Tag Archives: Dana Rostro

Health Insurance Served On A Silver Platter

January 1, 2014 marks the start of Obamacare as the U.S. will experience changes in health insurance. With the health insurance marketplaces opening all over the nation in October, 2013, now is the time to be considering what type of health insurance you will be applying for, including Medicare or Medicaid.

Medicare vs. Medicaid

Medicare and Medicaid are both government programs that help people pay for health care. Medicare is generally for the elder and disabled, while Medicaid is for people with limited income and resources. Many low-income individuals are unaware of the positive opportunities the healthcare reform will create for them.

Comprehensive Coverage

Under the health care reform, all health plans being offered on state exchange must provide comprehensive coverage, but not all plans offer the same level of coverage. For many people Medicaid will serve as a safety net for health coverage. Medicaid is a free and comprehensive health plan that is easy to apply for. In order to receive Medicaid, however, you need to be approved as eligible. You will be asked to provide your social security number as well as an income statement. So although you will not get denied health coverage under Obamacare, Medicare or Medicaid may deny you.

Coverage That Works For You

Do you want to opt for Medicaid or Medicare? A good thing about Obamacare is that it will result in free Medicare preventative services. Although without fear of denial when applying for any type of health insurance coverage, it may be worth looking into other options. When the health care exchange takes place in October make sure you weigh your options based on both coverage and cost.

Benefits of Obamacare

Besides having your pick of the litter when it comes to coverage, there are several other important benefits of Obamacare. Beginning in 2014 no one will be able to be denied health care as a result of a pre-existing condition. This is important to everyone who has conditions ranging from cancer to pregnancy. This also affects children under the age of 19 who have pre-existing conditions. There will be free preventative services to all women including breastfeeding, contraception, domestic violence, and HIV screening and counseling. Obamacare will also limit insurers’ ability to charge unreasonably high premiums for private coverage.

Have more questions? Visit our Healthcare Reform Library or contact us  for more information.

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IRS Guidance on Delay of Employer Mandate Penalties and Reporting Requirements

On July 9, 2013, the Internal Revenue Service (IRS) issued Notice 2013-45 to provide formal guidance on the delay of the Affordable Care Act (ACA) large employer “pay or play” rules and related information reporting requirements. The provisions affected by the delay are:

  • § 4980H employer shared responsibility provisions;
  • § 6055 information reporting requirements for insurers, self-insuring employers and certain other providers of minimum essential coverage; and
  • § 6056 information reporting requirements for applicable large employers.

For 2014, compliance with the information reporting rules is completely optional and the IRS will not assess penalties under the pay or play rules. Both the information reporting and the employer pay or play requirements will be fully effective for 2015.

Information Reporting Requirements

The ACA amended the Internal Revenue Code (Code) to require large employers, health insurance issuers and self-funded plan sponsors to report information about health plan coverage to the IRS so that the federal government can enforce the employer mandate.

Code § 6055 requires annual information reporting by health insurance issuers, self-insuring employers, government agencies and other providers of health coverage. Code § 6056 requires annual information reporting by applicable large employers related to the health coverage that the employer offers (or does not offer) to its full-time employees.

Employer Shared Responsibility Requirements

Under the ACA, large employers that do not offer their full-time employees (and dependents) health coverage that is affordable and provides minimum value may be subject to penalties. The ACA’s employer mandate provisions are also referred to as the employer shared responsibility or pay or play rules.

One-year Implementation Delay

The large employer pay or play rules and related reporting requirements were set to take effect in 2014. However, on July 2, 2013, the Treasury announced that these will be delayed for one year, until 2015. This means that:

  • Information reporting under §§ 6055 and 6056 will be optional for 2014 and no penalties will be applied for failure to comply with these requirements for 2014; and
  • No employer shared responsibility payments will be assessed for 2014.

However, both the information reporting and the employer pay or play requirements will be fully effective for 2015.

The IRS issued Notice 2013-45 to provide more information on the delay.

According to the IRS, the delay of the reporting requirements provides additional time for input from employers and other reporting entities in an effort to simplify these requirements, consistent with effective implementation of the ACA. This delay is also intended to provide employers, insurers and other providers of minimum essential coverage time to adapt their health coverage and reporting systems.

The delay of the employer mandate penalties was required because of issues related to the reporting requirements. Because the reporting rules were delayed, the Treasury believed it would be nearly impossible to determine which employers owed penalties under the shared responsibility provisions.

The pay or play regulations issued earlier this year left many unanswered questions for employers. The IRS highlighted several areas where it would be issuing more guidance. Presumably, the additional time will give the IRS and Treasury the opportunity to provide more comprehensive guidance on implementing these requirements.

Effect on Other ACA Provisions

The delay does not affect any other provision of the ACA, including individuals’ access to premium tax credits for coverages through an Exchange and the individual mandate.

Individuals will continue to be eligible for the premium tax credit to purchase coverage through an Exchange as long as they meet the eligibility requirements (for example, their household income is within a specified range and they are not eligible for other minimum essential coverage).

Future Guidance

Proposed rules for the information reporting provisions are expected to be published this summer. The proposed rules will reflect the fact that transition relief will be provided for the information reporting requirements.

It is still unclear how the new deadline will impact guidance that has already been issued, such as the transition relief for non-calendar year plans and the optional safe harbor for determining full-time status. Future guidance may affect these and other rules under the ACA.

What this Means for Employers

The Obama Administration’s decision to delay the employer mandate penalties and related reporting requirements will have a significant effect on many employers. See below for an overview of the ACA provisions that are affected by the delay, the provisions that are not affected by the delay and steps that employers are encouraged to take in 2014.

For 2014, the IRS is encouraging employers to voluntarily:

  • Comply with the information reporting requirements once the IRS issues information reporting rules (which are expected this summer)
  • Maintain or expand health coverage to prepare for when the employer pay or play rules become effective in 2015.

         Delayed                                                                              Not Delayed

Information Reporting Requirements

The following employers will not have to report on coverage they provide:

Pay or Play Requirements

Employers will not be required to:


Current Provisions

Future Provisions

Prohibition on pre-existing condition exclusions (PCEs) for children

Subsidies for low-income individuals for Exchange coverage

Large employers with at least 50 full-time employees, including full-time equivalents (FTEs) Consider whether they employ on average 50 or more full-time employees, including FTEs, on business days during the previous calendar year

Small business tax credit

Individual mandate

Appeals process and external review rules

Establishment of Exchanges

Lifetime limits prohibited

Limits on cost-sharing

Employers with self-insured health plans Count employees’ hours to determine whether they average 30 or more hours per week

Required coverage of preventive care services

New requirements for wellness programs

Patient protections

Annual limits prohibited

Offer minimum essential coverage to substantially all full-time employees and dependents

Over-the-counter drug reimbursement limits

Employee notice of Exchanges

Rescissions prohibition

Rating restrictions

Offer coverage to employees who average 30 or more hours per week

PCORI fees

Health insurance provider fee and reinsurance fee

Health FSA limits

Guaranteed issue and renewability

Offer coverage that is of minimum value

Additional Medicare tax for high-wage earners

90-day waiting period limit

Offer coverage that is affordable

Uniform summary of benefits and coverage

Comprehensive benefits coverage

W-2 reporting

Prohibition on all PCEs

Dependent coverage up to age 26

Coverage for clinical trial participants

Medical loss ratio rules

Cadillac tax

Increased tax on withdrawals from HSAs and Archer MSAs

Automatic enrollment for employers with 200+ employees and nondiscrimination rules for fully-insured plans (effective dates TBD, but not affected by this delay)

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Reporting Requirements for Employers and Health Plans

The Affordable Care Act (ACA) created a number of federal reporting requirements for employers and health plans. The additional reporting (in addition to current W-2 reporting) is intended to promote transparency with respect to health plan coverage and costs. It will also provide the government with information to administer other ACA mandates, such as the large employer shared responsibility penalty and the individual mandate.


  • Large employer health coverage reporting (Code § 6056)
  • Reporting of health coverage by health insurance issuers and sponsors of self-insured plans (Code § 6055)
  • Transparency in coverage reporting and cost-sharing disclosures
  • Quality of care reporting

It is expected that federal agencies will issue more guidance on the new reporting requirements in the future. The Department of the Treasury recently announced that it is considering ways to simplify the new reporting requirements consistent with the ACA, particularly the reporting required under Internal Revenue Code (Code) sections 6055 and 6056, and that it expects to issue more guidance later this summer.

Texas Associates Insurors will continue to monitor health care reform developments and will provide updated information when it becomes available.

Form W-2 Reporting – currently effective

The ACA requires employers to report the aggregate cost of employer-sponsored group health plan coverage on their employees’ Forms W-2. The purpose of the Form W-2 reporting requirement is to provide information to employees regarding how much their health coverage costs.

In general, all employers that provide “applicable employer-sponsored coverage” must comply with the Form W-2 reporting requirement. Applicable employer-sponsored coverage is, with respect to an employee, coverage under any group health plan made available to the employee by the employer which is excludable from the employee’s gross income under Code section 106.

The Form W-2 reporting requirement is optional for small employers for 2012 and 2013. Small employers will continue to be exempt from the reporting requirement for later years, unless and until the IRS issues further guidance. An employer is considered a small employer if it had to file fewer than 250 Forms W-2 for the prior calendar year.

Large employers (those that file 250 or more Forms W-2) were required to comply with the reporting requirement beginning in 2012 for the Forms W-2 that were due by the end of January 2013.

Large Employer Health Coverage Reporting (Code § 6056) – Delayed until 2015

Large employers subject to the ACA’s shared responsibility provisions must file a return with the IRS that reports the terms and conditions of the health care coverage provided to the employer’s full-time employees for the calendar year. Related statements must also be provided to employees. The effective date for this reporting requirement has been delayed for one year, until 2015. Returns will be due in 2016 for coverage provided in 2015.

An employer qualifies as a “large employer” under the ACA’s shared responsibility provisions if it employed on average at least 50 full-time employees, including full-time equivalents (FTEs) on business days during the preceding calendar year.

The IRS will use the information that employers report to verify employer-sponsored coverage and administer the ACA’s shared responsibility provisions for large employers. The ACA’s shared responsibility provisions impose penalties on large employers that do not offer affordable, minimum value coverage to their full-time employees and dependents. The ACA’s employer penalties were set to take effect on Jan. 1, 2014, but have been delayed until 2015.

The large employer’s return must include the following information:

  • The employer’s name and employer identification number (EIN);
  • The date the return is filed;
  • A certification of whether the employer offers its full-time employees (and their dependents) the opportunity to enroll in minimum essential coverage under an eligible employer-sponsored plan;
  • The number of full-time employees for each month during the calendar year;
  • The name, address and taxpayer identification number (TIN) of each full-time employee employed by the employer during the calendar year and the months (if any) during which the employee and any dependents were covered under the eligible employer-sponsored plan during the calendar year; and
  • Any other information required by the IRS.

Most employer-sponsored health plans will qualify as minimum essential coverage. The ACA broadly defines “minimum essential coverage” to include both insured and self-insured group health plans, as well as plans with grandfathered status under the ACA. However, minimum essential coverage does not include specialized coverage, such as coverage only for vision care or dental care, workers’ compensation, disability policies or coverage only for a specific disease or condition.

In addition, large employers that offer the opportunity to enroll in minimum essential coverage must report:

  • The duration of any waiting period with respect to the coverage;
  • The months during the calendar year when coverage under the plan was available;
  • The monthly premium for the lowest-cost option in each enrollment category under the plan; and
  • The employer’s share of the total allowed costs of benefits provided under the plan.

Large employers must also provide each full-time employee with a written statement that includes the information relating to that employee (and dependents) that is required to be reported on the IRS return. The statement must be provided to full-time employees by Jan. 31 following the calendar year for which the information was required to be reported to the IRS.

In Notice 2012-33, the IRS requested comments on how to implement this employer reporting requirement. It is expected that future guidance will address how to coordinate this reporting requirement with similar ones, such as the return required under Code § 6055, to minimize duplication. For example, under the ACA, the IRS may allow a large employer with an insured health plan to agree with the issuer that issuer will include the information required under Code § 6056 with the return and statement provided by the issuer under Code § 6055.

Reporting of Health Coverage for issuers and self-insured plans (Code § 6055) – delayed until 2015

The ACA requires every health insurance issuer, sponsor of a self-insured health plan, government agency that administers government-sponsored health insurance programs and any other entity that provides minimum essential coverage to file an annual return with the IRS reporting information for each individual who is provided with this coverage. Related statements must also be provided to individuals.

The effective date for this reporting requirement has been delayed for one year, until 2015. Returns will be due in 2016 for coverage provided in 2015.

For employers with insured group health plans, it is anticipated that future IRS regulations will make the health insurance issuer, and not the employer, responsible for this health coverage reporting.

The IRS will use the information from the returns to implement the ACA’s individual mandate (that is, the requirement that individuals obtain acceptable health insurance coverage for themselves and their family members or pay a penalty). The ACA’s individual mandate goes into effect in 2014.

The return must include the following information:

  • The name, address and TIN of the primary insured and each other individual covered under the policy or plan;
  • The dates each individual was covered under the policy or plan during the calendar year;
  • If the coverage is health insurance coverage, whether the coverage is a qualified health plan (QHP) offered through an Exchange;
  • If the coverage is a QHP offered through an Exchange, the amount of any advance payment of the premium tax credit or of any cost-sharing reduction for each covered individual; and
  • Any other information required by the IRS.

In addition, if health insurance coverage is through an employer’s group health plan, the return must contain the following information:

  • The name, address and EIN of the employer maintaining the plan;
  • The portion of the premium (if any) to be paid by the employer; and
  • Any other information the IRS may require to administer the ACA’s small employer health care tax credit.

The entity required to file the IRS return must also furnish a written statement to each individual listed on the return. The statement must be provided by Jan. 31 following the calendar year for which the information was required to be reported to the IRS.

The IRS may allow for a return or written statement required under this health insurance coverage reporting provision to be coordinated with the reporting requirement for large employers under Code § 6056. In Notice 2012-32, the IRS requested comments on this reporting requirement, including how to coordinate and minimize duplication of ACA reporting.

Transparency in coverage Reporting and cost-sharing disclosures – delayed until at least 2015

The ACA requires health insurance issuers seeking certification of a health plan as a QHP under an Exchange to disclose certain information to the Exchange, Department of Health and Human Services (HHS) and state insurance commissioner. QHP issuers must also make this information available to the public. The information subject to reporting includes, for example, claims payment policies and practices, data on enrollment and disenrollment, data on the number of claims denied, data on rating practices and information on cost-sharing and payments for any out-of-network coverage.

Also, a health plan seeking QHP certification must provide certain cost-sharing disclosures (including deductibles, copayments and coinsurance) to participants upon request. At a minimum, this information must be made available through an Internet website and by other means for individuals without Internet access.

The ACA’s transparency in coverage reporting and cost-sharing disclosure requirements also apply to non-grandfathered group health plans and health insurance issuers offering group or individual coverage outside of an Exchange. The reporting requirements are identical to those for QHPs, except plans and issuers outside of the Exchange are not required to report information to an Exchange.

Because QHP insurers will not have certain required data until the first year of operation, this reporting requirement will go into effect after a QHP has been certified for one benefit year. This reporting requirement will become applicable to other group health plans and insurers no sooner than when the QHP reporting requirement becomes effective.

It is expected that HHS will issue more guidance on this reporting requirement, including how it applies to health plans and issuers offering coverage outside of an Exchange.

Quality of Care Reporting – Effective date To Be Determined

The ACA requires group health plans and health insurance issuers to submit an annual report to HHS regarding plan benefits and provider “reimbursement structures” that may affect the quality of care in certain ways. Grandfathered plans are not subject to the ACA’s “quality of care” reporting requirement.

In general, the report must address whether the plan or coverage:

  • Improves health outcomes through activities such as quality reporting, effective case management, care coordination, chronic disease management, and medication and care compliance initiatives (including the medical homes model);
  • Implements activities to prevent hospital readmissions using a comprehensive discharge program and post-discharge reinforcement;
  • Implements activities to improve patient safety and reduce medical errors through best clinical practices, evidence-based medicine and health information technology; and
  • Implements wellness and health promotion activities.

The annual quality of care reports will be available to the public through an Internet website. This report must also be provided to enrollees under the plan or coverage during each open enrollment period.

The ACA does not include a compliance deadline for the quality of care reporting requirement. The ACA required HHS to issue guidance on this reporting requirement by March 23, 2012 (that is, two years after the ACA’s enactment date). However, HHS has not yet issued this guidance. When this guidance is issued, it will likely specify a compliance deadline for plans and issuers.

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Getting the Word Out About Healthcare Reform

It seems everyone is talking about Health Care Reform, but is what they’re saying right? There might be a great deal of talk going around about Health Care Reform but for a long time it was speculative while the legislation was being debated, then it was reactive when the Act was signed and now we are still very much in the preparation stages with a lot of grey areas when it comes to clarity of information.

The Need for Education in Health Care Reform

Of the 50million Americans currently without any form of health insurance, 78% of these are unaware that there is a change coming. The main concern is that among these are a large proportion of young people who are vital to the success of the program.

Younger, healthier participants are valuable contributors to the insurance pool, without them the system won’t work. There is a national effort to educate and enroll people in health care and make them aware of their options. This is being orchestrated through hospitals, healthcare companies, insurance providers, community organizers, media groups and representatives from federal to local level.

Ongoing Campaigns in Health Care Reform Education

Enroll America are one group getting involved with the education campaign, announcing more than 50 events in 18 states, canvassing neighborhoods and giving speeches explaining the need for health insurance. The efforts are particularly focused on young people. The aim of the group is to overcome the public skepticism that exists around Health Care Reform and prove the new plans are worthwhile. President of the group, Anne Filipic summarized it as an attempt to create “an echo chamber or information”.

Shared Responsibility 

The responsibility lies with everyone when regarding health care reform information. Government are to inform and regulate through legislation, insurance agents and brokers are to pass on their knowledge to our clients and it is also the public’s responsibility to seek out this information. This “echo chamber” as opposed to Chinese whispers is about finding information and educating ourselves on our options and how Health Care Reform will affect us. What are our rights as employees? How are my family affected? What options are available if we are out of work?

Education campaigns and the overall success of the reformed Health Care system rely on our individual efforts to seek out information and educate ourselves.

How have you approached learning about Health Care Reform?

If you need some free, solid insurance advice, look no further than the questions section of our website.

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3 Steps to Avoiding HIPAA Breaches

The Department of Health & Human Services has begun to come down hard on Healthcare Providers for HIPAA Breaches. The Department of Health & Human Services has fined the Hospice of North Idaho for failing to encrypt a stolen laptop. The Hospice Organization has agreed to pay a $50,000 HIPAA Penalty for this single violation.

An important note here is that the $50,000 penalty does not include or cover the expenses the Hospice Organization will incur to notify affected patients. That additional cost could be as much as $83,000. All in all that’s a huge impact for a single HIPAA breach. The message for healthcare organizations is clear, it’s time to check on your HIPAA compliance and breach procedure.

Review Policies & Best Practice

HIPAA breaches should never happen. Organizations that properly manage their data and monitor tier procedures won’t suffer breaches. You need to review your security policy and procedure and perform a risk analysis. Cyber security is a vital issue for all organizations that carry personal information. For the healthcare industry that information is more comprehensive and more sensitive, you need to ensure that your data is secure on every level.


Once you have preformed a risk analysis and ensured that you are following best practice, you need to think about insurance. HIPAA breaches don’t happen to organizations that properly manage their data, but that relies on people following procedure. People make mistakes, so you need to ensure you are covered. The cost that the Hospice of North Idaho have incurred will be huge, insurance coverage could really soften that blow.

Create an Internal Plan

When HIPAA breaches do occur, the organization will suffer a variety of setbacks. Alongside the financial cost, there is also the practical issue of informing patients. You will need to create in internal plan for dealing with a breach. That means your organization should have a clear strategy for informing those affected and a contingency plan to ensure that normal service is not affected.

HIPAA breaches can be avoided with effective risk management, but you need to prepare for them anyway. Few medical organizations could deal with the cost incurred in Idaho.

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How Will Obamacare Affect My Wellness Program?

Beginning in 2014, the Affordable Care Act (ACA) imposes “pay or play” requirements on large employers. Under these rules, large employers that do not offer health coverage to their full-time employees and their dependents, or that offer coverage that is either unaffordable or does not provide minimum value, may be subject to a penalty. This penalty is also referred to as a “shared responsibility payment.”

On May 3, 2013, the Internal Revenue Service (IRS) released a proposed rule on ACA’s minimum value and affordability requirements. This proposed rule includes guidance on how health reimbursement arrangements (HRAs) and wellness program incentives are counted in determining the affordability of employer-sponsored coverage.

The regulation is not final. However, employers may rely on the proposed regulation until final regulations or other applicable guidance is issued.


The affordability of any health coverage offered by a large employer is a key point in determining whether the employer will be subject to a shared responsibility penalty. The coverage is considered affordable if the employee’s required contribution to the plan for self-only coverage does not exceed 9.5 percent of the employee’s household income for the taxable year.

“Household income” means the modified adjusted gross income of the employee and any members of the employee’s family, including a spouse and dependents. The IRS established three safe harbors for employers to use, which measure affordability based on the employee’s W-2 wages, the employee’s rate of pay or the federal poverty level for a single individual.

HRA contributions and wellness program incentives

The proposed regulation includes special rules for determining how HRAs and wellness program incentives are counted in determining the affordability of eligible employer-sponsored coverage. Employer contributions to health savings accounts (HSAs) do not affect the affordability of employer-sponsored coverage because HSA amounts generally may not be used to pay for health insurance premiums.

HRA Contributions

The proposed rule provides that amounts made newly available under an HRA that is integrated with an eligible employer-sponsored plan for the current plan year are taken into account only in determining affordability if the employee may either:

  • Use the amounts only for premiums; or
  • Choose to use the amounts for either premiums or cost sharing.

Treating amounts that may be used either for premiums or cost-sharing only toward affordability prevents double counting the HRA amounts when assessing minimum value and affordability of eligible employer-sponsored coverage.

Wellness Program Incentives

The proposed rule also contains clarification on affordability when premiums may be affected by wellness programs. Under the proposal, the affordability of an employer-sponsored plan is determined by assuming that each employee fails to satisfy the wellness program’s requirements, unless the wellness program is related to tobacco use. This means the affordability of a plan that charges a higher initial premium for tobacco users will be determined based on the premium charged to non-tobacco users, or tobacco users who complete the related wellness program, such as attending smoking cessation classes.

Transition relief is provided in the proposed rule for plan years beginning before Jan. 1, 2015. Under this relief, if an employee receives a premium tax credit because an employer-sponsored health plan is unaffordable or does not provide minimum value, but the employer coverage would have been affordable or provided minimum value had the employee satisfied the requirements of a nondiscriminatory wellness program that was in effect on May 3, 2013, the employer will not be subject to the employer mandate penalty.

The transition relief applies for rewards expressed as either a dollar amount or a fraction of the total required employee premium contribution. Also, any required employee contribution to premium determined based upon assumed satisfaction of the requirements of a wellness program under this transition relief may be applied to the use of an affordability safe harbor.

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New Legislation Will Help Businesses Avoid Higher Costs Due to ACA

 From the Texas Association of Health Underwriters

Legislation signed by Gov. Rick Perry will allow thousands of Texas businesses to keep for now their status as large employers and avoid additional regulations that businesses considered to be small employers may face as a result of the Affordable Care Act (ACA).

SB 1332, sponsored by Sen. Robert Duncan (R-Lubbock) and Rep. John Smithee (R-Amarillo) amends Texas law to allow for the inclusion of part-time employees in the methodology used to classify a business as a large or small employer. Current Texas law defines a small employer as an entity that employs 2-50 employees and a large employer as a business with 51 or more employees. Current law does not include part-time employees in that methodology.

SB 1332 redefines large and small employers using the total number of employees, including those that are part-time, rather than defining eligible employees as those who work 30 hours or more. The legislation amends the state insurance code to apply provisions of the Health Insurance Portability and Availability Act to health benefit plans of small and large employers using the new methodology.

Effective January 1, 2014, for the purposes of implementing the ACA, the federal government will define a small employer as an entity that employs 1-100 employees, meaning that some employers currently considered to be large employers in Texas (51-100 employees) will be reclassified as small employers. Actuarial studies of new rating requirements that will apply to small employers have projected premium increases ranging from 40-100 percent. SB 1332 will allow those businesses to avoid the higher premiums and small employer regulations of the ACA.

The ACA’s “pay or play” provision requiring employers with more than 50 employees to provide insurance coverage will still apply.

SB 1332 was a legislative priority of the Texas Association of Health Underwriters. The measure was also supported by the Texas Association of Business and National Federation of Independent Businesses.

“Our goal in championing the legislation was to help this group of Texas employers avoid premium rate shock as a result of changes in federal law,” said Kelly Fristoe, president of TAHU.

Fristoe continued, “The ACA will bring tough changes for many Texas businesses, but SB 1332 will help ease the burden for thousands of employers, workers and their families. We applaud and thank Sen. Duncan and Rep. Smithee for their leadership in providing this relief for Texas businesses”.

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Risk Assess Your Employee Benefits

When it comes to signing up for your Employee Benefits you will want to perform some level of risk assessment. Employee Benefits packages are carefully constructed by your employer and provider and are legally obliged to conform to statutory regulations so it’s unlikely they will contain a large risk. But it’s always advised that you take the time to look at your options and become acquainted with and possible long term risks and be in the position have your questions answered.

Cost of Options

Some employers offer a number of packages available at varying prices. This could include added benefits, variation in cover types or increased coverage. The affordability of the health cover your employer offers is only measured on the lowest available option, additional extras are not subject to the affordability regulations.

For this reason, you might want to take extra time to assess the cost of the your options and look at the affordability on your own terms. You may find you don’t want anything above the lowest cost option or an alternative package may be better value for your situation.

Family coverage

Some companies offer the option of family insurance coverage, but at a cost. Affordability penalties do not apply to the coverage offered to employee families, so there is no guarantee the cost of family coverage will be in line with the affordability of your self-only policy.

Compare the cost of family insurance with an outside provider against the cost of the premium through your employer. Family insurance can be very expensive; including this in your employee benefits may come at a very high price in the long term.


Employee Benefits packages differ from business to business and even within business, with different packages on offer to employees. Many packages include retirement benefits, including pensions and extended health care – but there is no standard requirement. If you have any existing plans for your retirement, look to see how your employee benefits package fits this plan or what changes might take place.

If you haven’t put any plans in place, look to see if the options available appeal to you as an outcome. If your retirement benefits don’t meet your expectations, talk to your employer about your plans or look into alternative options such as outside providers or investments for an option that suits.

Risk assessing your Employee Benefits package has a lot to do with assessing the possible long term affects on your situation. By taking the time to look at these points in the beginning, you are in a good position to bring any queries to your employer and fully understand your options.

If you have questions about Employee Benefits, ask an expert here.

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Healthcare Reform and COBRA FAQ

In 2010, health care reform became a reality with the passage of the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010. The U.S. Department of Labor has issued Frequently Asked Questions on how the health care reform law affects COBRA and the COBRA premium subsidy.

Did the health care reform legislation extend the COBRA premium reduction (subsidy)? No. The new health care reform legislation, The Patient Protection and Affordable Care Act (PPACA) as amended by the Health Care and Education Reconciliation Act, did not extend the eligibility time period for the COBRA premium reduction. Eligibility for the subsidy ended May 31, 2010; however, those individuals who become eligible on or before May 31, 2010 can still receive the full 15 months as long as they remain otherwise eligible.

Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage.

Individuals who become disabled can extend the 18 month period of continuation coverage for a qualifying event that is a termination of employment or reduction of hours. To qualify for additional months of COBRA continuation coverage, the qualified beneficiary must:

  • Have a ruling from the Social Security Administration that he or she became disabled within the first 60 days of COBRA continuation coverage (or before); and
  • Send the plan a copy of the Social Security ruling letter within 60 days of receipt, but prior to expiration of the 18-month period of coverage. If these requirements are met, the entire family qualifies for an additional 11 months of COBRA continuation coverage.

Did the health care reform legislation eliminate COBRA?
No. The new health care reform legislation, The Patient Protection and Affordable Care Act (PPACA) as amended by the Health Care and Education Reconciliation Act, did not eliminate COBRA or change the COBRA rules. See An Employee’s Guide to Health Benefits Under COBRA-The Consolidated Omnibus Budget Reconciliation Act for more information about COBRA.

How does the new health care reform legislation affect my coverage under my group health plan?
The new health care reform legislation, The Patient Protection and Affordable Care Act (PPACA) as amended by the Health Care and Education Reconciliation Act, makes many changes to employee health benefit plans. Some of the changes go into effect for the first plan year that begins on or after six months after enactment (September 23, 2010), so for calendar year plans, January 1, 2011. However, many changes do not go into effect until the first plan year beginning on or after January 1, 2014.

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HIPAA Certificates Required During 2014

For plan years beginning on or after Jan. 1, 2014, the Affordable Care Act (ACA) prohibits group health plans and issuers from imposing pre-existing condition exclusions (PCEs) on any enrollees.

Currently, ACA prohibits PCEs for enrollees who are under 19 years of age. ACA’s restrictions on PCEs apply to both grandfathered and non-grandfathered plans.Until ACA’s full prohibition on PCEs takes effect in 2014, the HIPAA rules regarding PCEs will continue to apply. HIPAA currently allows plans and issuers to exclude pre-existing conditions from coverage, but places significant limitations on those exclusions. For example, the length of any PCE must be reduced by the amount of creditable coverage the individual had prior to enrollment in the plan. An individual’s prior creditable coverage is documented in a HIPAA Certificate of Creditable Coverage, provided by the prior plan or issuer.

ACA’s prohibition on PCEs for plan years beginning on or after Jan. 1, 2014, will eventually make HIPAA Certificates unnecessary.

Proposed rules issued on March 21, 2013, state that the requirement to provide HIPAA certificates will be eliminated effective Dec. 31, 2014. The need for plans to continue providing HIPAA Certificates during 2014 recognizes that participants may need HIPAA Certificates during 2014 to avoid PCEs under non-calendar year plans. Although the proposed rule is not yet in final form, plans and issuers should plan on providing HIPAA Certificates during 2014.

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