Preventive Items and Services – Final Rules Clarify Matters
Posted August 28, 2015 by PHaynes
The Affordable Care Act requires non-grandfathered group health plans to cover certain mandated preventive care services at no cost. On July 14, 2015, the Departments of Labor, the Treasury and Health & Human Services (the “Departments”) issued final regulations. These regulations are effective for plan years beginning on or after October 1, 2015.
Background
The preventive services that must be provided without cost sharing fall into four different categories: services with an “A” or “B” recommendation from the U.S. Preventive Services Task Force (USPSTF), vaccines recommended by the Centers for Disease Control and Prevention (CDC), the Bright Futures guidelines developed by the American Academy of Pediatrics with support from the Health Resources and Services Administration (HRSA), and certain women’s services listed in HRSA guidelines (supplementing some of the USPSTF recommendations). The requirement to provide free contraceptive services to women emanates from the latter, and it took effect with the plan year beginning on or after August 1, 2012.
Notably, the guidance:
- Clarifies that if a plan that does not have in its network a provider who can provide a particular recommended preventive service, the plan is required to cover the service when performed by an out-of-network provider without cost sharing (i.e., at 100%).
- Indicates the effective date for changing required preventive services when new guidelines are issued.
- Rules issued in 2010 provide that if a recommended preventive service does not include specific frequency, method, treatment or setting rules for the provision of that service, a plan sponsor can use reasonable medical management techniques to determine any coverage limitations. The new final rule clarifies that plan sponsors may continue to rely on the relevant clinical evidence base and established reasonable medical management techniques, and do not generally have to defer to the recommendations of a treating physician.
- Rules issued in 2010 state that plan sponsors may stop providing an item or service once the underlying guideline or recommendation has been changed. The new final rule requires that plan sponsors continue to provide the coverage (without cost sharing) through the end of the plan year, except when the USPSTF has downgraded the recommendation from “A” or “B” to “D” or there is a safety concern. The Departments intend to issue guidance if these types of situations arise.
- BBB
If there is a change in the guidelines that occurs during a plan year, the group health plan must provide coverage for that item or service until the end of the plan year, except to the extent the change constitutes a downgrade to a “D” rating or the item was part of a safety recall or otherwise poses a significant safety concern. In such circumstances, the Departments will issue guidance addressing the change during the plan year. Note that any such change that occurs outside of renewal and affects the SBC (Summary of Benefits and Coverage) will require 60 days advance notice before the change can be made.
Employer Action
Employers should:
• Review existing preventive care practices and, in the event network providers do not perform certain required services, ensure the plan provides them at
100% out-of-network; and
• Be aware that changes to mandated preventive care services will generally take effect with the following plan year, except when downgraded to “D” or are
subject to a safety review. The DOL will provide further comment in the event this occurs.
Links:
Webinar: Medicaid Expansion & Medicaid Migration – Increasing Coverages While Reducing Employer Premiums – HRCI Preapproved*
Posted August 24, 2015 by Megan DiMartino
Join us for this one hour, HRCI pre-approved webinar* and learn about ACA Medicaid Expansion and the potential impact on employee coverages and employer plans. Most employers are unaware of the benefits available to help lower-wage employees and their families, who might not be able to afford health insurance. Medicaid can provide these employees access to free comprehensive healthcare, at a much lower cost than private sector plans. Employers participating in Medicaid Migration programs can also reduce health plan costs and ensure ACA compliance. Employers that migrate low-wage workers to Medicaid can realize a healthier, more productive workforce, and an improved bottom line. Topics include:
- Qualification criteria for Medicaid Migration
- Helping low low-wage employees sign up
- Educating employees about their healthcare options
- Determining if employees are eligible for other benefits (food stamps, a free phone, etc.)
* This webinar has been approved for 1 HR General recertification credit hour toward California, GPHR, HRBP, HRMP, PHR, and SPHR recertification through the HR Certification Institute. The use of this seal is not an endorsement by HRCI, it means that this activity has met the HR Certification Institute’s criteria to be pre-approved for recertification credit.
Date & Time: Thu, Sep 10, 2015 12:00 PM – 1:00 PM EDT
Open to all HR professionals – but not brokers, agents, TPAs, PEOs
Space is limited – click here to reserve yours today.
ACA Compliance: A bswift FAQ
Posted August 19, 2015 by Megan DiMartino
From bswift.com
We received a number of thoughtful questions during our July webcast, “Compliance 101: The Risks and Practical Realities of Producing Form 1095,” and we’d like to share our responses to some of them.
What effect does smoking status have on affordability standards for the employer?
Affordability standards for employers compare the employee’s cost of coverage to either the employee’s income (W-2 wages or rate of pay) or to the federal poverty limit (FPL). Since the employee’s cost may be affected by certain wellness incentives, the employer should carefully consider whether those incentives should be taken into account for purposes of determining affordability. If tobacco-related incentives are part of the employer’s plan, the employer is at liberty to consider all employees as non-tobacco users when calculating affordability, regardless of whether the incentive is a carrot (credit for non-tobacco use) or a stick (surcharge for tobacco use). For other non-tobacco wellness incentives, the employer’s affordability calculation must assume that the employee does not benefit from the program. Simply put, employers may calculate affordability using the lowest possible cost amount under tobacco-related programs but must use the highest possible number under any non-tobacco wellness plan.
Should a taxpayer receive a Form 1095 if he or she is not covered?
Maybe. A non-covered taxpayer only receives a Form 1095-C if the individual is employed by an applicable large employer, in which case the employer supplies the form with Section III (coverage information) left blank. The chart below indicates which form a taxpayer should receive for any given time period. As a side note, and to avoid confusion, large employers that are fully insured might consider communicating with covered employees to clarify that the employee should expect to receive two forms (Form 1095-B from the insurer and Form 1095-C from the employer) for the same coverage period.
If an employer is fully insured, what documents do part-time employees covered on health plans need to receive?
Employers are required to supply Form 1095-C to part-time employees only when the part-time employee is covered on the plan and when the plan is self-insured. In that case, the employer provides Form 1095-C with all sections completed, including Section III on coverage information. See the chart below for reference regarding which version of Form 1095 should be supplied by the employer and which applicable sections of Form 1095-C need to be completed.
Do large employers that qualify for transition relief in 2015 (50–99 employees) need to send out Form 1095-C to employees even though they are not subject to penalties?
Yes. Certain mid-size employers may qualify for transition relief in 2015, but those employers are still required to send Form 1095-C to employees and to file Form 1094-C with the IRS. The employer may check a box on Form 1094-C and supply a code that indicates the employer is eligible for transition relief. Employers that qualify for transition relief are not subject to the employer mandate penalties for that period. These employers should complete sections I & II of Form 1095-C for full-time employees who are fully insured and Sections I, II and III of Form 1095-C for all covered employees if the plan is self-insured.
A bswift FAQ. Original article here.
New Affordable Care Act Guide Now Available for Employers
Posted August 11, 2015 by Megan DiMartino
As the implementation and ramifications continue to roll out in 2015 and beyond, AP Benefit Advisors has released a new Affordable Care Act Guide for Employers to cover a variety of important ACA-related issues. Failing to prepare for ACA policy shifts, failing to understand the significance of regulatory compliance, and failing to anticipate the costs associated with these issues can have devastating consequences for your business. Stay abreast of the latest issues by visiting our blog, and with this informative guide. Topics include:
- What are current ACA requirements for employers
- Who is required to comply?
- Who is considered an employee?
- How to calculate full-time equivalency
- What are the safe harbor provisions?
- And more – click on the thumbnail below to open
Guardian Workplace Benefits Study
Posted August 7, 2015 by Megan DiMartino
This year’s Guardian Workplace Benefits Study confirms employees continue to value and rely on the benefits their employer offers. The average Benefits Value Index (BVI) score is 7.1, consistent with last year and up from 6.8 when the Index was established in 2013. Employees believe their benefits positively impact their financial security, and they feel they need help. Only 3 in 10 workers feel financially secure, and this study shows what little security they feel hinges — to a large degree — on the insurance and savings benefits they receive at the workplace. Given their reliance on workplace benefits for overall financial preparedness, it’s not surprising employees believe that employers have a responsibility to offer core insurance and retirement benefits to workers. Without those benefits, most say they would face financial hardship.
Treasury & IRS Second Notice Regarding 40% Excise Tax: The Who, What, When, Where, Why and How update.
Posted August 3, 2015 by Megan DiMartino
The Department of the Treasury and the Internal Revenue Service (IRS) issued a second notice regarding the 40% Excise Tax, which provides additional details on possible approaches for the administration of the Excise Tax (Cadillac Tax). We’ve simplified this into a: Who, What When, Where, Why and How update.
Who Pays This Tax
The coverage providers listed below must pay the Excise tax on their respective share of the excess benefit.
- Health insurers.
- Employer for accounts such as the HSAs to which the employer contributes.
- Plan benefits administrators – the IRS is seeking comments on this.
