Compliance Guidebook Revised October 25, 2010

Transcription

1 Cmpliance Guidebk Revised Octber 25, 2010 Health Care Refrm Laws f 2010 Patient Prtectin and Affrdable Care Act and Health Care and Educatin Recnciliatin Act f 2010 Imprtant: This Cmpliance Guidebk is a summary f ntable, emplyee-related prvisins f the Health Care Refrm Laws f 2010, based n Delta Health Systems interpretatin f the regulatins. The laws, and a result this Cmpliance Guidebk, are subject t change based n final regulatins and interpretatins prvided by the regulatry agencies.

2 TABLE OF CONTENTS COMPLIANCE DEADLINES...1 Definitin f Health Plans... 1 Excepted Benefits... 1 GRANDFATHERED VS. NON-GRANDFATHERED STATUS...2 Mdel Disclsure Ntice: Status... 3 DETAILED INFORMATION ABOUT GRANDFATHERED VS. NON-GRANDFATHERED STATUS...4 IMMEDIATE REQUIREMENTS: Mdel Disclsure Ntice: Ntice that Lifetime Limit N Lnger Applies and Enrllment Opprtunity... 8 Mdel Disclsure Ntice: Ntice f Opprtunity t Enrll in Cnnectin with Extensin f Dependent Cverage t Age Restricted Annual Limits n Essential Benefits... 9 Waiver fr Annual Limits n Essential Benefits FUTURE REQUIREMENTS: Summary f Benefits and Cverage What is a Material Mdificatin? Material Mdificatins and Ntificatin t Emplyees SAMPLE HEALTH CARE REFORM AMENDMENT ADDENDUM: LIST OF PREVENTIVE SERVICES... I

3 Cmpliance Deadlines The fllwing table utlines Health Care Refrm Laws f 2010 cmpliance deadlines. Grup Health Plan r Individual Cverage (Self-Insured Plans and Fully-Insured Plans) Cllective Bargaining Agreements (Self-Insured) If the PLAN YEAR begins: Then the Plan Will Need t be in Cmpliance: Between March 23, 2010 thrugh September 22, 2010 Fr the next plan year beginning in 2011 Between September 23, 2010 thrugh December 31, 2010 On the date that the plan year begins On, r after, January 1, 2011 On, r after, January 1, 2011 * Plan year = Frm 5500 filing. Definitin f Health Plans Generally, the "insurance market refrm" prvisins f PPACA apply t bth fully-insured and self-insured "grup health plans"; emplyee welfare benefit plans prviding medical benefits. These PPACA prvisins amended the HIPAA prtability prvisins f the Public Health Service Act (PHSA), which already cntained several exceptins (ften referred t cllectively as "excepted benefits") t cmpliance. Excepted Benefits If a plan falls int ne f the categries f excepted benefits, then the plan will nt need t cmply with the majr insurance market refrm prvisins in PPACA. The categries f excepted benefits include: Limited Scpe Benefits: Benefits that are nt an integral part f a grup health plan. Examples include: limited scpe dental and visin benefits and lng-term care benefits prvided under a separate plicy. The plan is exempt frm prtins f PPACA if the plan requires: 1. a separate electin fr the limited scpe benefits, and 2. a separate premium/cntributin fr benefits. Nn-crdinated Benefits: Benefits that are prvided nly fr a specified disease/illness r any fixed indemnity insurance (fr example, paying a set dllar amunt per day f hspitalizatin). The benefits must be prvided under a separate plicy with n crdinatin between the plicy and a grup health plan maintained by the same plan spnsr. Supplemental Benefits: Medicare supplemental insurance r similar supplemental cverage prvided under a separate plicy, certificate r cntract f insurance. Flexible Spending Arrangements (FSAs): FSAs are excepted benefits nly if they satisfy the fllwing: 1. ther grup health plan cverage, nt limited t excepted benefits, is made available fr the year t the participants by reasn f their emplyment, and 2. the arrangement is structured s that the maximum benefit payable t any participant fr a year cannt exceed tw times the participant s salary reductin electin under the arrangement fr the year (r, if greater, cannt exceed $500 plus the amunt f the participant s salary reductin electin). While there are arguably drafting errrs in sme f these prvisins, PPACA appears t retain the exceptins listed abve with respect t the insurance market refrm requirements. S, many visin and dental plans will be excluded frm these new PPACA requirements if they fall under the "limited scpe" benefits exceptin. Nte that there are certain categries f benefits that are nt cnsidered t be health cverage and include: accident cverage, disability incme cverage, liability insurance, supplements t liability insurance, wrkers' cmpensatin and similar cverage, autmbile liability insurance, credit-nly insurance (including mrtgage insurance) and cverage fr n-site medical clinics. Therefre, these categries f benefits wuld nt be subject t PPACA cmpliance. 1

4 vs. Nn- Status Nte: Additinal, detailed infrmatin is prvided n the fllwing pages. One f the first steps in cmplying with the prvisins f the Health Care Refrm Laws f 2010 is t understand whether r nt a plan has grandfathered status. and nn-grandfathered plans have different cmpliance requirements. Belw is a list f questins t assist with the determinatin f a plan s status. 1. Was yur grup health plan in existence n March 23, 2010? Yes N 2. Regardless f the cmpany s Plan Year and/r when the cmpany needs t cmply with the Health Care Refrm Laws f 2010, the fllwing changes are measured frm March 23, Please check any bx belw that applies t the cmpany s existing plan: eliminating all, r substantially all, benefits t diagnse r treat a particular cnditin; increasing the participant s cinsurance percentage (even if changing the ut-f-netwrk cinsurance amunt); significantly increasing the participant s c-payment charges (ut-f-pcket amunts); significantly increasing the participant s deductibles; significantly lwering emplyer cntributins by mre than 5 percent; r adding r tightening an annual limit n what the insurer pays. If a plan makes a change t the benefits mid-year that causes the plan t lse its grandfathered status, the cmpany will need t cmply immediately with all regulatins. A cmpany des nt establish grandfathered status; a plan has grandfathered status. Each plan a cmpany ffers needs t establish grandfathered status. See Mdel Disclsure Ntice n page 3. These changes are based n interim final regulatins issued n June 14, Fr further explanatin, see Detailed Infrmatin Abut vs. Nn- Status. Example: If a cmpany des nt have t cmply until July 1, 2011, that cmpany must still live within the limits set abve if it wants t maintain grandfathered status when it becmes required t cmply with the laws. If the cmpany has made ne r mre f the changes listed abve between March 23, 2010 and June 14, 2010, the cmpany has until the first day f its first plan year n r after September 23, 2010, t revke any impermissible changes and mdify the plan, thereby preserving its grandfathered status. Pending further regulatry guidance, these events may/may nt cause a plan t lse grandfathered status: changing insurance, r eliminating a plan. As sn as the agencies issue further regulatry guidance n the matter f changing an insurance carrier, an update t the Guidebk will be issued. If yu are eligible fr grandfathered status, and yu chse t make any f the abve changes in #2 t yur plan, then the plan will lse its grandfathered status; yu will be respnsible fr fllwing the prvisins f the Health Care Refrm Laws f 2010 fr nn-grandfathered plans. 2

5 3. If the plan is eligible fr grandfathered status, and yu are nt making any f the changes listed n the previus page, then the plan will keep its grandfathered status even if: an existing participant renews cverage; an existing participant enrlls family members; a new participant (and his r her family members) enrll in cverage under the plan; the plan reasnably raises premiums t keep pace with health care csts; the plan makes sme changes in the benefits that it ffers; the plan, within limits, increases deductibles and ther ut-f-pcket expenses; r the plan is changing third party administratrs. If yu are eligible fr grandfathered status, and yu chse t make any f the abve changes in #3 t yur plan, then the plan may still maintain its grandfathered status. 4. In rder fr a plan t maintain grandfathered status, a plan is required t prvide the fllwing infrmatin n all materials distributed t emplyees: a statement t participants which prvides that the grup health plan believes it is a grandfathered health plan within the meaning f Sectin 1251 f the Patient Prtectin and Affrdable Care Act (PPACA), and the plan s cntact infrmatin fr questins and cmplaints. See Mdel Disclsure Ntice n page A plan s grandfathered status can be revked under the Health Care Refrm Laws f 2010 if the plan: frces cnsumers t switch t anther grandfathered plan that, when cmpared t the current plan, has less benefits r a higher cst sharing in rder t avid the requirements f the Health Care Refrm Laws f 2010, r is bught by, r merges with, anther plan in rder t avid cmpliance with the Health Care Refrm Laws f Mdel Disclsure Ntice: Status T maintain status as a grandfathered health plan, a plan r health insurance cverage must include a statement, in any plan materials prvided t a participant r beneficiary describing the benefits prvided under the plan r health insurance cverage, that the plan r cverage believes it is a grandfathered health plan within the meaning f sectin 1251 f the Patient Prtectin and Affrdable Care Act and must prvide cntact infrmatin fr questins and cmplaints. The fllwing mdel language can be used t satisfy this disclsure requirement: This [grup health plan r health insurance issuer] believes this [plan r cverage] is a grandfathered health plan under the Patient Prtectin and Affrdable Care Act (the Affrdable Care Act). As permitted by the Affrdable Care Act, a grandfathered health plan can preserve certain basic health cverage that was already in effect when that law was enacted. Being a grandfathered health plan means that yur [plan r plicy] may nt include certain cnsumer prtectins f the Affrdable Care Act that apply t ther plans, fr example, the requirement fr the prvisin f preventive health services withut any cst sharing. Hwever, grandfathered health plans must cmply with certain ther cnsumer prtectins in the Affrdable Care Act, fr example, the eliminatin f lifetime limits n benefits. Questins regarding which prtectins apply and which prtectins d nt apply t a grandfathered health plan and what might cause a plan t change frm grandfathered health plan status can be directed t the plan administratr at [insert cntact infrmatin]. [Fr ERISA plans, insert: Yu may als cntact the Emplyee Benefits Security Administratin, U.S. Department f Labr at r This website has a table summarizing which prtectins d and d nt apply t grandfathered health plans.] [Fr individual market plicies and nnfederal gvernmental plans, insert: Yu may als cntact the U.S. Department f Health and Human Services at 3

6 Detailed Infrmatin Abut vs. Nn- Status 1. Was yur grup health plan in existence n March 23, 2010? Yes* N** *If yur plan was in existence n March 23, 2010, then the plan is eligible fr grandfathered status. A plan s grandfathered status extends nt nly t emplyees and their family members enrlled n that date, but als t later added family members f already enrlled emplyees and t new emplyees (whether newly hired r newly enrlled) and their family members. If a plan is eligible fr grandfathered status, then the plan may be exempt frm certain cmpliance prvisins f the new Health Care Refrm Laws f ** A nn-grandfathered plan is a plan that was nt in existence n March 23, If yu entered int a new (ie., nt renewed) plicy, certificate r cntract f insurance after March 23, 2010, then that new plicy, certificate r cntract f insurance is nt a grandfathered plan. If the plan is nt eligible fr grandfathered status, then the plan must cmply with certain prvisins f the new Health Care Refrm Laws f Imprtant: The determinatin f grandfathered health plan status is made separately with respect t each benefit plan available frm a cmpany. 2. Under interim final regulatins issued n June 14, 2010, a plan's grandfathered status can be lst by implementing the fllwing changes measured frm March 23, 2010: eliminating all, r substantially all, benefits t diagnse r treat a particular cnditin; [Fr example, if a grandfathered plan decides t n lnger cver care fr patients with diabetes, cystic fibrsis r HIV/AIDS, then the plan will lse its grandfathered status.] increasing the participant s cinsurance percentage; [Fr example, if a grandfathered plan requires a patient t pay 20% f a hspital bill, a grandfathered plan cannt increase this percentage. If the plan increases the cinsurance percentage, then the plan will lse its grandfathered status.] significantly increasing the participant s c-payment charges; [If a grandfathered plan requires a patient t pay a fixed-dllar amunt fr a dctr s ffice visit and ther services, then, cmpared with the cpayments in effect n March 23, 2010, the grandfathered plan will be able t increase thse cpays by n mre than the greater f $5 (adjusted annually fr medical inflatin) r a percentage equal t medical inflatin plus 15 percentage pints. Fr example, if a plan raises its cpayment frm $30 t $50 ver the next 2 years, then the plan will lse its grandfathered status.] significantly increasing the participant s deductibles; [If a grandfathered plan requires a patient t pay a deductible (i.e., the first $500, $1,000 r $1,500 f the bills the patient receives each year), then, cmpared with the deductible in effect n March 23, 2010, the grandfathered plan can nly increase these deductibles by a percentage equal t medical inflatin plus 15 percentage pints. In recent years, medical csts have risen an average f 4-5%; this frmula wuld allw deductibles t increase, fr example, by 19-20% between 2010 and 2011, r by 23-25% between 2010 and Fr a family with a $1,000 annual deductible, the grandfathered plan is allwed t increase the deductible $190 r $200 frm 2010 t 2011; the grandfathered plan culd then increase the deductible again by anther $50 the fllwing year. If the deductible s percentage increases are larger, then the plan will lse its grandfathered status.] 4

7 significantly lwering emplyer cntributins by mre than 5 percent; r [If a grandfathered plan allws fr the emplyer t cntribute a prtin f its emplyee s premiums fr insurance, then the grandfathered plan cannt decrease the percent f premiums the emplyer pays by mre than 5 percentage pints. Fr example, under the grandfathered plan, the emplyer cannt decrease its share f the premium payment and increase the emplyees share f the premium frm 15% t 25%. If the plan decreases the emplyer s premium payment by mre than 5 percent (and shifts the cst t the patient), then the plan will lse its grandfathered status.] adding r tightening an annual limit n what the insurer pays. [An insurer may limit the amunt that the insurer will pay fr cvered services each year. If a plan wants t retain its status as a grandfathered plan, then the plan cannt reduce any annual dllar limit in place as f March 23, If a grandfathered plan des nt have an annual dllar limit in place, the grandfathered plan cannt add a new ne unless the grandfathered plan is replacing a lifetime dllar limit with an annual dllar limit that is at least as high as the lifetime limit.] 5

8 Immediate Requirements: IMPORTANT: The fllwing chart is a prvisinal summary f the Health Care Refrm Laws f 2010; the infrmatin may be subject t change based n final regulatins and interpretatins prvided by the regulatry agencies. Cmpanies shuld dcument their decisins regarding cmpliance with the Health Care Refrm Laws f 2010 t shw gd faith fr why a decisin was made/nt made. Plan Changes In existence n 03/23/10 Material Mdificatins 1. N pre-existing cnditin limitatins are permitted fr children under age 19. (In 2014, n pre-existing cnditin limitatins will be permitted fr adults.) Pre-existing cnditin limitatins impsed befre the plan year begins/needs t cmply are allwed. 2. N lifetime maximum n essential benefits (as listed n page 9). A plan needs t prvide an enrllment pprtunity even if the participant maxed ut while paying fr COBRA. See Page 8 fr Mdel Ntice language. Under the interim final regulatins, individuals wh reached a lifetime limit under a plan r health insurance cverage prir t the applicability date f these interim final regulatins and are therwise still eligible under the plan r health insurance cverage must be prvided with a ntice that the lifetime limit n lnger applies. If such individuals are n lnger enrlled in the plan r health insurance cverage, these interim final regulatins als require a special enrllment (in the individual market, reinstatement) pprtunity fr such individuals. 3. Dependent cverage up t age 26, regardless f: marital status financial dependency enrllment in schl residency See Page 8 fr Mdel Ntice language. Nn- A New Plan r a Plan that has lst Status Effective Date Plan Year beginning n r after Plan Year beginning n r after Plan Year beginning n r after Special Ntice Required: Annual r SPD* N/A Ntice / 30- day special enrllment pprtunity Ntice / 30- day special enrllment pprtunity Under IRC 152(f)(1), children are defined as: sns, daughters, stepchildren, adpted children (including children placed fr adptin) and fster children. IF the plan cvers any f these individuals, the plan must cmply with the dependent cverage requirements. IF the plan elects t cver any ther dependents (ie, grandchildren, nieces r nephews), then a plan can cnditin health cverage n supprt, residency, age, student status r ther dependency requirements. Nte that IRC 152(f)(1) des nt require a grup health plan t prvide cverage t stepchildren r fster children. A plan cannt have different benefits fr ages 0-18 and A plan is nt required t cver pregnancy-related expenses f a cvered dependent child. If a plan des, then it must include cverage f the hspitalizatin fr the cvered dependent child in cmpliance with the Newbrns and Mthers Health Prtectin Act (48 / 96 hurs). Issue: Can a plan exclude adult children wh are eligible t enrll in an emplyerspnsred health plan (ther than that f their parent)? Yes, until 2014 N * All infrmatin listed in this sectin needs t be cmmunicated t emplyees. This clumn pertains t additinal requirements that are required in additin t the SPD. 6

9 Plan Changes In existence n 03/23/10 Material Mdificatins 4. N rescissin f cverage unless a 30-day prir ntice has been prvided t the participant (except in the cases f fraud r misrepresentatin). Terminatin f cverage fr nn-payment f premiums is nt cnsidered a rescissin. It is imprtant t knw whether an emplyee pays the premiums and when premium deductins are taken ut f the emplyee s pay. (i.e., If premiums have been taken ut f the emplyee's pay, can t rescind; if premiums have nt been taken ut, can terminate.) 5. Essential benefits may nly have restricted annual limits. The annual limit is a cmbined limit. (See infrmatin n page 9 fr details.) 6. Ntificatin f Material Mdificatins: At least 60 days prir t effective date f change. (Pending regulatry guidance. Pssibly effective in 2011 / 2012.) 7. N reimbursement frm FSA/HRA/HSA fr ver-the-cunter drugs, except when prescribed by a physician 8. Ntificatin t participants in plan dcument materials that the plan is a grandfathered plan. Ntificatin f grandfathered status des nt need t be included in Explanatin f Benefit frms. 9. Preventive Care and Immunizatins must be prvided in-netwrk withut cst sharing (within specified guidelines, as prvided in the Recmmendatins by the U.S. Preventive Services Task Frce). A health plan may allw a participant t receive these services frm an ut-f-netwrk prvider, but may charge a fee fr the services frm the ut-f-netwrk prvider. 10. Access t designate any PCP (including pediatrician and OB/GYN) withut the need fr a referral r prir authrizatin. 11. Emergency Services: N prir-authrizatin is required whether the services are prvided innetwrk r ut-f-netwrk. Requirements r limitatins n benefits fr ut-f-netwrk emergency services cannt be mre restrictive than the requirements r limitatins that apply t in-netwrk emergency services. Out-f-netwrk cst sharing cannt exceed the cst sharing requirements that wuld be impsed if the services were prvided in-netwrk. Nn- A New Plan r a Plan that has lst Status Effective Date Plan Year beginning n r after Plan Year beginning n r after See Material Mdificatins and Ntificatin t Emplyees Expenses incurred n r after 1/1/11 N/A Plan Year beginning n r after N/A unless status is lst N/A unless status is lst N/A unless status is lst Plan Year beginning n r after Plan Year beginning n r after Plan Year beginning n r after Special Ntice Required: Annual r SPD* Ntice N/A Ntice Ntice Ntice N/A Ntice N/A Ntice/certificatin after the fact can be required. The determinatin f an emergency is based n what a prudent lay persn thinks nt the actual medical diagnsis in an emergency. 12. Re-vamped appeals prcess: A plan must prvide bth internal and external reviews. If an individual has a claim in prcess, even if the claim happened befre the plan was required t be cmpliant with PPACA, a participant can request an external review accrding t the new regulatins - as lng as the timeframe fr requesting an external appeal has nt expired. N/A unless status is lst Plan Year beginning n r after Ntice * All infrmatin listed in this sectin needs t be cmmunicated t emplyees. This clumn pertains t additinal requirements that are required in additin t the SPD. 7

10 Plan Changes In existence n 03/23/10 Nn- A New Plan r a Plan that has lst Status Material Mdificatins (Plan Amendment Nt Required) IRS Reprting: Emplyer must reprt value f each emplyee s health cverage n W-2 < 100 Emplyees: Simplified Cafeteria Plans Simplified nndiscriminatin rules apply if an emplyer makes a cntributin tward benefits fr each eligible emplyee. All Benefits ptins ffered n equal terms t emplyees with 1000 hurs f service Effective Date Special Ntice Required: Annual r SPD 1/1/11 ptinal; 1/1/12 - mandatry N/A 1/1/2011 N/A 200+ Emplyees: Autmatic Enrllment 3/23/10 (Pending regulatry guidance) N/A Mdel Disclsure Ntice: Ntice that Lifetime Limit N Lnger Applies and Enrllment Opprtunity The fllwing mdel language can be used t satisfy the ntice requirement regarding n lifetime maximums: The lifetime limit n the dllar value f benefits under [Insert name f grup health plan r health insurance issuer] n lnger applies. Individuals whse cverage ended by reasn f reaching a lifetime limit under the plan are eligible t enrll in the plan. Individuals have 30 days frm the date f this ntice t request enrllment. Fr mre infrmatin cntact the [insert plan administratr r issuer] at [insert cntact infrmatin]. Mdel Disclsure Ntice: Ntice f Opprtunity t Enrll in Cnnectin with Extensin f Dependent Cverage t Age 26 The fllwing mdel language can be used t satisfy the ntice requirement regarding extensin f dependent cverage t Age 26: Individuals whse cverage ended, r wh were denied cverage (r were nt eligible fr cverage), because the availability f dependent cverage f children ended befre attainment f age 26 are eligible t enrll in [Insert name f grup health plan r health insurance cverage]. Individuals may request enrllment fr such children fr 30 days frm the date f ntice. Enrllment will be effective retractively t [insert date that is the first day f the first plan year beginning n r after September 23, 2010.] Fr mre infrmatin cntact the [insert plan administratr r issuer] at [insert cntact infrmatin]. 8

11 Restricted Annual Limits n Essential Benefits A plan is nt required t cver any, r all, f the essential benefits t its participants. Hwever, if the plan des cver an essential benefit, then the plan must cmply with the annual dllar limit restrictins. Definitin f essential benefits (as defined in Sectin 1302(b) f the Affrdable Care Act): ambulatry care, emergency care, hspitalizatin, maternity/newbrn care, mental health and substance abuse use disrder services, prescriptin drugs, rehabilitatin services, lab services, preventive/wellness care, chrnic disease management, and pediatric care, including ral and visin care*. Regulatins under sectin 1302(b) f the Affrdable Care Act have nt yet been issued. Fr plan years beginning befre the issuance f regulatins defining "essential health benefits", fr purpses f enfrcement, IRS, DOL, and HHS will take int accunt gd faith effrts t cmply with a reasnable interpretatin f the term "essential health benefits." Fr this purpse, a plan r issuer must apply the definitin f essential health benefits cnsistently. *Pending regulatry guidance n what cnstitutes ral and visin care as well as if any age limitatins apply (ie, thrugh what age is pediatric care required). Until HHS issues such guidance n the definitin f essential benefits, the regulatry agencies will take int accunt a plan s effrt t administer the actual benefits based n gd-faith cmpliance. Fr example, a plan may include the fllwing benefits under its definitin fr rehabilitatin services (chirpractic care, acupuncture, physical therapy, ccupatinal therapy and speech therapy) if the plan applies the definitin cnsistently. Nte: The plan shuld dcument its reasns fr nt selecting benefits that may be cnsidered essential benefits t participants. The fllwing restricted annual limits are fr essential benefits (cmbined) per individual: $750,000 fr plan years beginning n r after 9/23/2010 but befre 9/23/2011 $1.25 millin fr plan years beginning n r after 9/23/2011 but befre 9/23/2012 $2 millin fr plan years beginning n r after 9/23/2012 but befre 1/1/2014 A plan can impse visit r service limits and change a dllar annual limit t a visit limit. These types f changes will nt trigger a cmpany t lse its grandfathered status. A plan may nt place a specific limit n a particular benefit. Fr example, fr a plan year beginning n r after 9/23/2010 but befre 9/23/2011, the restricted minimum annual limit fr essential benefits is $750,000, which is a cmbined limit amunt fr all f the essential benefits. A plan cannt place an annual limit f $50,000 n hspitalizatin and maintain the remaining $700,000 limit fr all ther cvered essential benefits. 9

12 Waiver fr Annual Limits n Essential Benefits The interim final regulatins published n June 28, 2010, als prvided that these restricted annual limits may be waived by the Secretary f Health and Human Services (HHS) if cmpliance with the interim final regulatins wuld result in a significant decrease in access t benefits r a significant increase in premiums. A grup health plan r health insurance issuer that prvides cverage that wuld meet the criteria fr a waiver [(as utlined in sub-regulatry guidance issued n September 2, 2010) ( )] and that wishes t btain a waiver f the restricted annual limit requirements shuld apply fr such waiver by submitting the requested items within the apprpriate timeframe t HHS, Office f Cnsumer Infrmatin and Insurance Oversight, Office f Oversight, attentin James Mayhew, Rm 737-F-04, 200 Independence Ave. SW, Washingtn, DC r ing the items t healthinsurance@hhs.gv (use waiver as the subject f the ). If a plan has questins regarding the sub-regulatry guidance, then the plan can cntact the Office f Cnsumer Infrmatin and Insurance Oversight at (301) r at healthinsurance@hhs.gv (use waiver as the subject f the ). 10

13 Future Requirements: IMPORTANT: The fllwing chart is a list f the Health Care Refrm Laws f 2010; the infrmatin may be subject t change based n final regulatins and interpretatins prvided by the regulatry agencies Issuance f a standardized Summary f Benefits and Cverage (utlined belw) Annual Reprts: HHS is required t develp reprting requirements by 3/23/ FSA: Annual cntributin is $2,500 Medicare Tax: Emplyee prtin f Medicare tax increases t 2.35% fr wages ver $200, N waiting perids lnger than 90 days N pre-existing cnditins fr adults N annual dllar limits n essential health benefits Clinical trials: Csts fr participatin in certain clinical trials by qualified individuals must be cvered Deductibles: Fr small emplyers, deductibles may be capped (It is unclear whether the deductible requirement may nly apply t fully insured plans.) Free Chice vuchers Excise ( Cadillac ) tax n high cst plans 2018 Summary f Benefits and Cverage The Patient Prtectin and Affrdable Care Act (PPACA) implemented additinal, new reprting requirements fr health plans. By March 23, 2011, the US Department f Health & Human Services is required t establish standards fr grup health plans t fllw in prviding benefits summaries and cverage explanatins, which accurately explain the benefits and cverage prvided under the plan. In additin t the Summary Plan Descriptin, a new Summary f Benefits and Cverage dcument is t be prvided t plan applicants, enrllees and plicy hlders (regardless f grandfathered status) by March 23, This new Summary f Benefits and Cverage dcument: may nt be lnger than fur (4) pages in length, and must use language that is understandable t the average plan enrllee. The Summary f Benefits and Cverage must include the fllwing items: unifrm definitins f standard insurance and medical terms (t be develped by HHS); descriptin f cverage fr (i) essential health benefits and (ii) ther benefits t be identified by HHS; exceptins, reductins and limitatins n cverage; cst-sharing prvisins, including descriptins f deductibles, cinsurance, and c-pays; renewability and cntinuatin f cverage prvisins; cmmn benefit scenaris based n clinical practice guidelines t illustrate csts fr pregnancy and serius r chrnic medical cnditins; a statement that the plan prvides minimum essential cverage; a statement that the plan s share f ttal allwed csts f benefits is nt less than 60% f csts; a statement that the utline is a summary f the plan and that the cverage dcument (SPD) shuld be cnsulted t determine the plan s gverning cntractual prvisins; and a cntact number fr the cnsumer t call with additinal questins and an internet web address where a cpy f the actual plan dcument can be reviewed r btained. 11

14 What is a Material Mdificatin? Under the interim disclsure rules, a material reductin in cvered services r benefits means any mdificatin t a grup health plan r change in the infrmatin required t be included in the summary plan descriptin that, independently r in cnjunctin with ther cntempraneus mdificatins r changes, wuld be cnsidered by the average plan participant t be an imprtant reductin in cvered services r benefits under the grup health plan. The interim rules cite examples f reductins in cvered services r benefits as generally including any plan mdificatin r change that: eliminates benefits payable under the plan, reduces benefits payable under the plan, including a reductin that ccurs as a result f a change in frmulas, methdlgies r schedules that serve as the basis fr making benefit determinatins, increases deductibles, c-payments r ther amunts t be paid by a participant r beneficiary, reduces the service area cvered by a health maintenance rganizatin, r establishes new cnditins r requirements (e.g., preauthrizatin requirements) t btain services r benefits under the plan. Material Mdificatins and Ntificatin t Emplyees Under the ntice f mdificatins prvisin in the Health Care Refrm Laws f 2010, a plan spnsr must prvide persns cvered by the plan with a ntice f mdificatin(s) t the plan at least 60-days prir t the effective date f the change. If a grup health plan r health insurance issuer makes any material mdificatin in any f the terms f the plan r cverage invlved that is nt reflected in the mst recently prvided Summary f Benefits and Cverage, then the plan r issuer shall prvide ntice f such mdificatin t enrllees nt later than 60-days prir t the date n which such mdificatin will becme effective. There are many differing pinins n the effective date f this ntificatin prvisin. PPACA ties the effective date f the 60-day advance ntice rule t the release f agency guidance defining the Summary f Benefits and Cverage. The 60-day advance ntice rule cannt g int effect until the agencies release guidance n the Summary f Benefits and Cverage dcument. Therefre, the 60-day advance ntice rule is nt in effect at this time. NOTE: If a plan will be unable t prvide a ntice f material mdificatin due t timing factrs, then the plan shuld pstpne the effective date f the plan changes until the 60-day prir ntice requirement can be met. 12

15 Client Lg Sample Health Care Refrm Amendment Issue: Lifetime Maximum Amendment: 1 f 11 Effective Date: January 1, 2012 Dcument being Amended: 2010 Summary Plan Descriptin As f [Mnth/Day/Year], [Client Name] has: Status Nn- Status Effective, in cmpliance with the Patient Prtectin and Affrdable Care Act (PPACA) and the Health Care and Educatin Recnciliatin Act f 2010, [Client] hereby amends the plan as fllws: Placement f Change Page Number Sectin Header 1. Page 25: Summary f Deductibles, Out-f-Pcket Maximums and Lifetime Maximums Current Lifetime Maximum $2,000,000 Imprtant: Each change that will need t be made by emplyees fr each Issue (as utlined in the title abve) will be listed by page number; there will be ne amendment per issue. New There is n lnger a Lifetime Maximum n Essential Benefits. Replace $2,000,000 with Unlimited. It is understd and agreed by [Client] that the abve stated amendment and the prvisins cntained in the Summary Plan Descriptin as amended herein are acceptable and will be the basis fr the administratin f the plan beginning. In witness wheref, this Agreement has been executed this day f, Name (printed) Signature Title Date Imprtant: Future amendments will include the fllwing language: Effective Date The date the Material Mdificatin(s) will be effective; must be at least 60 days frm the date Emplyees are ntified f the change; see Ntificatin Date belw. Ntificatin Date The date Emplyees were ntified f the changes (i.e., Material Mdificatin) that are being made t the plan. Ntificatin Methd Methd used t ntify Emplyees f the changes (i.e., Material Mdificatin). 13

16 Addendum: List f Preventive Services Preventive Services The fllwing preventive services are cvered withut yur having t pay a cpayment r cinsurance r meet yur deductible, when these services are delivered by an in-netwrk prvider. Nte: These benefits are subject t change peridically; check the website at the end f this sectin fr the mst up-t-date infrmatin. Cvered Preventive Services fr Adults (Age 18 and Older) Abdminal Artic Aneurysm One-time screening fr men f specified ages wh have ever smked Alchl Misuse Screening and cunseling Aspirin Recmmended use fr the preventin f heart disease Bld Pressure Screening fr all adults Chlesterl Screening fr adults f certain ages r at higher risk Clrectal Cancer Screening fr adults ver 50 Depressin Screening fr adults Diabetes (Type 2) Screening fr adults with high bld pressure Diet Cunseling fr adults at higher risk fr high chlesterl r heart disease HIV Screening fr all adults at higher risk Immunizatin and Vaccines Dses, recmmended ages and recmmended ppulatins vary Obesity Sexually Transmitted Infectin (STI) Syphilis Tbacc Use Hepatitis A Hepatitis B Herpes Zster Human Papillmavirus Influenza Measles Mumps Meningcccal Pneumcccal Tetanus Diphtheria Pertussis Varicella Rubella Screening and cunseling fr all adults Preventin cunseling fr adults at higher risk Screening fr all adults at higher risk Screening nly Additinal Cvered Preventive Services fr Wmen (Age 18 and Older) BRCA Gene Cunseling abut genetic testing fr wmen at higher risk Breast Cancer Mammgraphy Screenings every 1 t 2 years fr wmen ver 40 Breast Cancer Chempreventin Cunseling fr wmen at higher risk Cervical Cancer Screening fr sexually active wmen Chlamydia Infectin Screening fr yunger wmen and ther wmen at higher risk Flic Acid Supplements fr wmen wh may becme pregnant Gnrrhea Screening fr all wmen at higher risk Osteprsis Screening fr wmen ver age 60 depending n risk factrs Anemia Bacteriuria Breast Feeding Hepatitis B Rh Bld Typing Tbacc Use Syphilis Preventive Services fr Cvered Pregnancies Screening n a rutine basis fr pregnant wmen Urinary tract r ther infectin screening fr pregnant wmen Interventins t supprt and prmte breast feeding Screening fr pregnant wmen at their first prenatal visit Screening fr all pregnant wmen Screening, interventins and expanded cunseling fr pregnant tbacc users Screening fr all pregnant wmen r ther wmen at increased risk Addendum: List f Preventive Services - I

17 Cvered Preventive Services fr Children (Birth up t age 18) Alchl and Drug Use Assessment Adlescents Autism Screening 18 and 24 mnths Behaviral Assessments All children thrughut develpment Cervical Dysplasia Screening Sexually active females Cngenital Hypthyridism Screening All newbrns Develpmental Screening Children under age 3 and surveillance thrughut childhd Dyslipidemia Screening Children at higher risk f lipid disrders Fluride Chempreventin Supplements Children withut fluride in their water surce Gnrrhea Preventive Eye Medicatin All newbrns Hearing Screening All newbrns Height, Weight and Bdy Mass Index All children thrughut develpment Hematcrit r Hemglbin Screening All children Hemglbinpathies/Sickle Cell Screening All newbrns HIV Screening Adlescents at higher risk Immunizatin Vaccines Dses, recmmended ages and recmmended ppulatins vary Irn Supplements Lead Screening Medical Histry Obesity Screening and Cunseling Oral Health Risk Assessment Phenylketnuria (PKU) Genetic Screening Sexually Transmitted Infectin (STI) Preventin Cunseling Tuberculin Testing Visin Screening Diphtheria Tetanus Pertussis Haemphilus Influenzae (Type b) Hepatitis A Hepatitis B Human Papillmavirus Inactivated Plivirus Influenza Measles Mumps Rubella Meningcccal Pneumcccal Rtavirus Varicella Children ages 6 t 12 mnths at risk fr anemia Children at risk f expsure All children thrughut develpment All children thrughut develpment Yung children All newbrns Adlescents at higher risk Children at higher risk f tuberculsis All children Sme Imprtant Details: If yur health plan uses a netwrk f prviders, be aware that health plans are nly required t prvide these preventive services thrugh an in-netwrk prvider. Yur health plan may allw yu t receive these services frm an ut-f-netwrk prvider, but may charge yu a fee. Yur dctr may prvide a preventive service, such as a chlesterl screening test, as part f an ffice visit. Be aware that yur plan can require yu t pay sme csts f the ffice visit, if the preventive service is nt the primary purpse f the visit, r if yur dctr bills yu fr the preventive services separately frm the ffice visit. If yu have questins abut whether these new prvisins apply t yur plan, cntact the Plan Spnsr r Claims/Cntract Administratr. T knw which cvered preventive services are right fr yu based n yur age, gender and health status ask yur health care prvider. If yur plan is grandfathered, these benefits may nt be available t yu. References: Regulatin: Overview: Addendum: List f Preventive Services - II