States Offer Privacy Protections To Young Adults On Their Parents’ Health Plan
Michelle Andrews gives insight on how the ACA is impacting HIPPA and privacy for young adults. See her article below.
Original Post from Kaisher Health News on June 28, 2016.
The health law opened the door for millions of young adults to stay on their parents’ health insurance until they turn 26. But there’s a downside to remaining on the family plan. Chances are that mom or dad, as policyholder, will get a notice from the insurer every time the grown-up kid gets medical care, a breach of privacy that many young people may find unwelcome.
With this in mind, in recent years a handful of states have adopted laws or regulations that make it easier for dependents to keep medical communications confidential.
The privacy issue has long been recognized as important, particularly in the case of a woman who might fear reprisal if, for example, her husband learned she was using birth control against his wishes. But now the needs of adult children are also getting attention.
“There’s a longstanding awareness that disclosures by insurers could create dangers for individuals,” said Abigail English, director of the advocacy group Center for Adolescent Health and the Law, who has examined these laws. “But there was an added impetus to concerns about the confidentiality of insurance information with the dramatic increase in the number of young adults staying on their parents’ plan until age 26” under the health law.
Federal law does offer some protections, but they are incomplete, privacy advocates say. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a key federal privacy law that established rules for when insurers, doctors, hospitals and others may disclose individuals’ personal health information. It contains a privacy rule that allows people to request that their providers or health plan restrict the disclosure of information about their health or treatment. They can ask that their insurer not send the ubiquitous “explanation of benefits” form describing care received or denied to their parents, for example. But an insurer isn’t obligated to honor that request.
In addition, HIPAA’s privacy rule says that people can ask that their health plan communicate with them at an alternate location or using a method other than the one it usually employs. Someone might ask that EOBs be sent by email rather than by mail, for example, or to a different address than that of the policyholder. The insurer has to accommodate those requests if the person says that disclosing the information would endanger them.
A number of states, including California, Colorado, Washington, Oregon and Maryland, have taken steps to clarify and strengthen the health insurance confidentiality protections in HIPAA or ensure their implementation.
In California, for example, all insurers have to honor a request by members that their information not be shared with a policyholder if they are receiving sensitive services such as reproductive health or drug treatment or if the patient believes that sharing the health information could lead to harm or harassment.
“There was concern that the lack of detail in HIPAA inhibited its use,” said Rebecca Gudeman, senior attorney at the National Center for Youth Law, a California nonprofit group that helps provide resources to attorneys and groups representing the legal interests of poor children. She noted that HIPAA doesn’t define endangerment, for example, and doesn’t include details about how to implement confidentiality requests.
Concerns by young people that their parents may find out about their medical care leads some to forgo the care altogether, while others go to free or low-cost clinics for reproductive and sexual health services, for example, and skip using their insurance. In 2014, 14 percent of people who received family planning services funded under the federal government’s Title X program for low-income individuals had private health insurance coverage, according to the National Family Planning and Reproductive Health Association.
Even though most states don’t require it, some insurers may accommodate confidentiality requests, said Dania Palanker, senior counsel for health and reproductive rights at the National Women’s Law Center, a research and advocacy group.
“Inquire whether there will be information sent and whether there’s a way to have it sent elsewhere,” Palanker said. “It may be possible that the insurer has a process even if state doesn’t have a law.”
Insurers’ perspective on these types of rules vary. In California, after some initial concerns about how the law would be administered, insurers in the state worked with advocates on the bill, Gudeman said. “I give them a lot of credit,” she said.
Restricting access to EOBs can be challenging to administer, said Clare Krusing, a spokesperson for America’s Health Insurance Plans, a trade group. A health plan may mask or filter out a diagnosis or service code on the EOB, but provider credentials or pharmacy information may still hint at the services provided.
There’s also good reason in many instances for insurers and policyholders to know the details about when a policy is used, experts say. Policyholders also may have difficulty tracking cost-sharing details such as how much remains on the deductible for their plan.
In addition, “if a consumer receives a filtered or masked EOB, he or she has no way of knowing whether their account has been compromised or used as part of fraudulent activity,” Krusing said.
Read the full article and learn more at: https://khn.org/news/states-offer-privacy-protections-to-young-adults-on-their-parents-health-plan/
Source:
Adnrews, M. (2016, June 27). States offer privacy protections to young adults on their parents’ health plan [Web log post] Retrieved from https://khn.org/news/states-offer-privacy-protections-to-young-adults-on-their-parents-health-plan/
5 Top Employee Benefits Questions and How to Answer Them
Original Post from BenfitsPro.com
By: Monica Majors
Legislative changes continue to markedly affect the health benefits marketplace. Employers and their workers face challenges on a number of fronts. Along with those challenges come questions that range from current and future requirements of health care reform, to providing adequate plan coverage that serves employees well.
By understanding the top-of-mind employer benefit issues and responding to them appropriately and effectively, brokers and advisors can better serve existing clients, attract new ones, and help employees protect themselves and their families going forward.
1. How can I meet my employees’ needs?
A key concern of today’s employers is making sure benefits they offer for both prospective and current employees are competitive. Businesses recognize the role a solid benefit program plays in attracting and keeping good talent, and they want to know what is included in plans offered by their competitors.
Brokers serving the health benefits marketplace can best serve customers by knowing the current market landscape well, speaking confidently about it and sharing that knowledge with customers. Key to this knowledge is understanding what the employer currently offers, what types of employees make up its workforce, what their needs are, and what gaps may currently exist.
Then, talk with insurers and learn what industry and market insight they may possess based on geographic and industry-specific factors. Search out findings made available from insurance- and customer-specific industry research organizations and trade associations. You can also mine data from within your own office, such as aggregated customer information by industry.
Integrate all of this information with comprehensive benefit offerings available from the carriers you represent, and show employers how they can gain a competitive market advantage with the right benefit plan.
2. How can I control my costs?
The question of controlling costs is common for obvious reasons. Small groups, in particular, are looking for creative ways to keep their health benefit expenses down. Brokers can address this question by understanding current offerings and combining that with knowledge of the plans available through the carriers they represent.
Understanding the various coverage tiers available and sharing that knowledge with employers is key. Often, implementing a health benefit program that meets the minimum required coverage levels brings the lowest cost.
Other cost-reduction strategies include addressing coverage for dependents or part-time employees. Some employers may consider eliminating dependent coverage or reducing contributions for this coverage. Also, determine with the employer the cost versus the benefit of including part-time staff in the plan. Employers may need to make tough decisions to maintain viable programs for employees.
Employers need to consider other costs that may come into play. For example, new IRS and ACA reporting requirements for employers to notify employees about new mandates bring with them administrative expenses. While they may not be able to eliminate these costs, brokers can help provide guidance and increase awareness around the changing requirements. They can also recommend approaches that might help employers streamline the process to reduce the impact of the requirements.
3. What about exchanges?
Employer questions about health benefit exchanges are prevalent. How do the exchanges align with the employer’s desire to deliver benefits in a cost-effective manner? What advantages do they offer? What are the drawbacks? Brokers need to be familiar with individual and group exchanges — both private and public.
Brokers working with some employers may find that certain tax advantages come along with using a public exchange. Private exchanges offer other benefits, from cost-management tools to a broader set of administrative support options and a choice of benefit options that extend beyond basic medical coverage. Group or employer-focused exchanges are becoming increasingly popular as a way to efficiently manage health benefits. Brokers should become familiar with the pros and cons, as well as processes involved.
It’s important to understand the advantages for different employer groups, as well as the reputation and satisfaction levels of exchanges, and use that knowledge to help employers select the right option.
4. What’s on the horizon?
Large employers are concerned about looming changes. They wonder how new regulations—for example, the Cadillac tax —may affect them in the future. Brokers need to be knowledgeable about what is coming down the pike, and how to minimize negative resulting impacts.
Preparing for the Cadillac tax, for example, may require a strategy shift. While the tax is primarily levied against health plans for coverage deemed “too rich,” it will ultimately affect employers and workers. Health plans are likely to pass off at least some of the costs to employers in the form of higher premiums. Employers may then pass costs off to workers in the form of higher cost-sharing arrangements. Of course, employers will have to consider how this will impact employee retention and recruitment.
The Internal Revenue Service posts helpful information about the ACA’s requirements on employers on its website: irs.gov/affordable-care-act. The Centers for Medicare & Medicaid Services website is another valuable resource: cms.gov/cciio/.
5. Why you?
The final top question may be one employers don’t explicitly ask; but it’s one you need to answer: “Why should I use you as a broker?” How is it that you set yourself apart from other brokers — industry knowledge, market strategy or customer service? Brokers need to carefully and clearly explain benefit plan designs, educate employers, guide them through the maze of changes in the benefits arena, and explain all the implications.
Building knowledge is the first part of the answer. Learn about laws, regulations and your employers’ workforce attributes. Learn more about the products offered by carriers and through the exchanges. Combine that knowledge with employer and employee data you capture to design programs that can help employers attract and retain good workers. Work with financially strong carrier partners to find and deliver the right benefit plans, and consider offering your clients a multi-year strategy where appropriate. And leverage administrative, technology, client portals and other resources your carrier partners offer.
Be sure to document and explain the advantages you can bring to the employer. Also, encourage satisfied customers to provide testimonials, directly and on social platforms, and then share these testimonials and references to help differentiate yourself and your shop from your competitors.
By understanding the needs of your clients, offering cost control solutions and keeping businesses apprised of changes on the horizon, you set yourself apart from other brokers and demonstrate your value as a trusted adviser. New and existing clients will come to you year after year for help in designing affordable health benefit plans that will attract and hold onto good workers.
How to Avoid Penalties Under the Affordable Care Act
Original Post from SHRM.org
By: Lisa Nagele-Piazza
2016 is expected to be the most expensive year for businesses complying with the Affordable Care Act (ACA), said David Lindgren, senior manager of compliance and public affairs for Flexible Benefit Service Corporation, a benefit administrator headquartered in Rosemont, Ill.
It’s the first year for dealing with ACA reporting, which many employers will have to complete by the end of June, Lindgren said during a concurrent session at the Society for Human Resource Management 2016 Annual Conference & Exposition.
There are more than 30,000 pages of guidance about the law, but Lindgren said the ACA is fairly easy to comprehend. “Of course, many people would disagree with me,” he noted.
“It’s not necessarily easy to comply with the ACA, and it’s not financially inexpensive, but most of the rules aren’t overly complicated,” he said.
The federal agencies that regulate the ACA have said they intend to monitor all businesses for compliance. This may not be realistic, but employers should keep in mind that more auditing can be expected.
Lindgren identified 30 penalties associated with noncompliance and provided insight on how to avoid them.
Employers can choose to pay the penalties for noncompliance, but steep fines are often attached, he said. For example, market reform violations carry a penalty of $100 per participant per day, up to $500,000 for each violation.
Employees Must Receive Notices
Some noteworthy penalties to avoid are those associated with the failure to provide required notices to plan participants, including a written notice of patient protections.
Lindgren said sometimes employers aren’t clear about who has been designated to provide this notice. “A lot of times the insurance company thinks the employer provided it and the employer thinks the insurance company did,” he said. “So it’s important to double check who is in fact giving the notice.”
Participants must also be provided with a summary of benefits and coverage in a standardized format. Lindgren likened this format to a nutrition label on a can of soup.
A participant should be able to easily compare the benefits to other plans, such as a spouse’s plan, just as the nutrition facts for two cans of soup can be easily compared.
There is a standardized template for the summary of benefits and coverage on the Department of Labor website.
The requirement to provide a summary of benefits and coverage applies to medical plans, but not to dental or vision plans.
The summary should be distributed at the time of open enrollment and special enrollments related to qualifying events, as well as at the request of participants and when a material modification has been made to the plan.
Although there is no penalty attached for noncompliance, employers must also provide written notice about the health insurance marketplace to new hires within 14 days of their start date.
This applies even for organizations that don’t offer benefits and even to those employees who aren’t eligible for benefits, Lindgren said.
There are some exceptions. For example, if an employer isn’t subject to the Fair Labor Standards Act, then it doesn’t have to provide the marketplace notice.
Exceptions for Grandfathered Plans
Grandfathered plans aren’t subject to some of the requirements under the ACA. This includes plans purchased on or before March 23, 2010, that haven’t made certain material changes.
Lindgren noted that employers with grandfathered plans must provide written notice to participants notifying them that it is a grandfathered plan and describing what that means for participants.
If participants aren’t provided this information, the plan will lose its grandfathered status, Lindgren said.
HR Takes the Lead
Benefits compliance isn’t just a human resources issue anymore, but HR often takes the lead in compliance efforts, according to Lindgren.
However, other departments, such as finance, legal and information technology, are increasingly getting more involved.
Are You Ready for the Marketplace Notices?
Original Post from ThinkHR.com
By: Laura Kerekes
Under the Affordable Care Act (ACA), each Health Insurance Exchange (Marketplace) must notify employers when they have an employee who has received a government subsidy to enroll in a health plan through the Marketplace. These notices will begin being sent to employers in the coming weeks and months, either individually or in batches. Because the notice procedure is being phased in, you may or may not receive notices, even if you have employees who received subsidies through a Marketplace. Here’s what you need to know.
Reason for Notice
These notices, also called 1411 Certifications in reference to the pertinent section of the ACA, will be sent to employers as part of the government’s verification efforts regarding persons who received Marketplace subsidies for individual health insurance. Marketplaces want to confirm whether the individual was eligible for, or enrolled in, an employer’s health plan since those facts can affect someone’s eligibility for subsidies.
You may receive a notice (similar to the sample found here) for each employee that received a subsidy to enroll in insurance through a Marketplace. The notice only informs you that the employee was granted a subsidy — it is not a notification that you have been assessed any penalty. Under the ACA’s play or pay rules, penalties may be assessed later by the Internal Revenue Service to applicable large employers for failing to offer full-time employees affordable minimum value coverage; however, play or pay penalties, and notice of them, are a separate process entirely.
What You Should Do
- Even if you do not believe that any of your employees obtained individual coverage through a Marketplace, be on the lookout for these notices because you have 90 days from the date of the notice to file an appeal, if necessary. Notices may go to a subsidiary instead of the parent company or to a particular worksite instead of the employer’s main office, depending on the information the employee provided to the Marketplace. Alert all departments and worksites to watch for mail in envelops from a government agency or insurance Marketplace.
- Important:Keep these notices confidential because employers are prohibited by law from discriminating or retaliating against employees who may receive subsidies. Consider segregating functions so staff involved in reviewing notices is separate from staff involved in employment or benefit plan decisions.
- Establish your audit process for reviewing any notices you may receive and for filing appeals when appropriate. Confirm that the information is correct based on your employment and payroll records. If you are an applicable large employer subject to the ACA’s play or pay rules, you also should check if the employee was a full-time employee and, if so, whether you had offered affordable minimum value coverage to the employee. Read more about the notice and appeal process here.
- File an appeal within 90 days of receipt of the notice if any of the information is incorrect. To do this, be sure to retain the notice and follow the directions for appeal. Remember that these notices will not advise you of any penalties on large employers, so appeals at this stage are to correct any mistakes in employment information. In addition:
- If you are a small employer and not subject to the ACA play or pay rules, you are not impacted directly but your appeal may alert the Marketplace that the individual was enrolled in your group health plan and not eligible for subsidies.
- If you are an applicable large employer who is subject to the ACA’s play or pay rules, you should be proactive in appealing the Marketplace’s subsidy determination if any information is incorrect. (An applicable large employer generally is one that employed an average of 50 or more full-time and full-time-equivalent employees in the prior calendar year. Related employers in a controlled group are counted together.) Although Marketplaces cannot access play or pay penalties, your appeal may help establish the facts and head off later penalty action by the IRS.
You may not receive Marketplace notices, but if you do, be prepared, review them thoroughly, and appeal incorrect information quickly.
Final Rule on Nondiscrimination in Health Programs and Activities
From the Department of Health and Human Services.
Final rule prohibits discrimination based on race, color, national origin, sex, age or disability; enhances language assistance for individuals with limited English proficiency; and protects individuals with disabilities.
The Department of Health and Human Services (HHS) issued a final rule to advance health equity and reduce health care disparities. Under the rule, individuals are protected from discrimination in health care on the basis of race, color, national origin, age, disability and sex, including discrimination based on pregnancy, gender identity and sex stereotyping. In addition to implementing Section 1557’s prohibition on sex discrimination, the final rule also enhances language assistance for people with limited English proficiency and helps to ensure effective communication for individuals with disabilities. The protections in the final rule and Section 1557 regarding individuals’ rights and the responsibilities of many health insurers, hospitals, and health plans administered by or receiving federal funds from HHS build on existing federal civil rights laws to advance protections for underserved, underinsured, and often excluded populations.
The Nondiscrimination in Health Programs and Activities final rule implements Section 1557 of the Affordable Care Act, which is the first federal civil rights law to broadly prohibit discrimination on the basis of sex in federally funded health programs. Previously, civil rights laws enforced by HHS’s Office for Civil Rights (OCR) broadly barred discrimination based only on race, color, national origin, disability, or age.
“A central goal of the Affordable Care Act is to help all Americans access quality, affordable health care. Today’s announcement is a key step toward realizing equity within our health care system and reaffirms this Administration's commitment to giving every American access to the health care they deserve," said HHS Secretary Sylvia M. Burwell.
The final rule helps consumers who are seeking to understand their rights and clarifies the responsibilities of health care providers and insurers that receive federal funds. The final rule also addresses the responsibilities of issuers that offer plans in the Health Insurance Marketplaces. Among other things, the final rule prohibits marketing practices or benefit designs that discriminate on the basis of race, color, national origin, sex, age, or disability. The final rule also prohibits discriminatory practices by health care providers, such as hospitals that accept Medicare or doctors who participate in the Medicaid program.
The final rule prohibits sex discrimination in health care including by:
- Requiring that women must be treated equally with men in the health care they receive. Other provisions of the ACA bar certain types of sex discrimination in insurance, for example by prohibiting women from being charged more than men for coverage. Under Section 1557, women are protected from discrimination not only in the health coverage they obtain but in the health services they seek from providers.
- Prohibiting denial of health care or health coverage based on an individual’s sex, including discrimination based on pregnancy, gender identity, and sex stereotyping.
It also includes important protections for individuals with disabilities and enhances language assistance for people with limited English proficiency including by:
- Requiring covered entities to make electronic information and newly constructed or altered facilities accessible to individuals with disabilities and to provide appropriate auxiliary aids and services for individuals with disabilities.
- Requiring covered entities to take reasonable steps to provide meaningful access to individuals with limited English proficiency. Covered entities are also encouraged to develop language access plans.
While the final rule does not resolve whether discrimination on the basis of an individual’s sexual orientation status alone is a form of sex discrimination under Section 1557, the rule makes clear that OCR will evaluate complaints that allege sex discrimination related to an individual’s sexual orientation to determine if they involve the sorts of stereotyping that can be addressed under 1557. HHS supports prohibiting sexual orientation discrimination as a matter of policy and will continue to monitor legal developments on this issue.
The final rule states that where application of any requirement of the rule would violate applicable Federal statutes protecting religious freedom and conscience, that application will not be required.
For more information about Section 1557, including factsheets on key provisions and frequently asked questions, visit https://www.hhs.gov/civil-rights/for-individuals/section-1557.
To learn more about non-discrimination and health information privacy laws, your civil rights, and privacy rights in health care and human service settings, and to find information on how to file a complaint, visit us at www.hhs.gov/ocr.
EEOC Issues Final Rules on Employee Wellness Programs
From the U.S. Equal Employment Opportunity Commission.
WASHINGTON, DC--The U.S. Equal Employment Opportunity Commission (EEOC) today issued final rules that describe how Title I of the Americans with Disabilities Act (ADA) and Title II of the Genetic Information Nondiscrimination Act (GINA) apply to wellness programs offered by employers that request health information from employees and their spouses. The two rules provide guidance to both employers and employees about how workplace wellness programs can comply with the ADA and GINA consistent with provisions governing wellness programs in the Health Insurance Portability and Accountability Act, as amended by the Affordable Care Act (Affordable Care Act).
The rules permit wellness programs to operate consistent with their stated purpose of improving employee health, while including protections for employees against discrimination. The rules are available in the Federal Register at Regulations Under the Americans with Disabilities Act and Genetic Information Nondiscrimination Act (GINA). EEOC also published question-and-answer documents on both rules today, available at Q&A ADA Wellness Final Rule and Q&A GINA Final Rule, and two documents for small businesses Facts on ADA and Wellness and Facts on GINA and Wellness.
Many employers offer workplace wellness programs intended to encourage healthier lifestyles or prevent disease. These programs sometimes use medical questionnaires or health risk assessments and biometric screenings to determine an employee's health risk factors, such as body weight and cholesterol, blood glucose, and blood pressure levels. Some of these programs offer financial and other incentives for employees to participate or to achieve certain health outcomes.
The ADA and GINA generally prohibit employers from obtaining and using information about employees’ own health conditions or about the health conditions of their family members, including spouses. Both laws, however, allow employers to ask health-related questions and conduct medical examinations, such as biometric screenings to determine risk factors, if the employer is providing health or genetic services as part of a voluntary wellness program. Last year, EEOC issued proposed rules that addressed whether offering an incentive for employees or their family members to provide health information as part of a wellness program would render the program involuntary.
The final ADA rule provides that wellness programs that are part of a group health plan and that ask questions about employees’ health or include medical examinations may offer incentives of up to 30 percent of the total cost of self-only coverage. The final GINA rule provides that the value of the maximum incentive attributable to a spouse’s participation may not exceed 30 percent of the total cost of self-only coverage, the same incentive allowed for the employee. No incentives are allowed in exchange for the current or past health status information of employees’ children or in exchange for specified genetic information (such as family medical history or the results of genetic tests) of an employee, an employee’s spouse, and an employee’s children.
The final rules, which will go into effect in 2017, apply to all workplace wellness programs, including those in which employees or their family members may participate without also enrolling in a particular health plan.
“The EEOC received comments on both rules from a broad array of stakeholders and considered them carefully in developing this final rule,” said EEOC Chair Jenny R. Yang. “The Commission worked to harmonize HIPAA’s goal of allowing incentives to encourage participation in wellness programs with ADA and GINA provisions that require that participation in certain types of wellness programs is voluntary. These rules make clear that the ADA and GINA provide important safeguards to employees to protect against discrimination.”
Program Design
Both rules also seek to ensure that wellness programs actually promote good health and are not just used to collect or sell sensitive medical information about employees and family members or to impermissibly shift health insurance costs to them. The ADA and GINA rules require wellness programs to be reasonably designed to promote health and prevent disease.
Protecting Confidentiality
The two rules also make clear that the ADA and GINA provide important protections for safeguarding health information. The ADA and GINA rules state that information from wellness programs may be disclosed to employers only in aggregate terms.
The ADA rule requires that employers give participating employees a notice that tells them what information will be collected as part of the wellness program, with whom it will be shared and for what purpose, the limits on disclosure and the way information will be kept confidential. GINA includes statutory notice and consent provisions for health and genetic services provided to employees and their family members.
Both rules prohibit employers from requiring employees or their family members to agree to the sale, exchange, transfer, or other disclosure of their health information to participate in a wellness program or to receive an incentive.
The interpretive guidance published along with the final ADA rule and the preamble to the GINA final rule identify some best practices for ensuring confidentiality, such as adopting and communicating clear policies, training employees who handle confidential information, encrypting health information, and providing prompt notification of employees and their family members if breaches occur.
EEOC enforces federal laws prohibiting employment discrimination. Further information about the EEOC is available on its web site at EEOC.gov.
Employers' Greatest Fears: PPACA & Compliance
Original post benefitspro.com
The last few years have put employers in the position of becoming compliance officers. The Department of Labor, Health and Human Services, and the Internal Revenue Service have actively been pursuing small- and mid-size businesses about various issues, from PPACA reporting to wage and hour miscalculations.
It is becoming a full-time job for manager HR representatives to keep up with the requirements of a compliant business.
The average employer cannot tell you what the affordability test is compared to the value test, but they know that it is now a requirement. Most important is the employer's concern for their employees to have the best health insurance available for the least expensive price. The employees are now looking for jobs that will provide them with health insurance in order to not be penalized at tax filing time. Employers are trying to understand what exactly they should be providing under health care reform in order to not pay additional fines for doing it incorrectly.
IRS fines are increasing in 2016 for employees to either $695 or 2.5 percent of adjusted family income per uninsured adult, whichever is greater. Employers will have to pay $2,160 per employee (after the first 30) if not providing health insurance or for an incorrect plan, and $3,240 for each employee getting a subsidy through the marketplace. Penalties for not filing certain documents in time, such as form 5500 or form 1094C, can add up to $1,100 per late day.
Insurance agents are becoming consultants in a very different world than we first began. Employers are asking accounting and legal questions which are requiring research and partnerships with other professionals.
Employers want to know the difference now in using a professional employer organization (PEO) versus outsourcing their HR and payroll departments. If the employer decides to do it themselves, questions they ask are:
- How long do I keep the necessary paperwork?
- Should I use the qualifying offer method or the 98 percent offer method?
- Which Safe Harbor would be best for my situation?
Insurance consultants will be the ones answering these questions with their employers as well as reviewing the documents and procedures.
Education and wisdom are the most important values for an insurance consultant’s job security. Just about the time you learn it, it will change.
How Agents Can Help Comply with PPACA
Original post benefitspro.com
“You can help your employer clients comply with the Patient Protection and Affordable Care Act [PPACA] by becoming their trusted advisors,” Julie L. Hulsey, CLU, LUTCF, president and CEO, Zynia Business Solutions, Amarillo, Texas, told her audience in her presentation, “Employers’ Greatest Fears: PPACA and Compliance.”
As of Jan. 1, 2016, Hulsey reminded the audience, employers of 50 or more full-time equivalent (FTE) employees are required to provide health insurance to at least 95% of their employees or face a penalty. One key issue for employers is that many federal government entities are auditing small businesses with little to no coordination, for example:
1. Department of Labor, including the Wage and Hour Division, the Equal Employment Opportunity Commission and the Occupational Safety and Health Administration
2. Internal Revenue Service
3. Office for Civil Rights
4. Immigration Customs Enforcement
5. Department of Transportation
“Smaller employers, those with less than 50 employees, or 50 to 100 employees, don’t have an HR department or even an HR professional on staff,” Hulsey observed. One way agents and brokers can demonstrate their value is by providing clients with charts showing affordable coverage employee wage calculations for a 40-hour work week and for a 30-hour work week, she explained, showing the charts she had created for her clients.
Penalties 101 for agents and brokers
Hulsey reminded the audience that for 2016 the employer shared responsibility penalty of $2,000 is now $2,160, and the $3,000 penalty is now $3,240. If an employer is considering paying the penalty instead of offering insurance, you can point out that the penalty is not a tax deductible business expense but health insurance premiums are, which may affect the employer’s decision.
“Penalties will be calculated on a monthly basis so if you are out of compliance for just one month, you will only be penalized for that month,” Hulsey pointed out. “Therefore, become compliant as soon as possible to avoid accumulating more monthly penalties.”
If an employer offers a “minimum essential coverage” plan that meets the “affordable” and “minimum value” tests to an employee who declines it, no employer penalty will be owed for that employee. “Tell the employer to keep a copy of the signed waiver of coverage form, and get a signed waiver every year!” Hulsey said.
It’s important to let our clients know what the Department of Labor and the Department of Justice are targeting, Hulsey said. Quoting from a recent presentation by the DOL and DOJ that she attended, Hulsey said that the DOL’s FY 2013 Strategic Plan has a goal to generate $1,172,108,000 in enforcement results through 4,330 reporting compliance reviews. They indicated their enforcement program will use a series of approaches (including national/regional priorities, civil/criminal litigation, and sample Investigation Programs) to achieve this goal. The current strategic plan is under review and that enforcement goal is likely to increase.
Hulsey acknowledged that agents and brokers are losing commissions but you can take some action to limit those losses “Connect with professionals like TPAs and payroll vendors to offer some of those third party services,” she suggested. “Also, be sure you understand your clients’ needs so you can answer their questions.” Employers need answers about PPACA and compliance, and they’ll be calling you or their attorneys. “It’s better if they call you,” she said.
Counting Employees Doesn't Always Add Up
Original post benefitspro.com
Employee counts are used to determine what laws, rules, fees and penalties apply to a health plan and/or the employer sponsor. But the methods for counting employees are as varied as the laws that affect them. This creates confusion and frustration among employers and can significantly hinder their compliance efforts. To make sense out of all this, we have put together a synopsis of 12 counting methods that employers must utilize to properly administer their health plans. Read on to find out how to stay compliant as you move forward.
Employers with at least 15 employees
Law or compliance requirement applied:
Title VII of the Civil Rights Act, as amended by the Pregnancy Discrimination Act (PDA): Employers may not consider a person's race, color, sex (including sexual orientation), national origin, religion, or pregnancy in determining eligibility for, amount of, or charges for employee benefits. Denying coverage for a condition or treatment that disproportionately affects members of a protected group is also considered a violation of Title VII.
Americans with Disabilities Act (ADA): An employer may not deny an individual with a disability equal access to insurance, or require such an individual to have terms and conditions of insurance different than those of employees without disabilities. The ADA also applies to wellness and disease management programs.
Who to count: Employees working 20 or more calendar weeks in the current or preceding calendar year.
How to count: Count each full-time and part-time employee as one.
Consequences of noncompliance: The EEOC may bring an action in court, and individuals may file private lawsuits to correct violations and obtain appropriate legal or equitable relief (including attorney’s fees and other costs).
Employers with at least 20 employees
Law or compliance requriement applied:
Genetic Information Nondisclosure Act (GINA): Group health plans may not discriminate against individuals based on genetic information and may not use this information in underwriting or determining premiums or contributions. It also restricts questions that can be asked on a Health Risk Assessment (HRA) if an incentive is offered for its completion.
Age Discrimination in Employment Act (ADEA): Benefits provided to older workers (40 years and older) must be the same as those provided to younger workers in all respects, including payment options, types of benefits and amount of benefits (although certain exceptions may apply).
Who to count: Employees working 20 or more calendar weeks in the current or preceding calendar year.
How to count: Count each full-time and part-time employee as one.
Consequences of noncompliance: The DOL may assess special penalties and the EEOC may bring an action in court against a plan sponsor for violations. Individuals may file private lawsuits to correct violations and obtain appropriate legal or equitable relief (including attorney’s fees and other costs).
Employers with at least 20 employees
Law or compliance requriement applied:
COBRA: COBRA provides certain former employees, retirees, spouses, former spouses, and dependent children the right to temporary continuation of health coverage at group rates.
Who to count: Employees (in all commonly-owned businesses) on more than 50 percent of the typical business days in the previous calendar year.
How to count: Count each full-time employee as one. Each part-time employee counts as a fraction, with the numerator equal to the number of hours worked by that employee and the denominator equal to the number of hours that must be worked on a typical business day in order to be considered full-time.
Consequences of noncompliance: COBRA compliance failures can result in excise taxes and statutory penalties. Qualified beneficiaries may also file private lawsuits to correct violations and obtain appropriate legal or equitable relief (including attorney’s fees and other costs).
Employers with 20 or more employees
Law or compliance requriement applied:
Medicare Secondary Payer (MSP) rules based on age: A group health plan is the primary payer and Medicare is the secondary payer for individuals age 65 or over if their group health coverage is by virtue of the individual's (or his/her spouse’s) current employment status.
Who to count: Employees on each working day in at least 20 weeks in either the current or the preceding calendar year. The 20-employee test must be run at the time the individual receives the services for which Medicare benefits are claimed.
How to count: Count each full-time and part-time employee as one.
Consequences of noncompliance: Medicare can collect any incorrect claim payments directly from the employer, regardless of whether the employer's plan is fully insured or self-insured.
Employers with at least 50 employees
Law or compliance requriement applied:
Family and Medical Leave Act (FMLA): FMLA requires employers that sponsor group health plans to provide group health plan benefits to employees on an FMLA leave. Please note that public agencies and public and private schools are covered regardless of the number of employees.
Who to count: Employees working 20 or more weeks in the current or preceding calendar year within a 75 mile radius of the applicable work location.
How to count: Count each full-time and part-time employee as one.
Consequences of noncompliance: The EEOC may bring an action in court and individuals may file private lawsuits to correct violations and obtain appropriate legal or equitable relief (including attorney’s fees and other costs).
Applicable Large Employers (ALEs)
Law or compliance requriement applied:
Shared responsibility provisions of the Affordable Care Act (ACA): ALEs must offer minimum essential coverage that is “affordable” and that provides “minimum value” to their full-time employees, must report to the IRS information about the health care coverage, if any, they offered to full-time employees, and must provide a statement to employees.
Who to count: Full-time employees and full-time equivalent (FTE) employees in each month of the preceding year. Divide this number by 12, and if the result is 50 or greater, the employer is an ALE for the current year.
How to count: Count full-time (30 or more hours per week determined on a monthly basis) and FTE employees as one. Aggregate part-time hours (no more than 120 hours per employee) and divide by 120 to determine FTEs. Special counting rules apply with respect to special situations, such as teachers, seasonal workers, etc.
Consequences of noncompliance: ALEs are subject to a penalty if one or more full-time employees are certified to the employer as having received an applicable premium tax credit or cost-sharing reduction, and either: 1) the employer fails to offer to its full-time employees (and their dependents) minimum essential coverage; or, 2) the employer's coverage is deemed to be unaffordable or does not provide minimum value (as defined by the ACA). Failure to file a return with the IRS or furnish a statement to employees can result in penalties up to $250 per return/statement, with a maximum penalty of $3 million.
Law or compliance requriement applied:
Mental Health Parity and Addiction Equity Act (MHPAEA):Group health plans that provide mental health coverage must provide parity between medical/surgical benefits and mental health/substance use disorder benefits.
Who to count: Employees on business days during the preceding calendar year.
How to count: Count each full-time and part-time employee as one.
Consequences of noncompliance: Individuals and the DOL may use ERISA's civil enforcement provisions to file lawsuits to enforce the MHPAEA's requirements. In addition, noncompliance with the MHPAEA can trigger an IRS excise tax.
Employers with 100 or more employees
Law or compliance requirement applied:
Medicare Secondary Payer (MSP) rules based on disability:A group health plan is the primary payer, and Medicare is the secondary payer for individuals under age 65 entitled to Medicare on the basis of a disability, if their group health coverage is by virtue of the individual's (or his/her spouse’s) current employment status.
Who to count: Employees on at least 50 percent of regular business days during the previous calendar year.
How to count: Count each full-time and part-time employee as one.
Consequences of noncompliance: Medicare can collect any incorrect claim payments directly from the employer, regardless of whether the employer's plan is fully insured or self-insured.
Welfare plans that cover at least 100 employees
Law or compliance requirement applied:
Form 5500: Employee benefit plans must file the Form 5500 reporting and disclosure document on an annual basis with the Department of Labor (DOL). Please note that the Form 5500 requirement applies to ERISA plans only.
Who to count: Employees enrolled in the plan at the beginning of the plan year.
How to count: Count each full-time and part-time employee as one.
Consequences of noncompliance: The penalty for failing to file a Form 5500 is $1,100 per day, which is cumulative from the filing deadline. Lesser penalties may be assessed for incomplete or otherwise deficient Form 5500s.
Employers that filed 250 or more W-2s
Law or compliance requirement applied:
Reporting the cost of health benefits on W-2: The Affordable Care Act (ACA) requires employers to report the total cost of employer-provided health coverage on Form W-2.
What to count: W-2s filed with the IRS in the preceding calendar year.
How to count: W-2s for full-time and part-time employees count as one.
Consequences of noncompliance: Penalties for compliance failures range from $30 to $250 per form.
All self-insured medical plans
Law or compliance requirement applied:
Transitional reinsurance program fee: The ACA requires self-insured group health plans to make contributions to help stabilize premiums for coverage in the individual market during the years 2014 through 2016.
Who to count: Covered lives, which includes both employee and dependent lives.
How to count: The fee is calculated based on the average number of covered lives, which can be determined using one of the following four methods:
- Actual Count: Add the total number of lives covered for each day of the first nine months of the calendar year and divide that total by the number of days in the first nine months.
- Snapshot Count: Add the total number of lives covered on any date during the same corresponding month in each of the first three quarters of the calendar year, and divide that total by the number of dates on which a count was made.
- Snapshot Factor: Use the Snapshot Count method, except the number of lives covered on a given date is calculated by adding the number of participants with self-only coverage to the product of the number of participants with coverage other than self-only coverage and a factor of 2.35. This method can be used to estimate the number of total lives included in coverage that is not self-only coverage.
- Form 5500 Method: The number of participants as of the beginning and end of the plan year as reported on Form 5500 for the last applicable time period.
Consequences of noncompliance: As with any amount owed to the federal government, an unpaid/underpaid Reinsurance Program Fee will be subject to federal debt collection rules.
All self-insured medical plans
Law or compliance requirement applied:
Patient-Centered Outcomes Research Institute (PCORI) fee:The PCORI fee supports the Patient-Centered Outcomes Research Trust Fund and will be imposed for each policy year ending on or after October 1, 2012 and before October 1, 2019.
Who to count: Covered lives, which includes both employee and dependent lives.
How to count: The fee is calculated based on the average number of covered lives, which can be determined using one of the following three methods:
- Actual Count Method: Add the total lives covered for each day of the plan year and divide that total by the total number of days in the plan year.
- Snapshot Method: Add the total number of lives covered on one date during the first, second or third month of each quarter, and divide that total by the number of dates on which a count was made.
- Form 5500 Method: The number of participants as of the beginning and end of the plan year as reported on Form 5500 for the last applicable time period.
Consequences of noncompliance: As with any amount owed to the federal government, an unpaid/underpaid PCORI Fee will be subject to federal debt collection rules.
6 Tips for Moving Wellness Beyond Biometrics
Original post benefitsnews.com
Employers are increasingly moving from traditional wellness programs to a more comprehensive, total well-being approach.
While this might seem to be unique, it is part of a greater trend — a growing list of employers are moving beyond the standard “one-size-fits all” approach to wellness and toward a more holistic view of total well-being.
In this post-ACA era, employers are facing the reality of ever-increasing medical costs and the need to engage their employees in their personal healthcare decisions. To achieve these goals, more and more are turning to wellness strategies, with over two-thirds of U.S. employers now offering some type of wellness program.
In the past, many implemented turnkey programs that focused purely on physical health. Who among us hasn’t heard about a company that did a 10,000 steps challenge or “Biggest Loser” competition?
Although these programs were a strong first step in the right direction — accepting the critical role that employers can play in improving the health of their employees — the current understanding is that physical health is only one small component of total well-being.
In our drive to promote employee engagement, we are likely missing the mark if we don’t realize that many employees have more urgent needs that divert their attention from focusing on physical health. An employee may have the desire and intent to attend the onsite biometric screening, but it ends up taking a backseat to more urgent needs — financial stress, an aging parent who needs to be cared for, or exhaustion from late nights caring for a sick child.
If our goal is to really move the needle — to increase productivity, enhance engagement, reduce healthcare costs, and position ourselves as employers-of-choice — we must take a more holistic approach to well-being. It is time to move beyond the singular focus on physical health, and begin to address the financial, emotional, spiritual, and social aspects of total well-being.
Luckily, with recent advancements in technology tools, and our greater understanding of employees’ needs, today more than ever employers have the ability to do just that.
Sleep, or lack thereof, has been identified as a major issue for its employees, and organizations are starting to offer sleep programs as an investment in its people. It is believed that this will lead to more productive and mindful employees, and eventually, a better bottom line for the company.
Similarly, companies across the country are implementing other all-encompassing “well-being” programs — such as financial education, yoga and meditation classes, volunteer opportunities, and flex-time — all of which are aimed at helping their employees be more engaged and productive.
Whether your company is already well on your way to developing a comprehensive well-being program or just beginning the journey, many best practices apply to both:
1. Assess your population and offer programs that fit your employees’ unique needs and interests. Just because Google offers a certain program doesn’t mean that it would work well for your company. If you have an older population, a financial education program about saving for retirement will have higher engagement than a program for college loan forgiveness.
2. Ask your employees about the causes of stress that impact them and their families.You can get firsthand feedback about the types of issues that are most relevant in their lives, and then tailor your program to target these high impact areas.
3. Take a multi-year strategic approach. At the outset, determine your desired end-result. Then set goals and implement programs along the way that ensure consistent progress and engagement toward those ends.
4. Use technology to interact with the employees in their preferred social medium. Whether it is a smart phone mobile app, their Fitbit or Apple watch, a Facebook page, or face-to-face contact, employees are more likely to engage if you connect with them through their social channel of choice.
5. Move away from a check-the-box approach in favor of more robust program.Programs with the highest levels of engagement tend to be those that allow employees to personalize their experience and choose from a variety of options and activities.
6. Provide consistent and frequent messaging. Your communication should continue throughout the year and align with your company’s culture and brand.
We’re moving “beyond biometrics” to a more holistic view. Is your company ready to embrace the change?