Healthcare Reform: The Road Ahead

To protect the confidential and proprietary information included in this material, it may not be disclosed or provided to any third parties without the approval of Aon Hewitt.

Health Care Reform Update:The Road AheadPresented May 9, 2013

2Consulting | U.S. Health & BenefitsProprietary & Confidential | 02/2013

Agenda

IntroductionHealth Care Reform – The Road AheadQ&A


Introduction

Patient Protection and Affordable Care Act (PPACA)– Also known as:

• The Affordable Care Act (ACA)• “Obamacare”• Health Care Reform (HCR)

Co-employment and the Affordable Care Act (ACA)– No PEO-specific provisions in the ACA– PEO clients should be looked at separately from the PEO in terms of complying with the law,

based on legislative history and guidance from AlphaStaff compliance resources and ERISA counsel• Employer Play or Pay requirement• Nondiscrimination testing (postponed)• Small Business Tax Credits

All AlphaStaff-sponsored major medical plans are fully insured and are compliant with current ACA requirements and will continue to be updated as new provisions become effective.


The Rules of Health Care Reform

Deal with what you know Apply the “Jello” Theory

Consulting | U.S. Health & BenefitsProprietary & Confidential | 02/2013

Current State of PPACA

Health Insurance Exchanges with Reformed Rules

Expanding/Improving Coverage Paying for Expanded Coverage

OptionalState Expansion of

Medicaid

EmployerMandate

“IndividualMandate”—now a

“Shared Responsibility Payment”

Federal Subsidies To Buy Health Insurance

In Exchanges

Medicare/MedicaidPayment Changes

Taxation of High-Cost Employer

Health Care Coverage

Increase in Other Taxes

= Direct impact to employers

= Indirect impact to employers

= Direct and indirect impact to employers

Increased MedicareTaxes on High-

Income Individuals

ACA Penalties on Employer

1 Supreme Court ruled states could decline to expand Medicaid eligibility without losing existing Medicaid funding 2 Supreme Court ruled “mandate” is a tax on not having health insurance

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2011 Plan Year 2011 2012 2013 2014 2018

• Lifetime dollar limits on

Essential Health Benefits

(EHB) prohibited*

• Preexisting Condition

Exclusions Prohibited for

Children under 19*

• Overly restrictive annual

dollar limits on EHB

prohibited*

• Extension of Adult Child

Coverage to Age 26*

• Prohibition on Rescissions*

• No Cost Sharing and

Coverage for Certain In-

Network Preventive Health

Services**

• Effective Appeals Process**

• Consumer/patient

protections**

• Nondiscrimination

requirements on fully insured

plans** (DELAYED)

• Certain Retiree Medical

Claims Reimbursable (ERRP)

• Retiree Drug Plan FAS

Liability Recognition

• Over-the-Counter

Medicines Not

Reimbursable Under

Health FSA, HRAs, or

from HSAs Without a

Prescription, Except

Insulin

• HSA Excise Tax Increase

• Public Long-Term Care

Option (CLASS Act) –No

Longer Supported by

HHS

• Medicare Part D

Discounts for Certain

Drugs in “Donut Hole”

• Employer Distribution of

Summary of Benefits

and Coverage to

Participants* (DELAYED)

• Comparative

Effectiveness Fee

• Employer Quality of Care

Report**

• Medical Loss Ratio

rebates (insured plans

only)*

• Employer Reporting of

Health Coverage on

Form W-2 (due January

31, 2013)

• Notice to Inform

Employees of Coverage

Options in Exchange

(DELAYED)

• Limit of Health Care FSA

Contributions to $2,500

(Indexed)

• Elimination of Deduction

for Expenses Allocable

to Retiree Drug Subsidy

(RDS)

• Medicare Tax on High

Income

• Addition of women’s

preventive health

requirements to No Cost

Sharing and Coverage

for Certain In-Network

Preventive Health

Services **

• Determining full-time

employees

• Non-discrimination rules

(DELAYED)

• Individual Mandate to

Purchase Insurance or Pay

Penalty

• State Insurance Exchanges

• Employer Responsibility to

Provide Affordable Minimum

Essential Health Coverage***

• Preexisting Conditions

Exclusions Prohibited*

• Annual Dollar Limits on EHB

Prohibited*

• Automatic Enrollment

(DELAYED)

• Limit of 90-Day Waiting

Period for Coverage*

• Employer Reporting of

Health Insurance

Information to Government

and Participants

• Increased Cap on Rewards

for Participation in Wellness

Program**

• Cost-sharing limits for all

group health plans, not just

HDHPs/HSA (deductibles

and OOP maximum)**

• Excise Tax on

High-Cost Coverage

*Denotes group/insurance market reforms applicable to all group health plans. **Denotes group/insurance market reforms not applicable to grandfathered health plans. *** This requirement applies to full time employees (e.g., 30 hours per week) and will require coverage that is affordable and satisfies a certain actuarial value to avoid the penalty. Guidance forthcoming.

Health Care Reform General Timeline

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Small Employer Provisions – Small Business Tax Credits

Effective January 1, 2010

Employers with fewer than 25 full-time equivalent employees and average wages below $50,000 that provide qualified health plan coverage are eligible to receive a health insurance federal tax credit

Employer must pay a uniform % not less than 50% of the premium

Credit of up to 35% on health premiums (50% in 2014) for eligible small employers or 25% for tax-exempt small employers

Premium taken into account capped at average small group market premium for State or local area

The Internal Revenue Service has mailed postcards to 4 million small employers publicizing the new tax credits and to remind them that the new tax credits take effect this year. The postcard and additional information can be located at http://www.irs.gov/newsroom/article/0,,id=221511,00.html

http://www.irs.gov/newsroom/article/0,,id=221511,00.html


Employer Checklist—Act on 2013 Provisions Now

2013 ProvisionsAdministrative & Communication Actions

Medicare taxes for high-income Do calculations Coordinate with payroll Tell affected employees (optional)

$2,500 FSA Limit Communicate in off-cycle enrollments Provide decision support Update SPDs

Women’s preventive health coverage Communicate in off-cycle enrollments Update SPDs

Notifying employees about state exchanges (Delayed)

Communicate to all employees about exchanges (eligibility, services and contact information)

Patient-Centered Outcomes Research Institute (PCORI) Trust Fund Fee

Based on average covered lives $1 for 2013; $2 for 2014 Reporting and payment of fees on IRS

Form 720


Start Preparing for 2014 Provisions

2014 Provisions Administrative & Communication Actions

Employer mandate

Free-rider penalties

Premium tax credits

Automatic enrollment (Delayed)

Minimum essential benefits

Fully-effective group market and insurance reforms

Educating employees on how state exchanges will work

Transitional Reinsurance Fee

Increased wellness rewards cap 30% of cost of health coverage

Expanded preventive care

Incorporate provisions into enrollment

Develop a communication strategy and tactics

Provide decision support

Create or update SBCs/ SPDs/ SMMs

Guiding Principles Focus on participant actions Stay objective Simplify messages Provide guidance Capitalize on the opportunity


2014—Exchange Update

Coverage through the exchanges will begin in every state on January 1, 2014, with enrollment beginning October 1, 2013.

States can elect to: – build a fully state-based exchange, – enter into a state-federal partnership exchange, or – default into a federally-facilitated exchange.

The Affordable Care Act (ACA) directs the Secretary of Health and Human Services (HHS) to establish and operate a federally-facilitated exchange in any state that is not able or willing to establish a state-based exchange.

In a federally-facilitated exchange, HHS will perform all exchange functions. States entering into a state-federal partnership exchange may administer plan management functions, in-person consumer assistance functions, or both, and HHS will perform the remaining exchange functions. If a state opts for a state-federal partnership exchange, it has until February 15, 2013, to submit an exchange blueprint to HHS.


2014—SHOP Exchange

Small Business Health Options Program (SHOP) will be designed to make insurance options available for small businesses.

THE SHOP will allow the small business to select the level of coverage offered to the employees and how much the employer will contribute.

There will be an expanded Small Business Healthcare Tax Credit that will provide a tax credit of up to 50% of the employer’s contribution towards providing coverage to low and middle income employees.

Premiums will be impacted by Medical Loss Ratio requirements. Employers will be able to enroll through a broker, through a website or through a toll

free telephone number. .These were to become effective January 1, 2014. However, the federal government

recently announced that the federal SHOP Exchanges only will now be postponed until January 1, 2015.

State SHOP Exchanges may follow suit, to be determined. This delay does not preclude an employer from meeting the employer mandate

requirements.


Public Exchange Status by State

CA

ORE

WA

NEV

UTAHCO

IDAHO

WYO

NMARIZ

ND

SD

NEB

KANSAS

OK

TEXAS

MINN

IOWA

MO

Ark

LA

MS

FLORIDA

GA

SC

KY

WIS MN

IL INDOHIO

PA

W VAVA

NCTN

NY

NJ

MD

DE

CT

RI

VT NH

MAINE

MASSACHUSETTSMONTANA

ALASKA

ALA

HA

Won’t Create Exchange

Creating Exchange

Partnership Exchange with Feds

Democrat Governor

Republican Governor

WA

NY

VT

MASSACHUSETTS

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Half of States Are Expanding Medicaid in 2014

CA

OR

WA

NV

UTCO

ID

WY

NMAZ

ND

SD

NB

KS

OK

TX

MN

IA

MO

AR

LA

MS

FL

GA

SC

KY

WI

MN

IL IN

OHPA

WVVA

NCTN

NY

NJ

MD

CT

RI

VT NH

ME

MAMO

AK

AL

HI

9 States Won’t Expand Medicaid

13 States Will Expand Medicaid

16 States Undecided on Medicaid Expansion

Democrat Governor

Republican Governor

5 States Leaning toward expanding Medicaid

5 States Leaning toward Not Expanding Medicaid

DhE

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2014—Individual Mandates

Individual Mandate– In 2014, participants will be required to maintain health coverage that meets Minimal

Essential Coverage or they will be subject to a shared responsibility payment which is a tax on not having health insurance• This is known as the Individual Mandate• An individual avoids the Individual Mandate by enrolling in Minimum Essential Coverage

– The penalties will be as follows:• 2014: Greater of 1% of salary or $95• 2015: Greater of 2% of salary or $325• 2016: Greater of 3% of salary or $695

– If the cost of insurance exceeds 8.0% of an individual’s income, then the individual is not subject to the mandate. Other exemptions include religious exemptions and persons in jail


What’s Next for Health Care Reform: 2014

• Individuals earning up to 400% of the Federal Poverty Level that are not Medicaid eligible will have tax credits available to them to help cover the costs of medical premiums in a state exchange. The levels of income qualification, based on 2012 guidelines, would be as follows:

Individuals in Household 2012 FPL 400% of FPL

1 $11,170 $44,680

2 $15,130 $60,520

3 $19,090 $76,360

4 $23,050 $92,200

5 $27,010 $108,040

6 $30,970 $123,880

7 $34,930 $139,720

8 $38,890 $155,560

Qualification of Federal Subsidies



• The amount of the tax credit is based off the cost of the second lowest cost Silver plan which would have an actuarial value of 70%. The actual amount of the tax credit would vary based on income and family size as follows:

Up to 133% FPL 2.0% of income

133% to 150% 3.0 to 4.0% of income

150% to 200% 4.0 to 6.3% of income

200% to 250% 6.3 to 8.05% of income

250% to 300% 8.05% to 9.5% of income

300% to 400% 9.5% of income

As an example, Sue is single and has an annual income of $28,000, which is 250% of the FPL. Based on her age of 45 and where she lives, the cost of the second lowest Silver plan is $5,733. She would not have to pay more than 8.05% of her income or $2,254 to enroll. Her tax credit would then be $3,479 ($5,733 minus $2,254).

Qualification of Federal Subsidies (cont’d)


2014—Employer Mandates

Employer Mandate– The Employer Mandate is also referred to as

• The free rider penalty (historical terminology), shared responsibility payment, the assessable payment, and the employer responsibility payment

– A Large Employer is one that employs 50 or more FTEs• FTE generally means an individual, with respect to any month, who is employed on average at least

30 hours of service per week

– The Employer Mandate requires a Large Employer to offer• Minimum Essential Coverage that meets Minimum Actuarial Value requirements• Coverage that is “affordable”• Available to “substantially all” (i.e., 95% or more) full time employees

Employers must also offer coverage to dependent children up to age 26, however this coverage does not need to be affordable

The dependent definition does not include spouses


2014—Employer Mandate - Detail

Penalties for failing to comply with the Employer Mandate $2,000 Tax Penalty

– Applies when an employer fails to offer its FTEs the opportunity to enroll in Minimum Essential (health) Coverage (MEC) • If one full-time employee goes to an Exchange and qualifies for a subsidy, then the employer would

be subject to a $2,000 penalty for each individual that was not offered coverage that met MEC guidelines

• There is a waiver for the first 30 full-time employees.• The penalty is calculated on a monthly basis.

$3,000 Tax Penalty– Applies when an employer offers its FTEs the opportunity to enroll in MEC and the employee

contribution for single coverage exceeds 9.5% of their income, thus being considered unaffordable • The penalty generally is $3,000 per year for each full-time individual who enrolls in an Exchange and

qualifies for a subsidy• There is no 30 life waiver• Example of 9.5%: Employee earning $35,000/year; 9.5% of salary = $3,325 annually or $277 per

month. This is the most that an employee can be asked to contribute for single coverage.



• Employer A: 15 FT employees, 10 PT employees @15 hrs/wk, 10 Seasonal Workers

• Total 20 FTEs (15 FTs + 5 FTEs + 0 for seasonal workers) = Penalties do not apply. Applies to employers with at least 50 Full-Time Employees (FTEs), which includes a combination of full-time workers (those working 30+ hours/week) plus part-timers (seasonal workers with fewer than 120 days do not count).

• Employer B: An employer with 35 full-time employees and 30 part-time employees who each work 15+ hours/week = 50 FTE.

• There are two penalties:

• The first penalty is $2,000 per all full-time employees for not offering coverage if one employee goes into a state Exchange and qualifies for a subsidy. There is a waiver for the first 30 full-time workers. Employer B potential penalty is $20,000 ($2,000 x 5 full-time employees)

• $3,000 penalty per each employee whose premium contribution is greater than 9.5% of income or whose plan covers less than 60% Actuarial Value (AV) based on Minimal Essential Coverage (MEC) of allowable costs. Applied to each individual that goes into a state Exchange and qualifies for a federal subsidy.

Calculation


Defining Full-Time Employees

Recent guidance on definition of full-time employee (FTE) provides safe harbor methods for determining whether– An existing (ongoing) employee is an FTE; and– A newly-hired employee is an FTE

Guidance applies to– Variable Hour Employees

• Based on facts and circumstances at start date, it cannot be determined that employee is reasonably expected to work 30 hours/week

– Seasonal Employees• A worker who performs labor/services on a seasonal basis; good faith test for now. Generally

considered to be less than 120 calendar days or three months.


Defining Full-Time Employees—Ongoing

2013 Measurement Period (MP) 2013 Administrative Period (AP) 2014 Stability Period (SP)

3 – 12 months Up to 90 daysAt least 6 months but no

shorter than MP

Determines coverage in stability period

Average hours worked

Buffer between MP and SP

Allows for measuring and enrolling full-timers

Eligibility period for employees averaging 30 hours or more during MP

MP Considerations

Longer period reduces number of full-timers given high turnover

Shorter period provides more time to make workforce adjustments to mitigate cost

SP Considerations

Shorter period reduces coverage commitment but creates administrative complexity

Longer period that aligns with calendar years is most practical administratively

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Defining Full-Time Employees—Newly Hired

New Variable Hour and Seasonal Employees

Initial Measurement Period (IMP) Administrative Period (AP) Stability Period (SP)

3 – 12 months Up to 90 days Same length as ongoing employees

Considerations

IMP plus AP must not last beyond last day of first calendar month following employee’s one-year anniversary

– No more than 13 months plus a partial month

Transition to ongoing allows for extension of coverage for balance of overlapping ongoing stability period

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The Health Care Reform Law prohibits non-grandfathered insured group health plans from discriminating in favor of highly compensated individuals

Rules similar to those under Internal Revenue Code (Code) section 105(h) that are applicable to self-insured medical reimbursement plans will apply to non-grandfathered insured plans. Final rules are being defined.

Highly compensated individuals generally include:

the 5 highest paid officers,

any 10% owners, and,

the highest paid 25% of all employees

Testing is required to ensure that a sufficient number of non-highly compensated individuals benefit under the plan

Potential penalty is $100 per day per discriminated employee up to $500,000.

Final rules are expected for 2014.

Non-Discrimination Testing


Leading to Significantly Different Decisions

Employer Plan

State Exchanges

Medicaid

Opt-OutSelf Insure

• If offered, generally the best choice for employees who do not receive a federal subsidy in the exchanges

• Insurance plan familiar to most employees

• Employees with low family incomes may receive better benefits at a lower cost in a state exchange

• These individuals can only receive federal subsidies if employer does not offer an affordable plan

• Only available in states that choose to expand Medicaid coverage

• Employees receive nearly full coverage, although provider access is limited

• Employees may opt-out for many reasons including a spouse with a better/cheaper plan, TriCare coverage, or simply not wanting to own health insurance

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Individual Factors Driving Insurance Choice

Demographics Age Family Size Geography

$Financials Family income Premiums or

contributions

Protection Provider Access Health Status Insurance coverage

Loyalty Satisfaction with current

insurance product Willingness to change

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Considerations for Dropping Group Coverage

Exchange costs for employers may significantly increase by the time Exchanges are available in 2014.

These are hard dollar penalties and are not tax deductible. Employers likely will be pressured to provide additional compensation to

employees who participate in an Exchange Any additional compensation to cover Exchange costs may increase payroll

(FICA/FUTA) taxes for the employer, and income and payroll (FICA) taxes for the employee

How does the employer want to be viewed as in terms of “An Employer of Choice”

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Co-employment Responsibility

HCR PROVISIONS 2013 - 2014 HCR Effective Date

AlphaStaff Plan Effective Date Responsible Party Comments

Determine Large Employer status subject to Play or Pay

2013 for 1/1/2014 effective date N/A Employer (Client) Contact AlphaStaff for assistance. This is

determined by employer size in 2013.Establish measurement/admin/stability periods for variable hour employees 1/1/2014 N/A Employer (Client) Contact AlphaStaff for assistance.

Perform IRS Employee Affordability Analysis (9.5% safe harbor) 1/1/2014 N/A Employer (Client) Contact AlphaStaff for assistance.

Waiting period maximum 90 days 1/1/2014 9/1/2013 AlphaStaff/Client/ Carrier

Note that AlphaStaff sponsored plans will require a maximum 1st of month following 60 days as waiting period due to plan design (no mid-month coverage dates). Client-sponsored plans will vary based on plan design and AlphaStaff administration requirements.

Health Care Market Place ("Exchange") employee notifications required by FLSA

10/1/2013, then all new hires N/A AlphaStaff on behalf of

client companyExpect guidance on content and Model Notice - tentative delivery date August-September

Review / Update plan documents and regulatory disclosures (AlphaStaff sponsored plans). Varies N/A AlphaStaff

Updates to plan documents (SPD/Wrap Document) at year end, other docs will be updated as new regs/guidance are issued

IRS Reporting on employer provided coverage 1/31/2015 N/A Client/AlphaStaffGuidance not yet issued on content and reporting requirements. Unknown if AS or client company will be required to do reporting

Automatic Enrollment Unknown N/A AlphaStaff/Client Originally was effective 1/1/2014, but provision has been delayed

Nondiscrimination Rules Unknown N/A AlphaStaff/Client Originally was effective 1/1/2014, but provision has been delayed

Review Plans for minimum value standards 1/1/2014 9/1/2013 Carrier/AlphaStaffAlphaStaff sponsored plans only. Clients maintaining own plans will need to consult with broker/carrier

PPACA 2014 Plan requirements (AlphaStaff sponsored plans) 1/1/2014 9/1/2013 Carrier/AlphaStaff

Removal of all pre-ex, no annual max on Essential Health Benefits (EHB), updates to cost-sharing provisions, and others as identified under PPACA

HCR taxes/fees included in premiums (PCORI, Insurer Fee, Transitional Reinsurance Fee) 1/1/2014 9/1/2013 Carrier Will be included in renewal premium for fully

insured plans; self-funded plans must self-pay


2012 and 2013 Provisions by Year

2012 Comments 2013 Comments

1. Employer Distribution of Uniform Summary of Benefits to Participants

1. Limit of health care FSA contributions to $2,500

Effective for taxable years beginning after December 31, 2012.

2. Comparative Effectiveness Fee(Patient Outcomes Research Institute – PORI)

Applies to Plan Years ending on or after 10/01/2012; for 2012 this fee is $1.00 per employee enrolled in health plan or Flexible Savings Account (FSA). Fee not assessed on employees not enrolled in either the FSA or medical plan options. Fee to be remitted via IRS Form 720 by 7/31/2013.

2. Comparative Effectiveness Fee(Patient Outcomes Research Institute – PORI)

For each Plan Year 2013 through 2018; this fee is $2.00 per employee enrolled in health plan or Flexible Savings Account (FSA). Fee not assessed on employees not enrolled in either the FSA or medical plan options. Fee to be remitted via IRS Form 720 by 7/31/2014.

3. Medical Loss Ratio (MLR) rebates Applies to insured plans only. 3. Addition of Women’s preventive health requirements to no cost sharing (such as deductibles, coinsurance) and coverage for certain in-network preventive health services

Effective January 1, 2013 for calendar year plans.

4. Employer Reporting of Health Coverage on Form W-2

Due January 31, 2013; reporting does not need to include standalone dental, vision or FSA plans.

4. Medicare Tax on High Income• Increases Medicare tax by 0.9% to 2.35% for individuals earning over $200k and joint filers over $250k• New 3.8% tax on unearned income for individuals earning over $200k and joint filers over $250k

Final guidance pending.

5. Employer Quality of Care Report Final guidance pending 5. Notice to Inform Employees of Coverage Options in Exchange - delayed

Guidance pending (overdue)

6. Elimination of Deduction for Expenses Allocable to Retiree Drug Subsidy (RDS)

Not applicable to DMS


2014 Provisions by Year

2014 Comments 2014 Comments

1. Shared Responsibility Payment(Individual Mandate)

Employee must go to Exchange because employer’s plan • Was not “minimum essential coverage” or• Was either “unaffordable” or did not provide minimum value

5. Reinsurance Fees • Fees will be charged for 2014, 2015 and 2016

• Declared amount is $63 PMPY

2. Minimum Essential Coverage Employers that do not offer “minimum essential coverage” to all full-time employees pay a penalty of $2,000 for each of its full-time employees, until the employer offers such coverage• Subject to an exemption for the first 30 full time employees• Penalty applies if at least one FTE receives a subsidy

6. Comparative Effectiveness Fee For 2014 this fee is $2.00 per employee enrolled in health plan or Flexible Savings Account (FSA). Fee not assessed on employees not enrolled in either the FSA or medical plan options. Fee to be remitted via IRS Form 720 by 7/31/2015.

3. “Unaffordable” or not “Minimum Value”

•Unaffordable - <9.5% of W-2 wages•Minimum Value – 60th percentile actuarial value

If coverage offered by employer is “unaffordable” or not “minimum value”, employer pays a penalty of $3,000 for each FTE who• Purchases a qualified health plan in the Exchange• Receives a Federal Subsidy

7. Auto Enrollment • Postponed – likely delayed to 2015

• Plans must automatically enroll all of their eligible employees in health coverage unless employee specifically opts out

4. State Exchanges • Exchanges open (bronze, silver, gold platinum)

• Subsidies from 133% to 400% of Federal Poverty Level

• Fees on Insurance Companies

8. Wellness Program Rewards Cap Increased cap on rewards for participation in wellness programs from 20% to 30% and 50% for smokers


2017 and 2018 Provisions by Year

2017 and 2018 Comments

1. Large employers (> 50 lives) may be allowed into Exchanges

2. Excise Tax on “Cadillac” Plans 40% excise tax on insurers and TPS that offer health care coverage costing more than• $10,200 individual (indexed)• $27,500 family (indexed)Increased threshold applies for retirees ages 55-64 and for selected high-risk occupations• $11,850 individual• $30,950 family - Adjusted for age and gender


How Can We Help?

Analyze current employee population to help determine if you will be subject to the Employer Shared Responsibility penalty (Play or Pay) by evaluating your company’s full time and full time equivalent employees.

Establish Measurement, Administrative, and Stability Periods. Provide PPACA updates through our Knowledge Center, AlphaAdvisor, and

AlphaAlerts. Ensure plans are meeting minimum value requirements Determine what your minimum contribution should be to comply with the 9.5%

affordability rule. Look for updates in the AlphaStaff Knowledge Center, AlphaAdvisor, open enrollment

communications and future forums such as today’s webinar. Health Care Reform Questions? Contact [email protected] or contact

your benefits or HR representative.

mailto:[email protected]