1. Implementing Health Care Reform National Association of Health Underwriters June 17, 2010

3. Recap on Legislation President signed Patient Protection and Affordable Care Act (PPACA) on March 23 Reconciliation bill signed on March 30 Interpretation of legislation now requires examining multiple sources: – Senate-passed bill, H.R. 3590 (now P.L. 111-148) – Manager’s amendment to the Senate bill – Reconciliation bill, H.R. 4872 Very important: Check all three sources when considering how the bill works

4. Recap on Legislation What is the size of a small employer in the new law? – Two to 50 – One to 100 – One to 200 What is a full time employee in the new law? – Thirty hours a week – Forty hours a week

5. PPACA Overview Makes significant statutory changes affecting the regulation of and payment for many types of private health insurance – many insurance market reforms Will require almost all private sector employers to evaluate the health benefits they currently offer and consider whether they are compliant For those without access to employer coverage, new individual mandate to purchase and maintain minimum coverage in 2014

6. Grandfathered Plans Essentially all plans in effect on date of PPACA enactment (March 23, 2010) are “grandfathered” What does this mean? Is it a big deal? – Grandfather plans exempt from some, but not all, of PPACA requirements Regulations were issued this week – Eligible family members of existing employee plan OK, as well as new employees and their eligible family members

7. 2010 Issues Small business tax credit Medicare Part D subsides are not taxable High risk pool for the uninsured with pre- existing conditions Early retiree reinsurance program New federal insurance plan requirements

8. PPACA in 2010 Eligible small businesses are eligible for phase one of the small business premium tax credit. – Small employers with fewer than 25 employees may receive a maximum credit, based on number of employees, of up to 35% of premiums until 2014. Employer must contribute at least 50% of the total premium cost. Businesses do not have to have a tax liability to be eligible Non-profits are eligible Average salary must be $50,000 or less (owner income exempted) – Note: the credit reduces amount of premiums that can be deducted – This may or may not be helpful.

9. PPACA in 2010 Owner’s benefits and income generally not included in the credit calculation. IRS has a Q and A section and helpful information on its website. Not all questions are answered at this point.

10. PPACA in 2010 Deductibility for Part D subsidies is eliminated in 2013, but this results in an immediate accounting impact. – AT&T, Caterpillar, Verizon and other large corporations reported the fiscal impact immediately

11. PPACA in 2010 Creates high-risk pool coverage for people who cannot obtain current individual coverage due to preexisting conditions. – Employers cannot put people in the pool—would pay penalty – Eligibility: Uninsured for 6 mos and denied coverage for a pre-existing condition This national program can work with existing state high- risk pools and will end on January 1, 2014, once the Exchanges become operational and the other preexisting condition and guarantee issue provisions take effect Financed by a one-time $5 billion appropriation

12. PPACA in 2010 California opted to participate in the program – Federal gov’t will operate the pools in about 20 states CMS Actuary says $5B could be exhausted by as early as 2012. – Further appropriations to fund the program? Pool should be operational around June 23, 2010.

13. PPACA in 2010 Establishes federal review of health insurance premium rates. Secretary of HHS, in conjunction with the states, will have new authority to monitor health insurance carrier premium increases beginning in 2010 to prevent unreasonable increases and publicly disclose such information. In addition, $250 Million is appropriated for state grants to increase their review and approval process of health insurance carrier premium rate increases.

14. PPACA in 2010 2010 Reinsurance Program for employer “early retiree” health benefits (age 55-64) provides for subsidies up to 80 percent of the insurance costs (claim corridor of $15- 90K) IF they invest the difference in wellness and chronic care management programs, among other things – Medicare Part D subsidy model – Regulations have been issued. – The program becomes effective June 23, 2010. – Self-funded and fully insured plans eligible.

15. PPACA in 2010 Payments are retroactive for a plan year, so employers and early retirees will be able to take advantage of them for costs incurred from the date the program is established. Payments will be made to employer-sponsored health plans on behalf of an early retiree. To receive assistance, plans must apply, document claims, and implement programs and procedures to generate cost savings for participants with chronic and high-cost conditions. Savings for enrollees: Plans must use these proceeds to lower health costs for enrollees (e.g., premium contributions, copayments, deductibles, etc.)

16. Effective Plan Years on/after Sep. 23 – All Plans, Including Grandfathered Restrictions on annual limits – Plans may impose only “restricted annual limits” on the dollar value of “essential benefits.” HHS to establish annual limits on the dollar value of essential benefits. On and after January 1, 2014, no annual limits will be permitted No lifetime limits – Plans may not impose lifetime limits on dollar value of “essential benefits”

17. Effective Plan Years on/after Sep. 23 – All Plans, Including Grandfathered New strictures on “rescissions” – Plans may not rescind coverage unless person commits fraud or makes a material misrepresentation prohibited under the terms of the plan Pre-Ex Restrictions – Plans may not impose any preexisting condition restriction on children under the age of 19. After January 1, 2014, plans may not impose preexisting condition restrictions on anyone

18. Effective Plan Years on/after Sep. 23 – All Plans, Including Grandfathered Coverage for dependents to age 26 – If a plan offers dependent coverage of children, such coverage must extend to a child until the child reaches age 26 – Some carriers are implementing this change early – For grandfathered plans, this requirement applies before January 1, 2014 only if the adult child is not eligible to enroll in another plan – Point of confusion: the legislation increased the IRS definition of dependent up to age 27

19. Effective for Plan Years on/after Sep. 23, 2010 (Grandfathered Exempt) Nondiscrimination rules under IRS Code 105(h) applies to fully-insured plans Preventive care without cost sharing on services that receive an “A” or “B” rating from the US Preventive Services Task Force New appeals process rules for coverage determinations and claims Certain new patient protections

20. New Patient Protections (Grandfathered Plans Exempt) For all group and individual plans, including self- insured plans, emergency services covered in- network regardless of provider Enrollees may designate any in-network primary care physician as their primary care physician New coverage appeal process

21. 2011 Issues New requirements for insurance plans Payroll deduction for a new long-term care program Federal wellness grants for small businesses without wellness programs

22. PPACA in 2011 Minimum loss ratio requirements will be established for insurers in all markets. How will this affect coverage? The MLR is 85% for large group plans and 80% for individual and small group plans (100 and below). – May impact provisions that reduce claims cost, such as pay for performance, nurse lines, disease management, etc. – May result in fewer carriers offering coverage in some areas, particularly rural, resulting in less consumer choice. Carriers will have to issue a premium rebate to individuals when MLR is too low.

23. PPACA in 2011 Creates a new public long-term care program. Premiums could be collected as early as January 1, 2011. – Unknown what the premium will be but CMS actuary estimates premium as high as $240/mo. with 2% enrolled Benefits won’t be known until October 2012. Cannot make a claim for 5 years so earliest would be 2015, but more likely 2017. Must be attached to work to be eligible.

24. PPACA in 2011 Employers are expected to auto-enroll employees – Employees can opt-out. In order to meet actuarial requirements, the price of the plan will have to be very high. Administrative burden on employers.

25. PPACA in 2011 – Beginning in 2011, $200 million over 5 years in grants for employees of small businesses to participate in comprehensive workplace wellness programs Eligible employers are those 100 employees who work 25 hours or more per week, and did not have a workplace wellness program as of March 23, 2010 First-come, first-serve – Grants to allow state and local health departments to design community-based public health interventions and screenings for people age 55-64; and – $25 million child obesity demonstration project

26. PPACA in 2011 and 2012 All employers must include on their W2s the aggregate cost of employer-sponsored health benefits If employee receives health insurance coverage under multiple plans, the employer must disclose the aggregate value of all such health coverage, – Excludes all contributions to HSAs and Archer MSAs and salary reduction contributions to FSAs – Applies to benefits provided during taxable years after December 31, 2010 A new federal tax on fully insured and self-funded group plans, equal to $2 per ee/yr, takes effect to fund federal comparative effectiveness research takes effect in 2012

27. PPACA in 2013 FSA contribution limits of $2,500 Additional 0.9% Medicare Hospital Insurance tax on self- employed individuals and employees with respect to earnings and wages received during the year above $200,000 for individuals and above $250,000 for joint filers (not indexed) – Self-employed individuals are not permitted to deduct any portion of the additional tax Reconciliation measure levied a new 3.8% additional Medicare contribution on certain unearned income from individuals with AGI over $200,000 ($250,000 for joint filers) – The “House tax” email

28. 2014 Issues Individual mandate Employer mandate Other significant changes: – Modified community rating – Individual market guaranteed issue – Subsides available – New taxes on fully-insured plans

29. PPACA in 2014 Imposes new annual taxes / fees (non-deductible) on private health insurers based on net premiums – $8.1 billion annually beginning in 2014 and rising to $14.3 billion by 2018 (and indexed for medical inflation thereafter) – Small businesses and employees could be disproportionately affected because tax only applies to fully insured health benefits (self-funded plans exempt)

30. PPACA in 2014 Coverage must be offered on a guarantee issue basis in all markets and be guarantee renewable Exclusions based on preexisting conditions would be prohibited in all markets Full prohibition on any annual limits or lifetime limits in all group (even self-funded plans) or individual plans Redefines small group coverage as 1-100 employees. – States may also elect to reduce this number to 50 for plan years prior to January 1, 2016

31. PPACA in 2014 Creates sliding-scale tax credits for non-Medicaid eligible individuals with incomes up to 400% of FPL to buy coverage through the exchange. The requirement that the subsidies are only available through the exchange is a significant problem. It is a particular threat to employer plans due to other provisions that allow employees to opt out of employer sponsored coverage.

32. PPACA in 2018 40% excise tax on insurers of employer-sponsored health plans with aggregate values that exceed $10,200 for singles and from $27,500 for families takes effect in 2018. Arbitrary numbers and lack of adequate indexing make this a very unfair tax. Many people will be impacted due to the way the bill defines what is included in the premium calculation. – Dental and vision not included

33. Exchanges By 2014, all states will be required to establish insurance exchanges What are they? – Regulatory bodies – Subsidy administrators – Enrollment portals – Information portals

34. Utah Health Exchange

35. “Travelocity” model – Minimal infrastructure – Provides information to consumers (Information Connector or Portal) Does not administer additional programs Agent search function

36. Massachusetts Health Connector

38. Bricks and mortal exchange – 45 employees Administers programs – Commonwealth Care – Commonwealth Choice (commissions) – Cost Containment Commission Many regulatory functions – Determining minimum creditable coverage – Approving (or rejecting) insurance plan bids

39. Connectors In 2014, we will have very complicated marketplace: Connector (individual and small group) and non-Connector (individual, small group and large group) Producers are permitted, by law, to enroll individuals in the Connector No two Connectors will be the same Massachusetts and Utah results are not necessarily indicative of future results

40. Connectors What will a 2014 Connector look like? – Board of Directors – Approve plans for sale – Information resource for consumers – Subsidy administrator and enrollment facility – Sign agreements with Navigators – Ombudsmen offices

41. Agent/Broker Issues Individual, small group and large group coverage will be available inside and outside of the exchanges Agents and brokers are included in the legislation Commissions will be a state-level or carrier issue Exchange will contract with “Navigators” to promote exchanges, tax credits and subsidies and send consumers to new consumer advocates called “ombudsmen” – Massachusetts did something similar: contract with groups to enroll the uninsured in Medicaid – Large Medicaid expansion in 2014

42. What can you do? Working with NAHU members in addressing questions to regulatory agencies — reformimplementation@nahu.org Those of you with “practical” business knowledge give a unique perspective Talk with your clients, your payroll vendors and tax advisors Will be updating as more information is available

43. Discussion and Questions Adam Brackemyre Director of Federal Affairs (703) 276-3808 abrackemyre@nahu.org