Open enrollment for the 2015 New York individual market season is right around the corner. Below are answers to commonly asked questions pertaining to individual market coverage for residents of New York State:
Q: What is the New York State of Health (NYSOH) exchange website? A:NYSOH provides NYS residents living between 139%-400% of the Federal Poverty Level, access to lower cost health insurance by supplying them with tax credit premium subsidies. Additional Cost Sharing subsidies are available to those living between 139%-250% of the FPL. All subsidy programs are subject to eligibility requirements. Additionally, NYSOH is where individuals can enroll in Medicaid (for those living below 139% of the FPL).
Q: Is the NYSOH government health insurance? Is that what “Obamacare” means? A: No. Individual health insurance is a relationship between a consumer, and a private health insurance company. NYOSH slips in between this relationship by forwarding tax credit money to the carrier on behalf of the subsidy-eligible consumer, and then the carrier bills the consumer for the difference in premium owed. “Obamacare” is simply the nickname of the new health insurance law, which (in part) assists individuals in obtaining health insurance.
Q: Do I have to have health insurance? A: Yes. As part of the individual mandate, all US citizens must enroll in Affordable Care Act-compliant health insurance…be it through your employer, the individual market, Medicare, or Medicaid. Citizens not enrolled in coverage will be fined by the IRS (less those who qualify for exemptions).
Q: What is the fine for not having health insurance? A: In 2015, the fine is 2% of household income per uninsured month. In 2016, this increases to 2.5% of household income per uninsured month.
Q: Do I have to enroll in individual coverage through NYSOH? A: No. Only people in need of tax credit subsidy assistance must enroll through the NYSOH exchange website.
Q: What if I don’t earn enough income to qualify for subsidy assistance for on-exchange health plans? A: People in NY living below 139% of the FPL will be eligible for Medicaid. Medicaid enrollments are conducted on the NYSOH website.
Q: If I am over the subsidy income limit threshold, how do I apply for coverage outside of the NYSOH website? A: You can enroll directly with a carrier, or, by contacting a licensed insurance broker for assistance. Off-exchange carrier applications are extremely simplified, requiring only a 1-2 page paper/PDF application to be completed in most cases, and with no government intervention.
Q: Can brokers assist me with my individual coverage written through the NYSOH website as well? A: Yes. Licensed brokers, who are also certified to write health plans on the exchange, can be found in the Broker directory on the NYSOH website. You can search using a specific broker’s first and last name, by selecting a specific Agency from the drop down list, or you can enter your ZIP Code to find one in your region.
Q: Do brokers charge fees for helping me secure an individual health plan? A: Brokers are not allowed to charge fees for assisting individuals with writing their health insurance.
Q: How do brokers get paid? A: Every time you pay your health insurance bill, a portion of your payment is allocated towards compensating a broker (just like with your auto or homeowners insurance). Most carriers pay broker commissions on the back end, which is completely transparent to the consumer. If no broker is utilized by the consumer, the carrier retains the commission. This means that whether you use a broker or not, you’ll be paying for one anyway.
Q: Don’t Navigators already provide these broker services? A: No. Sometimes referred to as “in person assistors” or “experts” by the NYSOH, Navigators are not licensed to write health insurance. They are trained employees or contracted agencies of the NYS government (funded by Federal grant money) to help individuals navigate the enrollment process on the NYSOH website only. They are not required by federal law to undergo criminal background checks, nor are they licensed by the NYS Department of Financial Services, which means they cannot make plan recommendations to health insurance consumers.
Q: Can a certified broker process my NYSOH enrollment for me? A: Yes. Brokers that are certified to write business on the NYSOH exchange website can drive the entire online enrollment process for the consumer. You just need to authorize a broker through your NYSOH account by logging in, and then clicking “Find a Navigator/Broker” towards the bottom left side of your NYSOH account home page. Once authorized, the broker you have selected will receive an email from the NYSOH that you are in need of assistance, and can now enroll you on your behalf.
Q: When can I enroll in individual health insurance? A: Like Medicare, the individual health insurance market is setup to have an open enrollment season. The individual market open enrollment window is from 11/15/14 through 2/15/15.
Q. Are there any exceptions to the open enrollment period?
A. Enrollment in Medicaid, Child Health Plus and the Small Business Marketplace continues all year.
Have a Qualifying Event?
Enroll Now using our online shopping tool where you can compare plans and prices and enroll
Find us on the Health Insurance Marketplace where you may qualify for help to pay for your health insurance. Qualifying Events for Exchange Marketplace. 76 percent of the uninsured are unaware of the looming March 31 sign-up deadline. Contact us at (855)667-4621.
Q: Can I enroll in coverage outside of the open enrollment season? A: Consumers can enroll in individual coverage outside the open enrollment season so long as a “Qualifying Life Event” exists. Examples of such events include the loss of a job, marriage, divorce, birth of a child, a change in subsidy eligibility, and others. Written proof of the QLE will be required when enrolling outside of the open enrollment season as established by the US Department of Health and Human Services.
Q: If I am subsidy eligible, and my income changes, what do I do? A: Consumers enrolled through the exchange who receive tax credits must notify the NYSOH Marketplace whenever a change of income is experienced. You can contact the marketplace call center at 855-355-5777 to update your income information.
Q: Am I limited to certain insurance companies if I am subsidy-eligible? A: No. Consumers who are subsidy-eligible may pick any plan they wish that is available on the NYSOH exchange website. However, subsidy-eligible individuals may not apply those tax credits towards health plans written outside of the NYSOH website (for example, Oxford Liberty plans, which are only available outside of the NYSOH Marketplace).
Q: I have completed the income portion of my on-exchange application, and I’m now ready to pick a plan. How can I find out more specific information pertaining to the available options in the market? A: A licensed insurance broker can help you understand the available health plans in the market, and can make plan recommendations specific to your needs and financial situation.
Q: I started my current individual plan in July 2014. Do I have to renew my plan on January 1st 2015? A: Yes. All individual market plans have calendar year deductible and maximum out of pocket accumulation periods, which resets on January 1st of any given year. So for example, if you lost your job (and your health insurance) effective 12/1/14, and then you enroll for individual coverage effective 12/1/14, you must renew your individual plan the following month (for 1/1/15) at the new carrier plan structures and rates.
Q: I already have individual market based health insurance. Can I change plans during the open enrollment season? A: Yes. Existing individual health insurance policyholders may change their plan during the open enrollment season. You may also change carriers should you wish to find a better solution for your needs. Talk to your licensed insurance broker about the available plan options in the market for 2015.
Q: My employer is offering me a health plan that I am not interested in. Can I waive my employer health plan and replace it with an individual plan, and receive tax credit subsidy assistance? A: The answer to the first part of the question is yes. Employees can choose to opt out of employer-sponsored health insurance, and can replace their coverage in the individual market.
With regards to receiving tax credit subsidies in these situations, yes, an individual can receive tax credit subsidies to help pay the cost of individual health insurance. However, in addition to the employee needing to meet tax credit eligibility requirements as discussed earlier, one of two additional conditions must be met to be eligible to receive subsidy assistance: 1) The employer’s health plan does not meet the minimum actuarial value of 60%, or 2) The employee’s single rate cost (self-only coverage, no dependents) for employer-sponsored coverage exceeds 9.5% of their household adjusted gross income (defined as “unaffordable” under the health care law).
Q: I’m applying for a tax credit subsidy. How do I determine my adjusted gross income? A: Your adjusted gross income can be found on line 37 of your 1040 tax return. Subsidy applicants who have a steady income can use this figure as a guide when determining tax credit eligibility for the upcoming tax year.
Those that do not have a steady income (e.g. sole proprietors, freelancers, single-person businesses, etc.) should speak with their accountants to determine their estimated adjusted gross income for the upcoming tax year.
Q: I was determined Medicaid eligible after applying for tax credit subsidy on the NYSOH website. However, my doctors do not take Medicaid. Can I opt out of medicaid and get a subsidized individual health plan instead? A: You may choose to opt out of Medicaid if you wish. However, those who are Medicaid eligible will not qualify for tax credit subsidies for individual health plans. You can enroll in a health plan, but you must pay the full price of the plan.
Q: I was determined subsidy eligible, and I want to pick a plan to enroll in through the NYSOH website. Can I put my children on my health plan with my spouse and I? A: No. Those who are subsidy eligible must insure their dependent children through a Child Health Plus plan. CHP (or “chip”) plans are selected during the plan check out process at the end of the NYSOH application. Only the applicant and spouse will qualify for a private health plan with subsidy assistance. If you choose to opt your children out of CHP, you and your spouse will lose subsidy eligibility for your private health plan.
Q: How can I find out if my doctors take a particular health plan? A: Your licensed insurance broker can provide you with carrier-specific tools to look up providers in particular networks.
Q: How can I get a copy of the full benefit summary for a particular health plan I’m interested in? A: Your licensed insurance broker can provide you with electronic benefit summaries for most health plans upon request.
Q: How can I find a licensed broker to assist me? A: Licensed insurance brokers, and who are also certified to write on-exchange plans, can be found in the Broker directory on the NYSOH website. You can search using a specific broker’s first and last name, by selecting a specific Agency from the drop down list, or you can enter your ZIP Code to find one in your region.
For more information regarding both Exchanges – Individual Exchanges or SHOP please contact our team at Millennium Medical Solutions Corp (855)667-4621. We have Spanish, Russian, and Hebrew speakers available. Quotes can also be viewed on our site.
IRS Releases Draft of Employer Reporting Form for Health Reform Law Compliance
Business Insurance
Story by Matt Dunning
Click Above
July 28, 2014
The Internal Revenue Service has issued draft versions of the reporting forms most employers will begin using next year to show that their group health insurance plans comply with the health care reform law.
The long-awaited draft forms, posted late Thursday afternoon to the IRS’ website, are the first practical application of employers’ health care coverage and enrollment reporting obligations under the Patient Protection and Affordable Care Act since the regulations were finalized in March.
The forms are the primary mechanism through which the government intends to enforce the health care reform law’s minimum essential coverage and shared responsibility requirements for employers.
Beginning in 2015, employers with at least 100 full-time employees will be required to certify that benefits-eligible employees and their dependents have been offered minimum essential coverage and that their employees’ contributions to their premiums comply with cost-sharing limits established under the reform law. Smaller employers with 50-99 full-time employees are required to begin reporting in 2016.
Additionally, self-insured employers will be required to submit documentation to ensure compliance with minimum essential coverage requirements under the reform law’s individual coverage mandate.
“In accordance with the IRS’ normal process, these draft forms are being provided to help stakeholders, including employers, tax professionals and software providers, prepare for these new reporting provisions and to invite comments from them,” the IRS said in a statement released Thursday.
The IRS said it expects to publish draft instructions for completing the reporting forms by late August and that both the forms and the instructions would be finalized later this year.
Last year, the Obama administration announced it would postpone implementation of employers’ minimum essential coverage and shared responsibility obligations under the reform law for one year, largely due to widespread complaints about the complexity of the reporting requirements.
Though several months have passed since the administration issued a simplified set of information reporting rules, many employers have delayed preparations for meeting the requirements until the forms and instructions are available for review, said Richard Stover, a principal with Buck Consultants at Xerox in Secaucus, New Jersey.
“A lot of employers really haven’t been doing anything about reporting requirements, even with the final regulations in place, because they were waiting for these forms,” Mr. Stover said. “This is something they’ve been anxious to see.”
Adding a one-month orientation period may help an employer avoid complying with the new health benefits. Federal agencies are offering employers a benefits-free 30 day orientation period option in final regulations. There is also clarification on how employers must treat certain categories of new hires, as either FT , PT or Seasonal employees
The Final Regulations
These final regulations provide that the one month period would be determined by adding one calendar month and subtracting one calendar day, measured from an employee’s start date in a position that is otherwise eligible for coverage. For example, if an employee’s start date in an otherwise eligible position is May 3, the last permitted day of the orientation period is June 2. Similarly, if an employee’s start date in an otherwise eligible position is October 1, the last permitted day of the orientation period is October 31.
The new regulations implement part of the “employer shared responsibility mandate” provisions created by the Patient Protection and Affordable Care Act (PPACA). In all categories of new hire the e final regulations provide that one month is the maximum allowed length of an employment-based orientation period. For any period longer than one month that precedes a waiting period, the 90-day period begins after an individual is otherwise eligible to enroll under the terms of a group health plan.
When must an employer offer coverage:
The final regulations continue to provide that if a group health plan conditions eligibility on an employee’s having completed a reasonable and bona fide employment-based orientation period, the eligibility condition is not considered to be designed to avoid compliance with the 90-day waiting period limitation if the orientation period does not exceed one month and the maximum 90-day waiting period begins on the first day after the orientation period.
These final regulations apply to group health plans and health insurance issuers for plan years beginning on or after January 1, 2015.
When the Employer Might be Subject to a Penalty:
If at least one full-time employee of the employer buys health insurance in a public Exchange (Marketplace) and qualifies for a subsidy (either a premium tax credit or a cost-sharing reduction), the employer must pay a penalty.
There are two different types of penalties.
)The IRC section 4980H(a) penalty applies if a large employer offers coverage to less than 70% of its full-time employees in 2015 (or to less than 95% after the 2015 plan year). This penalty is $2000 annually or $166.67/month times the total number of “full-time” employees minus the first 80 (minus the first 30 after 2015). The penalty calculation does not include variable hour or seasonal employees who are in their measurement or administrative periods, even if they in fact worked on average at least 30 hours/week or 130/month during those periods. Nor does it include those who are in their stability periods but who did not qualify for coverage based on their hours worked during the associated measurement period.
IRC section 4980H(b) penalty. It applies if a large employer offers coverage to at least 70% of its full-time employees (95% after 2015), but for some full-time employees the coverage is either not “affordable” or does not provide minimum value. This penalty is $3,000 annually or $250/month for each full-time employee who buys health insurance in a public Exchange (Marketplace) and qualifies for a subsidy and for whom the employee cost for self-only coverage under the lowest-cost option available from the employer is more than 9.5% of the employee’s household income (or one of three safe harbors), or for whom the employer coverage offered does not provide at least minimum value. Again, the penalty calculation does not apply if the employee who qualified for a subsidy was a variable hour or seasonal employee who was in his/her measurement or administrative periods, nor does it include those employees who are in their stability periods but who did not qualify for coverage based on their hours worked during the associated measurement period. Additionally, the (b) penalty cannot be more than the (a) penalty would have been had it applied.
Summary and Employer Action Items
The bottom line is this:
If you hire a non-seasonal employee whom you reasonably expect (at date of hire) to work at least 30 hours/week or 130 hours/month, you must track hours each calendar month and offer benefits by the first day of the fourth month if the employee averages at least 130 hours/month for the first three months. This applies even if you hire this employee for a short-term position or a summer internship (unless you take the position, upon advice from your legal counsel, that a summer intern is a “seasonal” employee).
If you hire a non-seasonal employee and you cannot reasonably determine at date of hire if they will work on average at least 30 hours/week (130 hours/month), you can track their hours over their “initial measurement period” and not offer benefits until the associated “stability period,” if the employee averaged at least 130 hours/ month during the measurement period. The stability period might not begin until 13-14 months after the date of hire.
If you hire an employee who meets the new definition of a “seasonal employee,” you can track their hours over their “initial measurement period” and not offer benefits until the associated “stability period” if they averaged at least 130 hours/month during the initial measurement period. You do not have to offer benefits by the first day of the fourth month.
A copy of the final regulations can be obtained by clicking on the link below:
Sign up for latest news updates. Please contact us for immediate information on how to implement these initiatives for your group-specific needs at info@medicalsolutionscorp.com or Call (855) 667-4621.
A: You are eligible for our Travel Medical Insurance plan if you reside outside of the U.S. or have a good faith intent to reside outside of the U.S. for six months or more in a calendar year. Please note that Travel Medical Insurance does not meet the definition of “minimum essential coverage” under PPACA. Travel Medical Insurance is not intended to provide U.S. citizens residing in the U.S. with health insurance. While your Travel Medical Insurance plan for worldwide coverage will not be affected by PPACA, you should review the information below to see if you are exempt from the requirements of PPACA or not, and whether you will have to pay a tax penalty or not. Under PPACA, all U.S. citizens, nationals and resident aliens will be required to purchase minimum essential coverage (PPACA compliant coverage), unless they are exempt. Exempt U.S. citizens include U.S. citizens who reside outside of the U.S. The exemption applies to a U.S. citizen who has a tax home (main place of work or employment, or if you don’t have a main place of work or employment, your main residence) in a foreign country, and is a bona “de resident of a foreign country. See details under the IRS foreign earned income exclusion test. If a person was required to purchase minimum essential coverage and did not, she/he would be required to pay a tax penalty for not purchasing PPACA coverage (if she/he “les a U.S. tax return). In many cases, this tax is far less than the premiums that a person would pay for obtaining PPACA coverage.
Travel Medical Insurance is not intended to provide U.S. Citizens residing in the U.S. with health insurance. While your Travel Medical Insurance plan for worldwide coverage will not be affected by PPACA, you should review the information below to see if you are exempt from the requirements of PPACA or not, and whether you will have to pay a tax penalty or not.
Under PPACA, all U.S. citizens, nationals and resident aliens will be required to purchase minimum essential coverage (PPACA compliant coverage), unless they are exempt. Exempt U.S. citizens include U.S. citizens who reside outside of the U.S.
The exemption applies to:
A U.S. citizen who has a tax home (your main place of work or employment, or if you don’t have a main place of work or employment, your main residence) in a foreign country, and
has been a bona fide resident of a foreign country or countries for an uninterrupted period that includes an entire taxable year; or
» is present in a foreign country or countries during at least 330 full days in a twelve month period. See details under the IRS foreign earned income exclusion test.
Even if a person was required to purchase minimum essential coverage and did not, she/he would only be required to pay a tax penalty for not purchasing PPACA coverage (if she/e/she’s a U.S. tax return). In many cases, this tax is far less than the premiums that a person would pay for obtaining PPACA coverage.
Penalty Tax
Q: What will my tax be if I am required to have PPACA coverage, but do not purchase it?
A: Tax Calculations:
Taxes begin in 2014 and rise in years following. In each year, the tax consists of the higher of a dollar amount or a percentage of household income. For a given household, the tax applies to each individual, up to a maximum of three. Following is the schedule of taxes:
2014: The higher of $95 per person (up to 3 people, or $285) OR 1.0% of taxable income.
2015: The higher of $325 per person (up to 3 people, or $975) OR 2.0% of taxable income.
2016: The higher of $695 per person (up to 3 people, or $2,085) OR 2.5% of taxable income.
After 2016: The same as 2016, but adjusted annually for cost-of-living increases.
Tax Examples
2014 – family of 2; taxable income = $26,000; tax = $260 because $260 ($26,000 x 1%) is higher than $190 ($95 x 2 persons).
2014 – family of 3; taxable income = $26,000; tax = $285 because $285 ($95 x 3 persons) is higher than $260 ($26,000 x 1%).
Non-U.S. citizen With Global Medical Insurance
Q. I am a non-U.S. citizen that will be temporarily traveling to the U.S. Do I need PPACA coverage?
A. Travel Medical Insurance short-term international travel medical products are not a substitute for minimum essential coverage that you may need to have under PPACA. If you are a U.S. citizen, national or legal resident alien in the U.S., you will need to maintain minimum essential coverage unless you are exempt. Exemptions include:
However please understand that under PPACA, as of January 1, 2014, extensions of short-term coverage will be limited to less than 12 months to meet the definition of a short-term limited duration plan.
U.S. Citizen – Short-Term Travel Medical Insurance:
Q. I am a U.S. citizen that will be temporarily traveling outside of the U.S. Do I need PPACA coverage for this?
A. IMG’s short-term international travel medical products are not a substitute for minimum essential coverage that you may need to have under PPACA. However, since most PPACA plans do not provide the types of international benefits and assistance that travelers need, you should strongly consider purchasing an international travel medical plan such as IMG’s Patriot Travel Medical Insurance for coverage while you travel outside of the U.S.
If you are a U.S. citizen, national or an “alien lawfully present” in the U.S., you will need to maintain minimum essential coverage unless you are exempt. Exemptions include:
However, please understand that under PPACA, as of January 1, 2014, extensions of short-term coverage will be limited to less than 12 months to meet the definition of a short-term limited duration plan.
Q: I am an individual residing outside of my home country and covered under an employer group plan. Does PPACA apply to me?
IMG’s short-term international travel medical products are not a substitute for minimum essential coverage that you may need to have under PPACA. However, since most PPACA plans do not provide the types of international benefits and assistance that travelers need, you should strongly consider purchasing an international travel medical plan such as IMG’s Patriot Travel Medical Insurance for coverage while you travel outside of the U.S.
If you are a U.S. citizen, national or an “alien lawfully present” in the U.S., you will need to maintain minimum essential coverage unless you are exempt. Exemptions include:
Individuals with a coverage gap of less than 3 months.
Individuals who cannot afford coverage (i.e. required contribution exceeds 8% of household income).
Individuals with a religious conscience exemption (applies only to certain faiths).
Members of a health care sharing ministry.
Incarcerated individuals.
Individuals with income below the tax filing threshold; and
Members of Indian tribes.
In general, PPACA does not govern short-term limited duration insurance, like IMG’s short-term travel medical insurance programs.
However, please understand that under PPACA, as of January 1, 2014, extensions of short-term coverage will be limited to less than 12 months to meet the definition of a short-term limited duration plan.
Expatriate Groups (GEO)
Q. I am an individual residing outside of my home country and covered under an employer group plan. Does PPACA apply to me?
On March 8, 2013, the Departments of Labor, Health and Human Services and Treasury issued a Frequently Asked Question (FAQ) announcing that, for expatriate plans, compliance with most PPACA provisions is being delayed until January 1, 2016. The relief from compliance applies for plan years 2014 and 2015 on plans that meet the following definition:
“Insured group health plans with plan years ending on or before December 31, 2015, in which enrollment is limited to individuals residing outside of their home country for at least six months of the plan year and any covered dependents.”
Q: I am a non-U.S. citizen and an international student. Will PPACA’s individual mandate affect my IMG plan?
As non-resident aliens, international students on F, J, M and Q visas (and certain family members of students) are not subject to the individual mandate for their first 5 years in the U.S. All other J categories (teacher, trainee, work and travel, au pair, high school, etc.) are not subject to the individual mandate for 2 years (out of the past six).
Since international students are not subject to the mandate, they are not required to purchase a plan that meets PPACA requirements and can purchase an appropriate IMG plan.
International Students – Exempt as Non-Resident Aliens
Under the IRS international student exemption, anyone “temporarily in the United States on an “F”, “J”, “M”, or “Q” visa for the primary purpose of studying at an accredited academic institution or vocational school (and certain family members of students), and who substantially complies with the requirements of that visa,” is exempt from being treated as a resident alien, and is therefore exempt from the individual mandate as a non-resident alien.
Even after 5 years in the U.S., an international student may continue to be a non-resident alien for tax purposes under the “Closer Connection” exception if they can prove that they still have a closer connection to their home country than to the U.S.
The Individual Mandate and Alien / Non-Alien Status
The IRS provides a questions and answers page on the individual mandate. Question 11 asks whether all individuals living in the U.S. are subject to the mandate. The answer is that U.S. citizens and permanent legal residents are subject to the mandate, as are “foreign nationals who are in the U.S. long enough during a calendar year to qualify as resident aliens for tax purposes.” Thus, non-resident aliens are not subject to the individual mandate, even if they have to file a tax return.
Under IRS Publication 519, Tax Guide for Aliens (the green card test), green card holders are resident aliens for tax purposes. The substantial presence test uses a formula to count the number of days present in the U.S. over the past 3 years. Generally, you a resident alien after six months of presence in the U.S. – unless you are exempt.
Resources
For Travel Insurance questions and to discuss options please contact our team at Millennium Medical Solutions Corp (855)667-4621. We have Spanish, Russian, and Hebrew speakers available.
After three (3) years of spirited debate, numerous lawsuits, and a Supreme Court ruling, the individual mandate kicked in January 1, 2014. Individuals must have health insurance or pay a tax (as defined by the Supreme Court). As an employer what should you be prepared for this year?
It has been an eventful year for the American health care system, to say the least. More parts of the Patient Protection and Affordable Care Act (PPACA) have gone into effect and the launch of the health care exchanges across the country is now under way. There have been numerous challenges to the PPACA and many of its components. The U.S. Supreme Court has ruled the Act’s individual mandate constitutional, but continues to examine the constitutionality of other aspects of the law.
Insurers have shifted more and more of the health care cost burden to enrollees through high deductible, higher co-pays and fixed benefits plans. An increasing number of payers are using Medicare based pricing, data analytics and wellness programs in their efforts to control ever rising costs. Narrow networks are popping up across the country as a vehicle for cost control.
Whatever the New Year brings, we look forward to supporting you in your continuing efforts to control costs while maintaining a high standard of care.
The New Year Ushers in Health Care Reform
All employers will have to pay additional taxes on their health insurance plans which may result in about a 5% average increase in premiums.
Waiting periods for benefits may not exceed 90 days from the date of hire. This will be effective with your 2014 renewal.
Small group employers (2-50 employees) will have to include pediatric dental and vision in their 2014 health plans.
Small employers who qualify for the Small Business Health Care Tax Credit, and want to take advantage of the tax credit, must purchase their health insurance through the SHOP Marketplace. Yes, as your broker, we can assist you with the SHOP Marketplace.
Applicable Large Employers are employers with 50 FTE (full-time equivalents) or more, and must offer affordable and minimum value coverage to full-time employees (employees who work 30 hours or more per week). Employers must offer minimum value coverage to dependents, but do not have to meet the affordable test. Employers are not required to offer coverage to spouses. Penalties for not offering coverage have been delayed until 2015. However, we do not know if penalties will begin January 1, 2015 or with the 2015 health insurance renewal; awaiting a response from the IRS.
Applicable Large Employers who have variable hour employees, employees who have a fluctuating schedule, should select a measurement period (3, 6, 9, 12 months) and begin tracking hours to determine if variable hour employees meet the 30 hour requirement.
Employers who issued 250+ W-2 forms for the 2012 tax year will need to include the cost of health insurance on their W-2 forms for the 2013 tax year. Other employers may voluntarily include the cost of health insurance on their employees’ W-2 forms.
Individuals who do not have coverage in 2014 will be subject to a penalty which will be calculated one of two ways, whichever one is higher applies.
$95 per person, $47.50 for individuals under 18; the maximum penalty for a family under this calculation is $285.
1% of yearly household income; the maximum penalty is the national average yearly premium for a bronze plan.
The fee increases every year. In 2015 it’s 2% of income or $325 per person. In 2016 and later years it’s 2.5% of income or $695 per person. After that it is adjusted for inflation.
Individuals who are uninsured for just part of the year, 1/12 of the yearly penalty applies to each month the individual is uninsured. Individuals who have coverage for one (1) day during a month will be considered to have coverage and not pay a penalty for the month. Individuals who have a short gap in coverage, who are uninsured for less than 3 months, may not be required to pay a penalty for those months.
Health Care Reform 2014 Compliance Checklist – Click Here.Please contact us if you have questions, if you need assistance with SHOP Marketplace, or you have employees who need assistance getting individual coverage to avoid the penalty.
Breaking News President Announces Cancelled Policies Fix
Yesterday, the President announced that people with health care coverage that is not Affordable Care Act (ACA)-compliant may be able to keep their plans in 2014. Effectively “Grandfathering” of plans purchased after the original law has passed in 2010 There has been a great deal of concern being reported in the national media around the prospect of millions of people losing their health insurance coverage effective January 1, 2014 because of the Patient Protection and Affordable Care Act (“PPACA” aka “ObamaCare”).
We are awaiting how specifically your State’s Insurance Commissioner will react to this. Questions remain about how this new policy will work, including how insurance commissioners will react, whether insurance companies will choose to continue these policies, what the rates for the policies will be, and whether this grandfathering will extend past 2014.
To be clear, what’s being reported principally has to do with the individual health insurance market in the US which insures approximately 15 million people, or about 5% of the country’s population. Within that segment of the privately insured market, a large percentage, certainly more than half, of individual policies are not considered to be “grandfathered” under the law’s requirements for such status. As a result, to be in compliance with the law’s new mandates and coverage requirements, virtually all “non-grandfathered” policies are scheduled to be terminated January 1st, and it will be up to individuals to replace their existing coverage with new compliant policies after this date.
These recent developments have resulted in
1) President Obama issuing an apology to affected individuals on November 7th.
2) the President’s announcement earlier yesterday during a hastily called press conference at the White House that pursuant to an Executive Order, Americans may keep individual health insurance policies they were told will be canceled because these policies failed to meet requirements established by the new law.
President Obama has left it up to the states to independently determine how they will go about implementing this change which is being characterized as an “administrative fix”. However, since the insurance business is state-regulated, each state will need to determine whether or not they will implement this change, and if they choose to implement it, they will have control over defining some of the specific parameters. Insurance companies will also need to quickly make decisions on how to accommodate this new provision if the change is adapted in a state in which they operate.
In closing, if you should have any further questions or comments about the above or the attached, please let us know.We will continue to monitor this issue and all ACA implementation in an effort to keep you informed of new developments. In the meantime, please visit our https://medicalsolutionscorp.com/about-us/blog to view past blogs and Legislative Alerts.
Why are my rates going up? The recent 2014 health insurance rates ranging in 15-20% increase is having a profound impact especially on small businesses. Benefits are furthermore deteriorating with new deductibles adding a 10% to the out of pocket costs for a net total 25-30% rate increase.
No pre-existing condition. Several new cost contributors aside from Essential Health Benefits Mandate are assigned. Recent articles such as Kaiser’s Popular Provision Of Obamacare Is Fueling Sticker Shock For Some Consumers attributes new Pre-Existing condition waiver as a factor. Starting Jan 1, 2014 anyone with or without prior health insurance can get immediate treatment without a 12 month waiting period. “But the provision also adds costs. To a larger degree than other requirements of the law, it is fueling the “sticker shock” now being voiced by some consumers about premiums for new policies, say industry experts.” With the guaranteed issue there are unknown costs that cannot be accounted for just yet. Example: An uninsured individual we know is delaying needed surgeries until January for this reason. The member will pay a $250/month premium and get a $40,000 surgery paid for immediately. How many young healthy members are needed to offset this cost?
Transitional reinsurance fee. This is paid by fully insured and self-funded plans. The goal of the fee is to stabilize the individual markets by reimbursing companies who insure a disproportionately large number of individuals who are high utilizers of health care services. Fees will be collected between 2014, 2015, and 2016.
Health insurance providers’ fee, also referred to as a health insurance tax, annual fee, and insurer fee. This will be assessed annually beginning in 2014 on health insurance carriers. The total amount to be collected in 2014 is $8 billion. The tax is based on premiums and by some estimates is expected to have a cost impact of 2 to 2.5 percent in 2014, and higher in subsequent years.
Exchange fee. For 2014, our state’s online exchange marketplace is funded through federal start-up grants. But states that run their own exchange, such as Washington, have been tasked with implementing a funding mechanism after 2014. In the session that ended in June, the Washington State Legislature approved a funding plan for our exchange that authorizes the use of a current insurance premium tax for the qualified health plans (QHPs) sold in the exchange and, if necessary, an additional assessment on carriers who sell QHPs through the exchange.
Patient-Centered Outcome Research Institute (PCORI) fee (also known as comparative-effectiveness fee). Health insurance issuers and sponsors of self-funded group health plans will be assessed this annual fee beginning in 2012 and ending in 2019. It funds patient-centered outcomes research. PCORI is a nonprofit corporation whose mission is to help people make informed health care decisions, and improve health care delivery and outcomes. The Group Health Research Institute has received two research awards from PCORI to study ways to improve care for back pain, and connect patients with community resources.
Essential Health benefits. The quintessential question asked is why are my rates going up so much this year has multiple answers with new Essential Health Benefits leading the way. The Essential Health Benefits Not Delayedarticle explains that The Affordable Care Act mandates that the plans include ten essential benefits, from care for pregnant mothers to substance abuse treatment. Popular local plans such as Healthy NY and Brooklyn Healthworks have afforded coverage for over a decade are are missing Mental Health, Chiropractic, and have a $3,000 Rx limit. All Individual Healthy NY and Sole Proprietors are terminating this year . Existing small businesses must buy the full version with Essential Health Benefits.
CASE: A Healthy Ny client just had an increase for singles from $412 to $519. She is a successful generous Caterer who is covering majority of a staff of 10 employees which is unusual for that industry. Her staff had an affordable benefits as well. They loved paying only $20, her Rx copay was only $10/generic and $20/brand for providers she did not have any deductibles. Hospitalization had full coverage with a modest copay. Statistically nearly 90% do not use more than $3,000 Rx. her new plan rolls automatically into the GOLD PLAN increasing her premium 25% along with a new $600 deductible on all benefits and a $40 copay for Specialist. She asked me I thought the new tax was only .9% medicare tax but evidently this IS HER NEW TAX.
So much for if you like your plan you can keep it promise. Even supporters such as Former President ClintonWeighs in on Obamacare. “Obama should honor his health-care promise: Pres. Clinton”, He personally believes President Barack Obama should honor his promise that people who have and like their insurance can keep it.
Do not under estimate the power of the Bill. The President is reviewing ways to allow some to keep their health plan but this would only apply to policyholders losing coverage. Stay tuned.
You can download the complete Essential Health Benefits NYS. Also, for a downloadable guide on self-insuring and secondary market reinsurance for your group please send contact form below. In the meantime, please visit to view past blogs and Legislative Alerts at https://medicalsolutionscorp.com/feed.
Most employers search for methods of lowering their company’s spending on their health benefit plans. A Self Funded, or Self-Insured plan, is one in which the employer assumes the financial risk for providing health care benefits to its employees. In practical terms, Self-Insured employers pay for claims out-of-pocket as they are presented instead of paying a pre-determined premium to an insurance carrier for a Fully Insured plan. Typically, a self-insured employer will set up a special trust fund to earmark money (corporate and employee contributions) to pay incurred claims.
In a self-funded — also known as self-insured — health plan, the employer takes on direct financial responsibility for employees’ health care costs. Rather than being part of a larger risk pool, an employer that self-funds takes on the risk for its employee group alone. All of a health plan may be self-funded, or an insurance contract might be purchased to cover certain types of claims. Most self-funded employers buy stop-loss insurance to cover catastrophic claims
Being exempt from state insurance laws and mandates and not having to pay premiums on a regular basis to an insurance company can result in substantial cost savings. Yet, many employers, especially smaller employers, shy away from self-funding, perceiving it as too risky.
According to a Kaiser Family Foundation Health Benefits Survey, about 55 percent of all employees covered for health care are in self-funded plans. Among employers with 200 or more workers, 77 percent of employees are in self-funded health plans, compared to 12 percent of employees in firms with 3–199 workers.
What is a TPA?
A third party administrator (TPA) is an entity that processes or adjudicates claims for an employee benefit plan. A TPA may provide additional services to an employee benefit plan or employer, such as collecting premiums, contracting for PPO services, providing utilization review of claims, and similar ancillary services to the operation of the employee benefit plan. Self-insured employers can either administer the claims in-house, or subcontract this service to a TPA.
Why do employers self fund their health plans?
There are several reasons why employers choose the self-insurance option. The following are the most common reasons:
The employer can customize the plan to meet the specific health care needs of its workforce, as opposed to purchasing a ‘one-size-fits-all’ insurance policy.
The employer maintains control over the health plan reserves, enabling maximization of interest income – income that would be otherwise generated by an insurance carrier through the investment of premium dollars.
The employer does not have to pre-pay for coverage, thereby providing for improved cash flow.
The employer is not subject to conflicting state health insurance regulations/benefit mandates, as self-insured health plans are regulated under federal law (ERISA).
The employer is not subject to state health insurance premium taxes, which are generally 2-3 percent of the premium’s dollar value.
The employer is free to contract with the providers or provider network best suited to meet the health care needs of its employees.
Is self-insurance the best option for every employer?
No. Since a self-insured employer assumes the risk for paying the health care claim costs for its employees, it must have the financial resources (cash flow) to meet this obligation, which can be unpredictable. Therefore, small employers and other employers with poor cash flow may find that self-insurance is not a viable option. It should be noted, however, that there are companies with as few as 25 employees that do maintain viable self-insured health plans.
Can self-insured employers protect themselves against unpredicted or catastrophic claims?
Yes. While the largest employers have sufficient financial reserves to cover virtually any amount of health care costs, most self-insured employers purchase what is known as stop-loss insurance to reimburse them for claims above a specified dollar level.
With what laws must self-insured group health plans comply?
Self-insured group health plans come under all applicable federal laws, including the Employee Retirement Income Security Act (ERISA), Health Insurance Portability and Accountability Act (HIPAA), Consolidated Omnibus Budget Reconciliation Act (COBRA), the Americans with Disabilities Act (ADA), the Pregnancy Discrimination Act, the Age Discrimination in Employment Act, the Civil Rights Act, and various budget reconciliation acts such as Tax Equity and Fiscal Responsibility Act (TEFRA), Deficit Reduction Act (DEFRA), and Economic Recovery Tax Act (ERTA).
How can your organization benefit from self insurance or level funding? Are there Self-Insurance advantages of avoiding Essential Health Benefits and using the lower cost Minimum Actuarial Value in Health Care Reform?
For additional information on self-funding please contact us at 1-855-667-4621 or e-mail us at info@medicalsolutionscorp.com.
[tab_item title=”Reminder PCORI Research Fees Due by July 231st”]
Posted on July 24 2013
Fees Apply to Employers Sponsoring Certain Self-Insured Plans
Effective for plan years ending on or after October 1, 2012, and before October 1, 2019, employers that sponsorcertain self-insured plans are responsible for new fees to fund the Patient-Centered Outcomes Research Institute (also known as PCORI). HRAs and health FSAs that are not treated as excepted benefits are generally subject to the fees.
Fees are due no later than July 31st of the year following the last day of the plan year. The IRS has revised Form 720for affected employers to report and pay the required fees.
Review our Health Care Reform Checklist for information on other requirements impacting employers and group health plans this year.
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[tab_item title=”Affordable Care Act Weekly Webinar Series”]
Posted on July 23 2013
Free Series for Small Business Owners to Help Understand the Law
The U.S. Small Business Administration (SBA), together with the Small Business Majority (a national nonprofit advocacy organization), has launched the Affordable Care Act 101 Weekly Webinar Series. The webinars feature guidance on key pieces of the law for small business owners provided by SBA representatives, followed by a question and answer period.
Topics being discussed in the webinars include:
Small business tax credits—who is eligible and how to claim the credit;
Shared responsibility (also known as “pay or play”);
Cost containment; and
Tools and resources available for small businesses to learn more about the law.
The free series will take place every Thursday from now through the opening of the Health Insurance Exchanges (Marketplaces) in October. The first series of webinars will cover the same content; a second round of webinars featuring new content will be held later this fall.
The registration links for the first series of webinars can be found by clicking here. After registering, you will receive a confirmation email with all of the information needed to access the webinar either by telephone or online.
Visit our Health Care Reform Blog section to stay on top of the latest Affordable Care Act updates.
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[tab_item title=”4 Things Employers Should Know About Providing the Health Insurance Exchange Notice”]
Posted on July 19 2013
Notice Must Be Distributed to Current Employees No Later Than October 1, 2013
Following a delay in the original effective date, employers will need to comply with the new requirement to provide each employee a written notice with information about a Health Insurance Exchange (also known as a Marketplace) beginning this fall. Below are four important reminders about the notice.
The notice requirement applies to employers covered by the federal Fair Labor Standards Act (FLSA). In general, the FLSA applies to employers that employ one or more employees who are engaged in, or produce goods for, interstate commerce. For most firms, a test of not less than $500,000 in annual dollar volume of business applies. The FLSA also specifically covers certain entities such as hospitals, educational institutions, and government agencies.
Employers must provide the notice to each employee, regardless of plan enrollment status (if applicable) or of part-time or full-time status. Employers are not required to provide a separate notice to dependents or other individuals who are or may become eligible for coverage under the plan but who are not employees.
The U.S. Department of Labor has provided two sample notices employers may use to comply with this requirement. The law requires that specific information be included in each notice. One model notice is available for employers that offer a health plan to some or all employees, and another model notice may be used by employers that do not offer a health plan.
Notices must be provided to each current employee no later than October 1, 2013, and to each new employee at the time of hiring beginning October 1, 2013. In general, a notice will be considered provided at the time of hiring if it is provided within 14 days of an employee’s start date. The notice is required to be provided automatically and free of charge. Employers may distribute the notice by first-class mail, or electronically if certain requirements are met.
Visit our section on Health Reform Resource for information on other notices required to be provided and to download additional model notices available for employers and group health plans.
[/tab_item][tab_item title=”5 Q and As on Individual Shared Responsibility”]
Posted on July 12 2013
Employer-Sponsored Coverage Considered “Minimum Essential Coverage”
The individual shared responsibility provision, which goes into effect on January 1, 2014, requires individuals of all ages (including children) to have minimum essential health coverage for each month, qualify for an exemption, or make a payment when filing his or her federal income tax return. Below are five questions and answers related to the mandate that may be of interest to employers and employees.
1. What counts as minimum essential coverage?
Minimum essential coverage includes employer-sponsored coverage (including COBRA coverage and retiree coverage), coverage purchased in the individual market, Medicare Part A coverage and Medicare Advantage, Children’s Health Insurance Program (CHIP) coverage, and certain other types of coverage.
Minimum essential coverage does not include coverage providing only limited benefits, such as coverage only for vision care or dental care, workers’ compensation, or disability policies.
2. If an employee receives coverage from a spouse’s employer, will that employee have minimum essential coverage?
Yes. Employer-sponsored coverage is generally minimum essential coverage. If an employee enrolls in employer-sponsored coverage for himself and his family, the employee and all of the covered family members have minimum essential coverage.
3. Does an employee’s spouse and dependent children have to be covered under the same policy or plan that covers the employee?
No. An employee, his or her spouse, and dependent children do not have to be covered under the same policy or plan. However, the employee, spouse, and each dependent child for whom the employee may claim a personal exemption on his or her federal income tax return must have minimum essential coverage or qualify for an exemption, or a payment will be owed.
4. A company’s health plan is “grandfathered.” Does the employer’s plan provide minimum essential coverage?
Yes. Grandfathered group health plans provide minimum essential coverage.
5. Is transition relief available in certain circumstances?
Yes. Notice 2013-42 provides transition relief from the shared responsibility payment for individuals who are eligible to enroll in employer-sponsored health plans with a plan year other than a calendar year (non-calendar year plans) if the plan year begins in 2013 and ends in 2014. The transition relief applies to an employee, or an individual having a relationship to the employee, who is eligible to enroll in a non-calendar year eligible employer-sponsored plan with a 2013-2014 plan year. The transition relief begins in January 2014 and continues through the month in which the 2013-2014 plan year ends.
For More Information
You may review additional questions and answers in their entirety on the IRS website.
[/tab_item][tab_item title=”IRS Guidance on Delay of Pay or Play Requirements”]
Posted on July 10 2013
No Penalties Will Be Assessed for 2014
Formal guidance released by the IRS provides additional details regarding the delay of the Health Care Reform “pay or play” requirements. Under those provisions, certain large employers (generally those with at least 50 full-time employees) who do not offer full-time employees affordable health insurance that provides a minimum level of coverage may be subject to a penalty tax.
According to the guidance, no penalties (also known as employer shared responsibility payments) will be assessed for 2014. The “pay or play” requirements will be fully effective for 2015 and employers are encouraged to maintain or expand health coverage in 2014 in preparation for compliance.
The delay is a result of transition relief being provided for 2014 with respect to certain employer and insurer reporting requirements. Such reporting will be necessary for the IRS to determine whether a penalty may be due, and, consequently, the transition relief makes it impractical to determine which employers owe shared responsibility payments for 2014. Once the information reporting rules are issued, employers are encouraged to voluntarily comply with the reporting requirements in 2014.
The delay does not affect the application or effective dates of other Health Care Reform provisions, including the individual shared responsibility requirements and employees’ access to premium tax credits for enrolling in qualified health plans through the Health Insurance Exchanges.
“New Jersey and all other states still await substantial federal guidance on the functioning of all three types of exchanges,” Mr. Christie said in his veto message. “To be sure, the decision of whether to move forward with a state-based exchange can only be fully understood when competitively compared to the overall value of the other options.”
States have until Dec. 14 to decide whether to establish a state-based exchange. They have more time to decide whether to partner with the federal government or let federal bureaucrats design and run the state exchange. Many states with Republican governors have said they would not participate in the process, citing their opposition to the law and its potential costs. This is the current Map of State Exchange Status.
What is an Exchange? One of the centerpieces of the recently passed Patient Protection and Affordable Care Act (PPACA) is the establishment of state based health insurance exchanges by the year 2014.
An “Exchange” is a mechanism for organizing the health insurance marketplace to help consumers and small businesses shop for coverage in a way that permits easy comparison of
available plan options based on price, benefits, service and quality. By pooling individuals and small groups together, transaction costs can be reduced and transparency can be increased.
Exchanges can create more efficient and competitive markets for individuals and small employers.
States have until Dec. 14 to decide whether to establish a state-based exchange. They have more time to decide whether to partner with the federal government or let federal bureaucrats design and run the state exchange. Many states with Republican governors have said they would not participate in the process, citing their opposition to the law and its potential costs.
Many Republican governors were saying before the Court ruling that the Medicaid expansion was yet another unfunded federal mandate they could not afford. Yes the Supreme Court ruling has given the Republican governors enormous leverage. Republican governors have long argued that state control and flexibility can save lots of Medicaid money. If they put a reasonable plan on the table to expand their Medicaid programs to 133% of poverty–one that saves at least as much as their state match–it could be a win for everyone. The Republican governors get their flexibility and the Obama administration gets their expansion.
CLICK HERE TO DOWNLOAD PDF – 
Orientation Period for New Hires
In a self-funded — also known as self-insured — health plan, the employer takes on direct financial responsibility for employees’ health care costs. Rather than being part of a larger risk pool, an employer that self-funds takes on the risk for its employee group alone. All of a health plan may be self-funded, or an insurance contract might be purchased to cover certain types of claims. Most self-funded employers buy stop-loss insurance to cover catastrophic claims
