“Size Matters” How different size employer groups might adjust under the Affordable Care Act (ACA) 10/15/13 Agenda • FTE (Full Time Equivalent) • Individual coverage • What is a large group? • Who says? • “Pay or Play” - 50+ FTEs • Size Matters – group size influences: Sizes 1-100, 2-50, 2-25, 2-9 • Self-funding www.TheBrokerageInc.com 233 W Main St, Lewisville, TX 75057 469-635-6000 or 800-442-4915 Reality Check! • Nearly two-thirds of U.S. households earn less than 400% of the federal poverty level, the cutoff point for the subsidies • 49% of the people polled think the ACA has been repealed! • Announced at June 2013 NAHU Convention in Atlanta But first… • 1% of the people battling multiple chronic conditions account for 21% of the $1.3T total health care expenses, at an average of $88,000 per person • 5% accounted for 50% of the total • The bottom 50% = 2.8% of the total • Narrow Networks • ACOs Enrollment issues • CMS Enterprise Portal • Health Insurance Marketplace Certification • Setting up a user account at www.HealthCare.gov • Getting set up with the carriers • Cigna – Halt! Don’t enroll anyone yet… • Subsidized apps not working for brokers…paper apps? Medicaid Expansion, Medicare Reductions • Medicare reimbursement levels will go down between 1-3% for hospital readmissions within 30 days • Medicaid reimbursement is going to Medicare reimbursement levels starting 1-1-14 • “The Arkansas Approach” Arkansas is taking their Federal funds to expand Medicaid and enrolling this population into ACA compliant health insurance plans (Note – Texas State Rep John Zerwas, a Houston area doctor, has proposed a similar approach called “Texas Solution”, but it did not move in the last session.) Some of the ACA Delays • “Pay or Play” moves to 2015 • Employer penalties delayed to 2015 • Reporting will not be mandatory until 2015 • Information reporting by employers & health insurers regarding employer-sponsored coverage relative to the individual mandate • SHOP – Small Business Health Options Program • Was to be a multiple carrier choice • Now one carrier choice per employer in 2014 • In Texas, you get BCBSTX or BCBSTX as your option • Self-reporting to the IRS about status of your QHP in 2014 • IRS may still audit • You must still prove you had coverage People need to know is still in place • On January 1, 2014, every American is required by law to own a QHP with the EHBs or they will be penalized. • If they cannot afford it, they will be subsidized. • Subsidies are based on the 70% Actuarial Value Plan • a.k.a. – The Silver Plan • CSR – Cost Sharing Reduction applies at <250% FPL • Must own a 70% AV plan to qualify for CSR Newly proposed legislation to track • H.R. 2667 - “Authority for Mandate Delay Act", would create a law that would require the Obama administration to postpone implementation of ACA employer coverage mandate • Introduced by Rep. Tim Griffin, R-Ark. • H.R. 2575 - Would raise the definition of FTE in the law to be changed to those working an average of 40 hours per week • Introduced by Rep. Todd Young, R-Ind. What is a FTE = Full Time Equivalent? • Can we all just quit counting and worrying about FTEs for a year? • The generally accepted HR meaning for the "E" in FTE is "equivalent“ • FTE is often used to indicate a direct, as opposed to contract, fulltime employee • Example: • Jane is a regular employee, an FTE, W2 wage earner • Ralph works only under contract (1099) • The term WYE (Work Year Equivalent) is often used instead of FTE when describing the contractor work FTE • U.S. federal government, FTE is defined by the GAO as: • “# of total hours worked divided by the maximum # of compensable hours in a full-time schedule as defined by law” • For example: • The normal schedule for a quarter is defined as 411.25 hours • 35 hours per week (52 weeks per year - 5 weeks regulatory vacation) divided by 4 • Someone working 100 hours during that quarter represents • 100/411.25 = 0.24 FTE • 2 employees working in total 400 hours during that same quarterly period represent 0.97 FTE So what constitutes an individual? • Could be several unique situations to consider: • • • • • Sole proprietor A dependent child or spouse Court ordered child(ren) health insurance An employee that is not offered an affordable QHP How about a “retiree” not yet age 65? What about the individual coverage? • Individual mandate • Presumably, the IRS will monitor compliance with the individual mandate through self-certification on each individual’s tax return in 2014. • Health insurance exchanges • Pending further notice, open enrollment began on 10-01-13, for all statebased, partnership and federally facilitated marketplaces. What is a “Large Group” Depends on who you ask… • Aetna – 2-10 is small group, 101-3,000 is “mid-market” and 3,000 or more is “”public and labor” • BCBSTX – 2-100 is small group, with 2-50 being regulated and 51-100 being non-regulated. 101-2000 is mid-market. 2000+ is Nat’l Accts • CIGNA – 51 + • Humana - ? • UHC – 2-100 is small group, 101+ is large group 50+ life groups • Will be subject to “pay or play” in 2015, not 2014 • W-2 reporting requirements • Still apply for employers that issue more than 250 W-2s. • Reporting by: (a) employers & (b) health insurers • Regarding • (a) employer-sponsored coverage relative to the individual mandate • (b) pay-or-play reporting • will not be mandatory until 2015. “Pay or Play” delayed until 2015 • The individual mandate to have coverage in 2014 or pay a tax penalty is still in place • Individual exchanges are live and “operational” as of 10-1-13 • "Pay or Play“ probably won't go away • Now that the administration has postponed the implementation, they have 12 more months to strengthen their resolve, plug all the loopholes and prepare for more stringent enforcement in 2015. SHOP – Small Business Health Options Program • Intended to offer multiple carriers to one employer group • Example: • Employee 1 chooses an Aetna plan • Employee 2 chooses a Cigna plan • Employee 3 chooses a UNC plan • The choice part of SHOP has been delayed until 2015 • Example: • Employees 1, 2 and 3 all have a BCBSTX plan 1-100 life groups • The ACA defines a small group as 1-100 • Is 1 life a group? • But in Texas, we are still 2-50 • SB 1332 preserved the 2-50 size definition of FTEs • Maintains compliance with the ACA • Expires in 2016? 2-50 life groups • Texas HB 2055 & Texas HB 369 • For 2-50 size employers in Texas, nothing has changed • Texas SB 1332 • Businesses with fewer than 50 FTE employees will still have access to the SHOP Exchanges • Small Business Health Options Program • Approximately 55% of 2-50 size groups in Texas do not offer health insurance today 2-25 life groups • Health Insurance Tax Credits (HITCs) apply • 1-9 lives = 50% in 2014 • 10+lives = shrinking tax credit • HITCs present a great opportunity to work with local CPAs to help their clients qualify • How do you know if an employer group qualifies? • www.taxpayeradvocate.irs.gov www.taxpayeradvocate.irs.gov The Small Business Health Care Tax Credit Enter info on the employer Enter info about the group health plan Results To claim the credit – IRS Form 8941 2-9 life groups • Your traditional “Ma and Pa” market • Your bread and butter • You are their HR department • How do we maximize this demographic? • BCBSTX has 36,000 groups between 2-50 lives • Average case size is 9 lives Typical 2-25 size group • 1976 started group with one employee • Grew and grew • Now has 18 FTEs • The two owners (“Ma and Pa”) are now ages 65 and 72 • Max rated due to pre-ex • How much does it help to have 65+ year olds on the plan? • Recommend the owners take Medicare? • Will they qualify for HITCs? Self-funded plans • New health insurance premium tax does not apply to self funded plans • immediate 3% savings over fully insured plans • Employers have more say in the design of their health plan to fit to fit their specific group health insurance needs • Improves cash flow • Eliminates carrier profits and risk charges Self funded plans • ERISA preemption of state action • ACA does not subject self insured plans to state jurisdiction, eliminating many state mandates in the process • Specific stop loss • Separate deductible for any individual • Aggregate stop loss • Protects against an excessive amount of claims expenditures for the entire plan Comparison of fully insured vs. self funded • Company A • Fully insured, $1,500,000 total premium • $1,000,000 in claims = $500,000 profit for carrier • Company B • • • • • Self insured Worst case scenario is $1,650,000 exposure Pays $240,000 in projected costs (stop loss coverage) Reserves $1,360,000 in potential claims If claims are at $1,000,000, Company B keeps the $360,000 remaining in reserve • Saves $260,000 Wrap up • 6,200,000 uninsured Texans • 2,200,000 at <138 FPL or lower – not your customers • 4,000,000 left to decide: do I or don’t I enroll? • 1,000,000 probably will • About 13,000 true health agents in Texas to write 1,000,000 or 77 uninsured people per agent • What if only 3,000 actually wrote those 1M? 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