Letter from Karen Knippen PPACA Tidbits

Letter from Karen Knippen
PPACA Tidbits
The Patient Protection and Affordable Care Act (PPACA)
was passed in 2010. At that time, 2014 seemed like a
date that was so remote that it would never arrive.
When PPACA was passed it seemed like 2014 was
ridiculously far into the future. Time flies when
Despite the passage of time, now that most of the
Act is in the implementation stage, the myriad details
and idiosyncrasies of the law are emerging. This issue
of Legislative Review addresses some of those
idiosyncrasies and tidbits in complying with the law.
you’re having fun!
Latest FAQS – Part XVIII
we’d still have about implementing the law even as
What I didn’t foresee at all was how many questions
2014 begins. I must say I’m looking forward to a day
The 18th set of FAQs was issued by the US Department
of Labor in January 2014. This set of questions and
answers addressed a number of issues. Coverage of
preventive services was clarified and updated. The
update requires coverage for risk-reducing medications
to treat women at increased risk of breast cancer.
These include tamoxifen and reloxifene. These services
must be included for non-grandfathered individual and
group plans for plan or policy years beginning on or
after September 24, 2014.
The limit on out-of-pocket expenses has a transition
rule applicable for plan years beginning on or after
January 1, 2014 that allows the annual limit on out-ofpocket costs to be satisfied if:
• The plan complies with the requirements for
major medical coverage (excluding such
coverages as prescription drug and pediatric
when I feel like we all actually know all of the tidbits
and idiosyncrasies of this law.
Sincerely yours,
Karen Knippen, RHU, REBC, CLTC
EUCLID MANAGERS® has been serving the independent agent since
1976 with a portfolio of group health, professional liability and
individual health, life, annuity and long-term care products. We
proudly represent UnitedHealthcare, Delta Dental of Illinois,
MetLife and Humana Individual. We encourage your feedback and
suggestions. Please call your E UCLID MANAGERS® Marketing
Representative or Marcy Graefen at (630) 238-2915 for more
information. Outside Chicagoland, call (800) 345-7868. Website:
continued on page 2
The information contained in this publication is intended for the general information of our clients. It should not be construed as legal
advice or legal opinion regarding any specific or factual situation.
• If there are separate out-of-pocket maximums
for other coverage such as prescription drug
coverage that the out-of-pocket maximum
does not exceed the out-of-pocket maximum.
This transition relief is for one year only. Subsequent
years beginning on or after January 1, 2015 are subject
to the individual and family out-of-pocket limits
regardless of the number of service providers used.
and still be in compliance with the Affordable Care
Act (ACA).
With the initial open enrollment period coming to a
close, special enrollment periods (SEP) for individuals
will gain importance. After open enrollment, individuals
will only be able to enroll in individual coverage
through an exchange or in the individual market due
to a special enrollment period.
The FAQs do allow that beginning in 2015, plans may
allocate the dollar limit across multiple categories of
benefits. All totaled, however, these limits cannot
exceed the overall out-of-pocket limit. Moreover, an
out-of-pocket maximum cannot be imposed on mental
health and substance abuse benefits separate from any
limit on medical/surgical benefits.
A special enrollment period is available for the following:
As a reminder, the out-of-pocket limits for 2014
are $6,350 for self only coverage and $12,700 for
family coverage. Out-of-pocket limits for subsequent
years are indexed for medical inflation. Also, beginning
in 2015, the out-of-pocket maximum for family
coverage cannot be greater than two (2) times the
employee level.
• Permanently moving to a new area that offers
different health plan options
Other Tidbits
The $2,000 deductible limit cannot be increased
to reflect an employer’s contribution to a Health
Reimbursement Account (HRA), Health Savings
Account (HSA) or FSA. As an example, an employer
can’t contribute $500 to one of these accounts and
increase the deductible for the health plan to $2,500
-2 legislative review
• Marriage
• Birth of a child
• Adoption or placement for adoption
• Losing other coverage; note voluntarily
quitting other health coverage or coverage
termination due to non-payment of premiums
are not considered a loss of coverage nor is
losing coverage that is not minimum essential
• Exchange enrollees who have a change in
income or household status that affects
eligibility or cost-sharing reductions.
Most individual SEPs are 60 days in length. Special
enrollment periods will also apply to employer-based
plans. A SEP of 30 days is allowed following certain life
events that involved a change in family status or loss of
other job-based coverage.
seems to qualify for one. It’s important that individuals
check the box on the application form that indicates
that they wish to be evaluated for a subsidy.
It’s important to note that enrollment due to a SEP
may result in a gap in coverage. An employee whose
coverage is terminated on January 22nd, for example,
and who enrolls in individual exchange-based coverage
on that date will have coverage effective March 1st.
The exchange must notify employers every time one of
their employees receives a premium tax credit. The IRS
will also be notifying employers of this, especially if the
employer is a large employer subject to the employer
responsibility requirements. Individuals who willfully
misrepresent their employer-coverage may be subject
to fines and penalties ranging from $25,000 to
Individuals who know in advance that they will lose
employer-based coverage can enroll in exchange
coverage 60 days in advance of the loss of coverage.
They will not qualify for premium tax credits until they
actually lose their qualifying coverage.
COBRA coverage also presents unique considerations.
If a person is eligible for COBRA coverage and enrolls,
they are eligible for a SEP when the COBRA coverage
comes to an end. However, if the COBRA beneficiary
decides to drop coverage before the end of the COBRA
coverage, this is not a SEP. The beneficiary could drop
coverage and secure other coverage if the drop in
coverage coincided with an open enrollment period.
Someone facing the option of COBRA or statecontinuation can choose individual coverage before
opting for continuation coverage. The loss of employerbased coverage is considered an SEP. The caution,
however, is that once they’ve enrolled in continuation
coverage, they have lost the SEP right.
There have been numerous reports that individuals
are not obtaining subsidies although their income
It seems odd to have to consider whether someone
dead can enroll for coverage. However, if Social Security
records show that an applicant is dead, the applicant is
given 90 days to prove they are, indeed, alive. The
exchange will send a notice to the enrollee advising
them of the need to prove their status or coverage will
be terminated retroactively to the date of death.
Brokers who are qualified to sell on the exchange
created a FFM user ID as a part of the Part II agent/
broker registration process. The FFM user ID expires
60 days after creation. Brokers must reset their
password every 60 days or they may experience log-in
problems. To reset the FFM password, go to the CMS
Enterprise Portal log-in web page at
Click on the “Forgot Password?” link, at the far right
side of the page. Clicking this link will provide
instructions for how to initiate a password reset.
legislative review 3-
A service publication for brokers from Euclid Managers®, proudly
representing UnitedHealthcare of Illinois, Delta Dental of Illinois,
MetLife and Humana Individual.
HealthiestYou and Lifelock available through Euclid Managers Concierge Services.
Visit us online www.euclidmanagers.com.
Legislative Review is published by Euclid Managers®, 234 Spring Lake Drive., Itasca, IL 60143. For more information, contact your Marketing Representative or Marcy
Graefen at (630) 238-2915 or fax your request to (630) 773-8790. Outside Chicagoland: (800) 345-7868, Fax (877) 444-2250. © Permission to quote with credit to source.
PPACA Tidbits
First-Class Mail
U.S. Postage
Addison, IL 60101
Permit No. 210