Employer Responsibilities Under the Affordable Care Act: Navigating the Complexities … ·...

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Employer Responsibilities Under the Affordable Care Act:

Navigating the Complexities in 2014 and Beyond

* This outline is intended for general information

purposes and does not and is not intended to constitute legal advice. © 2014 Ice Miller LLP

Corn Belt Seed Conference

February 6, 2014

Indianapolis, Indiana

Sarah K. Funke

Ice Miller LLP

One American Square

Suite 2900

Indianapolis, IN 46282-0200

Phone: (317) 236-5883

[email protected]

mailto:[email protected]

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Individual Mandate

Health Care Exchanges

Expansion of Medicare/Medicaid

New Fees and Taxes

Pay or Play – Employer Shared Responsibility

New Reporting Requirements

Expansion of Employer Coverage – "Coverage Mandates"

What is Health Care Reform?

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Everyone – all individuals and all employees

Largest piece of employee benefit legislation ever – bigger than ERISA

Involves more federal agencies than any prior piece of benefits legislation:

DOL

IRS

Health & Human Services

Also involves States (State Departments of Insurance, Exchanges, etc.)

Who Does it Affect?

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General rule that individuals must either secure

"minimum essential coverage" or pay a tax

penalty. Must sign up by March 31, 2014.

Tax penalty

Taxpayer pays for him/herself and for tax

dependents.

No penalty if gap in coverage is less than 3 months.

Certain exemptions are available.

Individual Penalties - 2014

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Annual penalty is the greater of (1) a flat dollar

amount per individual (capped at 300% of the

flat dollar amount), or (2) a percentage of the

individual’s taxable income:

Individual Penalties – 2014 (cont'd)

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Year Penalty for Lacking Coverage (Half for Child Under 18)

2014 $95 per adult or 1% of household income over the threshold

2015 $325 per adult or 2% of household income over the threshold

2016 $695 per adult or 2.5% of household income over the threshold

2017 Flat dollar amount (indexed for cost of living) or 2.5% of household income over the threshold

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PPACA Exchanges are "marketplaces" through which

individuals and small employers (up to 100

employees) can purchase coverage.

Beginning in 2017, States may allow businesses with

more than 100 employees to purchase health insurance

through the Exchange in that State.

Who Runs the Public Exchanges?

State

Federal Government

Both

Understanding Public Exchanges

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What Do the Public Exchanges Do?

Certify health plans as "qualified health plans"

Determine exemption from the individual coverage mandate

and whether "affordable" and "minimum value" coverage is

available to an individual

Make eligibility determinations for Medicaid, CHIP, etc.

Administer

Operate a toll-free information line

Maintain an Internet website that allows consumers

to compare available plans

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Understanding Public Exchanges (cont'd)

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One-Stop Shop

Exchange provides one-stop shopping with

"apples-to-apples" comparisons and a single

place to enroll employees and remit premiums.

Educate

Establish the Navigator program to award grants

for education and outreach regarding the

qualified health plans available through the

Exchange and facilitation of enrollment.


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PRIVATE EXCHANGES

Private exchanges existed pre-ACA.

Privately-run exchange contracts with participating

insurers.

Can be single-carrier (e.g., insurer operates and offers

only its own products) or multi-carrier (e.g., third party,

such as a broker, operates and offers products of

multiple insurers).

Serves as an online marketplace through which

employees can purchase health insurance and evaluate

differences among carriers and their plan designs.


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PRIVATE EXCHANGES

"Defined Contribution" approach: Employer gives each

eligible employee a fixed dollar amount for either

individual/family coverage, regardless of the plan the

employee chooses.

Unlike the public exchanges, no federal premium

subsidy is available to lower-income employees who

purchase insurance through a private exchange.

Public Exchange vs. Private Exchange: What's the

difference?

They differ in several important ways:


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PRIVATE EXCHANGES

Employer still needs to consider "group health plan" compliance issues.


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Premium assistance tax credit subsidies and cost

sharing assistance to individuals between 100% and

400% of federal poverty level (FPL)

Subsidies on a sliding scale based on income

Premium assistance tax credit - refundable and advanceable

Cost sharing assistance

Not available to individuals eligible for public plans (e.g.,

Medicaid) or who are eligible for affordable employer coverage

that has minimum value

Employees eligible for employer coverage generally are

not eligible for subsidies.

Public Exchange Subsidies

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However, an employee can qualify for a Federal tax subsidy if:

the employee purchases coverage on an Exchange; and

the employee's household income is between 100% - 400% of the federal poverty level; and

EITHER:

the employer does not offer minimum essential coverage; OR

the employer offers coverage that is not affordable for the employee or that does not provide minimum value.

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Public Exchange Subsidies (cont'd)

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The premium

assistance tax credit

is calculated based

on:

premium cost of the

second-lowest-cost

"Silver" plan offered

through a State

health benefit

exchange; and

income level of the

applicant


Income Level (% above

federal poverty level)

Maximum Premium as % of income that person has to

pay

Up to 133% 2.0%

133-150% 3-4%

150-200% 4-6.3%

200-250% 6.3-8.05%

250-300% 8.05-9.5%

300-400% 9.5%

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The 2013 Poverty Guidelines for the 48 Contiguous

States and the District of Columbia


Persons in family Poverty Guideline 133% 400%

1 $11,490.00 $15,281.70 $45,960.00

2 $15,510.00 $20,628.30 $62,040.00

3 $19,530.00 $25,974.90 $78,120.00

4 $23,550.00 $31,321.50 $94,200.00

5 $27,570.00 $36,668.10 $110,280.00

6 $31,590.00 $42,014.70 $126,360.00

7 $35,610.00 $47,361.30 $142,440.00

8 $39,630.00 $52,707.90 $158,520.00

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An employer is not required to provide coverage, but a Large Employer will face a tax penalty beginning January 1, 2015 (delayed from 2014), if the employer:

fails to provide minimum essential coverage to at least 95% of its full-time employees and their dependent children (up to age 26) [Penalty #1], OR

provides minimum essential coverage to at least 95% of its full-time employees and their dependent children (up to age 26) but such coverage is either not affordable or does not provide minimum value [Penalty #2].

Controlled group rules are not applicable for purposes of application of the employer penalties, but are applicable to determining Large Employer status.

Employer Shared Responsibility (Pay or Play):

What Is It?

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A "Large Employer" is an employer with 50 or more full-time employees (including full-time equivalents).

Large Employer status is determined based on average number of employees in previous calendar year.

For 2015, look to 2014 to determine status.

A month-to-month determination.

Special transition rule for 2013 allowing reference to a period of at least six consecutive calendar months in 2013. [We are not sure how this transition rule will be applied with the 2015 delay.]

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What is a "Large Employer"?

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Penalty #1 may apply if Large Employer does NOT

provide "minimum essential coverage" under an

employer sponsored health plan to at least 95% (or, if

greater, 5) ("substantially all") of its full-time employees

and their dependent children (to age 26). No penalty for failure to provide minimum essential coverage

to part-time employees.

Employer may provide group health plan coverage to part-time

employees, and such coverage would not be required to meet

minimum essential coverage, affordability, or minimum value

standards (but still has to meet coverage mandates under

PPACA and nondiscrimination rules).

Penalty #1: Employer Does Not Offer Coverage – 4980H(a)

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"Minimum essential coverage" (MEC) has the

same definition as applicable under individual

mandate, and is generally coverage under a group

health plan offered to an employee by an

employer, whether grandfathered or non-

grandfathered.

Penalty #1: Employer Does Not Offer Coverage – 4980H(a)(cont'd)

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Very general and vague definition – includes coverage

under: Medicare, Medicaid, CHIP, Tricare, veteran's plan, or Peace

Corps volunteer plan.

An employer sponsored plan (whether fully insured or self-

insured).

A health plan offered in the individual market within a State

(including fully-insured student health insurance).

A grandfathered health plan.

State health benefits risk pool, or other health benefits coverage

recognized by the Secretary of HHS for purposes of this

requirement (for 2014)

Self-insurance student health insurance (for 2014).

MEC is not required to cover essential health benefits.


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Minimum Essential Coverage does not include the following HIPAA-excepted benefits:

Limited scope dental and vision provided in a standalone plan

Most flexible spending account plans

Long-term, nursing home, home health, or community based care in a standalone plan

Accident only, disability, liability, workers compensation, automobile medical payment, credit-only insurance, on-site medical clinics

Coverage for a specified disease or illness, hospital indemnity or other fixed indemnity if under separate policy and no coordination with group health plan

Medicare supplemental health if separate policy

Employee assistance plans (EAPs) (and probably wellness programs)


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When minimum essential coverage is not offered to at

least 95% of full-time employees and their dependent

children (to age 26), a penalty is assessed if: One or more full-time employees purchase coverage from an

Exchange, AND

Any such employee qualifies for a Federal subsidy.

Penalty amount is $166.67 per month (or $2,000 per

year) for each full-time employee, regardless of how

many full-time employees purchase coverage from an

Exchange or qualify for a Federal subsidy. Penalty amount increased for inflation for years after 2015.

First 30 full-time employees exempted.


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Example: Employer A has 100 full-time employees and does not provide minimum essential coverage. Employee B purchases coverage through an Exchange and qualifies for a Federal subsidy.

Calculation of penalty:

Per Month = 70 employees (first 30 excluded) x $166.67 = $11,666.90

Per Year = 70 employees (first 30 excluded) x $2,000 = $140,000

Employer A is subject to a penalty of $11,666.90 per month or $140,000 per year.

Penalty #1: Employer Does Not Offer Coverage – 4980H(a) (cont'd)

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Penalty #2 may apply if Large Employer

provides minimum essential coverage to at

least 95% of its full-time employees and their

dependent children (up to age 26), but the

coverage:

does not provide "minimum value," or

is not "affordable" with respect to at least one full-

time employee.

Penalty #2: Employer Coverage Does Not Provide

Minimum Value or is Not Affordable – 4980H(b)

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Coverage provides "minimum value" if its actuarial

value is at least 60%, e.g., the plan would pay for at

least 60% of medical expenses on average for a

standard population and for allowable charges.

Coverage is not affordable with respect to an

employee if the employee's required contribution for

self-only coverage under the employer plan

exceeds 9.5% of household income. Look to lowest

cost coverage that employer sponsors that provides

minimum value.


Minimum Value or is Not Affordable – 4980H(b) (cont'd)

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When coverage offered is not affordable or does not

provide minimum value, a PENALTY is assessed if: One or more full-time employees opt-out of employer coverage and purchase coverage from an Exchange, AND

Any such employee qualifies for a Federal subsidy.

Penalty amount is $250 per month (or $3,000 per year)

for each full-time employee who opts out and qualifies for

a Federal subsidy. Penalty amount increased for inflation for years after 2015.

The penalty is capped at $2,000 per year times total

number of full-time employees, with first 30 full-time

employees exempted. [following Penalty #1] Penalty amount increased for inflation for years after 2015.



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Affordability Example: Employer C has 100 full-time employees

and provides minimum essential coverage to all full-time employees

and their dependents.

Employee D's household income is $15,000, and he is charged $1,500 for

coverage under Employer C's plan, or 10% of his household income. Thus,

the coverage is not affordable with respect to Employee D.

Employee D opts out of Employer C's health plan, purchases coverage through

an Exchange, and qualifies for a Federal subsidy.

Employer C is subject to a penalty of $250 per month (or $3,000 per year) for

Employee D.

If any other employee of Employer C is similarly situated, Employer C will pay

the same penalty with respect to each such employee, capped at $140,000.

Calculation of maximum: 70 employees (first 30 excluded) x $2,000 = $140,000.

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To avoid penalties, an employer must offer coverage to:

All but 5% or (if greater) 5 of employer's full-time employees. Natural born, adopted, step, and foster children up to age 26.

An employer does not have to offer coverage to spouses to avoid penalties.

Spousal carve-outs still available.

Employees must have "effective opportunity" to elect coverage or to decline coverage that is not affordable or that does not provide minimum value, at least once a plan year.

Offering Coverage

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A full-time employee is a common law employee who is employed :

on average at least 30 hours of service per week; or

130 hours of service in a month.

Hours of service means:

each hour for which an employee is paid, or entitled to payment, for the performance of duties for the employer; and

each hour for which an employee is paid, or entitled to payment, for the period of time where no duties are performed due to vacation, holiday, illness, incapacity (including disability), layoff, jury duty, military duty, or leave of absence

What is a "Full-Time Employee"?

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All paid leaves must be included, and there is no

limitation on the amount of paid leave.

Hours do not include hours worked outside of the

U.S.

Employee may be classified as part-time, but

employee actually works an average of 30 or more

hours per week

What is a "Full-Time Employee"? (cont'd)

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Must count all common law employees (authority to

direct and control the manner in which services are

performed (actual control not required)).

Are these individuals common law employees?

Independent contractors

Staffing agency individuals


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Employers may be tempted to substitute independent contractors to:

Avoid the cost of healthcare; or

Avoid the penalties that would apply for failing to offer coverage to full-time employees.

Under health care reform, an "employee" means a common-law employee. Employers who misclassify workers may be exposed to payment of past employment taxes, as well as health care reform penalties.

The IRS is increasing its focus on worker reclassification.


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For hourly employees, count actual hours from

records of hours worked or for which payment is

made or due for vacation, holiday, illness, incapacity

(including disability), layoff, jury duty, military duty,

or leave of absence.

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For employees not paid on an hourly basis:

count actual hours same as for hourly employees;

or

use a days-worked equivalency of 8 hours of

service per day for each day employee would be

required to be credited with at least one hour of

service; or

use a weeks-worked equivalency of 40 hours of

service per week for each week employee would be

required to be credited with at least one hour of

service.


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IRS recognizes that a determination of full-time employee status on a month-to-month basis causes practical difficulties for employers, employees, and Exchanges, particularly if workforce is such that employees have varying hours or employment schedules.

Accordingly, proposed IRS regulations provide for "safe harbor" methods that an employer may use to determine the full-time status of the following:

ongoing employees,

newly-hired "full-time" employees,

newly-hired variable hour employees, and

newly-hired seasonal employees.


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What is a Full-Time Employee, and Counting

Hours (cont'd)

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So how are employers responding to these

rules in the Pay or Play Regulations?

There is talk of using many more part-time workers.

There is no penalty for not providing health coverage

to part-time employees.

Early statistics do not show a movement to part-time.

Why? Because a tradeoff between having a skilled

work force and reducing benefit costs.

Concern of the Complexity of Counting Employees and the Impact on Hiring

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Negatives of an increased part-time work force:

Competitive reasons

More administrative work and management

More supervisory time needed for training and

supervising

Supervisors will now need to manage hours more

closely – will have to educate numerous supervisors

on the very complex rules associated with counting

hours

More time spent hiring and on the hiring process

Concern of the Complexity of Counting Employees and the Impact on Hiring

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PPACA establishes a new "Patient-Centered Outcomes Research Institute" or "PCORI", a private non-profit whose mission is to research the outcomes and clinical effectiveness, risks, and benefits of medical treatments to help with informed health decisions.

PCORI is funded in part by a fee paid to Treasury by the:

Insurer for a fully-insured accident or health insurance policy

(including a policy under a group health plan) issued with

respect to individuals residing in the U.S.; and

Plan sponsor (generally, the employer) for any plan providing

accident or health coverage if any portion of the coverage is

self-insured and if the plan is established and maintained by

an employer for its employees.

NEW FEES AND TAXES

PCORI Fees

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When is the Fee Due?

Payable for the policy or plan years ending on or

after October 1, 2012, and before October 1, 2019

(for calendar year plans, 2012 through 2018).

Due by July 31 of the year following the last day of

the plan/policy year (by July 31, 2014 for 2013 for

calendar year plan) on IRS Form 720, Quarterly

Federal Excise Tax Return Form.

PCORI Fees (cont'd)

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What is the Fee Amount?

$2 times average number of lives (employee,

spouse, dependents) under policy/plan for the plan

year, for policy/plan years ending on or after October

1, 2013 (for calendar year plan, 2013).

Indexed for policy/plan years ending on or after

October 1, 2014.

Fee amount is that in effect on last day of applicable

policy/plan year.

Based on average number of lives for plan/policy

year – special rules for counting.

PCORI Fees (cont'd)

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PPACA establishes a transitional reinsurance

program to stabilize premiums for the individual

market during first three years of operation of

Exchanges.

Program funded by fees paid by: Health insurance issuers for fully-insured group health

plans that provide major medical coverage, and

Plan sponsors for self-insured group health plans that

provide major medical coverage.

Fee applies to "major medical coverage," whether

grandfathered or not.

Reinsurance Fees

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How Are Fees Assessed? Fees are assessed on a per-covered-life basis

(employee, spouse, dependent). Rules for

counting lives are not exactly the same as for

PCORI fees.

Fees must be paid for the calendar years 2014,

2015 and 2016.

Annual enrollment counts due to the Department of HHS

on November 15, 2014, 2015, and 2016.

HHS will notify of amount due within 15 days thereafter

or December 15 if later.

Reinsurance Fees (cont'd)

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Plan sponsors/issuers will be responsible for making payment within 30

days of notice of liability. Proposed to be paid in 2 installments.

Fee calculation is done on calendar year basis (unlike PCORI Fee,

which is based on Plan year).

Proposed regulations provide that the flat per capita per month amount for 2014 would be $5.25 per covered life per month, or $63 per covered life for the year.

Example: 5,000 covered lives x $63 = $315,000

Amount will go down for 2015 ($44) and then again for

2016.

Reinsurance Fee can be paid by TPA (unlike PCORI Fees) and deducted as a reasonable business expense

Reinsurance Fees (cont'd)

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Effective January 1, 2018, employer –sponsored health coverage that is "high cost" is subject to an excise tax.

Tax is equal to 40% of "excess benefit."

The "excess benefit" is the amount of annual coverage that costs more than $10,200 for single coverage and more than $27,500 for family coverage (limits may be adjusted before 2018).

Tax paid by insurer if fully-insured group health plan and by plan sponsor if self-insured group health plan.

Tax applies to group health coverage, including contributions made to health reimbursement accounts, salary-reduction contributions to a health FSA, and employer contributions made to an HSA.

Cadillac Tax

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Exchange Notice

Employers governed by FLSA are required to provide to each employee at the time of hire a written notice of the coverage options available through the Exchanges.

Notice must be provided to all employees (full-time or part-time and regardless of health plan eligibility):

For employees employed prior to October 1, 2013: By October 1, 2013

For new hires after October 1, 2013: Within 14 days after the employee's start date

DOL has provided model notices (one for employers that offer health coverage and one for employers that do not).

Notices explain:

Existence of Exchanges

Potential eligibility for a premium tax credit on the Exchange

Potential to lose employer contribution to employer health benefits and tax exclusion if employee purchases coverage on an Exchange

NEW EXCHANGE RELATED REPORTING

REQUIREMENTS

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New tax reporting requirements are foundation of

IRS enforcement of tax provisions of PPACA:

Individual mandate

Employer mandate

Premium tax credits

One year delay in reporting requirements.

Calendar year reporting regardless of plan year.

Important to have systems in place to track required

information by January 1, 2015.

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REQUIREMENTS (cont'd)

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Code Section 6055 Reporting: Insurer if a fully insured group health plan, or employer if a self-insured group health plan, must report coverage information to IRS in a new annual return to ensure that individuals are complying with the individual mandate and obtaining minimum essential coverage.

Voluntary for 2014; mandatory for 2015.

Report to employees by January 31, 2016 and to IRS by February 28, 2016 (March 31, 2016, if filed electronically).



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Code Section 6056 Reporting: Large Employers

(within the meaning of the employer shared

responsibility requirements) must report certain terms

and conditions of the health care coverage provided to

full-time employees for the year to IRS in a new annual

return for IRS to determine whether employer provides

adequate coverage to avoid employer shared

responsibility penalties.

Voluntary for 2014, mandatory for 2015.

Report to employees by January 31, 2016 and to IRS by

February 28, 2016 (March 31, 2016, if filed electronically).



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Summary of Benefits and Coverage (SBC)

W-2 reporting of cost of group health plan

coverage

Health FSA limit reduced to $2,500

Effective for plan years beginning on or after January 1,

2013.

Plans must be amended by December 31, 2014.

Initial coverage mandates

2013 Responsibilities (Ongoing)

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Initial Coverage Mandates

Initial Coverage Mandate

Applicable to

Grandfathered Plans?

No pre-existing conditions for < age 19 Yes

No lifetime or annual dollar limits (other than restricted annual limits) on EHBs

Yes

Adult child coverage (to age 26) Yes

No rescissions Yes

First dollar preventive health care coverage No

Internal and external appeals process No

Mandated patient protections No

Non-discrimination rules extended to insured plans (delayed enforcement)

No

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Second group of coverage mandates for group health plans effective for plan years beginning on or after January 1, 2014.

2014 Coverage Mandates

New Coverage Mandate Applicable to

Grandfathered Plans?

No pre-existing conditions for any enrollee Yes

No exclusion of adult children who have

coverage through employer Yes

No restricted annual limits Yes

No waiting period in excess of 90 days Yes

Limits on cost-sharing No

Mandated coverage of clinical trials No

No discrimination based on health status No

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PPACA increases the amount that an employer can reward employees for participation in a wellness program to up to 30% of the cost of health coverage, effective January 1, 2014.

Under final Federal regulations, the reward can be up to 50% of the cost of health coverage in connection with a program designed to prevent or reduce tobacco use.

Still have to comply with other laws, such as Americans with Disabilities Act, Genetic Information Nondiscrimination Act, ERISA, the Internal Revenue Code, etc.

Final regulations add much more complexity.

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Wellness Programs

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Employers subject to the Fair Labor Standards Act

must automatically enroll new full-time employees in

the employer’s health plan if:

employer has more than 200 full-time employees;

and

employer offers employees enrollment in one or

more health benefits plans.

Employers may still enforce waiting period if the

plan imposes one.

Automatic Enrollment

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The automatic enrollment program must include

adequate notice and the opportunity for an employee to

opt out of any coverage in which the individual was

enrolled.

Pre-empts state wage payment laws if they prevent

automatic enrollment.

Not yet clear into which of an employer’s plan options an

individual will be automatically enrolled.

Will be effective according to regulations to be issued by

Department of Labor (DOL), and DOL has said that it

does not expect to issue regulations before 2014.

Automatic Enrollment (cont'd)

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Nondiscrimination rules under Code Section 105(h)

already apply to self-insured group health plans.

Extension of similar rules relating to eligibility and

benefits to fully-insured non-grandfathered group

health plans.

Could impact fully-insured plans for executives as

well as fully-insured plans where employer pays

greater percentage of premiums for higher-paid

employees.

Nondiscrimination Rules for Insured Plans

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Could affect severance agreements.

Consider just grossing up severance payment equal to COBRA

premium.

Tax executive on the amount of the employer-provided

premium.

Not clear that these methods will work until guidance is

released.

Treasury expected to issue new regulations addressing

nondiscrimination under Code Section 105(h) for self-insured

plans, but Secretary of HHS is responsible for regulations for

fully-insured plans - expect new emphasis on compliance.

No enforcement until regulations issued.

Nondiscrimination Rules for Insured Plans

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Increase in part-time workers (?)

Less generous or no coverage for part-time workers.

More employers are looking to go self-insured due to expected increase in fully-insured rates.

Higher premium costs for most employees.

What is the Fall-Out of Health Care Reform?

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Unfortunately, the expansive nature and

complexities of health care reform require a

"village" of personnel to manage it.

More than ever before, in light of the numerous

pages of law and regulations to date, employers

need lots of help to ensure compliance.

It Takes a "Village"

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Players that are needed include:

Talented HR personnel.

A coordinated effort between HR, Finance, IT, and

Payroll like never before.

A deep compliance bench, typically provided by

outside ERISA legal counsel.

Engaged vendors, such as TPAs for self-insured

plans.

Knowledgeable brokers who are on the front line with

providers/vendors on product development.


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Engaged health care providers who will

actively participate in plan design

changes.

Good communication with employees to

assure them that you are all on the

same team trying to figure out what is

best for them and you.


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Department of Labor (DOL) website: http://www.dol.gov/ebsa/healthreform/

Health and Human Services (HHS) Health Reform website: http://cciio.cms.gov

Internal Revenue Service (IRS) website: http://www.irs.gov/uac/Affordable-Care-Act-Tax-Provisions

The preventive services list on the HealthCare.gov website: http://healthcare.gov/prevention/index.html

Resources

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http://www.dol.gov/ebsa/healthreform/

http://cciio.cms.gov/

http://www.irs.gov/uac/Affordable-Care-Act-Tax-Provisions









http://healthcare.gov/law/resources/regulations/prevention/recommendations.html

http://healthcare.gov/law/resources/regulations/prevention/recommendations.html

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