Small Business Health Options Program (SHOP)

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:

 

2015 Transition to Employee Choice

 
State

 

 State Implementing Employee Choice in 2015

 
Alabama NO
Alaska NO
Arizona NO
Arkansas YES
Delaware NO
Florida YES
Georgia YES
Illinois NO
Indiana YES
Iowa YES
Kansas NO
Louisiana NO
Maine NO
Michigan NO
Missouri YES
Montana NO
Nebraska YES
New Hampshire NO
New Jersey NO
North Carolina NO
North Dakota YES
Ohio YES
Oklahoma NO
Pennsylvania NO
South Carolina NO
South Dakota NO
Tennessee YES
Texas YES
Virginia YES
West Virginia NO
Wisconsin YES
Wyoming YES

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

in Uncategorized  by probityadmin 0 comments

Six basics you must know about health benefits

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.
in Uncategorized  by probityadmin 0 comments

Employer Health Care Arrangements

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

in Uncategorized  by probityadmin 0 comments

What are consequences to employer for not establishing health insurance plan?

Employer Health Care Arrangements

Q1.  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.

Q2. Where can I get more information?

On Sept. 13, 2013, the IRS issued Notice 2013-54, which explains how the Affordable Care Act’s market reforms apply to certain types of group health plans, including health reimbursement arrangements (HRAs), health flexible spending arrangements (health FSAs) and certain other employer healthcare arrangements, including arrangements under which an employer reimburses an employee for some or all of the premium expenses incurred for an individual health insurance policy.

DOL has issued a notice in substantially identical form to Notice 2013-54, DOL Technical Release 2013-03, and HHS will shortly issue guidance to reflect that it concurs with Notice 2013-54. On Jan. 24, 2013, DOL and HHS issued FAQs that addressed the application of the Affordable Care Act to HRAs.
Source: IRS, http://www.irs.gov/uac/Newsroom/Employer-Health-Care-Arrangements

in employee / Employer / health insurance  by probityadmin 0 comments

What constitutes Special Enrollment?

*Special Enrollment*

Now that open enrollment has ended, you can enroll in a Covered California health insurance plan only if you experience a qualifying life event.

The next open enrollment period will be in the fall of 2014. Remember, you can enroll in Medi-Cal at any time.

Common types of qualifying life events for special enrollment:

*You get married or enter into a domestic partnership.
*You have or adopt a child, receive a child into foster care, or you place a child in adoption or in a foster home.
*You change where you permanently live, and you gain access to new Covered California health insurance plans. This includes moving to California from another state. This also applies to individuals who are released from jail or prison.
*You lose your health coverage. For example, you are no longer eligible for Medi-Cal, or you lose health coverage through your job.
*Your income changes so much that you become newly eligible or ineligible for help paying for your insurance. For example, if you are already getting help paying for your insurance premium, and your income goes down, you may be able to get extra help.
*You become a citizen, national or lawfully present individual. This event applies only to people who were not previously citizens, nationals or lawfully present.
*Your enrollment was wrong, due to the misconduct or misrepresentation of your health insurance company, Covered California or a non-Covered California entity (such as a Certified Enrollment Counselor).
*You applied for health coverage before March 31 and got a denial for Medi-Cal after March 31. If you were incorrectly denied Covered California or Medi-Cal coverage, you can also file an appeal.
*If you are a member of a federally recognized American Indian or Alaska Native tribe, you may enroll in health insurance or change your health insurance plan once a month even if the open enrollment period is over.
*Covered California can also determine, on a case-by-case basis, that you experienced an exceptional circumstance, which could allow for a special enrollment period.

After my qualifying life event, how long do I have to sign up for health insurance or change my health insurance plan in Covered California?

You have 60 days from the date on which the qualifying life event happens to enroll in a Covered California health insurance plan or change your existing Covered California plan. For example, if you have a child on June 1, you have until July 31 to notify Covered California, complete an application for your new child, choose a health plan and pay for it. If you do not get health coverage for your child, you may have to pay a tax penalty.
If 60 days pass and you do not sign up for health coverage, you will have to wait until the next open enrollment period, which will be in the fall of 2014.

Keep in mind that you can enroll in Medi-Cal at any time. You do not need a special enrollment period to enroll in Medi-Cal. To see if you or someone in your family is eligible for Medi-Cal, complete the online application at www.CoveredCA.com.

Can coverage start right away?

For most qualifying life events, the start date for coverage depends on the date you enroll, as discussed in the question above. If you enroll by the 15th day of the month, your coverage will start on the first day of the next month. If you enroll after the 15th day of the month, you coverage will start on the first day of the second month.

But there are a few exceptions to the start date rule:
•    If you lose your Medi-Cal coverage, job-based coverage or other coverage, and you use a special enrollment period, your coverage would start on the first day of the next month following your plan selection, regardless of when during the month you make your plan selection.
•    If you get married and use a special enrollment period, your coverage will start on the first day of the next month following your plan selection, regardless of when during the month you make your plan selection.
•    If you have or adopt a child or place a child in adoption or foster care, and you use a special enrollment period, your coverage starts on the date of the birth, the adoption or the placement for adoption or foster care.
•    On a case-by-case basis, Covered California may start your coverage earlier.

http://www.coveredca.com/coverage-basics/special-enrollment/

in employee / health insurance / individual mandate  by probityadmin 0 comments

IRS Highlights Stiff Penalty for Reimbursing Individual Premiums

Since the IRS and Treasury published Notice 2013-54 in September 2013, pre-tax employer reimbursement of an employee’s individual health insurance premiums has been a hot topic of conversation.  Historically, many employers have provided this type of benefit in lieu of offering a group health plan – a strategy that now needs to be reevaluated as a result of regulations implementing the Patient Protection and Affordable Care Act (PPACA).

The IRS has affirmed its stance on these types of arrangements (called “employer payment plans”) in a short two question FAQ published on May 19, 2014.  Question 1 reads as follows:

Q1.  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)?

Referencing Notice 2013-54, the IRS emphasizes that these employer payment plans are considered group health plans under PPACA. As group health plans, these arrangements are subject to the market reforms, including the prohibition on annual limits and the requirement to cover preventive care without cost-sharing.  These arrangements cannot be integrated with individual health insurance plans in order to satisfy the market reform requirements.

Unlike Notice 2013-54, this recent FAQ shines a spotlight on the consequences for employers operating employer payment plans to reimburse employees for the cost of individual health insurance policies.  The potential penalty? Up to $100 per day per applicable employee, under Code 4980D.  The IRS also points out that the penalty could total $36,500 per year per employee.  This figure does not include potential liability as a result of additional DOL enforcement of compliance with the market reforms, incorporated into ERISA by the Public Health Service Act (PHSA).

The Department of Labor also issued Technical Release 2013-03, which is substantially similar to Notice 2013-54.  The IRS notes in the FAQ that HHS is expected to issue guidance in the near future concurring with Notice 2013-54 and Technical Release 2013-03.  Employers currently utilizing this strategy or who are considering the implementation of such an employer payment plan should consult with counsel on the impact of Notice 2013-54, Technical Release 2013-03 and this FAQ to consider the risks and find an alternative benefits strategy if necessary.  See http://www.irs.gov/uac/Newsroom/Employer-Health-Care-Arrangements

Source LISI, http://blog.lisibroker.com/irs-highlights-stiff-penalty-for-reimbursing-individual-premiums/

in Employer / health insurance / Premiums  by probityadmin 0 comments

Vacation Bible School Safety Ideas

Vacation Bible School

There are few things richer in tradition than Vacation Bible School.  Each summer the vast majority of religious institutions offer Vacation Bible School for its young members.  It is a great way to educate youth on religious teachings and beliefs in a fun and safe environment of faith-based activities.  To keep participants safe, please consider the following:

Security

•    Adhere to a strict check-in/out policy for all students at drop-off and pick-up times.  Allow children to be released only to parents.  Require parents notify you if an alternate person is picking up their child.  If notification is not received, do not release the child.
•    Conduct background checks on all volunteers and staff.  Everyone involved from the adult teacher, the teenage assistant and the parent volunteer should be checked.  It is a necessary precaution and most people understand and comply with such requirements.
•    Assign veteran staff members to oversee the program.  Encourage them to walk the church grounds, classrooms, restrooms and other multi-purpose locations.  They should be trained to look for inappropriate conduct, unsafe activities and unusual persons.
•    Incorporate emergency training like fire, tornado and lock-down drills.  Kids will recognize these drills from school and will know what to do in the event of a VBS emergency.

Students

•    Divide students into age appropriate groups.  Provide appropriate staff to student ratio for optimal safety.  Do not allow any one-to-one contact or closed door activities.
•    Select safe, fun and age-appropriate activities.  Be careful of craft items which may be toxic or dangerous to children.  Choose activities that involve simple and safe supplies.
•    Outdoor games are awesome for kids. They devour the opportunity to participate in simple outdoor games designed to grow team spirit and camaraderie.  Always conduct careful inspection of playground equipment and safety gear.

Odds-and-Ends

•    Review food safety rules and regulations.  Food allergies should be disclosed and clear guidelines and precautions should be followed by staff and volunteers.
•    Medical treatment options should be safely stored and easily accessible to adult staff members.  Special medication should be clearly marked with directions for use.  Properly stock all first aid kits with necessary supplies needed to aid a variety of ailments.
•    Apply sunscreen and bug spray for outdoor excursions.
•    Obtain permission slips and waivers for all off campus field trips and outings.

By following these simple steps, we can ensure a fun and safe VBS experience for our children.

Source: Church Underwriters, Inc., http://www.chuund.com/

in Commercial Insurance / Safety  by probityadmin 0 comments

How do employers and insurers report under the ACA?

FACT SHEET: Final Regulations Implementing Information Reporting for Employers and Insurers under the Affordable Care Act (ACA)

3/5/2014

WASHINGTON – Today, the U.S. Department of the Treasury and the Internal Revenue Service (IRS) released final rules to implement the information reporting provisions for insurers and certain employers under the ACA that take effect in 2015.

“Today’s announcement is part of the Administration’s effort to provide certainty and early guidance about major health policies so employers, small business owners and other individuals can plan for 2015,” said Assistant Secretary for Tax Policy Mark J. Mazur.  “Treasury’s final rules significantly streamline and simplify information reporting while making it easier for employers and insurers of all sizes to provide the quality, affordable health coverage that every American deserves.”

While 96 percent of employers are not subject to ACA reporting requirements or the employer responsibility provision because they have fewer than 50 employees, in 2015 requirements begin to phase-in for the remaining four percent of employers that are required to offer quality, affordable coverage to employees or make a payment.  The final regulations released today on information reporting by those employers will substantially streamline reporting requirements for employers, particularly those that offer highly affordable coverage to full-time employees.  Final rules were also released today to provide guidance for reporting by insurers and other parties that provide health coverage under the ACA.  Together, these rules respond to feedback from stakeholders and will help employers and insurers effectively comply with their responsibilities.

Today’s final rules include the following key provisions:

Single, Combined Form for Information Reporting

  • Employers that “self-insure” will have a streamlined way to report under both the employer and insurer reporting provisions.  Responding to widespread requests, the final rules provide for a single, consolidated form that employers will use to report to the IRS and employees under both sections 6055 and 6056, thereby simplifying the process and avoiding duplicative reporting.  The combined form will have two sections: the top half includes the information needed for section 6056 reporting, while the bottom half includes the information needed for section 6055.
    • Employers that have fewer than 50 full-time employees are exempt from the ACA employer shared responsibility provisions and therefore from the employer reporting requirements.
    • Employers that are large enough to be subject to the employer responsibility provisions and that “self-insure” will complete both parts of the combined form for information reporting.
    • Employers that are subject to employer responsibility but do not “self-insure” will complete only the top section of the combined form (reporting for section 6056). Insurers and other providers of health coverage will report only under section 6055, using a separate form for that purpose.  Insurers do not have to report on enrollees in the Health Insurance Marketplace, since the Marketplace will already be providing information on individuals’ coverage there.

Simplified Option for Employer Reporting

  • For employers that provide a “qualifying offer” to any of their full time employees, the final rules provide a simplified alternative to reporting monthly, employee-specific information on those employees.
    • A qualifying offer is an offer of minimum value coverage that provides employee-only coverage at a cost to the employee of no more than about $1,100 in 2015 (9.5 percent of the Federal Poverty Level), combined with an offer of coverage for the employee’s family.
    • For employees who receive qualifying offers for all 12 months of the year, employers will need to report only the names, addresses, and taxpayer identification numbers (TINs) of those employees and the fact that they received a full-year qualifying offer.  Employers will also give the employees a copy of that simplified report or a standard statement indicating that the employee received a full-year qualifying offer.
    • For employees who receive a qualifying offer for fewer than all 12 months of the year, employers will be able to simplify reporting to the IRS and to employees for each of those months by simply entering a code indicating that the qualifying offer was made.
    • To provide for a phase-in of the simplified option, employers certifying that they have made a qualifying offer to at least 95% of their full-time employees (plus an offer to their families) will be able to use an even simpler alternative reporting method for 2015.  Those employers will be able to use the simplified, streamlined reporting method for their entire workforce, including for any employees who do not receive a qualifying offer for the full year.  Those employers will provide employees with standard statements relating to their possible eligibility for premium tax credits.
  • The final regulations also give employers the option to avoid identifying in the report which of its employees are full-time, and instead to just include in the report those employees who may be full-time.  To take advantage of this option, the employer must certify that it offered affordable, minimum value coverage to at least 98 percent of the employees on whom it is reporting.

What Information Is Reported

The statute calls for employers, insurers, and other reporting entities to report information including:

  • For section 6055
    • Information about the entity providing coverage, including contact information.
    • Which individuals are enrolled in coverage, with identifying information and the months for which they were covered.
  • For section 6056
    • Information about the employer offering coverage (including contact information and the number of full-time employees).
    • For each full-time employee, information about the coverage (if any) offered to the employee, by month, including the lowest employee cost of self-only coverage offered.
  • Streamlined information:  The final rules omit data elements in the statute that are not necessary to understanding coverage offered and provided, in the interest of streamlining.  These include (but are not limited to):
    • The length of any waiting period;
    • Employer’s share of the total allowed costs of benefits provided under the plan;
    • The amount of advance payments of the premium tax credit and cost-sharing reductions.

For more information, see sections 6055 and 6056 final regulations here.

###​

Source:  US Dept of the Treasury, http://www.treasury.gov/press-center/press-releases/Pages/jl2310.aspx

in Employer / health insurance / Insurers  by probityadmin 0 comments

Is premium assistance for spouse and child coverage available?

Q: I have health insurance through my employer, but coverage for my spouse and child are too expensive. Would I be eligible for premium assistance for a plan for my child?

A: Whether you or your family are eligible for premium assistance depends on whether you  have an offer of coverage that includes your spouse and dependents and (1) is affordable and (2) meets the standard for minimum coverage. The affordability of  employer-provided coverage is evaluated on these two criteria:

1. The total annual premium you pay for self-only coverage is 9.5 percent or less of your annual household income.

2. Your employer-provided plan covers at least 60 percent of health care costs for an average population. Your employer or your health insurance plan should notify you as to how much the plan covers.

If those two criteria are met, your employer’s plan is considered “affordable” under the law, and your family members would not qualify for premium assistance through Covered California.

If your employer-provided coverage does not include dependent coverage, or if your employer does not offer dependent coverage, your spouse and child may qualify for subsidies through Covered California since they would not be offered coverage. In that case, their eligibility would be based on the family’s income.

https://www.blueshieldca.com/bsca/documents/about-blue-shield/health-reform/COVEREDCA_FAQs_092413.pdf

in child / coverage / health insurance  by probityadmin 0 comments

Premium assistance for a child’s plan.

I have health insurance through my employer, but coverage for my spouse and child are too expensive. Would I be eligible for premium assistance for a plan for my child?

Whether you or your family are eligible for premium assistance depends on whether you have an offer of coverage that includes your spouse and dependents and (1) is affordable and (2) meets the standard for minimum coverage. The affordability of employer-provided coverage is evaluated on these two criteria:

1. The total annual premium you pay for self-only coverage is 9.5 percent or less of your annual household income.

2. Your employer-provided plan covers at least 60 percent of health care costs for an average population. Your employer or your health insurance plan should notify you as to how much the plan covers.

If those two criteria are met, your employer’s plan is considered “affordable” under the law, and your family members would not qualify for premium assistance through Covered California.

If your employer-provided coverage does not include dependent coverage, or if your employer does not offer dependent coverage, your spouse and child may qualify for subsidies through Covered California since they would not be offered coverage. In that case, their eligibility would be based on the family’s income.

Source https://www.blueshieldca.com/bsca/documents/about-blue-shield/health-reform/COVEREDCA_FAQs_092413.pdf

in child / health insurance  by probityadmin 0 comments