Responding Strategically to The Patient Protection And Affordable Health Care Act

1. Responding Strategically to The Patient Protection And Affordable Health Care Act

2. The Health Care Reform Legislation Effective March 23, 2010: • Title I – Quality and Affordable Health Care for all Americans • Title II – Role of Public Programs • Title III – Improving the Quality and Efficiency of Health Care • Title IV- Prevention of Public Disease and Improving Public Health

3. Put the law in the proper perspective. (Or: After the Cow is slaughtered its time to make hamburgers) Step One: The Health Care Reform Legislation • Only 135 pages of the Act apply directly to employers • The first of the mandated changes for group health plans are required to be implemented for plan years beginning after September 23, 2010 • Most of the provisions of the Act are phased in between now and January 1, 2014 • Plans in existence on March 23, 2010, are “grandfathered” and are permanently exempt from some mandates under the Act • The Act exempts “small employers” • Includes tax credits

4. Determining which provisions of the Act apply to you. Step Two: The Health Care Reform Legislation • The rules for determining whether a person is eligible for cost-shared coverage under an individual policy. • The rules for determining number of employees • The rules defining large employers and small employers • The rules for determining whether a policy or group health plan a is “grandfathered” plan • The rules exempting grandfathered plans from certain requirements

5. Rules for persons covered under an individual policy. • Step Two: • Determining which provisions of the Act apply to you The Health Care Reform Legislation • The new legislation includes cost-sharing subsidies to individuals who are not eligible to participate in an employer plan and who participate in the silver level of a State Insurance Exchange. • The premium credits are for eligible individuals and families who pay more than a scaled percentage of income: 2% for 133% of FPL to 9.5% for 400% of FPL

6. Calculating the number of full time employees. • Step Two: • Determining which provisions of the Act apply to you • The Health Care Reform Legislation • A full-time employee (FTE) is one whose cumulative hours equal or exceed 30 hours per week • Full time equivalent employee (FTEE) are the cumulative hours of all part-time hours for a month divided by 120 • Seasonal employee exception applies if you have more than 50 FTEs for less than 120-days in the year and more than 50 were "seasonal" (defined by the DOL)

7. The definition of large employers and small employers under the rules. • Step Two: • Determining which provisions of the Act apply to you • The Health Care Reform Legislation • Small employers have 50 or less full-time equivalent employees • Small employers with less than 25 full-time equivalent employees are eligible for a phased tax credit • Large employer are defined as those which have more than 50 full-time equivalent employees

8. The rules for determining whether a Group Health plan is a “grandfathered” or a “new” plan. • Step Two: • Determining which provisions of the Act apply to you • The Health Care Reform Legislation • Any group health plan in existence on March 23, 2010, is considered a “grandfathered” plan under the Act. • It can lose its grandfathered status if it is materially changed • Grandfathered plans are not subject to certain mandatesbut are subject to others • Plans which are not grandfathered are considered “new” plans

9. The rules for determining whether a Group Health plan is a “grandfathered”. • Step Two: • Determining which provisions of the Act apply to you • The Health Care Reform Legislation • To be grandfathered: • the policy or group health plan must have had at least one covered person on March 23, 2010, and • continuously covered someone since March 23, 2010 (even if not the same individuals), and • is not materially changed since March 23, 2010

10. Interim final regulations define a “material change” in six instances The rules for determining whether a policy or group health plan is “grandfathered” • The Health Care Reform Legislation • 1. Eliminating or significantly reducing benefits • 2. Raising co-insurance or co-payments • 3. Raising deductibles • 4. Reducing employer contributions • 5. Adding or increasing an annual limit • 6. Changing insurance carriers

11. Grandfathered status applies separately to each benefit package offered under a policy or plan. The rules for determining whether a policy or group health plan is “grandfathered” • The Health Care Reform Legislation • A plan offers three options: Option 1 (self-funded), Option 2 (insured), Option 3 (insured). The Plan replaces the insurance issuer for Option 2. • Under the rules a plan loses grandfathered status if it changes providers. Option 2 is no longer grandfathered, but Options 1 and 3 retain grandfathered status.

12. Permissible changes which will not affect grandfathered status The rules for determining whether a policy or group health plan is “grandfathered” • The Health Care Reform Legislation • • Changes to premiums; • • Changes to comply with federal or state law; • • Changes to voluntarily comply with provisions of PPACA or to increase benefits; • • Changes to a plan's third party administrator • • Changes to plan structure, e.g., switching from a health reimbursement arrangement to major medical coverage, or from insured to self-funded coverage; • • Changes to a provider network; and • • Changes to a prescription drug formulary.

13. Caveats for grandfathered policies and plans The rules for determining whether a policy or group health plan is “grandfathered” • The Health Care Reform Legislation • Grandfathered plans must disclose its status in each participant communication • Grandfathered status is revoked if: • Participants are switched to another grandfathered plan with less benefits or protections • Merges into another plan for purposes of avoiding the obligations under PPACA

14. Understand your obligations under the Act Step Three: The Health Care Reform Legislation Mandates applicable to “new” plans Small employer exceptions Small Employer Tax Credit Mandates applicable to both new and grandfathered plans Play or Pay

15. Mandates applicable to “new” plans Step Three: Understand your obligations under the Act The Health Care Reform Legislation Non-discrimination rules will apply to fully-insured plans The plan must provide for an internal and external review process Emergency services must be covered without prior authorization (this may be found not to be exempt for grandfather plans) Participant can select own physician, pediatrician, and OB/GYN Must provide preventative care with no cost sharing

16. Small employer exceptions apply to employers with 50 or less full-time equivalent employees Step Three: Understand your obligations under the Act The Health Care Reform Legislation Only employers with more than 50 FTEEs are mandated to provide “minimum essential coverage”to FTEs Coverage is not required to be provided until January 1, 2014 Employers with less than 25 FTEE get a tax credit for 2010 phased out through 2014

17. Small Employer Tax Credit Step Three: Understand your obligations under the Act The Health Care Reform Legislation For tax years beginning in 2010, this new tax credit maybe taken by employers which meet the following three criteria: • have fewer than 25 full-time equivalent employees (50 part-time workers are an example of equivalent), • pay average annual wages of less than $50,000 for each full-time equivalent employee, and; • contribute a uniform* percentage of at least 50% of the employer’s cost of single coverage premiums* paid through a “qualifying arrangement”. Payroll deferrals into a cafeteria plan are considered employee contributions.

18. Mandates applicable to both new and grandfathered plans Step Three: Understand your obligations under the Act The Health Care Reform Legislation Effective January 1, 2010: No lifetime limits on coverage Coverage for adult children to age 26 Pre-existing condition exclusions Effective for plan years after September 30, 2012,: employers are to pay a $1.00 fee/participant for the first year; $2.00 the second; thereafter per formula notice and reporting requirements Effective 2013 3.8% Medicare tax on unearned income Effective 2014 Excise Tax for failure to provide coverage. The “Play or Pay” provision

19. Play or Pay Step Three: Understand your obligations under the Act The Health Care Reform Legislation The Act imposes a non-deductible excise tax upon “applicable large employers” which do not offer “coverage for all its full-time employees, under a plan which the total allowed participant’s cost of benefits is more than 60%, and any full-time employee is certified to the employer as having purchased health insurance through a state exchange with respect to which a tax credit or cost-sharing reduction is allowed or paid to the employee.

20. When the employer plays • Play or pay The Health Care Reform Legislation Employer with more than 50 FTEs determined on a controlled group basis Must provide minimum essential health coverage to be established by the Secretary of HHS and based on local markets and comparable to the average employer plan Employer plan must be affordable. Employer fails to offer either: "Qualifying Coverage" - plan's actuarial value more than 60% (i.e., participants pay 40% or less) Affordable Coverage – cost is equal to or less than 9.5% of household income

21. When the employer pays • Play or pay The Health Care Reform Legislation Free Rider Surcharge - Effective 2014 – is the penalty an employer may pay if it does not offer “minimum essential health coverage” The penalty for any month is an excise tax equal to the number of full-time employees over a 30-employee threshold during the applicable month (regardless of how many employees are receiving a premium tax credit or cost-sharing reduction) multiplied by one-twelfth of $2,000

22. Respond strategically • Step Four: The Health Care Reform Legislation Define your benefit philosophy Quantify your return on your health care dollar Identify and cost out your health care options Consider benefits as a part of total compensation package

23. Define your benefits philosophy • Step Four: • Respond strategically The Health Care Reform Legislation Is there an expressed policy as to what the employer wants to provide its employees in terms of health coverage? Is the current philosophy consistent with business needs?

24. Quantify your return on the health plan dollar • Step Four: • Respond strategically The Health Care Reform Legislation Costs – current and projected Tool for recruiting and retaining employees Consistent with employer’s philosophy on employee benefits Labor relations/Public Relations Administration and compliance costs and effectiveness Measure the qualitative and quantitative return on the dollar invested in health care

25. Develop a formal benefits strategy • Step Four: • Respond strategically The Health Care Reform Legislation Reconcile gaps between business needs and objectives and the current health benefits policies and practices NOTE: changes to a plan may affect its “Grandfather” status under the Act.

26. Manage your response to the Health Care Reform Act (PPACA) Next steps Management: ◙ Assemble your decision-making team ◙ Design a plan which will flex to meet forecasted business plans ◙ Consider employee relations and administrative issues Administration: ◙ Consult with your insurance carrier or actuary for a cost analysis ◙ Schedule the implementation of changes, communications, systems, and coordinate with vendors ◙ Operate in accordance with the fiduciary requirements of ERISA Finance: Project out costs for playing under both a grandfathered and new Project out costs for not playing Legal: Consider risk tolerance pending agency guidance