What You Need to Know About - PowerPoint PPT Presentation

Loading...

PPT – What You Need to Know About PowerPoint presentation | free to download - id: 512666-YmY1Z



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

What You Need to Know About

Description:

What You Need to Know About Health Care Reform Compliance Presented by Marcia S. Wagner, Esq. The Wagner Law Group Kim Buckey, Principal HighRoads – PowerPoint PPT presentation

Number of Views:51
Avg rating:3.0/5.0
Slides: 37
Provided by: LauraPar
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: What You Need to Know About


1
What You Need to Know About Health Care Reform
Compliance

Presented by Marcia S. Wagner, Esq. The Wagner
Law Group Kim Buckey, Principal HighRoads
1
2
Introductions Marcia S. Wagner
  • Marcia S. Wagner is a specialist in pension and
    employee benefits law, and is the principal of
    The Wagner Law Group in Boston, Massachusetts,
    which she founded approximately 15 years ago. A
    summa cum laude and Phi Beta Kappa graduate of
    Cornell University and a graduate of Harvard Law
    School, she has practiced in Boston for over
    twenty-four years.
  • Ms. Wagner is recognized as an expert in a
    variety of employee benefits issues and executive
    compensation matters, including qualified and
    non-qualified retirement plans, rabbi trusts,
    all forms of deferred compensation, and welfare
    benefit arrangements.

3
Introductions Kim Buckey
  • Kim Buckey is the Principal for the HighRoads
    Communications consulting practice focused on
    delivering high value strategic and practical
    solutions for clients in an efficient manner
    leveraging the HighRoads technology platform.
  • Previously, Kim served as national compliance
    champion and global quality leader for Watson
    Wyatt's communication practice. In her 30-year
    career Buckey has helped dozens of companies meet
    their compliance requirements by completing
    hundreds of health and welfare and retirement
    plan SPDs.

4
From the Beginning
  • Legislation
  • Patient Protection and Affordable Care Act
  • Health Care and Education Affordability
    Reconciliation Act of 2010
  • Main Objectives Consequences
  • Increase transparency and efficiency of the
    health care system
  • Require health care coverage for individuals
  • Provide premium subsidiaries for lower income
    individuals
  • Impose new taxes, responsibilities, and penalties
    on employers and others

4
5
Mandatory Coverage for Individuals
  • Effective 2014
  • Most U.S. residents must have minimum essential
    health benefits or pay a penalty
  • Penalty
  • 95 or 1 of income in 2014
  • 695 or 2.5 of income in 2016

5
6
Premium Assistance
  • Small employer subsidies
  • Employees eligible if income between 100 and
    400 of federal poverty level
  • Cost sharing subsidy for those with income below
    200

6
7
American Health Benefit Exchanges
  • Operational in 2014
  • Offer Bronze, Silver, Gold, Platinum, and
    Catastrophic Plan coverage to individuals
  • Out of pocket costs reduced for lower income
    individuals
  • SHOP

7
8
Insurance Market
  • Guaranteed Issue
  • Guaranteed Renewability
  • High Risk Pool
  • Rating only by
  • Family structure
  • Community rating value of benefits
  • Age
  • Smoking

8
9
Medicare and Medicaid
  • Reduce certain Medicaid payments
  • Independent Advisory Panel
  • Close Medicare Part D doughnut hole

9
10
Funding
  • Additional taxes imposed on the insurance
    industry
  • A 40 excise tax is imposed on Cadillac plans
  • Increase Medicare portion of FICA
  • A 3.8 surtax is imposed in 2013 on net
    investment income
  • Reduction of Medicare Part D premium subsides
  • Elimination of the deduction for expenses
    attributable to the Medicare Part D subsidy
  • Increase in the deduction threshold on medical
    expenses from 7.5 to 10
  • A 10 excise tax on indoor tanning services

10
11
Employer Group Health Plans Future
Consideration
  • Employers with more than 50 employees who do not
    offer minimum essential health coverage will be
    assessed a fee of 2,000 per employee, with an
    exception for the first 30 employees
  • If contributions are in excess of 9.8 of income,
    the employer will be assessed a penalty of 3,000
    for each employee who receives a premium tax
    credit, with an exception for the first 30
    employees
  • Maximum 90 day waiting period
  • Employers with more than 200 employees must
    automatically enroll their employees in the
    employer-sponsored group health plan

11
12
Employer Group Health Plans Future
Consideration (continued)
  • Employer must offer a free choice voucher
  • Health care flexible spending account plans will
    be limited to 2,500
  • Notification requirements
  • Uniform summary of benefits
  • W-2 reporting
  • Individual coverage report

12
13
Grandfather Rules
  • Definitions
  • A group health plan that was in existence on
    March 23, 2010
  • Identity of participants may change
  • Each benefit package examined separately
  • To maintain grandfather status, a plan must
  • Include a statement saying plan is a
    grandfathered health plan
  • Maintain records that document the terms of the
    plan in effect of March 23, 2010
  • Make records available
  • Provide contact information

13
14
Grandfather Rules (continued)
  • Grandfather status will be lost if the plan
  • Enters into a new policy, certificate, or contact
    of insurance after March 23, 2010
  • Eliminates substantially all benefits for a
    specific illness
  • Increases co-insurance or cost sharing
  • Decreases employer contribution percentage
  • Imposes certain new annual limits on benefits

14
15
Provisions Applicable to All Plans
  • Coverage for adult children
  • Restrictions on annual and lifetime benefit
    limits
  • Elimination of pre-existing condition exclusions
  • Limitation of rescissions
  • Over-the-counter medications

Provisions Applicable to Non-Grandfathered Plans
  • Provide free preventative care services
  • Participants may select primary care providers,
    including pediatric care providers, and OB/GYNs
  • Insured group health plans will be subject to
    nondiscrimination rules
  • Emergency care services without prior
    authorization
  • Internal and External Appeals Process

15
16
Coverage of Adult Children
  • Must make health care coverage available to
    children of plan participants until age 26
  • May not consider
  • Tax dependency
  • Residency
  • Student status
  • Marital status
  • Employment status
  • May exclude adult child who is eligible for
    health coverage under another employers plan
  • Cannot require additional contributions because
    child is adult

16
17
Coverage of Adult Children (Continued)
  • Special enrollment period
  • For adult children who lost, or never had,
    coverage
  • Enrollment period must be at least 30 days
  • Must receive written notice of enrollment
    opportunity
  • Taxation
  • No imputed income even if adult child not tax
    dependent until end of tax year in which child
    turned 27
  • Pre-tax contributions to cafeteria plan permitted
    if plan amended
  • Change in Status rules include adult,
    non-dependent children

17
18
Restrictions on Annual and Lifetime Benefit
Limits
  • No lifetime dollar limits on essential health
    benefits
  • Must notify individuals who reached prior
    lifetime limit of 30-day opportunity to re-enroll
  • Annual limits on essential health benefits must
    be at least
  • 750,000 per plan years beginning after September
    22, 2010
  • 1.25 million for plan years beginning after
    September 22, 2011
  • 2 million for plan years beginning after
    September 22, 2012

18
19
Restrictions on Annual and Lifetime Benefit
Limits (Continued)
  • Annual limit applies separately to each
    individual
  • Annual limit cannot be offset by non-essential
    health benefits
  • Exceptions to annual limit
  • Health FSAs
  • HSAs
  • Mini-med or limited benefit plans
  • New open enrollment period

19
20
Pre-Existing Conditions
  • Pre-existing conditions definition
  • Cannot impose on child under 19
  • Cannot impose on anyone as of 2014
  • Cannot exclude from coverage

Rescission
  • Rescission is a retroactive cancellation of
    coverage
  • Rescission only permitted for fraud or
    intentional misrepresentation
  • Thirty day notice requirement

20
21
Over-the-Counter Medications
  • Effective January 1, 2011
  • Applies to all non-prescribed over-the-counter
    medications, except insulin
  • Health Care FSAs, HRAs cannot reimburse. HSA
    distributions taxable

Preventative Care Services
  • Cannot have cost sharing such as co-pays or
    deductibles
  • Preventative Care includes
  • Well baby care mammograms services recommended
    by certain government agencies services to be
    included by HHS

21
22
Choice of Health Care Provider and OB/GYN
Referrals
  • Must allow selection of any primary care or
    pediatric care provider in plans network
  • Referral to OB/GYN not required

Non-Discrimination Rules for Insured Plans
  • Non-discrimination rules for insured plans will
    be similar to self-funded plan rules
  • IRS guidance needed

22
23
Emergency Care Services
  • Must be provided without prior authorization or
    regard to plans network
  • Out-of-network and cost sharing requirements must
    be the same as for in-network
  • Emergency Medical Conditions expectation of
    serious jeopardy or impairment to bodily
    functions or organs
  • Emergency service provider may balance bill
    patient

23
24
Internal and External Reviews
  • Internal
  • Comply with DOLs current claims requirements
    plus six new requirements including
  • Urgent care claims resolved within 24 hours
  • Plan must hire independent decision makers
  • Must provide culturally and linguistically
    appropriate notices
  • External
  • Comply with state external review process for
    insured plans, or
  • Comply with procedures in new DOL Technical
    Release

25
Communicating About Health Care Reform
  • Employees are looking for information about how
    health care reform will affect them and their
    benefits
  • Opportunity for employers to enhance employee
    perception about their plans
  • Potential for improved employee engagement
  • Recent studies show that employers with good
    benefits communications have more satisfied and
    engaged employees

25
26
Theres a Lot to Communicate
Year Topics
2010 Auto enrollment and opt out Dependent eligibility Changes to annual and lifetime limits
2011 OTC drugs no longer eligible medical expenses W-2 reporting
2012 Benefit summaries
2013 Changes to FSA contribution limit Information about the Exchange and how employer plan coordinates
26
27
Your Options
Approach Pros Cons
Update your SPDs May be out of compliance anyway Long shelf life May not have time before the end of the year, especially if you have many, or complex, SPDs Can be costly to produce
Issue SMMs Often less costly to produce and mail Can be generated relatively quickly May get separated from SPDs Fulfillment may be a challenge (who gets what)
Other tools (enrollment materials, newsletters, meetings) Timely May have more visual impact Likely to end up in the trash
27
28
The Role of SPDs
  • Legally required
  • Every five years if plan has changed
  • Every 10 years if no changes
  • User guides for benefits
  • Can help participants make informed decisions
    about what coverage to elect
  • Explain how to use the benefits
  • Regulations spell out
  • Content (specific to the type of plan being
    described)
  • Style (easily understood by average participant
    no jargon)

28
29
The Role of SPDs (contd)
  • Not all plans require SPDs
  • Non-ERISA plans
  • DC FSA
  • May depend on services provided
  • EAP
  • Severance
  • Distribution is an issue
  • Print vs. electronic
  • Answer may depend on the audience
  • Trend is definitely away from print
  • Cost
  • Green initiatives

29
30
Whats Next?
  • Summaries of coverage
  • Distributed on or before March 30, 2012, and at
    enrollment
  • 60-day advance notice of changes to benefits
    (effective 2012)

30
31
You Need a Plan
  • The volume, frequency and complexity of changes
    over the coming years demand a strategy
  • Map out
  • What needs to be communicated when
  • When guidance is coming from HHS
  • Who needs what information when
  • Who needs to review and approve what information
  • What decisions will need to be made about benefit
    strategy and design
  • What is best timing/media to get messages across
  • Whos going to do the work
  • How can technology help

31
32
  • Why worry?

32
33
Penalties
  • 110 per day penalty for failure to provide
    compliant SPD
  • Potential back benefits court fees if SPD found
    to be lacking
  • HIPAA Penalties
  • 100 to 50,000 based on number and nature of
    violations
  • Maximum penalty 1,500,000 per year
  • Separate violation occurs on each day of
    non-compliance

33
34
Conclusion Action Steps for Employers
  • Determine if you are a grandfathered plan
  • Assess plan with regards to new requirements
  • Prepare in advance for
  • Required open enrollments
  • Plan amendments
  • New required communication materials and notices
  • Revisions of summary plan descriptions and new
    summaries of material modifications
  • Keep Alert! Government agencies will be issuing
    additional regulations and revising those that
    have already been issued

34
35
QA
  • Have a question later? Ask the Experts
  • Marcia Wagner
  • Tel (617) 357-5200 marcia_at_wagnerlawgroup.com
  • Website www.erisa-lawyers.com
  • Kim Buckey
  • Tel (781) 503-4000 x 3085 kbuckey_at_highroads.com
  • Blog http//newsroom.highroads.com/

36
Thank you
  • Thank for attending todays webinar. You will be
    receiving several reference materials
  • Electronic distribution guideline
  • SPD Content Checklist
  • What Plans Require an SPD
  • Best Practices of Health Care Reform Compliance
  • article by the presenters
About PowerShow.com