Tag Archives: Obamacare

FAQ on Exchange Notice Penalties

The Affordable Care Act (ACA) requires employers to provide all new hires and current employees with a written notice about the ACA’s health insurance exchanges (Exchanges), effective Oct. 1, 2013.

On Sept. 11, 2013, the Department of Labor (DOL) issued a frequently asked question (FAQ) on the penalties for failing to provide an Exchange Notice. In this FAQ, the DOL stated that there is no fine or penalty under the ACA for failing to provide the notice.

Exchange Notice Requirements

The ACA requires all employers that are subject to the Fair Labor Standards Act (FLSA) to provide a written notice to their new and current employees about the Exchanges.

The notice should inform employees:

  • About the Exchange;
  • That they may be able to get lower-cost private insurance in the Exchange; and
  • That they may lose the employer contribution (if any) to their health benefits if they buy insurance through the Exchange.

The DOL has issued two model notices to help employers comply. There is one model for employers that do not offer a health plan and another model for employers that offer a health plan for some or all employees:

Employers may use one of these models, as applicable, or a modified version. More compliance assistance information is available in a Technical Release issued by the DOL.

The deadline for providing the Exchange Notice is Oct. 1, 2013.

Penalties for Failing to Comply

Although employers that are subject to the FLSA should provide a written notice to their employees about the Exchange by Oct. 1, 2013, the DOL asserted in the FAQ that there is no fine or penalty under the ACA for failing to provide the notice.

This means that employers cannot be fined for failing to provide employees with notice about the ACA’s new Exchanges.

What This Means for Employers

Although this FAQ asserts that there will be no penalties for failing to provide an Exchange Notice, there are several reasons employers may still want to provide the notice.

The Exchange Notice can help employers answer employee questions about:

  • What the Exchange is;
  • Whether the employer will still provide a plan once the Exchanges are operational;
  • How Exchange plans are different from the employer’s plan; and
  • Whether the employer’s plan is intended to be affordable and provide minimum value.

If the employer’s plan is affordable and provides minimum value, employees will not be eligible for federal subsidies through the Exchange. However, most employees will have the option of waiving employer-sponsored coverage and, instead, enrolling in coverage through the Exchange.

In many cases, employer-sponsored coverage may be a better option for employees than Exchange coverage. For example, premiums for employer-sponsored coverage will often be cheaper for the employee than premiums for coverage through the Exchange. Additionally, the employee portion of the premium for employer-sponsored coverage is typically excluded from taxable income and is therefore tax-free. This is not the case in the Exchange.

More Information

Please visit the DOL website or contact us for more information on the Exchange Notice requirement.

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What Businesses Need to Know About Healthcare Reform

Over 3 years have passed since the Obama Administration signed off on the Affordable Care Act which was considered the first step in a long journey towards lowering the number of American citizens without Health Insurance. With the State and Federally-operated Health Insurance Exchanges opening on October 1, and the January 1 2014 deadline looming, it seems we are finally beginning to see the journey towards Nationwide Health Insurance Coverage take pace.health care benefits

However, a number of hiccups have slowed the implementation of the Affordable Care Act and following the recent postponement of the employer’s mandate, many US citizens and Businesses have been left to ponder the timeframe of Health Care Reform and whether or not it will take off as anticipated. In light of this confusion and uncertainty, here are a few points you need to know so that you and/or your Business can be fully prepared come January 2014.

What the Affordable Care Act means

The Affordable Care Act is a law which requires almost all American citizens to maintain a minimum level of health insurance coverage or else face a tax penalty. It also provides that large employers must offer coverage to full-time employees or else pay a penalty of up to $2,000 per employee. Smaller Business owners must also offer employees Health Insurance coverage but will be eligible for a tax credit to help cover the costs. The law also calls for Insurers to accept applicants regardless of pre-existing conditions or health issues, meaning employees and retirees no longer need an employment relationship to gain access to health coverage.

So far, 25 states have opted for federally-based exchanges while 19 have declared their preference of state-based exchanges. These exchanges will allow US citizens and Business owners to shop for Health Insurance coverage after October 1 which has been set as the opening date. Fees on employers, insurers, drug and device makers and higher earners as well as the introduction of new taxes will help fund the programme which is due to take effect on January 1, 2014.

Healthcare Trends in the US

Employer-based Health Benefits are the dominant source of Health Coverage in the US, however, this form of coverage has steadily declined since the year 2000, something that the Affordable Care Act aims to stabilise and rejuvenate. According to reports, 155.5m non-elderly US citizens with coverage in 2011 were covered by employer-based Health Insurance programmes. That figure represents a stark drop of 14.2m from 2000. The Affordable Care Act targets Employers, Big and Small, in an attempt to make Health Insurance a complete necessity for US citizens who may have opted against it in the past for financial reasons or other.

Over the past 20 years, Health Care Costs in America have increased dramatically, subsequently increasing the financial pressure on Businesses in providing Health Insurance coverage for employees. The Affordable Care Act will see the introduction of tax benefits as part of the long term objective of lowering Medicare costs.

Perhaps the most important figure of all is the 45 million US citizens who lacked Health Insurance in 2012, according to reports. This has been taken as a confirmation of the need for Health Care Reform across the country.

The role of Businesses

From discussing the provisions of the Affordable Care Act in relation to Health Care trends in America, it is clear to see that the substantiality of Health Care Reform will have much to do with the role of US Businesses, big and small. From providing Health Insurance to introducing preventative measures such as Wellness programmes, US Businesses will be at the heart of Health Care Reform.

Although the Employer’s mandate delay has caused confusion among employers, the decision is a clear indication that the implementation of the Affordable Care Act is in fact working. Businesses are still encouraged to purchase employee Health coverage after October 1, however, penalties for failing to provide Health Insurance will not take effect until 2015, giving employers more time to restructure. It has also been suggested that this delay will give the Obama Administration time to look at the law itself and make changes if necessary.

The eventuality factor remains, and employers now have more time to plan ahead and consider the long-term future of their organization. Businesses now have adequate time to conduct a reassessment of their Risk Management Strategy, consider introducing Wellness Programmes and consult their Insurer on the best possible Health Insurance policy that can be incorporated into their overall process. Although you won’t be subject to a penalty, now is the time to act ahead of the October 1 exchange window.

Health Care Reform can be quite confusing for both employers and employees. If you need to study up and see how you you’re affected by the Affordable Care Act, speak to one of our experts.

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Will Healthcare Reform Lead to Increased Patient-Centered Care?

With the Health Care Exchanges now less than two months away, we are well and truly on the verge of long-awaited Health Care Reform. Over 3 years since it was passed, the Affordable Care Act (ACA) will begin to take effect in the coming months ahead of January 2014, which will mark the beginning of the new legislation. doctor, clipboard, stethescope

Under the ACA, every US citizen will be legally obliged to purchase Health Insurance of some form or another or else face heavy fines come January. Those who were previously unable to afford Health Insurance will be entitled to a tax credit, depending on their income. Ultimately, the objective of ‘Obamacare’ is to get the ball rolling on Nationwide Health Care, available to everyone at affordable rates. However, while the ACA will see changes in Health Insurance coverage, what does it mean for the actual services available to US citizens? For many, Health Care Reform is seen as an opportunity for Patient-Centered care.

What is Patient-Centered Care?

Nationwide coverage is the aim of Health Care Reform, but there are many other provisions worth considering as you prepare yourself for the October 1 exchanges deadline, including how Health Care itself will be affected by the huge increase in patients across the country.

Many Physicians and Health Care specialists have already started to move towards a Patient-Centered Care system which is an innovative approach to the planning, delivery and evaluation of health care based on mutually beneficial relationships between providers, patients and families. Patient-Centered Care is about respect for patient’s preferences and values and providing emotional support, physical comfort and consistent care. Communication, education and coordination of care to include family involvement are all elements of a patient-focused initiative which ultimately provides an engaging and personally-tailored Health Care programme for patients.

Patient-Centered Care in the Affordable Care Act

Patient-centeredness is very much at the heart of Health Care Reform having been integrated into a number of health reform initiatives in the past. The ACA includes a number of innovative pilot programs that will evaluate the Patient-Centered Medical Home. It calls for the creation of a ‘Physician Compare’ website allowing the public to compare quality data at the physician level, such as ‘an assessment of patient experience and patient, caregiver, and family engagement.’

Shared decision-making is another attribute of the ACA, with the objective of providing an increased level of adequate information to patients. Patients will be able to make informed health decisions, along with family and caregivers, as part of a person-focused system. Preventative Care starts at an education level and the ACA places significant focus on the introduction of schemes at school-level to educate the youth about their health.

In order for a Patient-Centered system to work, an adequate measurement scheme must be in place to assess patient satisfaction and in introducing a ‘Physician Compare’ initiative along with surveys, the ACA aims for patient-focused care that can help in future decision making.

What should you do to ensure you get the best Coverage/Treatment?

If you haven’t studied up on Health Care Reform and the legislative changes that will be introduced in January 2014, then talk to your insurance agent. Make sure you know what it means for you, your family and your health insurance plan. Understanding is the first step, once you understand what these changes mean you can compare health insurance plans and physicians so that you are prepared for 2014 and beyond.

While quantity of patients is set to increase, the role of Physicians will change with a stronger focus on patient’s personal conditions and requirements. A serious and sustained effort to build a Patient-Centered health care system is starting to gain momentum with Health Care treatment tailored to your needs along with Health Insurance Plans tailored to your needs, the main objective.

If you have a question about Health Care Reform and what Insurance plan best suits you, why not ask one of our experts for free.

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Will Healthcare Reform Actually Work?

After 3 long years, the countdown to the Health Care exchanges is coming to an end. While a lot of the confusion and uncertainty brought on by the heavily-debated 2010 Affordable Care Act remains, the October 1 deadline beckons, as we approach a new age of ‘Health Care for All’ here in the US.

There is no doubt that the Affordable Care Act was seen as a huge political victory for the Obama Administration. But the question of whether or not it will prove a historic one, also lingers.  As employers and citizens seek consultation on the best possible Health Insurance plan, a number of hiccups, including the recent postponement of the employer’s mandate, not to mention the 17 states who have opted out of ‘Obamacare’, have left many US citizens wondering whether or not Health Care Reform will actually work.

What exactly are we working towards?

‘Obamacare’ legislates that all US citizens must have some form of Health Care coverage come January 2014. Those who fail to buy Health Insurance by the turn of the year will be subject to hefty fines. The scheme also calls on large employers to provide Health Care coverage to employees, provided they have over 50 working staff. Making it a legal obligation for people to have Health Insurance is seen as the most effective way to achieve nationwide coverage come 2018, and while some states have opted out of a federal health insurance exchange, they have devised their own initiatives to roll out state-wide Health Care by January 2014.

Convincing the people

Up until now, the Obama Administration’s Health Care Reform initiative has received heavy criticism from various bodies and media figures from different backgrounds. But the White House ensures, job-growth, new and improved health care facilities as well as practitioners, and increased localisation of Health Care services are at the heart of the initiative which thus far, hasn’t resulted in job losses. Convincing doubters is arguably the biggest challenge President Obama has had to face during his tenure, which ultimately will be defined by the success of Health Care Reform.

Nurturing before and after 2014

Legislation will count for very little come the end of 2014 unless the initiative is nurtured into existence, enforced and invested in. Investment from the Government is as important as investment from the people, who are the main beneficiaries of Health Care Reform. While January 2014 is seen as a new dawn, people must go out, consult their insurance brokers and find the best possible health insurance package for them and their loved ones. The future of US Health Care depends on people making that step, regardless of their current state of health or financial situation. The ‘Health Care for All’ initiative must be supported by all so it can benefit all.

The role of employers

Large employers are responsible for providing Health Care coverage for employees and in many ways, they are the backbone of the Obamacare initiative. Critics claim some employers may let go of staff to lower their books and avoid having to provide health insurance, but this puts the sustainability of the company in doubt and also puts a business in an impossible position where they can be held subject to fines and penalties. Health Care reform depends on employers, both large and small, learning about the provisions of the Affordable Care Act and working to accommodate employees in a way that both ensures their health and the long term health of the company itself.

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Healthcare Reform and the Youth of America

The October 1 deadline for US Health Care Reform is fast approaching as president Obama continues to work on multiple strategies aiming to enroll 7 million US citizens to the news scheme by January 1 2014. The new scheme legislates that US citizens must have health insurance by 2014 or else face heavy fines.


At present, 17 States will offer insurance through their own exchanges, while the rest will offer health insurance through the federally managed programme dubbed ‘Obamacare’. Deputy White House advisor David Simas spoke to PBS recently about the challenges that remain in the Obama Administration’s implementation of the new Healthcare regime. “In order for the marketplace to be successful, a smaller subset needs to be at the centre of our focus for outreach, and that’s about 2-2.5 million, young and healthy, 18-35 year olds,” Simas said, confirming public opinion that the biggest challenge facing the Obama Administration is convincing young people who are healthy and active, to buy health insurance.

As the debate of whether or not Obamacare is good or bad for young Americans rages on, we look at the considerations of young people in the run up to the Oct 1 Healthcare exchange opening.


The number one reason that almost 20 million young adults in the US lack basic Healthcare coverage is the cost of Healthcare. Many between the ages of 18-35 are still in education be it school, part-time schooling or community college or else they are recent graduates, looking to secure full-time employment. For many of these people, particularly in the current climate, it is difficult to find that full-time job with benefits. With low disposable income, it is very difficult for young people to commit to health insurance, particularly when they have a clean bill of health and no urgent need for medical treatment.

While Obamacare provides that large companies must offer healthcare coverage for their employees, many young people who are recent graduates or are still in education, find themselves out of this loop.


While many young people may refrain from buying health insurance due to their state of health, there is no guarantee that someone between the ages of 18-35 will have a clean bill of health throughout those years. Those who are uninsured run the risk of paying huge fees if they end up having to seek medical care, something that happens quite regularly across the States. According to Aaron Smith, Executive Director of Young People advocacy agency ‘Young Invincibles,’ more young people than elderly are admitted to A&E during an average year and are therefore fully aware of the risk they run without health insurance.

While health insurance costs are generally avoided by young people who may not have the disposable income to avail of coverage, Obamacare will offer those young Americans who earn less than $44,000 dollars per year a tax credit that will help them to fund healthcare coverage. In addition, many young people may have been refused medicaid in the past unless they had children. 2014 will see Medacaid offered to people with incomes lower than $15,000, encompassing roughly 8 million US citizens. This will ensure that young Americans who fall into that low earners bracket can still avail of the care available to wealthier citizens.


While study, travel and securing full-time work are the things that most occupy the minds of 18-35 year olds, it is important for young Americans to think ahead with regards the Healthcare reform act. 2014 marks the beginning of this new era in US Healthcare, and young people must make sure to consider their future, economically, domestically and in terms of family planning in run up to the October 1 deadline.

Healthcare reform will give young Americans that safety blanket of health insurance coverage as they exit their leaner years. Financially, while many young people are convinced contributing funds towards healthcare is just a way of benefitting the older generation, they are contributing to US Healthcare as a whole, something they will certainly avail of in years to come, especially when they begin families of their own.

So whether they’re covered by Obamacare or state provided exchanges,Healthcare Reform is something everyone needs to prepare for, no matter what age they are or State they come from. Personal health is something everyone needs to manage and invest in and it is worth investigating the possibilities instead of accepting a hefty fine come 2014.

If you have a question about Healthcare Reform, ask it for free and get answers from an expert.

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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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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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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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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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