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Tag: Patient Protection and Affordable Care Act (PPACA)

ACA Exchange Notices

Federal and state governments are manufacturing insurance exchanges/market places as another resource for existing insurance carriers to offer their products and plans. These same products and plans will be available outside the exchanges/market places. For most employers, this new market place will be a redundancy to the way you currently understand insurance to work. The benefactors will primarily be the indigent and certain small businesses that qualify for financial assistance.  As always, Cosby Insurance group will provide you thorough analysis of all your choices.

However, the Affordable Care Act (ACA or health care reform law) added a section to the Fair Labor Standards Act (FLSA) that said employers must provide a written notice to each existing employee. The Department of Labor (DOL) provided an update with temporary guidance and templates of the required notices. Starting on October 1, 2013, the notices have to be given to new employees on the day they are hired. The notices have to be given to existing employees no later than October 1, 2013. The notices will:

  • Advise employees about exchanges including a description of the services provided and how they can contact exchanges to request assistance;
  • Let employees know they may be eligible for a premium tax credit if the employer-sponsored plan does not meet certain standards, and the employee buys a qualified health plan through an exchange;
  • Explains that if the employee buys a qualified health plan through an exchange, he or she may lose the employer contribution to any health benefit plan the employer offers, and that all or a portion of the contribution may be excluded from income for Federal tax purposes.

Please know that the quality and affordability of your employer-sponsored benefits is important to being  a competitive employer. Providing competitive and affordable  benefits is now more important than ever.

Important links:
Technical Release 2013-02
Model Exchange Notice
Cobra model

ACA Requirements To Consider for 2014

Many plan sponsors had been waiting for the Supreme Court’s decision on the Affordable Care Act (ACA) to fully launch the next phase of compliance and that they should review the upcoming requirements to make sure they are prepared to comply.

Here is a checklist of ACA requirements that apply to group health plans and plan sponsors for 2014.

Except where noted, these requirements generally apply to all group health plan coverage—insured and self-funded—including grandfathered plans. However, each requirement may have its own set of exceptions for more limited benefits, such as those excepted under the Health Insurance Portability and Accountability Act (HIPAA) or retiree-only coverage.

Plan sponsors should review this checklist and make sure they have a strategy for completing their own “to-do” lists.

2014 CHECKLIST

  • Individual mandate. Starting January 1, 2014, most U.S. taxpayers must be enrolled in “minimum essential coverage” or pay a penalty. Minimum essential coverage includes exchange coverage, individual insurance coverage, Medicare and most employer-sponsored coverage. We are waiting for guidance as to a more specific meaning of minimum essential coverage.
  • Exchange coverage begins. Starting January 1, 2014, state-based exchanges will be up and running. Where a state does not create an exchange, the U.S. Department of Health and Human Services (HHS) will create a federal exchange. Health coverage may be purchased on an individual basis through the exchange, even if an individual is eligible for employer coverage. Those who fall below certain income thresholds may qualify for a premium credit under the exchange. Small employers may be able to purchase group coverage through special Small Business Health Operations Program (SHOP) exchanges.
  • Employer mandate: Play or pay. Beginning in 2014, employers will be required to offer minimum essential coverage or face a penalty. Coverage will be considered to meet this standard if it passes an affordability test, stipulating that employee premiums not exceed 9.5% of the employee’s income, and a minimum value test stipulating coverage must have a value of 60%, presumably when compared to the employee cost share.
  • Waiting periods of 90 days. For plan years starting on or after January 1, 2014, waiting periods under group health plans may be no longer than 90 days.
  • Coverage for clinical trials. For plan years starting on or after January 1, 2014, group health plans must cover certain clinical trial costs and may not discriminate against individuals who participate in qualified clinical trials. We are waiting for more guidance on this provision. Grandfathered plans are excluded from this requirement.
  • Increased wellness program incentives. For plan years starting on or after January 1, 2014, the incentive amount that group health plans may offer under health-based wellness programs governed by the HIPAA wellness rules is increased from 20% of the cost of employee coverage to 30%.
  • No annual dollar limits on essential health benefits. For plan years starting on or after January 1, 2014, group health plans may no longer impose annual dollar limits on essential health benefits. Similar lifetime dollar limits were prohibited starting for plan years on or after September 23, 2010. Since then, plans have been permitted three years to phase in the restrictions; however, this policy will end, beginning in 2013.
  • No pre-existing condition exclusions (PCEs). For plan years starting on or after January 1, 2014, group health plans must eliminate all PCEs.
  • Cost-sharing limits. For plan years starting on or after January 1, 2014, group health plans must limit cost-sharing or out-of-pocket maximums to $5,950 for individuals and $11,900 for families; these are today’s numbers and will be adjusted for cost of living before 2014. Grandfathered plans are excluded from this requirement.
  • Deductible limits. For plan years starting on or after January 1, 2014, group health plans may not impose a deductible higher than $2,000 per individual or $4,000 per family (indexed). There is much debate about whether this provision applies only to the small group market or to the large group market, as well, and more guidance would be welcome. Grandfathered plans are excluded.
  • Essential health benefits. Starting in 2014, insured plans in the individual and small group markets must cover each of the essential benefits categories listed under the ACA. Grandfathered plans, self-funded plans and insured plans in the large group market are excluded.
  • Reinsurance fee. HHS will assess a fee on “contributing entities” to fund a reinsurance program to help cover costs for high-risk individuals in the individual market during the rollout of the exchange. A “contributing entity” is defined as a health insurance issuer or third party administrator (TPA) on behalf of self-insured group health plan coverage. The reinsurance fee will be payable for only three years—2014 to 2016—and will be collected on a quarterly basis starting January 15, 2014. The fee will be based on the number of covered lives under the plan, but HHS has yet to provide more specific guidance on the amount or how to calculate the fee. However, in the first year, the fee must total at least $10 billion on a national basis.
  • Insurer provider fee. Starting in 2014, insurers must pay an annual fee on net written health insurance premiums, calculated by dividing the covered entity’s net premiums by the net premiums of all covered entities and then multiplying this fraction by a set annual amount. In 2014, this amount will be $8 billion.
  • IRS reporting for employers (Sections 6055 and 6056). Starting in 2014, there will be an Internal Revenue Service (IRS) annual reporting requirement that applies to any entity that provides minimum essential coverage, which generally includes any “eligible employer-sponsored plan” (Internal Revenue Code [IRC] Section 6055). A separate reporting requirement requires large employers (generally, those with at least 50 full-time workers) to report to the IRS whether they offer full-time employees minimum essential coverage (IRC Section 6056).

Source: PlanSponsor.com

Twenty New FAQs on PPACA’s Out-of-Pocket Maximum and Preventive Services

AT A GLANCE

  • The FAQs clarify the limit on total out-of-pocket expenses beginning with the 2014 plan year, including a transition rule for some plans.
  • Most of the new FAQs address the mandate for preventive services without cost sharing, including contraceptive and other preventive services for women.
  • With the exception of high-deductible health plan options, almost all group health plans will require some design and administration changes for 2014 or 2015.

The Departments of Labor, Health and Human Services, and Treasury (the departments) have issued 20 frequently asked questions (FAQs) clarifying some compliance issues under health care reform. Non-grandfathered employer group health plans — whether insured or self-insured — must conform to a new limit on total out-of-pocket (OOP) expenses beginning with the 2014 plan year, although a transition rule will relax the standard for some plans for 2014.

Separately, employer group health plans that have lost grandfathered status must comply with the mandate to cover certain preventive services with no participant cost sharing, and most of the new FAQs address these issues, including contraceptive and other preventive services for women.

Most of these FAQs are effective immediately for non-grandfathered insured and self-insured group health plans. The FAQs clarifying the new OOP maximum take effect with the 2014 plan year.

COMPLIANCE WITH DEDUCTIBLE LIMITATIONS IN 2014
Large insured and self-insured employer group health plans (generally more than 100 employees) need not comply with the $2,000 limit on annual deductibles for single coverage ($4,000 for family coverage). Only plans and insurers in the small group market must comply with the deductible limit beginning in 2014. The departments plan to develop formal regulations reflecting this view and welcome public comments by April 22, 2013.

NON-GRANDFATHERED PLANS MUST MEET THE ANNUAL LIMITATION ON OOP EXPENSE
Beginning with their 2014 plan year, non-grandfathered employer group health plans generally must comply with a single OOP maximum for all plan coverage, including medical, prescription drug, and mental health and substance use disorder benefits. Under a special transition rule, however, plans currently using multiple claim payers, such as medical third-party administrators (TPAs) and separate pharmacy benefit management, have until the 2015 plan year to design a single OOP maximum and coordinate vendor arrangements.

The OOP maximums will be the same as those for health savings account-qualifying high-deductible health plans in 2014, which will be identified later this year (2013 maximums are $6,250 for single coverage and $12,500 for family). Thus, a group health plan using a single vendor to administer claims must implement a unified OOP maximum beginning with the 2014 plan year for all in-network copays, coinsurance and deductibles across all categories of covered expenses under the plan.

Multiple-vendor plans will be considered to have satisfied the annual OOP limit for the 2014 plan year if:

  • The plan’s major medical coverage complies with the maximum OOP requirements (excluding, for example, prescription drug coverage and pediatric dental coverage).
  • The plan includes a separate OOP maximum for nonmedical benefits, such as prescription drug coverage, that does not exceed $6,250 (single) or $12,500 (family), indexed for 2014.

Group health plans and insurers may not impose an annual OOP maximum on all medical/surgical benefits and a separate annual OOP maximum on all mental health and substance use disorder benefits.

This OOP maximum requirement is part of the group health plan mandates and insurance market reforms in the Patient Protection and Affordable Care Act (PPACA); group health plan sponsors that fail to comply may be subject to excise taxes.

PREVENTIVE SERVICES

The FAQs also clarify the following:

  • Aspirin and other over-the-counter (OTC) recommended items and services must be covered without cost sharing only when prescribed by a health care provider.
  • If a colonoscopy is scheduled and performed as a screening procedure, a plan or insurer may not impose cost sharing for the cost of polyp removal during the colonoscopy.
  • The preventive services recommendation for genetic counseling and evaluation for routine breast cancer susceptibility gene (BRCA) testing includes the BRCA test itself.

IDENTIFYING HIGH-RISK POPULATIONS
Clinical health care providers (not group health plans or insurers) will identify patients in a high-risk population for purposes of U.S. Preventive Services Task Force recommendations for certain high-risk populations. They will also decide whether a patient so identified should receive a preventive item or service recommended for those at high risk.

COVERING IMMUNIZATIONS
Coverage is required for immunizations recommended by the Advisory Committee on Immunization Practices (ACIP) for routine use. Vaccines administered by an in-network provider must be covered without cost sharing. The ACIP makes routine immunization recommendations for children, adolescents and adults that are population-based (e.g., age-based), risk-based (e.g., underlying medical conditions, work-related or other special circumstances that increase risk of illness), or based on catch-up recommendations. In some circumstances, the ACIP makes a recommendation that applies for certain individuals rather than an entire population. In these cases, health care providers should determine whether to administer the vaccine, and if the vaccine is prescribed by a health care provider consistent with the ACIP recommendations, the plan or issuer must cover it without cost sharing.

New ACIP recommendations must be covered without cost-sharing starting with the plan year (in the individual market, policy year) beginning on or after the one-year anniversary of the recommendation.

WOMEN’S PREVENTIVE SERVICES AND “WELL-WOMAN” VISITS
The regulations allow plans and insurers to use reasonable medical management techniques to determine the frequency, method, treatment or setting for a recommended preventive item or service, to the extent they are not specified in a recommendation or guideline. Although the Health Resources and Services Administration (HRSA) Guidelines list services individually, neither the law nor the regulations require that each service be provided in a separate visit. Efficient care delivery and the delivery of multiple prevention and screening services at a single visit is a reasonable and permissible medical management technique. For example, HIV screening and counseling and sexually transmitted infections counseling could occur as part of a single well-woman visit.

The HRSA Guidelines recommend at least one annual well-woman preventive care visit for adult women to obtain age- and developmentally appropriate recommended preventive services, including preconception and prenatal care. The guidelines recommend that well-woman visits include listed preventive services as well as others referenced in the law. If the clinician determines that additional well-woman visits are necessary, the visits may be subject to reasonable medical management but must be provided without cost sharing.

SCREENING AND COUNSELING FOR INTERPERSONAL AND DOMESTIC VIOLENCE
Screening may consist of a few brief, open-ended questions or be facilitated by using brochures, forms or other assessment tools, including chart prompts. Counseling provides basic information, including how a patient’s health concerns may relate to violence and referrals to local domestic violence support agencies when patients disclose abuse.

HPV DNA TEST AND ANNUAL HIV COUNSELING AND SCREENING
The HRSA Guidelines recommend high-risk HPV DNA testing for women with normal cytology results who are aged 30 or older no more frequently than every three years. The guidelines recommend annual HIV counseling and testing for all sexually active women.

CONTRACEPTIVES UNDER THE MANDATE
The HRSA Guidelines call for access to the full range of contraceptive methods approved by the Food and Drug Administration (FDA), including barrier methods, hormonal methods, implanted devices and others, as well as patient education and counseling, as prescribed by a health care provider. Intrauterine devices and implants are contraceptive methods under the HRSA Guidelines and therefore must be covered without cost sharing if approved by the FDA and prescribed by a woman’s health care provider. Plans and insurers may use reasonable medical management techniques to control costs and promote efficient delivery of care.

For example, plans may cover a generic drug without cost sharing and impose cost sharing for equivalent branded drugs. However, if a woman’s health care provider determines that the generic or a brand-name drug would be medically inappropriate, the insurer must waive the otherwise applicable cost sharing for the branded or non-preferred brand version.

Contraceptive methods that are generally available OTC, such as contraceptive sponges and spermicides, fall under the preventive services mandate only if the method is both FDA approved and prescribed by a woman’s health care provider. The HRSA Guidelines do not include contraception for men.

Services related to follow-up and management of side effects, counseling for continued adherence and device removal are included under the HRSA Guidelines and must be covered without cost sharing, subject to reasonable medical management.

BREASTFEEDING IN THE HRSA GUIDELINES
The HRSA Guidelines include comprehensive prenatal and postnatal lactation support, counseling and equipment rental. Accordingly, the included items and services must be covered without cost sharing, subject to reasonable medical management (which could include purchase instead of rental of equipment). Reimbursement policy for lactation consultants is outside the scope of the HRSA Guidelines and the regulations.

Coverage of comprehensive lactation support and counseling, and the costs of renting or purchasing breastfeeding equipment extends throughout the duration of breastfeeding. Nonetheless, group health plans and insurers may use reasonable medical management techniques to determine the frequency, method, treatment or setting to the extent not specified in the recommendation or guideline.

GOING FORWARD
Sponsors of non-grandfathered group health plans should review these new FAQs to identify whether and how the OOP limit will affect their current cost-sharing plan design as well as to coordinate the new OOP maximum among multiple claim payers serving the same plan. Plans must consider all non-premium cost sharing under the new OOP maximum — including deductibles, copays and coinsurance — which may require changes to the current plan. With the exception of high-deductible health plan options, almost all group health plans will require some design and administration changes for 2014 or 2015.

Separately, the new FAQs underscore the sophisticated claim administration competencies that will be necessary to administer the no-cost preventive services mandated by the PPACA. Employers should confirm that their TPAs or insurers are aware of and capable of administering the mandated preventive services benefits.

The latest set of 20 FAQs are at www.dol.gov/ebsa/healthreform/.

Source:  Tower Watson Insider

HHS: Seniors Have Saved $7 Billion On Drugs Thanks To Obamacare

President Obama’s signature healthcare law has saved seniors more than $7 billion on prescription drugs, the Health and Human Services Department said Monday.

The department highlighted the savings ahead on Medicare’s 48th anniversary. HHS touted new benefits the law made available to seniors, as well as savings on prescription drugs.

More than 6.6 million seniors have saved a total of $7 billion on prescription drugs because of ObamaCare, for average savings of more than $1,000 per person, according to HHS.

Click here to read full article.