SOUTH CAROLINA EAPA CONFERENCEMARCH 6 , 2014

STEVEN M. HAUGHT, LCPC, CEAP, CAADC PRESIDENT, EAPA

The Impact of the Patient Protection and Affordable Care Act

(PPACA) on EAPs

LEARNING OBJECTIVES

Healthcare (HC) Reform = PPACA = ACA= Obamacare

Attendees will:1. Better understand backdrop of PPACA,

referred to as the Affordable Care Act (ACA)2. Know implementation timelines for key

components of ADADiscuss ACA challenges and opportunities for

EAPs

ACA History

Passed by Congress, signed by President Obama 3/23/10

Declared constitutional by US Supreme Court 6/28/12

Key provisions: 1. Increase access to affordable health coverage (HC) to

62 million Americans 32 million uninsured 20 million will have increased coverage via parity for mental

health & substance abuse treatment services

Key Provisions (cont.)

Key provisions:

2. Reduce HC costs & improve quality of care3. Increase consumer choice & protections4. Provider consumers with tools to make “informed choice” re.:HC5. Hold insurance companies accountable

Rationale for ACA

Money: control HC costs and increase access2011 Federal Gov’t spending:

25% defense 23% health 21% pensions 13% welfare 18% all other programs

Estimate: between 2030-2040 mandatory spending will exceed revenue

US behind other 1st world countries in mortality rates amenable to HC France, Japan, Australia… US = #19 of 19

ACA Payment Reform

Shift from pay for service to pay for performance

Payers’ create capitated contracts with entities tasked to integrate and coordinate care for a defined group of Pts. Integrated Care Models, Accountable Care

Organizations (ACOs), Medical Homes ACOs will receive money back from Medicare if they

meet pre-determined “best practice” quality & outcome standards, cost benchmarks

Failure to meet goals/outcomes = penalties & reduced revenues

Involved Governmental Departments

Issuing rules and regulations:1. Department of Health & Human Services2. Department of Treasury: Internal Revenue

Service3. Department of Labor: Employee (Ee)

Benefits Security Administration Referred to as “The Agencies”; will also have

enforcement powers

ACA Timeline 2013

Many provisions already enacted Children may remain on parents’ HC plan until 26

Maximum contribution to Flexible Spending Accounts capped @ $2,500

Ers must notify Ees re.: state hlth insurance exchanges, whether Er plans to meet minimum coverage requirements, how to access info regarding premium subsidies available for hlth insurance exchanges

Timelines 2013 & 2014

Large Ers must report cost of Er-provided HC on Ees W-2s

HC plans must cover women’s preventive services, including contraception, without co-pays, co-insurance or deductibles

2014HC waiting periods > 90 days prohibitedStates must create exchanges to help small

Ers provide HC to Ees

2014 Timeline (cont.)

Individual mandate to purchase health insurance

Ers >200 Ees must auto-enroll FTEs (>30 hrs/wk) into default hlth plan with “affordable” coverage Will impact industries with hourly workers like retail,

restaurants, even academic institutions Cut Ee hours to <30 or provide HC?

2015 finalized provisions for EAPs as “excepted benefits” may be put into effect

Timelines (cont.)

2016 Ers > 50 Ees must offer HC or pay penalties

2017- State exchanges may allow large Ers to provide coverage through exchange plans

2018- Ers will pay 40% excise tax on “Cadillac” plans which exceed $10,200 for single coverage, $27,500 for family coverage

Health Insurance Market Reforms (1)

Final rules issued 2/20/13Insurance plans may not base rates on pre-

existing conditions, health status, claims history, duration of conditions, gender, occupation, Er size, Er industry

May base rates on age, tobacco use, family size & geography

10 categories “Essential Health Benefits” must be covered by all exchange offered insurance plans (for individual and small (50-110 Ees) business purchasers

Health Insurance Market Reforms (2)

1 of 10 “Essential Health Benefits” especially relevant to EAPs : Mental health & substance use disorder services

Another EHB of potential relevance to EAPs: Preventive & Wellness Services & Chronic Disease Management

Limits set on cost-sharing, i.e., out-of-pocket expenses like deductibles, co-pays, co-insurance Same as annual High Deductible Health Plan max

out-of-pocket; 2013: $6250 individual, $12,500 family

Health Insurance Market Reforms (3)

ACA will increase coverage of Mental Health & Substance Use Disorder Services by 1. Including them in Essential Health Benefits 2. Increases federal parity protections to include

individual & small group markets 3. Increases the number of Americans covered with

HC including these benefits

Impact on EAPs: ERISA

ERISA (Employee Retirement Income Security Act)Are EAPs covered?Answer complex due to variation in EAP designsAny plan defined as “Ee welfare benefit plan”

(EWBP) is subject to ERISAERISA Opinion letter 88 0004A, “…if a program

provides assistance in dealing with a wide range of personal problems affecting mental or physical health through a contractual arrangement with an independent organization staffed by trained counselors, the program is covered by ERISA.”

EAPs & COBRA

Consolidated Omnibus Budget Reconciliation Act amends ERISA

Requires offering ongoing coverage to Ees after loss of eligibility for certain benefits under “ group health plans” (GHPs)

GHPs are EWBPs providing “services” including “diagnosis, mitigation, treatment or prevention of disease, and any undertaking for the purpose of affecting the structure or function of the body”

GHPs must provide “Summary Plan Descriptions” to users

EAPs & COBRA (2)

EAPs choosing non-medical descriptions such as “assessment” vs. “diagnosis” or “short-term problem resolution” may not successfully avoid falling under COBRA

The issue is the function performed, not the description of the function

EAPs & HIPAA

Health Insurance Portability & Accountability Act- national standards for protection of electronically communicated personal health information (PHI) by health plan, health care clearinghouses and health care providers

HIPAA definition of GHP is same as COBRA and that’s essentially the same as for ERISA

So, what about your program?

EAPs & ACA

ACA regulations issued 2/9/13 require GHPs & health insurers to provide uniform Summary of Benefits & Coverage (SBC) to plan participants

Goal: help consumers compare health plans & HC options = informed choice 4 pages, includes glossary of HC options Ancillary to SPD

If an EAP provides counseling, even a few sessions: yes, have to provide SBC

EAPA website: blank SBC template (editable word document); instructions for completing SBC for

EAPS, ACA & SBCs

EAPs; sample completed SBC for with suggested language for EAPs

FAQ sheetWhen to comply? 1st day of 1st plan year

beginning 9/23/12How often must EAP furnish SBC? On/before

(1) day coverage begins, (2) within 7 days of receipt of request, (3) 30 days before start of each new plan year, (4) within 1st 90 days of “special enrollees”

If plan is modified, must issue a new SBC

EAPs, ACA & SBCs (2)

EAP is responsible for distribution, not the Er customer Unless Er chooses to include EAP SBC in their overall

health plan SBCSBC must be distributed to participants,

beneficiaries & special enrolleesMay be distributed by mail or electronically

(with specific requirements)

EAPS as “Excepted Benefits” (EB) - 1

12/24/13 The Agencies published “Amendments to EB”, Federal Register/Vol 78, # 247/Proposed Rules, pp. 77636-7

Addresses EAPs in Section C EB = benefits not considered HC plans under ACA &

HIPAAAn EAP will be excepted IF:I. It doesn’t provide “significant” benefits in

the nature of medical care

EAP as EB - 2

II. EAP benefits can’t be coordinated with group hlth plan benefits A. EAP can’t be required (“gatekeeper” ) pre access to

other hlth plan benefits B. EAP eligibility must not be dependent on

participation in another grp hlth plan C. EAP benefits must not be financed by another

group hlth planIII. No Ee premiums or contributions can be

required to participate in EAP

EAP as EB - 3

IV. No cost sharing under the EAP

Comments were due by 2/24/14>100 comments received

EAPA (4pp), EARF (5 pp), EAR (2 pp), EASNA (3 pp)These exceptions are effective until

“finalized”, at least through 2014

I. Doesn’t Provide Significant Medical Benefits

EAPA – Agree & endorse. Multi-modality service provision; many services offered, including legal, financial, etc. “Medical Necessity” not required for service

EARF – Agree. Workplace productivity mechanism; # sessions irrelevant

EASNA – “…doesn’t support this criterion because… no standard, accepted definition… regarding ‘significant’ benefits”; # sessions irrelevant

II. EAP benefits can’t be coordinated with group HP benefits - 1

A. EAPA agrees with A & B; C is “ambiguous”- EAPA doesn’t endorse; needs clarity If goal is to prevent EA “benefits” from being

subsidized by HP…EAPA supports…subsidization could distort referrals

If goal is to prevent EA cost from being subsidized by or embedded in hlth plan – EAPA agrees: other EA core activities like promo, Org. & Supv. Consults, etc., are minimized and decrease EA effectiveness

If goal is to prevent owners of grp hlth plan from providing EA under separate contractual agreement, EAPA opposed. This currently occurs: ownership is not the issue, service is

II. EAP can’t be coordinated with Grp Hlth benefits - 2

EARF A. Agree B. Agree C. Disagrees – issue is not financing

EASNA “…does not support this proposal…” A. EAP not HC benefit but a productivity tool, offered

to all Ees B & C – unlike HC plan, offered free to Ee

III. No Ee premiums or contributions for EAP

EAPA – agree; EAPs are paid for by ErEARF – supportsEASNA – supports

IV. No Cost Sharing Under EAP EAPA – agrees; cost sharing inconsistent with EA

practice EARF – agrees EASNA - supports

Additional Implications of ACA for EAPs

Interface with new ACOsIncreased numbers with access to HC may

strain current provider capacitiesEAPs need to consider technology-based

treatment models Video, telephone and internet technologies

Increase access by web, intranet and internet Changes in promotional materialsIncrease focus on outcomes using standardized

definitions and tools, not just utilization

Additional Implications (2)

Measure impact on productivity (pre/post service functioning- self report considered valid) HC costs, disability claims, absenteeism, presenteeism

Continued expansion into child & eldercare, legal & financial, critical incident response, webinars, seminars and resources via robust web-site info, assessment tools, links

Continued research into best practices like Strategic Brief Intervention, Referral & Treatment (SBIRT)

Additional Implications (3)

Some express concern that since many EAPs are being sold under cost, if not as a “give away”, there is not enough money to provide services to the organization

If small employers go to health exchanges, may cut EAPs, wellness, work-life and other ancillary services

Resources

Addiction Professional, www.addictionpro.com Department of Health & Human Services,

http://aspe.hhs.gov Employee Assistance Professionals Association,

www.eapassn.orgEmployee Benefit Adviser,

http://eba.benefitnews.comEmployee Benefit News, http://ebnbenefitnews.comFederal Register The Open Minds Circle, www.openminds.comWorkforce, www.workforce.com

Contact

Steven M. Haught, LCPC, CEAP, CAADCDirector, Social Services, Central RegionThe Actors Fund8 S. Michigan Ave., #601Chicago, Il 60603312-372-0989shaught@actorsfund.org