Transcript Shared Responsibility

What’s happening now?
What’s coming?
Norm Varin
March 20, 2014
Opening Joke (required)
Today’s Discussion
Shared Responsibility
Taxes, Assessments, Fees
State Legislative Update
Fine Print (thanks Josh Sears, Freestone Law, Chtd)
This presentation and any materials and/or comments
are training and educational in nature only and are not
legal advice, and do not serve as a substitute for legal
advice. No comment or statement in this presentation or
the accompanying materials is to be construed as an
admission. The presenter reserves the right to qualify or
retract any of these statements at any time. Likewise, the
context is not tailored to any particular situation and does
not necessarily address all relevant issues or necessarily
reflect the current state of the law in any particular
jurisdiction or circumstance as of the time of the
presentation. Parties participating in the presentation or
accessing of these materials should engage competent
counsel for consultation and representation in light of the
specific facts and circumstances presented in their
unique situation.
This is advice and sometimes conjecture…
Shared Responsibility
Applicable to large employers…
“An applicable large employer is an employer
who employed an average of at least 50 “fulltime employees” on business days during the
preceding calendar year, as provided in Code
Section 4980H(c)(2)(A).”
Shared Responsibility
Determining if you are a large
employer…
– in 2014 allow employers to choose to use either, or
both, a [6-month] period to prepare to count their
employees and a period afterward to ascertain and
implement the results of the determination.
– an employer not in existence during an entire
preceding calendar year is an applicable large
employer for the current calendar year if it is
reasonably expected to employ an average of at
least 100 full-time employees for 2015
Shared Responsibility
Determining if you are a large
employer…
– Number of full-time equivalents: add up all the hours
of service in a month for employees who are not fulltime and divide that aggregate number by 120.
– Number of full-time employees
– Special rule enables an employer that has more than
100 full-time employees solely as a result of
seasonal employment to avoid being treated as an
applicable employer. (120 days, or fewer)
Shared Responsibility
Determining if you are a large
employer…
Not Counted
• Bona fide volunteers
• Student Employees (work study)
• Members of Religious Orders
Shared Responsibility
2015: Applies to employer with 100+ employees
For groups <100, transition relief:
1.Limited Workforce Size
2.Maintenance of Workforce & Aggregate Hours of Service
3.Maintenance of Previously Offered Health Coverage.
4.Certification of Eligibility for Transition Relief.
2016: Applies to employer with 50+ employees
Shared Responsibility
The “Offer” Requirement
2015: Transition Rule
• offer coverage to >70% of full-time employees.
2016: Final Rule
• offer coverage to >95% of eligible employees
and dependents.
Shared Responsibility
2015: Non-Calendar Year Transition
Not required to comply with section 4980H until the start of their plan
years in 2015…
1.
Maintained non-calendar year plan before December 27, 2012,
2.
Did not modify plan year after December 27, 2012,
3.
Did not change eligibility rules after February 9, 2014.
Group needs to have met one of two coverage tests.
1.
the plan needs to have been either offering coverage to at least
33% of all employees or covering >25% of entire workforce,
including part-time workers.
2.
the group would have to demonstrate it has been offering
coverage to >50% of all full-time employees or covering >33% of
all full-time employees.
Shared Responsibility
Applicable to employees…
an employee is an individual who is an
employee under the common law standard, and
an employer is the person that is the employer
of an employee under the common law
standard.
Shared Responsibility
Employee Eligibility
– a “full-time employee” for any month is an
employee who is employed for an average of at
least 30 hours of service per week. The final
regulations would treat 130 hours of service in a
calendar month as the monthly equivalent of 30
hours of service per week (52 x 30) ÷ 12 = 130).
– A seasonal employee is an employee in a position
for which the customary annual employment is six
months or less.
Shared Responsibility
Employee Eligibility
– “ongoing employee” is generally an employee who
has been employed by the employer for at least
one complete standard look back measurement
period.
Shared Responsibility
Minimum Essential Coverage (MEC)
Under Code Section 5000A(f)(1), means coverage
under any of the following:
(a) a government-sponsored program, including coverage
under Medicare Part A, Medicaid, the CHIP program, and
TRICARE;
(b) an “eligible employer-sponsored plan;”
(c) a health plan offered in the individual market;
(d) a grandfathered health plan; or
(e) other health benefits coverage (such as a State health
benefits risk pool) as the Department of Health and Human
Services (“HHS”) recognizes.
Shared Responsibility
Minimum Essential Coverage (MEC)
Does NOT mean coverage under any of the following:
(a) Stand-alone HRAs that are not integrated with a
group health plan;
(b) HIPAA-excepted benefits such as: stand-alone
vision or dental, cancer-only policies, indemnity
plans (hospital or disease), accident or disability
plans, on-site medical clinics and other types of
coverage listed in PHSA §2791(c)
Shared Responsibility
Periods
– initial measurement period need not be based on
calendar months but instead may be based on months,
– a standard look back measurement period is a defined
time period of not less than three but not more than 12
consecutive calendar months
– administrative period (<90 days)
– a stability period – the first period in which the
employer is required to provide health coverage to the
employee – must be based on calendar months.
Shared Responsibility
Carrier Responsibility
–Guarantee Issue
–Guarantee Renewability
–Participation
Shared Responsibility
Resources
–http://www.irs.gov/uac/Newsroom/Q
uestions-and-Answers-onEmployer-Shared-ResponsibilityProvisions-Under-the-AffordableCare-Act
–NAHU
–www.larrygrudzien.com
Interim Joke (optional)
Fees
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Reinsurance
PCORI
Industry Fee
Other Fees
Reinsurance
• Temporary (think “tapered”)
– 2014:
– 2015:
– 2016:
– 2017:
$5.25 per member per month
$3.67 per member per month (proposed)
$?.??
Done
• Installments
– Twice per year (1st and 4th quarter)
• Possibility of ending early
– Self-funded
Patient-Centered Outcomes Research Institute
• Who Pays
– Fully insured medical - health plan pays; fee is built
into rates.
– Self funded medical
– Health Reimbursement Account (HRA) Plan
• How
– Fee is reported using Form 720, “Quarterly Federal
Excise Tax Return,” and paid directly to the IRS.
• How Much
– $2 per member for plan years ending on or after
October 1, 2013
Industry Fee
• Purpose
– fund premium subsidies or cost-sharing reductions
on the exchanges.
• How Much
– divided proportionately between all health issuers
– for-profit insurers will pay twice the amount as notfor-profit insurers.
– not applicable to self-funded health plans.
– increase premiums by 2%-2.5% percent in 2014
– increase premiums by 3%-4% percent after 2014
– not tax deductible
Other Fees
• Risk adjustment administration
– $1 per member per year
– Fully insured individual and small-group
markets
– not apply to large-group plans or self-funded
– not apply to any grandfathered plans
• Marketplace Administration
– Federal fee 3.5%
– Idaho current is 1.5%
Other Fees (bonus)
• Cadillac Excise Tax
– 40 percent tax on annual premiums
– generate revenue to finance health reform
– 2018, the thresholds are
• $10,200 for single coverage and
• $27,500 for family coverage.
– dollar amount over threshold will be taxed
• Applies to..
– health insurance issuer and self-funded plans
– will apply to both grandfathered and
non-grandfathered plans
Now the Legislative review…
State Legislative Update
Bill #
Description
2014 House Bills
HB358
Risk Based Capital (RBC): These changes are intended to align Idaho law with the NAIC RBC Model law.
HB393
HEALTH INSURANCE EXCHANGE Require the state health insurance exchange to allow shoppers to comparison shop
HB475
anonymously and not require identifying information until the consumer submits an application.
RS22606
ORAL ONCOLOGY - Requires certain insurers to provide certain orally administered medications on a basis no less favorable
than certain intravenously administered medications.
HB395
MEDICAID - Restores coverage for preventive dental services to adults with disabilities or special health needs.
HO418 &
HEALTH INSURANCE EXCHANGE – Repeals existing law relating to the Idaho Health Insurance Exchange Act
HO532
HO432
HO476
INDIGENCY; Clarifies that a subsidy received for health coverage through the exchange does not qualify as a factor for indigency
MEDICAID SERVICES – Amends existing law to revise provisions relating to restore home-based and community-based services
for persons with developmental disabilities (Community Supported Employment – removed in 2011 HO260
HO497
HOSPITALS (Transparency) - hospitals shall provide an estimate of actual charges to consumers when requested, …
HO533
COUNTY ASSISTANCE – Amends and repeals existing law relating to county assistance for healthcare
HO534
HEALTH INSURANCE – Adds to existing law to authorize medication synchronization and dispensing fee standardization
HO535
INDIGENT SICK – Amends existing law to provide that medical indigency means those at or below 100% of FPL
HO544
TAXES – Amends existing law revising provisions regarding taxation & contributions to medical savings accounts for state income
tax purposes
HO551
HEALTH INSURANCE – Adds to existing law to provide that medical retainer agreements shall not be regulated as health
insurance
HO558
INSURANCE – CONFIDENTIAL INFORMATION – Amends and adds to existing law to provide that certain information shall not
be deemed confidential, to define a term; and to require certain health carriers to file certain reports & to provide that certain
reports are not confidential
HO561
HOSPITAL ASSESSMENT – to revise duration of annual assessment; to revise how the assessment base is determined; and to
revise the duration and how the upper payment limit distributions are determined.
HCR39 &
All Payer Claims Database-instructs Dept. of Health & Welfare to investigate creating a hospital discharge database & an all
HCR49
payer claims database.
HCR46
TELEHEALTH/TELEMEDICINE – directs Department of Health and Welfare to convene a council to coordinate and develop a
comprehensive set of standards, policies, rules and procedures for the use of telehealth and telemedicine in Idaho.
HCR050
SOCIAL WORK – Recognizes March 2014 as Social Work Recognition Month
HJM06
PPACA Tax - Joint Memorial addressing PPACA tax on Healthcare industry
RS22685
Requires licensure for medical radiation technologists.
2014 Senate Bills
SB1329a
EMERGENCY MEDICAL SERVICES – amends existing law to revise the definition of “emergency medical services”
SB1329
TIME SENSITIVE EMERGENCIES- Adds to and amends existing law to create a Time Sensitive Emergency (TSE) System within
the Department of Health and Welfare; and to redesignate the Trauma Registry as the TSE Registry.
SB1243
Direct Primary Care/Medical Retainer Agreements. Defines medical retainer agreement and specifies that agreement must: (1)
describe the services included in the agreement, (2) state that the agreement is not health insurance, and (3) prohibit the health
care provider, but not the patient from billing an insurer. Establishes medical retainer agreements not subject to regulation as
health insurance.
SB1347
INDIGENT SICK – Amends, repeals and adds to existing law to remove references to the Catastrophic Health Care Cost
Program; and to establish a program and funding to aid community health centers
SB1355
STANDARD OF MEDICAL CARE - adds to existing law to provide that metrics established by the federal government under the
ACA and by insurers do not establish the standard of medical care in Idaho for purposes of disciplinary actions or malpractice.
S1363
OCCUPATIONAL LICENSES BUREAU – Adds to existing law to provide for the licensure of genetic counselors
State Legislative Update
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Updates
Catastrophic Funds
Transparency
Politics
Closing Joke (optional)
What’s happening now?
What’s coming?
Norm Varin
March 20, 2014