some of the major health care reform provisions that you will see over the next decade Employers: Small businesses can receive tax credits if purchasing insurance for employees. Insurers: Cannot impose pre-existing condition exclusions on coverage for children. Must cover preventive services without copays. Cannot remove coverage when a person becomes ill. Cannot impose lifetime coverage limits. Health care reform also regulates annual limits. Insurers must provide an improved way for consumers to appeal health care decisions. Uninsured: Individuals with pre-existing conditions receive immediate access to coverage through a high-risk pool. Dependent children can remain on parents plans until age 26. States will be allowed to cover more people on Medicaid. Early retirees: Employers were able to participate in a reinsurance program to help provide coverage for retirees and their spouses, surviving spouses and dependents over age 55 and not eligible for Medicare. Due to funding limits, this program stopped reimbursements for claims incurred after Dec. 31, Medicare Part D enrollees: A $250 rebate check received for those entering the donut hole gap in coverage in Rebate payable by April 1, Insurers: Required to spend at least 80 to 85 percent of premiums on medical services. Medicare Part D enrollees: Receive a 50 percent discount on brand-name prescription drugs when in donut hole coverage gap. Health care savings account holders: Federal tax on those who spend health care savings account money on ineligible expenses increases to 20 percent. Over-the-counter drugs: Except for insulin, OTC drugs without a prescription are not reimbursable from an FSA or HRA, and are not a tax-free reimbursement from an HSA. W-2: The value of employees health coverage must be disclosed on their W-2 forms (optional for 2011 for all employers, large employers must comply in 2012). This Know Your Benefits article is provided by MVP Premier Insurance and is to be used for informational purposes only and is not intended to replace the advice of an insurance professional. Visit us at Design Zywave, Inc. All rights reserved. 10 9

11 Health Care Reform: Who, What, When Seniors: Certain free preventive services are provided for seniors on Medicare Taxpayers: Medicare payroll taxes increase to 2.35 percent for individuals earning more than $200,000 and families earning more than $250,000. Those with flexible savings accounts: A federal limit of $2,500 for individual pretax contributions per year Insurers: Prohibited from refusing to sell or renew policies. Cannot deny coverage for adults with pre-existing conditions. Limits ability to set prices on the basis of sex, health status or other factors. Prohibited from imposing annual limits. Uninsured: Most Americans required to buy health insurance or pay fines of $95 per individual (or one percent of adjusted taxable income if this amount is greater) and up to $285 per family. Families will pay half the amount for children. Families can receive subsidies to buy insurance if they earn no greater than four times the federal poverty level (about $88,000 per year for a family of four). Individuals and small businesses can buy coverage through state exchanges Employers: Companies with 50 or more employees must provide affordable coverage with minimum value or may be subject to a penalty. Uninsured: Penalties for not carrying insurance increase to $325 per individual (or two percent of adjusted taxable income if this is greater) and up to $975 per family. Families will pay half the amount for children Uninsured: Penalties for not carrying insurance increase to $695 per individual (or 2.5 percent of adjusted taxable income if this is greater) and up to $2,250 per family. Families will pay half the amount for children Taxpayers: A 40 percent excise tax imposed on high-cost employer-provided policies ($10,200 for individual coverage or $27,500 for family coverage) Medicare Part D Enrollees: Prescription drug coverage gap eliminated. Source:

12 Health Care Reform: General Q&A for Employees Common questions answered I ve heard a lot about the health care reform law. When do the reforms become effective? The health care reform bill was signed into law in March The changes made by the health care reform law go into effect over a period of years. Some of the law s changes are already in effect, such as the prohibition on preexisting condition exclusions for individuals under age 19. Other key changes go into effect in 2014, such as the requirement for individuals to buy health coverage or pay a penalty. Does health care reform allow people to keep their current health coverage? Yes. Nothing in the new law requires individuals to terminate coverage that they had on the date the law was passed. However, due to new coverage requirements, the coverage provided under an individual's plan may change. Also, employers are not required to offer the same coverage in future years. If an employer s health plan existed on March 23, 2010, and the employer has not made certain changes to the plan, the plan may have grandfathered status. Grandfathered plans are subject to many, but not all, of the health care reform law s requirements. In 2014, most U.S. citizens must obtain health insurance coverage or they will be subject to penalties, with exceptions for low-income individuals and those unable to obtain affordable coverage. Are individuals required to have health coverage? Starting in 2014, most individuals will be required to obtain acceptable health insurance coverage for themselves and their family members or pay a penalty. This provision of the health care reform law is often called the individual mandate because it has the effect of requiring individuals to have health coverage. If you are covered under a health plan offered by your employer, or if you are currently covered by a government program such as Medicare, you can continue to be covered under those programs. Who is exempt from the individual mandate? Certain individuals are exempt from the individual mandate. For example, you may be exempt from the penalty for not maintaining acceptable health coverage if you: This Know Your Benefits article is provided by MVP Premier Insurance and is to be used for informational purposes only and is not intended to replace the advice of an insurance professional. Visit us at Design Zywave, Inc. All rights reserved

13 Health Care Reform: General Q&A for Employees Cannot afford coverage (that is, the required contribution for coverage would cost more than 8 percent of your household income) Have income below the federal income tax filing threshold Are not a citizen, national or lawfully present in the United States What are the penalties for individuals who don't have health coverage? The penalty for not obtaining acceptable health coverage will be phased in over a threeyear period. The amount of the penalty is the greater of two amounts the flat dollar amount and percentage of income amount. 2014: The penalty will start at $95 per person or up to 1 percent of income. 2015: The penalty increases to $325 per person or up to 2 percent of income and after: The penalty increases to $695 per person or up to 2.5 percent of income. The penalty for a child is half of that for an adult. The penalty is calculated on a monthly basis, and will be assessed for each month in which an individual goes without coverage. There is no penalty for a single lapse in coverage lasting less than three months in a year. Does the law affect health flexible spending accounts (FSAs), health reimbursement arrangements (HRAs) and health savings accounts (HSAs)? As of Jan. 1, 2011, the costs of over-the-counter medications can be reimbursed under a health FSA, HRA or HSA only if the medications are purchased with a doctor s prescription. This restriction does not apply to the purchase of insulin. Effective for 2013, there is an annual cap of $2,500 on employee pre-tax contributions to health FSAs. (The health care reform law does not change the limit on dependent care accounts, which remains capped at $5,000.) Also, if you are under age 65 and you withdraw money from your HSA for a purpose other than a qualified medical expense, you will be subject to an additional excise tax of 20 percent (up from 10 percent). How long can my adult child remain covered under my health plan? Health plans are required to permit children to stay on family coverage until they turn 26. This rule applies to all plans in the individual market and to non-grandfathered employer plans. It also applies to grandfathered employer plans; however, the 13 12

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15 MVP Premier Insurance Video Content Employer Videos Health Care Reform: W-2 Reporting Requirements This video gives the details of the health care reforms W-2 reporting requirement, what its purpose is and what it means for you as an employer. Health Care Reform: Summary of Benefits and Coverage This video explains the health care reforms disclosure requirement, the Summary of Benefits and Coverage, and how to ensure that you are in compliance with it. Employee Videos Health Care Reform: Age 26 Coverage Rule This video discusses health care reforms extension of dependent coverage to age 26, focusing on eligibility and coverage requirements. Health Care Reform: Patient s Bill of Rights This video explains the patient protections introduced by health care reform, including the prohibition of preexisting condition exclusions and lifetime limits, and the strict limitations on annual limits and rescissions Zywave, Inc. All rights reserved.