stefany martinsen
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Stefany Martinsen. Health Care Reform Information. TO SIMPLIFY THINGS: This is not legal advice Regulations and guidance is provided by HHS and is incomplete Anything can change without notice Consult your tax advisor for compliance with the IRS code - PowerPoint PPT PresentationTRANSCRIPT
Stefany Martinsen
Health Care Reform Information
Wellmark is not providing any legal advice with regard to compliance with the requirements of the Affordable Care Act (ACA) or the Mental Health Parity Addiction Equity Act (MHPAEA). Regulations and guidance on specific provisions of the ACA and MHPAEA have been and will continue to be provided by the U.S. Department of Health and Human Services (HHS) and/or other agencies. The information provided reflects Wellmark's understanding of the most current information and is subject to change without further notice. Please note that plan benefits, rates, renewal rate adjustments, and rating impact calculations are subject to change and may be revised during a plan’s rating period based on guidance and regulations issued by HHS or other agencies. Wellmark makes no representation as to the impact of plan changes on a plan's grandfathered status or interpretation or implementation of any other provisions of ACA. Any questions about Wellmark's approach to the ACA of MHPAEA may be referred to your Wellmark account representative. Wellmark will not determine whether coverage is discriminatory or otherwise in violation of Internal Revenue Code Section 105(h). Wellmark also will not provide any testing for compliance with Internal Revenue Code Section 105(h). Wellmark will not be held liable for any penalties or other losses resulting from any employer offering coverage in violation of section 105(h). Wellmark will not determine whether any change in an Employer Administered Funding Arrangement affects a health plan’s grandfathered health plan status under ACA or otherwise complies with ACA. Wellmark will not be held liable for any penalties or other losses resulting from any Employer Administered Funding Arrangement. For purposes of this paragraph, an “Employer Administered Funding Arrangement” is an arrangement administered by an employer in which the employer contributes toward the member’s share of benefit costs (such as the member’s deductible, coinsurance, or copayments) in the absence of which the member would be financially responsible. An Employer Administered Funding Arrangement does not include the employer’s contribution to health insurance premiums or rates.
The Lawyers made me say it.
TO SIMPLIFY THINGS: This is not legal advice Regulations and guidance is
provided by HHS and is incomplete
Anything can change without notice
Consult your tax advisor for compliance with the IRS code
Wellmark is not responsible for penalties or losses due to employer coverage violations
Seek legal advice to determine changes that may impact grandfathered status
Any questions, talk to your Wellmark representative
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Individual Shared Responsibility (Individual Mandate)
Guaranteed Issue
No Pre-existing Condition Exclusions
Three Primary Elements of the Affordable Care Act (ACA)
TERMS TO KNOWIndividual Shared Responsibility: Provision in the law that requires all Americans to have health coverage or pay a tax.
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Minimum Essential Coverage Requirements
Individual grandfathered & non-grandfathered plans
State & federal government plans Employer group plans
EXCEPTIONS TO MANDATE REQUIREMENT
Financial Hardships Members of federally
recognized Indian tribes Undocumented Immigrants Incarcerated Individuals Religious Objections No Coverage for up to three
consecutive months
EXCEPTED BENEFITS: Plans that are not within scope of most provisions of the Affordable Care Act (ACA), like dental or vision, long-term care and other supplemental coverage offered as a separate insurance policy and do not qualify as minimum essential coverage.
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You must decide: Get minimum essential coverage
Pay a tax (the greater of)
2014 – Pay $95 or 1% household income*
2015 – Pay $325 or 2% household income*
2016 – Pay $695 or 2.5% household income*
Individual Mandate Impact on You
* The tax will be based on whichever is greater: the flat fee or the percent of household income.
Example: Single person household2016 taxable household income = $65,000Tax owed = $1,625 (65,000 x .025)
Consult your tax and legal advisor.
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Grandfathered Plans
Non-Grandfathered Plans
ACA Compliant Plans
Plans active before ACA (3/23/10) Unaffected by some ACA provisions
Plans sold after 3/23/10 GF Benefit changes resulted in NGF status Must move to ACA compliant plan 1st plan year on or after 1/1/14 Must comply with ACA provisions
Plans effective 1/1/14 Plans must comply with ACA provisions
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Standardized Plans: Metallic Tiers
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Essential Health Benefits (EHB)
BENEFIT CATEGORIES Ambulatory Patient Services Laboratory Services Prescriptions Maternity and Newborn Care Preventive Care and Chronic
Disease Management Emergency Services Mental Health and Substance
Use Disorder Services and Behavioral Health Treatment
Rehabilitative and Habilitative Services/Devices
Hospitalization Pediatric Services, Including Oral
and Vision Care
A Bundle of Basic Medical Services
Cost-sharing Out-of-Pocket Maximum (OPM) Limits Apply
Required for Non-grandfathered Individual and Small Group (1-50) Plans
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Pediatric Dental and Vision EHB
Pediatric Dental EHB* Pediatric Vision EHB*
Eligibility Up to age 19 Up to age 19
Part of Health Plan
Yes – EHB included in medical plan
Yes – EHB included in medical plan
Covered Benefits
•Diagnostic & Preventive•Basic Restorative•Oral Surgery•Endodontics•Periodontics•Major Restorative•Medically necessary orthodontia
•Eye exam•Frames•Lenses•Contact lenses
OPM •Embedded in health plan•Feeds OPM
•Embedded in health plan•Feeds OPM
* Benefit limitations
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Cost-Sharing Limits
Required for non-grandfathered Individual and Small Group (1-50) plans
Limit on out-of-pocket maximum (OPM) for Essential Health Benefits to HSA qualified amounts
−(2014) $6,350 single/$12,700 family Essential Health Benefit health and drug
out-of-pocket payments include:
−Deductibles, coinsurance, and copayments
Small Group deductible limits
−(2014) $2,000 single/$4,000 family
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Premiums Will Reflect Increase
in Cost
Increase in Cost for Additional
Benefits
Additional Benefits
+ =2014
1.5% Small Group
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Premiums Calculated at a Member
Level
AgeCalculations
Premiums Varyby Geographic
Region
Health and Gender No Longer a Factor
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Premiums are member level rated, but capped at three dependents
Based off the three oldest dependents under the age of 21
Dependent Cap
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Example: Johnson Bros. Body Shop
Member Age Gender Low Risk ACA High Risk
George Jones 45 M $620 $435 $1,240
Nancy Jones 43 F $400
Jeff Jones 12 M $180
Sara Smith 30 F $620 $335 $1,240
Sam Smith 30 M $335
Emily Evans 25 F $300 $300 $600
Totals $1,540 $1,985 $3,080
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Depending on the health risk of the group, rate change of +29% to -36% Demographics as well as health risk will determine the change in premium
Medical Loss Ratio (MLR)
Individual: 80%Small group: 80%Large group: 85%
Wellmark already meets this requirement
How much of a premium dollar must be spent on medical care and quality improvement?
TERMS TO KNOWMedical loss ratio*: The ratio between how much premium dollar is spent on administrative expense compared to medical care and quality improvements.
Quality improvement: Expenses to reduce hospital re-admissions, improve patient safety, reduce medical errors, and health information technology investments.
Overhead expenses: Expenses like administration, marketing, profits, salaries, and agent commissions are paid from the remaining 20%.
*The calculation is based on a carriers total book of business and is not measured on an individual plan basis.
.
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Patient-Centered Outcomes Research Trust Fund
$1 per member1 in 2012 – 2013 $2 per member1 in 2014
Proposed total annual fees paid by 2019
$60 billion = Health insurers $26 billion = Drug manufacturers $20 billion = Medical device
manufacturers
Transitional Reinsurance Fee
Additional Impacts to Premiums
1 Fees will be included in the premium rates for all fully-insured plans.
Confidential and Proprietary – Wellmark Blue Cross and Blue Shield
Premiums Will Increase to
Account for Fees
ReinsuranceFee
Annual Health Insurer Fee
+ =2014
4% Small Group
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Fees apply to all GF & NGF Plans
Effective 1/1/14
TodayTERMS TO KNOW
The Marketplace:An online Marketplace for individuals and small businesses to shop for and compare health plans
Also known as: The Public
Marketplace The Amercian Health
Benefits Exchange (AHBE)
The Small Business Health Options Program (SHOP)
The Marketplace
Direct Brokers Employers Private Exchange
Public Marketplace
Tomorrow
Direct Brokers Employers Private Exchange
NEW
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Online marketplace
Easy to compare
Two types of marketplaces−American Health Benefit Exchange −Small Business Health Options Program (SHOP)
Initial Open Enrollment for individuals isOct. 1, 2013 – March 31, 2014
Special Enrollment Period for trigger events
Something New: The Marketplace
Onlineshopping sites
TERMS TO KNOWOpen Enrollment Period: Specified timeframe, established by the federal government, when individuals can sign up for health coverage or switch plans each year.
Special Enrollment Period: The ability for individuals to enroll in or switch plans outside of an open enrollment period. This is only available in limited circumstances when a qualifying life event takes place.
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Marketplace Notification
–Notification by October 1, 2013
–By first-class mail or electronically (in accordance with the DOL’s electronic disclosure safe harbor requirements)
–New hires within 14 days of start date
–“Employers must provide a notice of coverage options to each employee, regardless of plan enrollment (if applicable) or of part-time or full-time status.”
–DOL model notices available at www.dol.gov/ebsa
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Definition of a Small Group (1-50)
Open Enrollment–Late enrollees can enroll during this period
Special enrollment (60 days)
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2015 20182014
Small Group Definition
Applies to Non-grandfathered plans only
Applies to Non-grandfathered and Grandfathered plans
Non-discrimination
testing for fully-insured
groups
Employer Reporting
RequirementsMandatory
coverage for clinical trials
New Premium
Calculation
90-Day Max Waiting Period
Guaranteed Issued
Essential Health Benefits Package
Employer Shared
Responsibility
Dependent Age 26 - All
Annual Health
Insurer Fee
No Annual Limits on
EHB
Excise “Cadillac”
Tax
Quality of Care
Reporting
Group Size 1-50
Qualified Health Plan
Small Business tax
credit Small Business
Health Options Program
goes online (SHOP)
Pre-existing conditions limitations
Out –of-pocket cost-
sharing limits
Transitional reinsurance
program
Dependent Age 26 - All
Annual Health
Insurer Fee
No Annual Limits on
EHB
Guaranteed Issued
Mandatory coverage for clinical trials
90-Day Max Waiting Period
Pre-existing conditions limitations
Group Size 51-100
Small group definition
1-100
2016
TBD
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Individual Shared Responsibility - 2014 Coverage Period
2015: Employer reporting requirements
2015: Employer Shared Responsibility
2016: Small Group definition change of 1-100
Continued Fees
Additional Provisions
2015 & Beyond
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Our Pledge to You
October 22: AberdeenOctober 23: PierreOctober 24: Rapid CityOctober 29: Sioux FallsNovember 5: Sioux Falls
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More information
WEKNOW
REFORM.COM
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