DVHIT Health Reform Workshop final€¦ · 18/11/2013 · 10/30/2013 1 Health Reform Workshop Update on the Implementation of The Affordable ... 2015 Reporting of coverage information

10/30/2013

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Health Reform WorkshopUpdate on the Implementation of The Affordable Care Act:

Planning for 2014 and Beyond

Wednesday October 30, 2013

Presented by:

Geoffrey L. Beauchamp, Esq.Delaware Valley Health Insurance Trust719 Dresher RoadHorsham, PA 19044-2205(267) [email protected]

Stephen J. FallonInsurance Buyers’ Council, Inc. 9720 Greenside Drive Suite 1E Cockeysville, MD 21030(410)-666-0500, ext.224 cell: (609) [email protected]

Today’s Agenda

Review impact of recent ACA delays

Provide compliance strategy for plan sponsors

Update new benefit mandates

Cost impact of ACA (taxes/fees)

Health insurance exchanges (public and private)

DVHIT model in the post-ACA landscape

Employer options post-ACA

Preview future regulatory action

Open forum

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IRS Transition Relief For 2014

What exactly was postponed by the July 9, 2013 IRS Notice No. 2013-45?

Information reporting requirements under §6055 of the InternalRevenue Code applicable to insurers, self-insuring employers andother providers of minimum essential coverage (“MEC”)

Information reporting requirements applicable to certain largeemployers under §6056 of the Internal Revenue Code

The employer shared responsibility provisions under §4980H of theCode, which impose penalties on large employers (> 50 FT ees) thatfail to offer MEC or fail to offer “affordable” MEC with “minimumvalue”

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IRS Transition Relief for 2014

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Employers may delay compliance with the following provisions until January 1, 2015:

Coverage need not be offered to “substantially all” full time employees (30 or more hours)

Full time employee need not be defined as 30 or more hours per week

Single (i.e., employee-only) coverage need not be “affordable”

Coverage need not have “minimum value”

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IRS Transition Relief for 2014

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The employer need not use a look back period to determineeligibility for coverage for seasonal or variable hour employeesuntil a potential eligibility date of January 1, 2015

Reporting of coverage information to the government will bevoluntary


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On 09/09/2013, IRS issued proposed rules for the informationreporting requirements under §6055 and §6056. Once finalizedthey will be fully applicable on 01/01/2015, with voluntarycompliance encouraged for 2014

No effect on the effective date or application of otherAffordable Care Act provisions, including the individualmandate.

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Greater flexibility for large employers in 2014

- Maintain the pre-ACA hourly threshold for FT ee status

- Not required to offer health benefits to any FT employees to avoid penalties until 1/1/15

Use 2014 to prepare for the large employer mandate in 2015with DVHIT’s assistance

Impact Of 2014 Transition Relief Upon Calendar And Fiscal Year Plans

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Calendar Year Plans

- Must be compliant with employer mandate by 01/01/2015

Non-Calendar Year Plans

- In the prior guidance, a non-calendar year plan had until the first day of the plan year 2014 before being subject to the shared responsibility penalty provided that it met certain criteria (e.g., be “affordable”)

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For non-calendar year plan years beginning in 2014, it will beimportant to proceed with planning to modify eligibilityrequirements for the employer shared responsibility requirements tolimit penalties

- No announcement of transitional relief for fiscal year plans for 2015

- The penalty provision may be applicable to those plans as of January 1, 2015, regardless of plan year


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For example, depending on further IRS guidance, employers withJuly 1 fiscal year plans may opt to offer newly eligible FT ees healthbenefits as of:

‒ 07/01/2014

‒ 01/01/2015 or

‒ 07/01/2015

If the plans offered to newly eligible FT ees as of 01/01/2015 or07/01/15 are not “affordable”, employers may be exposed topenalties

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How Large Employers May Prepare In 2013/2014 For Compliance In 2015

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Use all of 2013 or, if allowed by future guidance, use aconsecutive 6 month period in 2014 or a consecutive 12month period in 2013/2014 to determine “largeemployer” status

Re-set measurement, administrative and stability periodsfor seasonal and variable hour ees- Work back from 01/01/2015 as the compliance date for

calendar and fiscal year plans


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Different treatment of ongoing and newly hired variable hour and seasonal ees

Example for calendar year plans: Measurement period (12 months): 11/01/2013 – 10/31/2014

Administrative period (2 months): 11/01/2014 – 12/31/2014

Stability period (12 months): 01/01/2015 – 12/31/2015

With a 90 day administrative period, the 12 month measurement period would start on 10/04/2013

See Handouts for FT employee identification methodology

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Areas of concern:

- Variable hour ees

- Seasonal ees

- Temporary workers

- Leased ees

- Professional employer organization (“PEO”) ees


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Workforce Changes

- Transition employees from FT to PT status as neededusing the 29 hour weekly threshold for part-timestatus

- Employee cut-backs

- Use of independent contractors, leased and PEO employees

- Be mindful of proposed IRS “anti-abuse” rules

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Implementation of work hour controls and tracking of ee hoursand update payroll system to support tracking

Plan Design Changes

- Offer high deductible plans ($6,350 individual /$12,700family maximum out-of-pocket limits) – with or withoutHSAs - using the Exchange “Bronze” level plans as abenchmark for “affordability”

- Offer plans with “minimum value” without regard to “affordability” for some or all employee classes

Essential Health Benefits

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Self-funded employers (all DVHIT groups) are not required to cover Essential Health Benefits (EHBs)

However, if an employer choses to cover EHBs, there can not be any annual or lifetime dollar maximum

DVHIT using PA EHBs (vary by state)

Cost and collective bargaining considerations

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Pennsylvania Essential Health Benefits

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PA Plan Cost and Impact

Accidental Dental Non-EHB

Acupuncture Non-EHB

Applied Behavioral Analysis Non-EHB

Bariatric Surgery Non-EHB

Chiropractic care EHBMost plan have day

limits/moderate if limits removed

Hearing Aids Non-EHB

Infertility Non-EHB

Nutritional Support/Enteral Formulas EHBPlans currently do not

cover/Expensive, but rare.

Source: Aetna

Pennsylvania Essential Health Benefits

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PA Plan Cost and Impact

Orthotics Non-EHB

Ostomy Supplies Non-EHB

Private Duty Nursing Non-EHB

Temporomandibular Joint (TMJ) Non-EHB

Wigs EHBCurrent limit is $500- cost impact minimal for removal of $ limit

Habilitaive/Autism EHB= no $ limits allowed/Non-EHB =Annual$ limits allowed

EHB

Note: Mandated benefit is not as broad as PA Act 62. Moderate to high for those covering at state level.

Note: DME is an essential benefit in all state benchmark plans.

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Plan Design MandateOut-of-Pocket Maximum (Non-Grandfathered plans)

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Maximum member out-of-pocket expense (in-network) $6,350 single/$12,700 family

‒ $10,000/$20,000 maximum out-of-pocket out of network (Aetna administrative requirement)

‒ Includes copays, deductibles, and coinsurance

Effective with first plan anniversary on or after 01/01/2014

Effective after one year “safe harbor” out-of-pocket maximum must also include prescription drug copays

Significant Cost Implications

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Many plans don’t have in network out-of-pocket maximum

Current OPM’s don’t contemplate inclusion of RX – some don’t contemplate medical copayments (typical current opm $1,500/$3,000)

In network out-of-pocket maximum can’t exceed out-of-network opm

Effective 01/01/2014 (except for July 1 plans) DVHIT will institute highest available OPM based on current benefit levels

Consult with labor attorney on impact to current contracts

Make negotiating OPM-in light of new mandate-a priority

Many commercial carriers unilaterally imposing new limits

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Out-of-Pocket Maximum Plan Design Examples

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Plan Type Current 01/01/2014 01/01/2015

HMO No OPM$6,350/$12,700Medical Only

$6,350/$12,700Medical and Rx

HMO $1,500/$3,000$1,500/$3,000Medical Only

$1,500/$3,000Medical and Rx

PPOIn Network: No OPM

Out of Network: $2,000/$4,000

In Network: $2,000/$4,000

Out of Network: $2,000/$4,000Medical Only

In Network: $2,000/$4,000

Out of Network: $2,000/$4,000

Medical and Rx

PPO

In Network:$1,000/$2,000

Out of Network:$5,000/$10,000

In Network: $1,000/$2,000

Out of Network:$5,000/$10,000Medical Only

In Network: $1,000/$2,000

Out of Network:$5,000/$10,000Medical and Rx

ACA Mandated Plan Design Features: Grandfathered vs. Non-GF Plans

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Requirement Description All PlansNon-Grandfathered

Plans

No annual dollar limit (essential benefits)

Adult children coverage expanded

(GF plans no longer allowed to exclude children eligible for other employer-sponsored coverage in

2014)

Eliminates key difference between GF and Non-GF

No pre-existing condition exclusion

(Expands previous prohibition for under age of 19)

Maximum deductibles $2,000/$4,000

(fully-insured-small group only)

Caps on Out-of-Pocket Maximums

(In-Network $6,350/$12,700 )

Includes prescription drugs after one year “safe harbor”

Non-discrimination rules - IRS 105(h)

(self-funded only)

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ACA Mandated Plan Design Features: Grandfathered vs. Non-GF Plans (cont.)

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Plans

Non-discrimination rules – PPACA

(fully insured plans only)Pending

Clinical trial coverage

Provider non-discrimination requirements

Expanded preventative services for women

No co-pays for preventative services

Wellness program non-discrimination rules

FSA contribution cap ($2,500)

90-day waiting period maximum

ACA Mandated Plan Design Features: Grandfathered vs. Non-GF Plans (cont.)

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Plans

Summary of benefits and coverage (SBCs)

60 day notice of material mid-year plan change(s) to SBC

Distribution of MLR Rebates

(only fully insured plans)

Rescission restrictions

Automatic enrollment

(> 200 ees-pending)

COBRA Admin./Notification requirements

Exchange plan notices

Coverage dispute appeals procedures

IRS employer reporting requirements

(beginning in 2015)

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What’s it Going to Cost?ACA Projected Premium Impact 2013/2014

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General estimates of the ACA costs to be passed through incommercial market premium increases and fees estimated at 4-6%*

ACA accounted for 2.5% of DVHIT 2014 renewals

ACA impact is in addition to standard premium increase

ACA cost drivers‒ Taxes/fee

‒ Benefit Mandates

‒ Administration

*Separate estimates by Milliman and NFIB and actual fully insured renewals

ACA Taxes and Fees Impacting Insured and Self-Funded Plan Sponsors

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Type of Fee/TaxApplies to:

Insured/Self-InsuredDescription

Expected Revenue Generated/Cost

Annual Health Insurance Provider Fee

Insured plans

Intent is to offset expenses of premium

subsidies and tax credits through exchanges

$25 billion

from 2014-2016

Transitional Reinsurance Contribution

Insured and Self-Insured plans

Intent is to fund high risk pools

$25 billion 2014-2016 (estimated first year cost:

$63 pmpy)

Patient-Centered

Outcomes Research Fee*

(PCORI)

Insured and Self-Insured plans

Intent is to fund clinical outcomes effectiveness

research

$1 per covered member year 1/$2 per member

thereafter through 2019 (subject to “adjustment”)

High Value Plan tax

(“Cadillac” tax)Insured and Self-Insured plans beginning in 2018

40% excise tax on plans with value of $850 single pepm/$2,291.67 family pepm

Federal Exchange User Fee (proposed)

Fee applies to insurersFee applies to insurers-To fund Federally Facilitated

Exchanges (FFEs)

3.5% of Exchange plan monthly premiums

Other taxes: pharmaceutical companies and medical device manufacturers

Medicare payroll taxes and capital gains

*Must be filed by 7/1/13- details of tax filing process TBDTaxes subject to increase in future years.

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Cadillac Tax

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Effective 2018

Need to begin planning now due to lead time required for contract changes- consult with labor attorney and use as leverage in negotiations

The tax is paid by the coverage provider (DVHIT or plan sponsor?)

No further guidance has been issued since passage of ACA

Higher limits for “high risk” population (uniform and pre-Medicare retirees)– Standard annual threshold: $10,200/$27,500

– High risk annual threshold: $11,850/$30,950

“Cadillac” Tax Liability Projection Example(Estimated at 6% and 10% Premium Trend)

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Notes and Assumptions:•Exhibit is illustrative, pending further regulatory guidance from Federal agencies charged with oversight.•Projected tax liability reflects ACA excise tax on Cadillac plans.•Higher limits exist for retirees and certain high-risk professionals, subject to additional regulatory guidance.•Additional regulatory guidance is expected in next few years. At this point, self-funded employers (the plan administrators) are responsible for paying the tax. For fully-insured plans, the tax will be paid by insurance companies and passed through to plan sponsor through premium increases.

Number of employees ‐ 58. Percentage of Uniform employees ‐ 29%.

Non‐Uniform

Employee Family

2014 $798.37 $2,586.44

2015

6% $846.27 $2,741.63

10% $878.21 $2,845.08

2016

6% $897.05 $2,906.12

10% $966.03 $3,129.59

2017

6% $950.87 $3,080.49

10% $1,062.63 $3,442.55

2018

6% $1,007.92 $3,265.32

10% $1,168.89 $3,786.81

Tax Threshold 2018 $850.00 $2,291.67

Taxable Portion

6% $157.92 $973.65

10% $318.89 $1,495.14

Projected Monthly Tax Liability Per Employee

6% $63.17 $389.46

10% $127.56 $598.05

Number of covered employees 4 37

Total Projected Annual Tax Liability

6% $175,952.54

10% $271,659.05

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“Cadillac” Tax Liability Projection Example(Estimated at 6% and 10% Premium Trend)

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Notes and Assumptions:•Exhibit is illustrative, pending further regulatory guidance from Federal agencies charged with oversight.•Projected tax liability reflects ACA excise tax on Cadillac plans.•Higher limits exist for retirees and certain high-risk professionals, subject to additional regulatory guidance.•Additional regulatory guidance is expected in next few years. At this point, self-funded employers (the plan administrators) are responsible for paying the tax. For fully-insured plans, the tax will be paid by insurance companies and passed through to plan sponsor through premium increases.

Uniform

Employee Family

2014 $784.27 $2,551.21

2015 6% $831.33 $2,704.28

10% $862.70 $2,806.33

2016

6% $881.21 $2,866.54

10% $948.97 $3,086.96

2017

6% $934.08 $3,038.53

10% $1,043.86 $3,395.66

2018

6% $990.12 $3,220.84

10% $1,148.25 $3,735.23

Tax Threshold 2018 $987.50 $2,579.17

Taxable Portion

6% $2.62 $641.67

10% $160.75 $1,156.06

Projected Monthly Tax Liability Per Employee

6% $1.05 $256.67

10% $64.30 $462.42

Number of covered employees 2 15

Total Projected Annual Tax Liability

6% $46,225.70

10% $84,779.27TOTAL FOR BOTH GROUPS

6% $222,178.23

10% $356,438.32

Reducing the Liability of the Cadillac Tax

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Reduce the benefits (and premium levels) that trigger the Cadillac Tax

‒ Avoid by getting below the threshold or at a minimum reduce liabilityby reducing rates

‒ Have employees pay a greater share of the out-of-pocket costs (i.e.deductibles, co-pays, etc.) for health plan benefits thereby reducingrates

‒ Note: employer reimbursements of deductibles and other plan expensesmust be included in calculation of premium

‒ DVHIT will use RSF to help members mitigate the impact of theCadillac Tax

Offset the cost of the tax by increasing employee contributions (totalbudget approach)

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Health Insurance Exchanges

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PA has deferred administration of state exchange to Federal Government– Individual– Small Group

Rates based on:– Age (maximum rate tiers 3:1- was 5:1 or more)– Geographic area– Plan type

Result:‒ Young subsidizing older enrollees‒ Rates competitive, but out-of-pocket costs are significant with “Bronze” and “Silver” plans‒ Sustainability of rates in question if carriers do not get a balanced risk mix‒ Provider networks/pharmacies and drug formulary being reduced for many Exchange plans

Obstacles‒ Developing the bureaucracy to implement/support exchange marketplace‒ Potential for adverse selection and low participation in key demographics‒ Consumer confusion ‒ Mandated Quality Health Plan (QHP) requirements and administrative burdens imposed on Health Insurers in

the Exchange Marketplace‒ “Harmonizing” Exchange and non-exchange Marketplaces- attempts to eliminate any advantage outside of

Exchange ‒ Plan design flexibility being reduced in small/midsized market

Plan Value Example

Benefit

Platinum PPO Gold PPO

Bronze In-Network Out of Network In-Network Out of Network

Deductible $0 $400/$800 $0/$0 $0/$0 $2,000/$4,000

Coinsurance 100% 70% 100% 80% 80%

Out-of-PocketMaximum

$0 $2,500/$4,000 $2,600/$3,700 $4,600/$7,000 $6,250

Office Visit $5 30% coinsurance$25 PCP/$40

specialist20% coinsurance 80% after deductible

Emergency Room $25 copay $250 copayment Ded, then $250 copay

IP Admission 100% 70% after ded $500 per admissionDed, then $300 per

admission

OP Facility 100% 70% after ded $150 per visit 20% coinsurance 80% after deductible

Prescription Drug $5 generic/$15 brand $10/$50/$70 w/ $150 specialty copayIntegrated rx, then

$15/$35/$75 w/$200 specialty copay

Projected MinimumValue

.985 .89 .68

Plan designs are for general comparisons only-specific values to be determined

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What is a Private Exchange?

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Large brokerage firms and other health benefits administrators creating an alternative marketplace for employers and

leveraging aggregated membership for scale pricing and enhanced consumer technology

Private exchanges are built around a defined contributionhealth benefits plan

Employee choice = reduction in benefits

Underwriting still controlled by commercial carriers

Opportunity to shift post retirement risk

DVHIT in the Era of Affordable Care The Advantages of the DVHIT Model will be Enhanced

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Financial Advantages– Competitive/sustainable rates over past 8 years

– DVHIT 2014 average increase 11.91% (9.22%after Rate Subsidy)

– Commercial market increases 14-26% (some as high as 50%)

– Not subject to onerous post-ACA rate regulation

– Homogenous and balanced risk pool/no fear of adverse selection of Exchange

– ACA places significant burden (risk, administration) on commercial carriers

– Commercial book of business will subsidize losses on Exchange plans

– Administrative efficiency 8% vs. 15-20% for commercial market

– Rate Stabilization Fund/multi-trust discounts (equity building)– Flexibility to use RSF and MTD to reduce rates and offset potential impact of Cadillac Tax

– Some ACA taxes not applicable to DVHIT

– Advantages of self-insuring without the risk

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DVHIT in the Era of Affordable Care The Advantages of the DVHIT Model will be Enhanced

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Administration– Plan Design Flexibility

• Commercial carriers streamlining plan offerings

• DVHIT does not impose unilateral plan changes

– Enhanced service platform

– “Value Added” benefits

– Member Wellness Initiative to focus on improving health and reducing claims long term

– Turn-key benefits administration and compliance

Be wary of commercial market short-term “acquisition” pricing and misuse of consumer directed high deductible plans

Employer Options Post-ACA

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Terminate plan and pay penalty (if applicable) and provide no employee subsidy

Terminate plan and pay penalty (if applicable) but provide employee subsidy to purchase insurance

Purchase coverage through alternative market– Commercial carrier

– Small group Exchange (SHOP Exchange)

– Private Exchange

– Self-insure on a stand-alone basis

Maintain plans (consider plan/contribution changes)

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Considerations

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Cost of providing coverage vs. penalty (if applicable) - the penalty always the lowest hard dollar cost

Variance in employer subsidy amounts due to age banded Exchange premiums

Collective Bargaining considerations - what is the cost of buy-out?

Employer philosophy (attract and retain talent- employee morale/productivity)

Cost and value of benefits available through the Exchange and Non-Exchange market (replacement cost)

– Do Exchange plans represent “apples to apples” comparison?– How sustainable are premium levels?

How prepared are my employees to navigate the Exchange?

How prepared is the Exchange to administer and service membership?

What Do Plan Sponsors Need to Do?

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Consult with advisors and assess impact of ACA on your organization

– On track for Cadillac tax liability?

– Plan design changes (out-of-pocket max)

Communicate changes to employees

– Distribute SBCs (remember notification requirements)

– Exchange Notices

– Continue health and wellness education

Prepare for Play or Pay (2014 is a rehearsal year)

– Determine number of employees working 30 hours

– Measure Seasonal and VHEs-determine which are entitled to benefits

Calculate:

– Managing or reducing “full-time” work force (beware hour-creep)

– Remember to calculate impact of dependent children to age 26 if currently Grandfathered (couple to family tier/rates)

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What Do Plan Sponsors Need to Do?

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Begin to consider impact of future elements of ACA and develop a group-specific strategy

– Organizational philosophy

• Why do you offer health benefits?

– Educate elected officials

– Opt-out vs. subsidize through exchange or status quo

– Implications for collective bargaining (leverage?)

• Recognize ACA defines the floor (Minimum Essential Coverage) and the ceiling (Cadillac Tax)

• Negotiate plan design changes

• Increase employee contributions-especially dependent coverage

• Re-opener clauses and other CBA Gambits

• Update CBAs to reflect ACA compliance requirements/increased flexibility

• Increase employee contributions-especially dependent coverage

What do Plan Sponsors Need to Do?

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Plan sponsors must continue to manage health care costs

– Recognize health care costs will continue to rise

– Address the underlying fundamentals driving health care costs

• Reducing costs requires tough choices and behavior change

‒ Use ACA changes as an opportunity to redefine the role of employee benefits and increase member engagement/responsibility

Consider:‒ Migrating to a “defined contribution” health plan

‒ Offsetting costs by reducing benefit levels (metal value)

‒ Focus on employee contributions (ACA establishes maximum employee contribution level)

Watch for updates and additional information in the weeks and months ahead

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Strategies for Shifting Costs to Employees

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Higher copays/hospital copays

Up-front deductibles

High deductible plans with some employer reimbursement of deductible

Base Plan and Buy-up strategy

‒ Two tiered plan – reduced benefit levels for new hires

Employee payroll deductions

‒ New Hires

‒ Dependent coverage

‒ Spousal opt-out

Consult DVHIT prior to negotiations for plan design options and pricing.

Future Regulatory Action

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Final large employer “anti-abuse” regulations

Guidance re: treatment of seasonal ees under employer mandate

Guidance re: auto enrollment and quality of care reporting

Final regulations on the annual health insurance providers fee

Final regulations on the large employer reporting requirements under §6056 of the Internal Revenue Code. Proposed regulations issued on 09/09/2013

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Final regulations on the reporting requirements for self-insuredemployers under §6055 of the Internal Revenue Code.Proposed regulations issued on 09/09/2013

Final regulations on the employer mandate

Proposed regulations under §4980G of the Internal RevenueCode on the interaction of that section and §125 (CafeteriaPlans) with respect to comparable employer contributions toemployee’s HSAs


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Guidance on HSAs for certain services required to beprovided without cost-sharing under §2713 of the PHS Act

Final regulations on cafeteria plans under §125 of the InternalRevenue Code

Revenue ruling under §419A of the Internal Revenue Code onthe definition of post-retirement medical benefits

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45

Proposed regulations for the Cadillac tax on high value plans

Final regulations regarding “minimum value” of eligibleemployer-sponsored coverage and other provisions relating tothe health insurance premium tax credit

Final regulations regarding information reporting by healthinsurance exchanges

Guidance as to the continued availability of transition relief fornon-calendar year plans regarding compliance with theemployer mandate


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Final regulations concerning the individual mandate penalty

Final regulations regarding the definition of “governmental plan”

Non-discrimination rules under ACA for fully insured plans

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Questions?

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This document is for informational purposes only and does not cover all of the exceptions or specifications of the PPACA law. It must not be used for compliance purposes or to provide tax, legal or plan design advice.

Please Contact:

Geoffrey L. Beauchamp, Esq.General Counsel

Anna Linn, MSM, CEBSBenefits Manager

Stephen J. FallonDirector, Employee

Benefits Practice

Delaware Valley Health Insurance Trust719 Dresher Road

Horsham, PA 19044-2205

Insurance Buyers’ Council, Inc.

9720 Greenside Drive Suite1E

Cockeysville, MD 21030

267-803-5715 267-803-5719 410-666-0500 xt. 224

[email protected] [email protected] [email protected]

Documents

DVHIT Health Reform Workshop final€¦ · 18/11/2013 · 10/30/2013 1 Health Reform Workshop Update on the Implementation of The Affordable ... 2015 Reporting of coverage information