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On May 27, 2014, the Department of Health and Human Services (HHS) published a final rule taking the next step in implementing “employee choice” in the Small Business Health Options Program (SHOP).  “Employee choice” provides employers the opportunity to allow employees to choose any health plan at the actuarial value, or “metal,” level selected by the employer.

Small business markets differ from state-to-state.  To smooth the transition to employee choice, HHS provided states with additional flexibility by allowing State Insurance Commissioners to request that the SHOP in their state not implement employee choice in 2015.

Under the final rule, State Insurance Commissioners were given an opportunity to submit a written recommendation to the SHOP that employee choice not be implemented in that state in 2015 if the State Insurance Commissioner concluded that not implementing employee choice would be in the best interest of small group market consumers in his or her state.  This would be the case if the Commissioner determines that implementing employee choice would cause issuers to price products and plans higher in 2015 due to issuers’ beliefs about adverse selection.  This transitional policy applies to 2015, as HHS expects that states and issuers will be able to learn from the experiences of issuers in those SHOPs that have decided to implement employee choice in 2015 to prepare for 2016. HHS is committed to implementing employee choice in a way that learns from early experience and ensures its success.

Insurance Commissioners in states with a Federally-facilitated SHOP were required to submit their recommendation letters to HHS by June 2, 2014.  Below is a list of all states with a Federally-facilitated SHOP and provides information on whether each state will implement employee choice in 2015 or instead allow for transition relief.  In total, 18 states with a Federally-facilitated SHOP will allow for this transition relief in 2015. The remaining 14 states with a Federally-facilitated SHOP will join most State-based SHOPs and have employee choice available to small businesses in 2015, doubling the number of states offering this option.  In 2015, nearly two-thirds of Americans will live in states where small business workers can choose a health plan rather than have their employer do it for them.

HHS Approval of State Recommendations to Not Implement Employee Choice in 2015:

Notes:

1. This is a one year not implemental policy and applies only for 2015. Employers in states not implementing to employee choice will be able to offer employees a single medical plan and a single dental plan.
2. The following FFM States will have the default policy of employee choice in 2015: Arkansas, Florida, Georgia, Indiana, Iowa, Missouri, Nebraska, North Dakota, Ohio, Tennessee, Texas, Virginia, Wisconsin, and Wyoming. Employers in these states may choose to offer employees either 1) all medical plans across a single metal level and all dental plans across a single coverage level, or 2) a single medical plan and a single dental plan.
3. Premium billing and payment services will be provided to all employers in FF-SHOPs—whether or not employee choice is available or chosen by an employer.
4. This list does not include SBM States. We will post SBM states defaulting to employee choice in 2015 as soon as all states have reported their decisions to us.

http://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Marketplaces/2015-Transition-to-Employee-Choice-.html

Six basics you must know about health benefits

Understanding these 6 basic ideas can help you save money and get the most out of your plan.

1. Premium: This is what you pay for health insurance. Sometimes you don’t pay the entire monthly premium yourself. This is common when you get your health insurance through your job.
2. Provider network: Health care providers in the network have agreed to offer care and services at discounted rates. This means you pay less when you see an in-network provider. The network includes doctors and many other health care providers.
3. Prior authorization: Is a requirement to obtain advanced approval to provide specific services or procedures. Prior authorization is required for many health services. To learn more about prior authorization, see this month’s IMP article Get the care you need — and avoid a surprise bill!
4. Claim: This is simply a request to pay for a health service covered by your plan. Usually, an in-network provider sends us all the information. However, if you use an out-of-network provider, you may have to send the claim form.
5. Cost sharing: Your health plan only pays part of your covered health care expenses. You’re responsible for paying some of your health care even when you have health coverage. This is known as “cost sharing” because you share the cost of your health care with your health insurer. The three most common types of cost sharing are Deductibles, Copays and Coinsurance. Not sure what some of these terms mean?
6. Out-of-pocket maximum: Once you meet your health plan’s annual out-of-pocket maximum, your health benefits will pay 100% of your covered health care expenses for the rest of the year.

What are the consequences to the employer if the employer does not establish a health insurance plan for its own employees, but reimburses those employees for premiums they pay for health insurance (either through a qualified health plan in the Marketplace or outside the Marketplace)?

Under IRS Notice 2013-54, such arrangements are described as employer payment plans. An employer payment plan, as the term is used in this notice, generally does not include an arrangement under which an employee may have an after-tax amount applied toward health coverage or take that amount in cash compensation. As explained in Notice 2013-54, these employer payment plans are considered to be group health plans subject to the market reforms, including the prohibition on annual limits for essential health benefits and the requirement to provide certain preventive care without cost sharing.  Notice 2013-54 clarifies that such arrangements cannot be integrated with individual policies to satisfy the market reforms.  Consequently, such an arrangement fails to satisfy the market reforms and may be subject to a $100/day excise tax per applicable employee (which is $36,500 per year, per employee) under section 4980D of the Internal Revenue Code.

You can get more information at:   http://www.irs.gov/uac/Newsroom/Employer-Health-Care-Arrangements

Preventive health services for adults

Most health plans must cover a set of preventive services like shots and screening tests at no cost to you. This includes Marketplace private insurance plans.

Free preventive services

All Marketplace plans and many other plans must cover the following list of preventive services without charging you a copayment or coinsurance. This is true even if you haven’t met your yearly deductible. This applies only when these services are delivered by a network provider.

1.Abdominal Aortic Aneurysm one-time screening for men of specified ages who have ever smoked

2.Alcohol Misuse screening and counseling

3.Aspirin use to prevent cardiovascular disease for men and women of certain ages

4.Blood Pressure screening for all adults

5.Cholesterol screening for adults of certain ages or at higher risk

6.Colorectal Cancer screening for adults over 50

7.Depression screening for adults

8.Diabetes (Type 2) screening for adults with high blood pressure

9.Diet counseling for adults at higher risk for chronic disease

10.HIV screening for everyone ages 15 to 65, and other ages at increased risk

11.Immunization vaccines for adults–doses, recommended ages, and recommended populations vary:

•Hepatitis A

•Hepatitis B

•Herpes Zoster

•Human Papillomavirus

•Influenza (Flu Shot)

•Measles, Mumps, Rubella

•Meningococcal

•Pneumococcal

•Tetanus, Diphtheria, Pertussis

•Varicella

12.Obesity screening and counseling for all adults

13.Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk

14.Syphilis screening for all adults at higher risk

15.Tobacco Use screening for all adults and cessation interventions for tobacco users

Source: https://www.healthcare.gov/what-are-my-preventive-care-benefits/

Some of the provisions of the Affordable Care Act, or health care law, apply only to small employers, generally those with fewer than 50 full-time employees or equivalents.

If you have fewer than 50 employees, but are a member of an ownership group with 50 or more full-time equivalent employees, you are subject to the rules for large employers.

Coverage

•If you have 50 or fewer employees, you can purchase affordable insurance through the Small Business Health Options Program (SHOP).

•To learn more about how the Affordable Care Act may affect your business, visit HealthCare.gov.

Reporting

•You must withhold and report an additional 0.9 percent on employee wages or compensation that exceed $200,000. Learn more.

•You may be required to report the value of the health insurance coverage you provided to each employee on his or her Form W-2.

•Effective for calendar year 2015, if you provide self-insured health coverage to your employees, you must file an annual return reporting certain information for each employee you cover. This rule is optional for 2014. Learn more.

Payments & Credits

•You may be eligible for the Small Business Health Care Tax Credit if you cover at least 50 percent of your full-time employee’s premium costs and you have fewer than 25 full-time equivalent employees with average annual wages of less than $50,000.

•If you self-insure, you may be required to pay a fee to help fund the Patient- Centered Outcomes Research Trust Fund.

Source: http://www.irs.gov/uac/Affordable-Care-Act-Tax-Provisions-for-Small-Employers

Your health is important.

How you take care of it plays a big role in what your future will be like.

Preventive care is the first step in knowing how healthy you are.

Why should you get preventive care?

• To catch health conditions early, when they may be treatable
• To help discover potential risks to your future health, and
• To get immunizations for the flu, pneumonia, booster shots and shots for children

Each year you should have an exam by your doctor and certain screenings recommended for your age and gender.

Most medical plans cover preventive care at 100% when you see an in-network doctor.

First things first!

When you make your appointment, and when you check in, be sure to let the scheduler know that your visit should be coded as preventive care.

If you are getting any other services because of an ongoing condition, or any diagnostic care, they will not qualify as preventive care services.

During your visit your doctor may check the following:

• Blood pressure
• Weight/Body mass index (BMI)
• Cholesterol levels
• Blood glucose level, and
• Immunization history

Women’s health services, including:

• Breast exam
• Pap smear, and
• Cervical Exam

Are covered at 100% as preventive care.

Are part of your preventive care coverage.

There are other services or screenings that may be scheduled at another time with the help of your primary care doctor that are also covered at 100% as part of your preventive care benefit,

Such as:

• Mammogram
• Colorectal cancer screening
• Prostate exam, and
• Bone density test

The goal of preventive care is to “prevent” a serious health condition by finding problems early.

Heart Disease is the number one killer for both men and women.

High blood pressure and high cholesterol are two main risk factors for heart disease, which kills 910,000* Americans every year.

8% of Americans have diabetes, 57 million have pre-diabetes**. High blood pressure, high cholesterol, obesity and an elevated blood glucose level are all factors that put you at risk for developing diabetes.

Getting regular screenings to check for cancer are important.

Don’t wait until it’s too late.

For better or worse, if you get a diagnosis early you may be able to treat it and make lifestyle changes that can possibly change your health outlook.

Remember, all of these screenings are covered at 100% when you see an in-network provider.

Take a step in the right direction and start by scheduling a preventive care examination with your doctor.

To see the preventive care guidelines, visit uhcpreventivecare.com

*American Heart Association
** American Diabetes Association
***American Cancer Society

Source: http://www.uhcpreventivecare.com/site/theme/assets/videos/PreventiveCare-Why-Transcript.html

According to a new survey from the Kaiser Family Foundation, many Americans may be willing “to trade access to a wide range of medical providers for lower premiums” on their health insurance. As the Los Angeles Times  (2/27, Levey) reports network limits stemming from the Affordable Care Act “have drawn criticism from opponents” of the law. However, the poll suggested this may not remain a point of contention, as “54% of those between the ages of 18 and 64 who are uninsured or who buy health coverage on their own said they would rather have a health plan that costs less, even if it has a limited range of doctors and hospitals.”

Bloomberg News  (2/27, Chen) reports that the poll shows “consumers shopping on the Obamacare exchanges are thriftier than the general public,” or as Dan Mendelson, chief executive officer of Avalere Health puts it, “The individual market has always been more sensitive to costs.”

The Kaiser Health News  (2/27, Rau) “Capsules” blog notes that among those who purchase coverage through their employer, the numbers are reversed: “fifty-five percent would rather buy a plan that costs more but allows them to see a wider range of doctors and hospitals.”

Yes. There’s a new voluntary long term care program. There are new nutritional labeling requirements. Chain retailers and vending machines must display nutrition information, mainly calories. Indoor tanning services pay a 10% tax. Nursing mothers get extended break times and private facilities (other than a bathroom). New adoption assistance includes new tax breaks.

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Medicare eligible employees are affected by PPACA as follows:
• Provides a $250 rebate to those who reach the Part D coverage gap in 2010.
• Phases down to 25% by 2020 the beneficiary coinsurance rate in the Part D coverage gap.
• For brand-name drugs, requires drug makers to provide a 50% discount on Part D prescriptions filled in the Part D coverage gap, in addition to federal subsidies of 25% of brand-name drug cost by 2020.
• For generics, provides federal subsidies of 75% of the generic drug cost by 2020 for prescriptions filled in the Part D coverage gap.
• Reduces, between 2014 and 2019, the out-of-pocket amount that qualifies an enrollee for catastrophic coverage.
• Possible reduction in access to providers or coverage options because of changes to provider reimbursement levels.

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Employee benefits coverages that must be reported on the W-2 include all health coverages such as:

• Medical, Dental, and Vision coverages
• Prescription drug coverage
• Executive physical benefits
• On-site clinics
• EAPs that provide medical care
• Wellness programs that provide medical care