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The Centers for Medicare & Medicaid Services (CMS) announced on February 20,2015 a special enrollment period (SEP) for individuals and families who did not have health coverage in 2014 and are subject to the fee or “shared responsibility payment” when they file their 2014 taxes in states which use the Federally-facilitated Marketplaces (FFM). This special enrollment period will allow those individuals and families who were unaware or didn’t understand the implications of this new requirement to enroll in 2015 health insurance coverage through the FFM.

For those who were unaware or didn’t understand the implications of the fee for not enrolling in coverage, CMS will provide consumers with an opportunity to purchase health insurance coverage from March 15 to April 30.  If consumers do not purchase coverage for 2015 during this special enrollment period, they may have to pay a fee when they file their 2015 income taxes.

Those eligible for this special enrollment period live in states with a Federally-facilitated Marketplace and:

  • Currently are not enrolled in coverage through the FFM for 2015, 
  • Attest that when they filed their 2014 tax return they paid the fee for not having health coverage in 2014, and  
  • Attest that they first became aware of, or understood the implications of, the Shared Responsibility Payment after the end of open enrollment (February 15, 2015) in connection with preparing their 2014 taxes.

 

The special enrollment period announced today will begin on March 15, 2015 and end at 11:59 pm E.S.T. on April 30, 2015.  If a consumer enrolls in coverage before the 15th of the month, coverage will be effective on the first day of the following month.

This year’s tax season is the first time individuals and families will be asked to provide basic information regarding their health coverage on their tax returns.  Individuals who could not afford coverage or met other conditions may be eligible to receive an exemption for 2014. To help consumers who did not have insurance last year determine if they qualify for an exemption, CMS also launched a health coverage tax exemption tool today on HealthCare.gov and CuidadodeSalud.gov.

“We recognize that this is the first tax filing season where consumers may have to pay a fee or claim an exemption for not having health insurance coverage,” said CMS Administrator Marilyn Tavenner.  “Our priority is to make sure consumers understand the new requirement to enroll in health coverage and to provide those who were not aware or did not understand the requirement with an opportunity to enroll in affordable coverage this year.”

Most taxpayers will only need to check a box when they file their taxes to indicate that they had health coverage in 2014 through their employer, Medicare, Medicaid, veterans care or other qualified health coverage that qualifies as “minimum essential coverage.”  The remaining taxpayers will take different steps. It is expected that 10 to 20 percent of taxpayers who were uninsured for all or part of 2014 will qualify for an exemption from the requirement to have coverage. A much smaller fraction of taxpayers, an estimated 2 to 4 percent, will pay a fee because they made a choice to not obtain coverage and are not eligible for an exemption.

Americans who do not qualify for an exemption and went without health coverage in 2014 will have to pay a fee – $95 per adult or 1 percent of their income, whichever is greater – when they file their taxes this year.  The fee increases to $325 per adult or 2% of income for 2015.  Individuals taking advantage of this special enrollment period will still owe a fee for the months they were uninsured and did not receive an exemption in 2014 and 2015.  This special enrollment period is designed to allow such individuals the opportunity to get covered for the remainder of the year and avoid additional fees for 2015.  

The Administration is committed to providing the information and tools tax filers need to understand the new requirements. Part of this outreach effort involves coordinating efforts with nonprofit organizations and tax preparers who provide resources to consumers and offer on the ground support. If consumers have questions about their taxes, need to download forms, or want to learn more about the fee for not having insurance, they can find information and resources at www.HealthCare.gov/Taxes or www.IRS.gov. Consumers can also call the Marketplace Call Center at 1-800-318-2596.  Consumers who need assistance filing their taxes can visit IRS.gov/VITA or IRS.gov/freefile.

Consumers seeking to take advantage of the special enrollment period can find out if they are eligible by visitinghttps://www.healthcare.gov/get-coverage. Consumers can find local help at: Localhelp.healthcare.gov or call the Federally-facilitated Marketplace Call Center at 1-800-318-2596. TTY users should call 1-855-889-4325. Assistance is available in 150 languages. The call is free.

For more information about Health Insurance Marketplaces, visit: www.healthcare.gov/marketplace

Nurse Hotline

May 15 - Posted at 2:01 PM Tagged: , , , , , ,

Imagine you are home cooking dinner on a Saturday night and you suffer a minor burn. You can not decide if the burn is serious enough to go to the Emergency Room or how exactly to care for the burn. Did you know that most major insurance carriers offer their members 24/7/365 access to a free Nurse Hotline for situations just like this?

 

These Nurse Hotlines help provide a free nurse to members who can help the member evaluate the best type of care for their situation (i.e. if they should go to the ER to have their burn looked at or if a home remedy will suffice). They can also offer members additional information on chronic conditions they suffer from, support when coordinating follow up care, or help direct them to other programs their insurance carrier may offer (i.e. weight loss discounts or free breast pumps to expectant mothers). 

 

For more information on your insurance carrier and if they offer this program, please contact our office. 

Obama Administration Extends Another ACA Compliance Deadline for Health Plans

March 07 - Posted at 3:51 PM Tagged: , , , , , , , , , , , , , ,

It was announced on Wednesday, March 5th, by the Obama Administration  that it would allow some health plans that do not currently meet all Affordable Care Act (ACA) requirements to continue offering non-compliant insurance for another two years. The Centers for Medicare and Medicaid Services (CMS) released the announcement, clarifying the new policy.

 

In November 2013, the Obama administration decided that some non-grandfathered health plans in the small group and individual markets would not be considered out of compliance if they failed to meet certain coverage provisions of the ACA. The transition relief was originally scheduled to last for one year, and was viewed as a response to the numerous health insurance policy cancellations that would result from the new requirements.

 

This recent announcement extends this relief for two additional years. CMS released the following:

“At the option of the States, health insurance issuers that have issued or will issue a policy under the transitional policy anytime in 2014 may renew such policies at any time through October 1, 2016, and affected individuals and small businesses may choose to re-enroll in such coverage through October 1, 2016.”

 

Who Will This  Impact?

 

This decision, which will likely prevent another wave of cancellations that were scheduled to begin November 1, 2014 and will impact some insurance offerings, but is unlikely to have a significant impact, since only about half of the states have opted to grant extensions to health plans within their jurisdictions. Further, the number of people currently on these non-compliant plans has been dropping, and is expected to continue to decline. Under the new policy, these plans (which typically offer fewer benefits at lower costs since they do not have to abide by the ACA’s minimum essential coverage) will still be available until plans expire in 2017.

 

Please note that it will be up to each individual state, as well as each individual insurance carrier, as to if they will decide to adopt this additional two year extension. Under the original one year transitional relief, even though it was allowed in the State of Florida, there are currently some health insurance carriers who have decided to not allow groups to renew their existing non-compliant medical plans.

 

We will continue to keep you up to date of new developments in ACA implementation as they arise. Please contact our office for additional information regarding your group’s medical policy and the impact of this recent change on it.

Florida Health Exchange Details Released

August 13 - Posted at 10:00 PM Tagged: , , , , , , , , , ,

For Florida residents hoping to purchase coverage through the new health insurance exchange, the state Office of Insurance Regulation has recently released information that your options will largely depend on where you reside.

As of August 2013, 10 insurance companies have received federal approval to sell Floridians health plans on the federally assisted health exchange, which rolls out Oct. 1. However, Kevin McCarty, Florida’s Insurance Commissioner, has said that not all companies will sell plans in all counties.

More than half of Florida’s counties will have only one or two insurance companies selling plans through the new marketplace and no county will offer plans from all 10 companies, according to the insurance commissioner’s office. The companies that will be actively selling within the Florida Exchange are:

  • Aetna Life Insurance Company
  • Blue Cross Blue Shield of Florida
  • Cigna Health and Life Insurance Company
  • Coventry Health Care of Florida, Inc.
  • Florida Health Care Plan, Inc.
  • Health First Health Plans
  • Health First Insurance Company
  • Health Options, Inc.
  • Humana Medical Plan, Inc.
  • Molina Healthcare Of Florida, Inc.

 

South Floridians will have the most choice, while residents in rural areas have the least. Broward and Miami-Dade counties will sell plans from nine federally approved insurers. In Central Florida, residents of Orange, Osceola and Lake counties will have options from five insurance companies, while Seminole and Volusia will have six. Population density and an insurer’s current presence in an area will determine if the carrier has choose to sell in your area.

 

Although the Florida insurance commissioner knows which 10 companies have been approved to sell plans in Florida, they would not disclose which companies would sell in each county yet.

 

A spokesman for Blue Cross Blue Shield made no secret they would be selling plans in all 67 Florida counties, making it the only insurer to do so. Blue Cross Blue Shield will in fact be the sole seller for exchange plans in 21 Florida counties.

 


Insurers can offer a tiered set of plans, ranging from bronze (a leaner choice) to platinum (with the most benefits). Still forthcoming, however, are details about what the individual plans will offer and what each will cost.

Florida residents should begin now to familiarize themselves with the exchange, explore the varied levels of coverage available and understand the possible tax credits available since open enrollment for the Exchange is scheduled to begin October 1st for a January 1, 2014 effective date. 
 
To qualify for tax credits available under the health-care overhaul, residents must get their insurance on the government exchange (healthcare.gov).


If you currently have an individual health insurance plan, you will be in for a big change when you sign up for your coverage in 2014.

 

Approximately 50% of the individual health plans that are currently being sold in the marketplace do not meet the standards of Obamacare to be sold in 2014. The reason for this is because the Affordable Care Act (ACA) sets new minimums for the basic coverage every individual health care plan must provide effective on renewals on or after January 1, 2014.

 

About 15 million Americans (or about 6% of non-elderly adults) currently have coverage in the individual health market. Beginning in the fall of 2013, they will be able to shop for and enroll in health insurance through state-based exchanges (aka SHOP or The Exchange) with coverage taking effect in January. By 2016, it is projected that around 24 million people will get their insurance through the exchanges, while another 12 million will continue to obtain individual coverage outside of the exchange.

 

Beginning in 2014, nearly all plans, both group and individual, will be required to cover an array of “essential” services regardless of if they are purchased within the exchange or not. These “essential” services will include medication, maternity, and mental health care. Many individual plans do not currently offer these benefits.

 

What will happen to the plans that do not meet the new minimum standards? They will more than likely disappear and you will not be allowed to renew your existing coverage on the plan you currently have. A handful of existing plans will be grandfathered in, but the qualifying criteria for a grandfathered plan is hard to meet. In order for your existing individual plan to be considered “grandfathered”, (1) you have to have been enrolled on this plan before the ACA was passed in 2010 and (2) the plan has to have maintained fairly steady co-pay, deductible and coverage rates until now.

 

Many insurers in the individual marketplace have already acknowledged that the majority of their existing individual plans do not meet Obamacare standards for 2014 and they are currently working to ready new product lineups for 2014.

 

In the future, consumers buying individual plans will be able to choose between four levels of coverage: platinum, gold, silver, and bronze.

 

Platinum plans will carry the highest premiums but will offer the lowest out of pocket expenses, with enrollees paying no more than 10%, on average. At the other end of the spectrum are the bronze plans, which will have the lowest monthly premiums but will have higher deductibles and copayments totaling up to 40% of the out of pocket costs on average.

 

Starting also in 2014, all Americans will be required to carry health care coverage or face fines. Those penalties will start at $95 per adult or 1% of the adjusted family income, whichever is greater, and will escalate in later years.

 

Individuals will annual incomes of up to 400% of the poverty line (or roughly $45,000 for an individual and about $92,000 for a family of four) will get federal subsidies to help defray the premium costs.

 

Most individual plans sold next year, even the lowest level bronze plans, are likely to charge higher premiums than today’s most “bare-bones” individual insurance plans. Many consumers feel the costs will be offset by having lower out of pocket costs and more comprehensive coverage than their current “bare-bones” plan offers.

 

In today’s marketplace, with deductibles of $10,000, an individual can buy a policy and then when they get sick, they may go broke because the policy leaves them with such a high level of out of pocket expenses to pay.  Many insurance industry experts feel, however, that consumers may now wind up with more coverage–and higher monthly costs– than they want. As a result, some individuals may just choose to simply pay the fine instead of obtaining health insurance coverage they will not use or can not afford.

 

The Patient Protection and Affordable Care Act (the “ACA”) adds a new Section 4980H to the Internal Revenue Code of 1986 which requires employers to offer health coverage to their employees (aka the “Employer Mandate”). The following Q&As are designed to deal with commonly asked questions.  These Q&As are based on proposed regulations and final regulations, when issued, may change the requirements.

Question 2: Who Is Eligible for a Premium Tax Credit or Cost-Sharing Subsidy?

As noted in Part 1, failing to offer full-time employees minimum essential coverage, or coverage that meets the affordability or minimum value requirements, is not enough to trigger liability under the Employer Mandate. Two additional things must occur before any penalty will be assessed:

 

  1. one of the full-time employees must enroll in health coverage offered through an Exchange.

     

  2. one of the full-time employees must also receive an Exchange subsidy (a premium tax credit or cost-sharing subsidy).

 

 

Thus, an employer should consider which employees are potentially eligible for an Exchange subsidy when deciding how to comply with the Employer Mandate. It is important to note that the employee must qualify for the Exchange subsidy. An employee’s dependent receiving an Exchange subsidy (i.e. an adult child who is not a tax dependent of the employee) will not cause an Employer Mandate penalty.

Coverage Through an Exchange

In order to be eligible to receive an Exchange subsidy, an individual must enroll in health coverage offered through the Exchange. Under the ACA, an Exchange will be established in each state, either by the state or by the federal government (or a combination of the two). An Exchange is a governmental entity or nonprofit organization that serves as a marketplace for health insurance for individuals and small employers. Health insurance offered through the Exchanges must cover a minimum set of specified benefits and must be issued by an insurer that has complied with certain licensing and regulatory requirements.

Eligibility for an Exchange Subsidy

There are two Exchange subsidies available:

 

  • The premium tax credit- This is intended to help individuals purchase health coverage through the Exchange. The credit is available only to legal U.S. residents whose household income is 100% - 400% of the federal poverty line (“FPL”). Legal resident aliens also qualify for the credit if their household income is below 100% of the FPL since they are not eligible for Medicaid. Individuals who are eligible for Medicaid or Medicare, or certain other government-sponsored coverage (like CHIP or VA health care), are not eligible for premium tax credits.

    An employee is not eligible for a premium tax credit if the employee is either (i) enrolled in an employer-sponsored plan or (ii) eligible for an employer-sponsored plan that meets the affordability and minimum value requirements.

 

  • The cost-sharing subsidy- Cost-sharing subsidies, which reduce cost-sharing amounts such as co-pays and deductibles, are available to individuals who have a household income no greater than 250% of the FPL and enroll in “silver-level” coverage through the Exchange. An employee whose household income is 200% of the FPL may as a result be eligible for a premium tax credit to help defray the cost of monthly insurance premiums, and a cost-sharing subsidy to help reduce the amount of out-of-pocket cost (like co-pays and deductibles) to which the Exchange-enrolled employee otherwise would be subject to.



“Certification” of Eligibility for an Exchange Subsidy to Employer

The Employer Mandate penalty applies only when the employer has first received “certification” that one or more employees have received an Exchange subsidy. The IRS will provide this certification as part of its process for determining whether an employer is liable for the penalty. This penalty will occur in the calendar year following the year for which the employee received the Exchange subsidy (i.e. the employer would receive the penalty in 2015 for a employee Exchange subsidy beginning in 2014). Under IRS issued procedures, employers that receive notice of certification will be given an opportunity to contest the certification before any penalty is assessed.

In addition, Exchanges are required to notify employers that an employee has been determined eligible to receive an Exchange subsidy. The notification provided will identify the employee, indicate that the employee has been determined eligible to receive an Exchange subsidy, indicate that employer may be liable for an Employer Mandate penalty, and notify the employer of the right to appeal the determination. These notices will be useful in giving employers an opportunity to correct erroneous Exchange information and protect against erroneous penalty notices from the IRS. These notices will also be useful in budgeting for any penalties that may be owed.

Planning Consideration
The Employer Mandate penalty applies only to an employer failing to offer health coverage if one or more of its full-time employees enrolls in insurance coverage through an Exchange, and actually receives either a premium tax credit or a cost-sharing subsidy. Unless a full-time employee enrolls in an Exchange and obtains the tax credit or subsidy, the employer is off the hook. This can lead to some surprising exemptions from the penalty.

The Patient Protection and Affordable Care Act (the “ACA”) adds a new Section 4980H to the Internal Revenue Code of 1986 which requires employers to offer health coverage to their employees (aka the “Employer Mandate”). The following Q&As are designed to deal with commonly asked questions.  These Q&As are based on proposed regulations and final regulations, when issued, may change the requirements.

Question 1: What Is the Employer Mandate?

On January 1, 2014, the Employer Mandate will requiring large employers to offer health coverage to full-time employees and their children up to age 26 or risk paying a penalty. These employers will be forced to make a choice:

 

  • “play” by offering affordable health coverage that is  considered “minimum essential coverage”

 

                             OR

 

  • pay” by potentially owing a penalty to the Internal Revenue Service if they fail to offer such coverage.

 

This “play or pay” system has become known as the Employer Mandate. The January 1, 2014 effective date is deferred for employers with fiscal year plans that meet certain requirements.

 

Only “large employers” are required to comply with this mandate. Generally speaking, “large employers” are those that had an average of 50 or more full-time or full-time equivalent employees on business days during the preceding year. “Full-time employees” include all employees who work at least 30 hours on average each week. The number of “full-time equivalent employees” is determined by combining the hours worked by all non-full-time employees.

To “play” under the Employer Mandate, a large employer must offer health coverage that is:

  1. “minimum essential coverage”
  2. “affordable”, and
  3. satisfies a “minimum value” requirement to its full-time employees and certain of their dependents.

 

This includes coverage under an employer-sponsored group health plan, whether it be fully insured or self-insured, but does not include stand-alone dental or vision coverage, or flexible spending accounts (FSA).

 

Coverage is considered “affordable” if an employee’s required contribution for the lowest-cost self-only coverage option does not exceed 9.5%  of the employee’s household income. Coverage provides “minimum value” if the plan’s share of the actuarially projected cost of covered benefits is at least 60%.

If a large employer does not “play” for some or all of its full-time employees, the employer will have to pay a penalty, as shown in following two scenarios.

Scenario #1- An employer does not offer health coverage to “substantially all” of its full-time employees and any one of its full-time employees both enrolls in health coverage offered through a State Insurance Exchange, which is also being called a Marketplace (aka an “Exchange”), and receives a premium tax credit or a cost-sharing subsidy (aka “Exchange subsidy”).

 

In this scenario, the employer will owe a “no coverage penalty.” The no coverage penalty is $2,000 per year (adjusted for inflation) for each of the employer’s full-time employees (excluding the first 30). This is the penalty that an employer should be prepared to pay if it is contemplating not offering group health coverage to its employees.

Scenario #2- An employer does provide health coverage to its employees, but such coverage is deemed inadequate for Employer Mandate purposes, either because it is not “affordable,” does not provide at least “minimum value,” or the employer offers coverage to substantially all (but not all) of its full-time employees and one or more of its full-time employees both enrolls in Exchange coverage and receives an Exchange subsidy.

 

In this second scenario, the employer will owe an “inadequate coverage penalty.” The inadequate coverage penalty is $3,000 per person and is calculated, based not on the employer’s total number of full-time employees, but only on each full-time employee who receives an Exchange subsidy. The penalty is capped each month by the maximum potential “no coverage penalty” discussed above.


Because Exchange subsidies are available only to individuals with household incomes of at least 100% and up to 400% of the federal poverty line (in 2013, a maximum of $44,680 for an individual and $92,200 for a family of four), employers that pay relatively high wages may not be at risk for the penalty, even if they fail to provide coverage that satisfies the affordability and minimum value requirements.

 

Exchange subsidies are also not available to individuals who are eligible for Medicaid, so some employers may be partially immune to the penalty with respect to their low-wage employees, particularly in states that elect the Medicaid expansion. Medicaid eligibility is based on household income. It may be difficult for an employer to assume its low-paid employees will be eligible for Medicaid and not eligible for Exchange subsidies as an employee’s household may have more income than just the wages they collect from the employer. But for employers with low-wage workforces, examination of the extent to which the workforce is Medicaid eligible may be worth exploring.

Exchange subsidies will also not be available to any employee whose employer offers the employee affordable coverage that provides minimum value. Thus, by “playing” for employees who would otherwise be eligible for an Exchange subsidy, employers can ensure they are not subject to any penalty, even if they don’t “play” for all employees.

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