Viewing posts from: July 2014

Doing Well by Doing Good – The Karis Home

Posted July 28, 2014 by Megan DiMartino

What happens to the leftovers after an appreciation breakfast or lunch that is held on a Friday?

Do you ever wonder what happens to the leftovers after an appreciation breakfast or lunch that is held on a Friday?  Several AP Benefit Advisors employees  made an awesome suggestion after the last Friday breakfast. Tosha suggested that the leftovers should be donated to a homeless shelter. Drew offered to drop the food off at a shelter he passes on his way home. A call was placed to Baltimore Rescue Mission/The Karis Home for Women and Children. The food and the shelter graciously accepted the donation. Thank you Tosha and Drew for this excellent suggestion!

The Karis Home – For Women and Children

baltimore rescue missionThe Karis Home is the women and children’s division of the Baltimore Rescue Mission. The term Karis Home means Grace Home. Karis is the Greek word for grace. The Karis Home has grown and developed through the years. The Karis Home is in operation to provide emergency short-term help for homeless women and children. Our guests check in each day around 4:00 P.M. They have assigned living areas where they can relax and unwind from the day. They eat their evening meal at 5:00 P.M. and participate in the evening gospel service at 6:30 P.M. After the service they can take showers and get ready for bed. The lights are out at 10 P.M. Lights are on at 6:00 A.M. Breakfast is served at 7:30 and after a brief morning devotional the ladies and children leave at 8:00 A.M. The normal stay for our guests is thirty days.

Update: Conflicting Rulings on Health Care Law

Posted July 22, 2014 by Megan DiMartino

council alertOnly hours after a diametrically opposed ruling from a different federal appeals court in the District of Columbia, the 4th Circuit Court of Appeals in Richmond upheld the IRS rule permitting subsidies for the millions of Americans who receive them through a federal exchange.

Earlier today, the D.C. Circuit had ruled that the Affordable Care Act only permits subsidies for individuals enrolling through state exchanges (not the federal exchange). The subsequent 4th Circuit ruling says that the rule issued by the Internal Revenue Service was “a permissible exercise of the agency’s discretion.” The conflicting rulings raise the possibility that the dispute will ultimately be resolved by the Supreme Court.

We continue to expect that the D.C. Circuit ruling, precluding subsidies from flowing through the federal exchange, will be stayed pending a final resolution of the matter. Stay tuned for more information and analyses on ACA developments from your government affairs and legal teams in Washington.

bswift ACA Management Suite

Posted July 22, 2014 by Megan DiMartino

The innovative technology employers need for ACA compliance

bswiftbswift now offers a suite of management solutions to help employers navigate the new world of health care and benefits and comply with the complex regulations of the Affordable Care Act (ACA). In today’s rapidly changing environment, these tools can be quickly and easily configured to meet specific business needs.

Features include:

Risk Management

9.5% Affordability reports
Automated 30-hour rule calculations
Service hours modeling for variable-hour and seasonal employees
Administrator alerts for eligibility status changes
Integrated status change and enrollment experience
Online access to all documents for employees and administrators
Configurable plan rules and auditing tools to ensure compliance with:
waiting period restrictions, auto-enrollment, waive coverage reporting

Employee Notification

Health Insurance Marketplace Notice
Summary of Benefits & Coverage (SBC)
Section 6055 statement of minimum essential coverage
Section 6056 statement of affordable coverage
Online portal for variable-hour and seasonal employees
Springboard Marketplace Specials

Employer Reporting Support

Employer-Sponsored Health Coverage (W-2 Box 12)
Section 6055 IRS return / individual mandate reporting
(Forms 1094-B / 1095-B)
Section 6056 IRS return / employer mandate reporting
(Forms 1094-C / 1095-C)
Transitional Reinsurance Fee

For ongoing program support and ACA risk management, take advantage of our fully automated tools backed by our team of experts. Reach out to your Client Services Team today to learn more.

New Questions on Health Law as Rulings on Subsidies Differ

Posted July 22, 2014 by Megan DiMartino

by Robert Pear, The New York Times

WASHINGTON — Two federal appeals court panels issued conflicting rulings Tuesday on whether the government could subsidize health insurance premiums for millions of Americans, raising yet more questions about the future of the health care law four years after it was signed by President Obama.

The contradictory rulings will apparently have no immediate impact on consumers. But they could inject uncertainty, confusion and turmoil into health insurance markets as the administration firms up plans for another open enrollment season starting in November.

By a vote of 2 to 1, a panel of the United States Court of Appeals for the District of Columbia Circuit struck down a regulation issued by the Internal Revenue Service that authorizes the payment of premium subsidies in states that rely on the federal insurance exchange.

If it stands, the ruling could cut off financial assistance for more than 4.5 million people who were found eligible for subsidized insurance in the federal exchange, or marketplace. It could also undercut enforcement of the requirement for most Americans to have insurance and the requirement for larger employers to offer it to their full-time employees.

The Justice Department said the government would continue paying subsidies to insurance companies on behalf of consumers in the 36 states that use the federal exchange, pending further review of the issue by federal courts.

Critics of the law, who said the ruling in Washington vindicated their opposition to it, did not have much time to celebrate. Within hours, a unanimous three-judge panel of the United States Court of Appeals for the Fourth Circuit, in Richmond, Va., issued a ruling that came to the opposite conclusion.

The Fourth Circuit panel upheld the subsidies, saying the I.R.S. rule was “a permissible exercise of the agency’s discretion.”

The language of the Affordable Care Act on this point is “ambiguous and subject to multiple interpretations,” the Fourth Circuit panel said, so it gave deference to the tax agency.

In a separate case, the Justice Department informed a federal appeals court in Denver on Tuesday that the Obama administration would issue new rules within a month revising a compromise on contraceptive coverage under the health care law in response to a recent Supreme Court ruling.

The court ruled this month that Wheaton College, a Christian college in Illinois, did not have to fill out certain forms that would result in birth control being provided by insurers. The administration is studying options for ensuring that women still receive the coverage. The court suggested that Wheaton could notify the government of its religious objections rather than send the opt-out forms to insurers.

Subsidies, in the form of tax credits, are a major element of the health care law. Without them, many more consumers would be unable to afford coverage and could be exempted from the “individual mandate” to have insurance.

The employer mandate is enforced through penalties imposed on employers if any of their workers receive subsidies, so it could become meaningless in states where subsidies were unavailable.

The White House rejected the ruling of the appeals court panel in Washington and indicated that the Justice Department would ask the full court to review it. The Obama administration has consistently underestimated court challenges to the health care law, including one decided in 2012 by the Supreme Court, which upheld the individual mandate.

At least two other cases on subsidies are pending in federal district courts, in Oklahoma and Indiana.

In the case decided in Washington on Tuesday, Halbig v. Burwell, the appeals court panel said that the Affordable Care Act made subsidies available only to people who obtained insurance through exchanges established by states.

The law “does not authorize the I.R.S. to provide tax credits for insurance purchased on federal exchanges,” the panel said. The law, it said, “plainly makes subsidies available only on exchanges established by states.”

Aides to Mr. Obama said the ruling seemed to fly in the face of common sense.

“You don’t need a fancy legal degree to understand that Congress intended for every eligible American to have access to tax credits that would lower their health care costs, regardless of whether it was state officials or federal officials who were running the marketplace,” said Josh Earnest, the White House press secretary. “I think that is a pretty clear intent of the congressional law.”

Reacting to the ruling, a Justice Department spokeswoman, Emily Pierce, said, “We believe that this decision is incorrect, inconsistent with congressional intent, different from previous rulings and at odds with the goal of the law.”

Under this ruling, many people could see their share of premiums increase sharply. Subsidies reduced the average premium to $82 a month from $346, according to the administration.

The majority opinion in the case here was written by Judge Thomas B. Griffith, who was appointed by President George W. Bush, with a concurring opinion by Judge A. Raymond Randolph, a senior circuit judge, who was appointed by the elder President George Bush.

“Our ruling will likely have significant consequences both for the millions of individuals receiving tax credits through federal exchanges and for health insurance markets more broadly,” Judge Griffith said. “But, high as those stakes are, the principle of legislative supremacy that guides us is higher still.”

Another member of the appeals court panel, Judge Harry T. Edwards, a senior circuit judge appointed by President Jimmy Carter, filed a dissent in which he described the lawsuit as an “attempt to gut” the law. The majority opinion, he said, “defies the will of Congress.” He said that the Obama administration’s reading of the law was “permissible and reasonable, and, therefore, entitled to deference.”

A similar approach was taken by the Fourth Circuit panel in its case, King v. Burwell. Judge Roger L. Gregory, who received a recess appointment from President Bill Clinton and a permanent appointment from President George W. Bush, said that the rival interpretations of the law by the plaintiffs and by the Obama administration appeared to be “equally plausible.”

But, Judge Gregory said, the administration’s position helps achieve “the broad policy goals” of the Affordable Care Act. “The economic framework supporting the act would crumble if the credits were unavailable on federal exchanges,” he said.

In a concurring opinion, Judge Andre M. Davis, a senior judge on the appeals court, said the plaintiffs’ argument “would effectively destroy the statute.” It would, he said, “deny to millions of Americans desperately needed health insurance through a tortured, nonsensical construction” of the law. Judge Davis and the other judge on the panel, Stephanie D. Thacker, were appointed by Mr. Obama.

The health law authorized subsidies specifically for insurance bought “through an exchange established by the state.”

When the law was adopted, Mr. Obama and congressional Democrats assumed that states would set up their own exchanges. But many Republican governors and state legislators balked, and opposition to the law became a rallying cry for the party.

The lawsuit in Washington, championed by conservative and libertarian groups, was filed by people in states that use the federal exchange: Tennessee, Texas, Virginia and West Virginia. They objected to being required to buy insurance, even with subsidies to help defray the cost.

One of the plaintiffs, David Klemencic, who has a carpet store in Ellenboro, W.Va., said: “If I have to start paying out for health insurance, it will put me out of business. As Americans, we should be able to make our own decisions in matters like this.”

Democrats said the Fourth Circuit ruling validated the law, which they passed in 2010 without any Republican votes. Representative Nancy Pelosi of California, the House Democratic leader, said the plaintiffs’ reading of the law was “obviously false.”

By contrast, Speaker John A. Boehner praised the ruling of the appeals court panel in Washington. It showed, he said, that “President Obama’s health care law is completely unworkable.”

HHS has no plans to post 2015 enrollee grades

Posted July 22, 2014 by Megan DiMartino

Health Overhaul-Penalty Waiverby Allison Bell,

Public health insurance exchanges and issuers of “qualified health plan” (QHP) coverage can decide for themselves whether to release their first batch of official federal enrollee experience survey results.

Officials at the Centers for Medicare & Medicaid Services (CMS) mention the agency’s enrollee survey data release schedule in a new QHP enrollee survey website established at

CMS and its parent, the U.S. Department of Health and Human Services (HHS), set the rules for the survey in a batch of final regulations released in May. CMS decided to call the survey a QHP “enrollee experience survey,” rather than an “enrollee satisfaction survey,” because one commenter said “experience” seems to be a more objective term than satisfaction.

CMS wants vendors to conduct a round of beta test surveys from January 2015 through April 2015. CMS will send the results from the beta test surveys to the exchanges and QHPs.

The exchanges and QHPs can do what they want with the data, but HHS has no plans to post it publicly, officials said in the preamble to the final regulations. Some commenters wanted CMS to make the first batch of survey results confidential. CMS officials said they decided to let exchanges and QHP issuers publish the results if they want, because of a belief that access to the beta test results might provide important early feedback for exchanges and consumers.

CMS is starting by having one vendor do a psychometric test of the survey this year, to see if a sample of 4,200 consumers can understand the survey and get through it quickly.

In 2015, CMS wants to have 40 vendors of its own conducting surveys. The agency expects each QHP issuer to pay for a satisfaction survey of its own.

In 2016, HHS plans to start publishing the enrollee survey results itself. HHS may also get enrollee satisfaction survey data for off-exchange plans.

Webinar: HDHPs – Complete Replacement, Additional Offering, Solution to The Cadillac Tax?

Posted July 15, 2014 by Megan DiMartino

hdhp webinarJoin AP Benefit Advisors Senior Counsel Patrick Haynes as he reviews High Deductible Health Plans (HDHP). Are these plans complete replacements, or should they be used as an additional offering? First introduced over 10 years ago, HDHPs (often coupled with HSAs) continue to gain traction among employers as a viable way to cost share health insurance benefits, lowering costs for themselves and their employees. It is estimated that 45% of all U.S. companies now offer an HSA-eligible HDHP. Attorney Haynes will review the facts and myths pertaining to the nuances of these plans.

Webinar Date & Time: Tue, Jul 22, 2014 12:00 PM – 12:30 PM EDT
Space is limited. Reserve yours here:

Topics include:

  • Common employer and employee HDHP misperceptions
  • ROI vs. HMO and PPO plans
  • Compliance, HDHPs and The Cadillac Tax
  • Transitioning employees from a PPO to an HDHP
  • HDHP challenges for larger employers
  • HDHP/HSA administration best practices

Open to all HR professionals – but not brokers, agents, TPAs

Effective Dates Have Arrived! Your Wellness Plan and Mental Health Coverages Must Comply

Posted July 10, 2014 by PHaynes

Insurers and Employer sponsoring self-funded plans should note that the Departments (IRS, DOL and HHS) have issued final regulations that apply to plan years beginning on or after July 1, 2014 (in the individual market they are referred to as policy years).  Calendar year plans (and policies) have until January 1, 2015 to comply; however, plans (and policies) with a July 1 plan or policy year must comply now.

Mental Health Parity And Addiction Equity Act (MHPAEA) Final Regulations

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA, enacted in 2008, details here) requires parity between mental health/substance abuse disorder benefits and medical/surgical benefits with respect to financial requirements, treatment limitations, preauthorization(s), etc. under group health plans and group and individual health insurance coverage. The Departments first grappled with the MHPAEA requirements in comprehensive interim-final (you have to love that term, “interim-final”) regulations issued in 2010. The interim final regulations established six classifications of benefits for comparison and required that parity be achieved across each classification, and created methodologies for determining whether parity had been achieved.

The final regulations issued by the Departments on November 13, 2013 make a number of clarifications to the interim final regulations, including:

  • Permitting outpatient benefits to be subdivided into office visits and other outpatient items and services
  • Limiting the lifetime and annual limit parity rules to benefits that are not considered to be Essential Health Benefits for purposes of complying with the PPACA’s prohibitions upon lifetime and annual limits
  • Clarifying that compliance with the PPACA’s preventive service requirements (which, for example, include requirements to offer alcohol abuse screening/counseling and depression counseling) will not (for that reason alone) require compliance with the Mental Health Parity Act (MHPAEA)
  • Providing two (2) more examples of non-quantitative treatment limitations
  • Providing a methodology for determining the increase in a plan’s costs attributable to MHPAEA (for purposes of the increased cost exemption).

Wellness Plan Final Regulations

Under HIPAA (the Health Insurance Portability and Accountability Act of 1996), group health plans and health insurance issuers are prohibited from discrimination against individuals in eligibility, benefits, or premiums based on a health factor, except that different premiums or other cost sharing may be applied under compliant wellness programs. To see our March 27, 2014 Webinar on this matter, you may view the slides here or you may register to view/hear a reply of that webinar here.

Previously the Departments issued joint final regulations setting forth the wellness plan standards and on November 26, 2012 the Departments published proposed regulations modifying the wellness plan standards to reflect changes required by PPACA.  The final regulations issued by the Departments on June 3, 2013 made a number of substantial changes and clarifications to the prior wellness plan regulations, including:

  • Retaining the Participatory and Health Contingent wellness program categories but breaking down the Health Contingent category into:
    • Activity-Only programs (which require an individual to perform or complete an activity related to a heath factor in order to earn a reward, but not to attain or maintain a specific health outcome); and
    • Outcome-Based programs (which require an individual to attain or maintain a health outcome in order to obtain an award) and providing rules for each sub-category.
  • Clarifications to the reasonable alternative standard that must be provided to individuals who are unable to meet the standards required under a Health Contingent program, including:
    • a requirement that, if an individual’s personal physician rejects a reasonable alternative standard as medically inappropriate, the individual must be offered a second reasonable alternative standard that incorporates the physician’s recommendations; and
    • a clarification that a full-year reward must be provided to individuals who meet an alternative standard mid-year, and methodologies for paying such award.

Next Steps?

Know your plan (or policy) year. For 7/1 Plan Years, you’ll need to comply now and will want to quickly ensure that your plans/polices comply with both the Mental Health Parity and Wellness rules. For all other plan years, please work with your Sales Executive and/or Account Manager to ensure compliance beginning with your plan year that begins on/or after 1/1/2015.



Popular Benefits Legislation & Compliance Blogs

Posted July 6, 2014 by Megan DiMartino

HCReformIt’s been an eventful few months in the realm of rulings and legislation on employee benefits, from transitional insurance and FTEs to legislation repeals and new reporting requirements, and things are just heating up! With so many complex and significant issues on the table, make sure you stay informed. Read some of our most popular recent blogs to catch up on the state of affairs, and if you have questions, ask us – we’re the experts!

Minimum Essential Coverage (Individual Mandate) Reporting Requirements

Posted July 2, 2014 by PHaynes

Social-Security-CardMinimum Essential Coverage (MEC) reporting is required to help the Internal Revenue Service (IRS) administer compliance with the individual mandate. All insurers and self-funded group plan sponsors are required to start reporting on the individuals covered under their insured health plans, starting with coverage in 2015. While these reporting requirements do not begin till 2016 for the 2015 year, certain components of the law require actions this year.Because Social Security Numbers (SSNs) and Tax Identification Numbers (TINs) are the main individual identifying data used by the IRS, reporting entities are required to make “reasonable attempts” to obtain this sensitive data from those individuals’ whose SSNs/TINs they don’t have on file.

“Reasonable attempts” are defined as three attempts to obtain the SSN/TIN, and may include electronic, paper, telephonic, etc. outreach*. These attempts must be made by certain dates, starting this year. The outreach is only to each employee or subscriber and their dependents whose SSN/TIN the reporting entities (Cigna for fully insured business and the client for self-funded business) don’t have, starting with those enrolling/enrolled in 2015 coverage.

First Attempt:

  • Current or previous enrollment can satisfy the first attempt, if applications have or had space for each employee and dependent to provide their SSNs/TINs. Enrollment forms/online forms do request the SSN.
  • If current or previous enrollment does not solicit SSN/TIN, a separate outreach must be made in 2014 to obtain employee and dependents’ SSNs/TINs. Since your Enrollment forms/online forms do request the SSN, this separate first attempt is not required for our customers covered under fully insured or self-funded plans.

Second Attempt:

  • A separate outreach must be made before December 31, 2014.**

Third Attempt:

  • A separate outreach must be made before December 31, 2015.

If the SSN/TIN is not obtained after making the three attempts, reporting entities may use the date of birth for any of those covered individuals.  Your ASO Medical provider (or fully insured carrier) is establishing processes to comply with the requirements.  This will (or should) include building awareness with clients on the inevitable outreach that will be required.


* Outreaches can be made to the employee only, to obtain all covered dependents’ SSNs. Separate outreach does not need to be made for each individual dependent enrolled in coverage.

** For individuals who enroll in December, 2014, the second attempt must be made before January 31, 2015.

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