United Benefit Advisors

advertisement
This Employer Webinar Series program
is presented by Spencer Fane Britt & Browne LLP
in conjunction with United Benefit Advisors
Thank You For Your Participation
Kansas City = Omaha = Overland Park
St. Louis = Jefferson City
www.spencerfane.com
www.UBAbenefits.com
Nondiscrimination Rules for
Insured Health Plans and
Latest Guidance regarding
“Grandfathered” Plans
Presented by:
Copyright 2010
Robert Browning, Esq. and Chadron Patton, Esq.
2
Nondiscrimination Rules - Overview


Copyright 2010
Section 105(h) and self-insured plans

What does it prohibit?

What is the consequence of a violation?
Applying 105(h) to fully-insured plans

What plans are subject to the rule?

What aspects of Section 105(h) apply?

What is the consequence of a violation?

What plans/arrangements are most at
risk?
3
Code Section 105



Copyright 2010
Code Section 105 – employees are not
taxed on the benefits they (or their
dependents) receive under employersponsored health plans where “premiums”
are paid by employer or paid with pre-tax
employee contributions via 125 plan
Section 105 is not applicable if premiums
are paid with employee after-tax amounts
Section 105(h) – taxes some or all of the
benefits paid to “highly compensated
individuals” in “discriminatory” self-insured
plans
4
Section 105(h) – “self-insured”

Existing Section 105(h) nondiscrimination
rule applies to all “self-insured” medical
reimbursement plans:


Plans are considered self-insured unless
reimbursements are provided under a policy of
accident or health insurance (or similar arrang.)
Even plans underwritten by an insurance policy
are self-insured if they do not shift the risk to an
unrelated third party


Copyright 2010
Cost-plus or administrative-services-only policies are
considered “self-insured”
Stop-loss insurance does not count as “insurance”
5
Highly Compensated Individuals

Highly Compensated Individual (HCI):

One of 5 highest paid officers; or

10% or more owner (after attribution); or

One of the highest paid 25% of all EEs.

Copyright 2010
For purposes of highest paid 25%, “all
employees” includes the 5 highest paid
officers, but excludes the “excludible”
employees who do not participate in any selfinsured plan of the employer
6
105(h) – Excludible Employees






Copyright 2010
Employees with less than 3 yrs of service
Employees under age 25
Employees who normally work less than 35
hours/wk (if others work more), or any
employee who works less than 25 hours/wk
Employees who normally work less than 9
months/year (if others work more), or any
employee who works less than 7 months/yr
Union employees (if benefits bargained)
Non-resident aliens
7
105(h) – Discrimination Tests


Copyright 2010
Self-insured plan must not discriminate in
favor of “highly-compensated individuals”
with respect to either:

Eligibility to participate; or

Benefits
If plan is discriminatory, HCIs will be taxed
on some or all of the benefits they receive
under the plan (i.e., no adverse
consequence for the plan sponsor)
8
105(h) – Eligibility Tests


Copyright 2010
Plan must “benefit”:

70 percent or more of all employees; or

80 percent or more of all employees who are
eligible to benefit, if 70 percent or more of all
employees are eligible to benefit; or

a “nondiscriminatory classification” of employees
(based on rules similar to the 410(b) coverage
test for qualified plans)
“Excludible Employees” excluded from tests:

But only if excluded from plan?

But only if no similar employee is included?
9
Nondiscriminatory Classification Test


Based on Treas. Reg. Section 1.410(b)-4
Two-part test:


Must be a “reasonable” classification of
employees based on objective business criteria
Must cover a “nondiscriminatory” percentage of
non-HCIs (as compared to the % of HCIs):



Copyright 2010
“Safe-harbor” ratio percentage; or
“Non-safe-harbor” ratio percentage with favorable facts
and circumstances
May pass with ratio percentages as low as 39%
(safe-harbor) or 29% (non-safe harbor)
10
Eligibility Test - Example

Copyright 2010
Plan covers 10 physicians and 10 staff, but
excludes 20 nurses and residents (assume
physicians = HCIs and no excludables)

Plan does not benefit 70% of all EEs

Plan does not pass 80%/70% test

Plan’s ratio percentage is 33.3%, so it does not
pass “safe-harbor” test

May or may not pass “non-safe-harbor” test,
depending on facts and circumstances
11
Benefits Test



Copyright 2010
105(h) Benefits Test – requires that all
benefits provided to any participant
who is an HCI must also be provided
to all participants who are non-HCIs
Also applies to benefits provided to
spouses/dependents of participants
Applies to benefits subject to
reimbursement (not actual benefits
paid)
12
Discriminatory Benefits





Copyright 2010
Better coverage (more covered conditions,
procedures, drugs, etc)
Lower copay, deductible, out-of-pocket
limits, etc.
Lower cost (employee’s share)
Longer coverage (employer-paid COBRA,
etc)
Exception for diagnostic tests (executive
physicals, etc.)
13
105(h) - Special Rules



Copyright 2010
HCIs are determined, and eligibility is
tested, as if the “employer” includes all
members of the “controlled group,” as
determined under Code Section 414
Employer may designate (and test)
two or more plans as a single plan
Retired employees may be tested
separately
14
Consequences



Copyright 2010
If a self-insured plan violates the 105(h)
eligibility test, a percentage of the benefits
paid to HCIs become taxable (based on the
ratio of the total benefits paid to HCIs vs. the
total benefits paid to all EEs under the plan)
If a self-insured plan violates the 105(h)
benefits test, then all discriminatory benefits
paid to HCIs are taxable
“Benefits” means actual reimbursements
(not the premiums paid for coverage)
15
Health Care Reform

Copyright 2010
Extends the “concept” of the 105(h)
non-discrimination rule to insured
group health plans, but with two
important differences:

Nondiscrimination requirements do not
apply to all insured plans;

Consequences of violation fall on the
plan sponsor, not the HCI(s)
16
Plans Subject to New
Nondiscrimination Rule

Copyright 2010
Rules similar to those under Section 105(h)
now apply to fully insured group health
plans, but do not apply to:

Excepted benefits – e.g., dental, vision, longterm care, accident or disability income, specific
disease/illness coverage, Medicare
supplemental coverage -- if offered separately
from group health plan coverage

Retiree-only plans

“Grandfathered” plans
17
Applying 105(h) to Insured Plans



Copyright 2010
Under health care reform, for plan
years beginning on or after Sept. 23,
2010, insured plans that are not
grandfathered must satisfy the 105(h)
discrimination tests (both the eligibility
test and the benefits test)
HCI is defined the same way
Employer means the entire controlled
group
18
Consequences – Insured Plans

Insured plans that are subject to
105(h), but fail either the eligibility or
the benefits test, are subject to:

Section 4980D excise tax = $100 per day
per non-HCI discriminated against


Copyright 2010
Limited exception for “small” employers (50
or less employees)
Civil action by participant to enjoin the
discriminatory practice
19
Examples of Discrimination




Copyright 2010
Management-only health coverage
Better benefits (reduced premium or
increased benefits) for management
Post-termination continuation
coverage (including COBRA) for
management or other HCIs only
Coverage provided to HCI as result of
resolution of employment litigation
20
Avoiding Discrimination


Offer broad coverage, equal benefits, and
equal cost
Switch to self-insured plan, and have HCIs
pay for coverage with after-tax $




Copyright 2010
May need to gross-up for tax effects
Keep insured plans “grandfathered” as long
as possible
Offer retiree coverage under separate plan
Limit discriminatory coverage to “excepted”
benefits
21
“Grandfathering” Guidance





Copyright 2010
Overview
Health care reform provisions
applicable to all plans
Additional provisions applicable to
non-grandfathered plans
Loss of grandfathered status
Recent guidance
22
Overview



Copyright 2010
Insurers and plan sponsors must
modify their plans/contracts to comply
with significant new market reforms
The Affordable Care Act (“ACA”)
"grandfathers" certain plans that were
in existence on the date of enactment
from some of the reform requirements
Effective the first plan year beginning
on or after September 23, 2010
23
Overview


Copyright 2010
To maintain status as a grandfathered health plan,
a group health plan or health insurance coverage
must include a statement, in any plan materials
provided to a participant or beneficiary describing
the benefits provided under the plan or health
insurance coverage, that the plan or coverage
believes it is a grandfathered health plan.
Also, the plan or health insurance coverage must
maintain records documenting the terms that were
in effect on March 23, 2010, and any other
documents necessary to verify, explain, or clarify its
status as a grandfathered health plan.
24
Overview


Copyright 2010
For health insurance coverage maintained
pursuant to a collective bargaining
agreement ("CBA") that was ratified prior to
March 23, 2010, the coverage is deemed to
be grandfathered until the date on which the
last of the CBAs in effect on March 23,
2010, terminates.
This special rule only applies to insured
plans maintained pursuant to a CBA, not to
self-funded collectively bargained plans.
25
Applicable Provisions- All Plans


Elimination of lifetime limits for “essential”
benefits
Restrictions on annual limits for “essential”
benefits



Copyright 2010
$750,000 for policy years beginning on or after
September 23, 2010 but before September 23,
2011
$1.25 million for following policy years beginning
before September 23, 2012
$2 million for following policy years beginning
before January 1, 2014
26
Examples of “Essential” Benefits










Copyright 2010
Ambulatory patient services
Emergency services
Hospitalization
Maternity and newborn care
Mental health and substance abuse disorder
benefits, including behavioral health treatments
Prescription drugs
Rehabilitative and habilitative services and devices
Laboratory services
Preventive and wellness services and chronicdisease management
Pediatric services, including oral and vision care
27
Potential “Essential” Benefits













Copyright 2010
Bariatric surgery and related treatments
Infertility treatments
Chiropractic care
Speech therapy
Physical therapy
Vision benefits
Applied behavioral therapy
Hearing aids
Acupuncture
Organ transplants
Hospice and palliative care
TMJ (temporomandibular joint disease)
Wigs
28
Applicable Provisions- All Plans



Copyright 2010
Preexisting condition exclusion prohibition
for those under 19
Coverage of dependents to age 26 (for plan
years prior to 2014, grandfathered plans do
not have to provide coverage if the child is
eligible for other employer coverage)
No rescission of coverage except in the
event of fraud or intentional
misrepresentation of material fact
29
Additional Provisions for “Nongrandfathered” Plans

Copyright 2010
Patient Protections. Non-grandfathered
plans:

must permit each participant to designate any
participating primary care provider who is
available to accept such individual;

must permit a participant to designate a
pediatrician as the primary care provider for a
child; and

may not require a referral or preauthorization for
obstetrical or gynecological care provided by a
specialist in those areas.
30
Additional Provisions for “Nongrandfathered” Plans



Copyright 2010
Emergency Services. Must provide
coverage for out-of-network emergency
services at in-network levels.
Preventive health services. Must provide
first-dollar coverage of certain preventive
services with no deductible.
Coverage to age 26. Must provide
coverage to age 26 regardless of whether
child has other employer coverage.
31
Additional Provisions for “Nongrandfathered” Plans


Copyright 2010
Appeals process. Must have an
effective independent review process
for appeals of coverage determinations
and claims.
Non-discrimination requirements
for fully-insured plans. Fully-insured
group health plans must satisfy
Section 105(h) non-discrimination
requirements.
32
Acceptable Changes to
“Grandfathered” Plans




Copyright 2010
Premium increases (except for those
that result in an impermissible
decrease in employer contribution)
Appointment of a new third party
administrator
Compliance with federal or state legal
requirements
Voluntary compliance with the ACA
33
Loss of “Grandfathered” Status



Copyright 2010
Elimination of all or substantially all benefits
to diagnose or treat a particular condition
Increase in a percentage cost-sharing
requirement (e.g., raising an individual’s
coinsurance requirement from 20% to 25%)
Increase in a deductible or out-of-pocket
maximum by an amount that exceeds
medical inflation plus 15 percentage points
34
Loss of “Grandfathered” Status



Copyright 2010
Increase in a co-payment by an amount that
exceeds medical inflation plus 15
percentage points (or, if greater, $5 plus
medical inflation)
Decrease in an employer's contribution rate
towards the cost of coverage by more than 5
percentage points (e.g., previously covered
55% of cost and now cover 49%)
Imposition of annual limits on the dollar
value of all benefits below specified
amounts
35
Recent Guidance

Copyright 2010
The federal agencies’ general
approach to implementation of health
care reform will be compliance
oriented, and will focus on assisting
plans, issuers, and others acting in
good faith, to comply with the law,
rather than on imposing penalties.
36
Recent Guidance

Fully insured group health plans will not be treated as having
lost grandfathered status due to a change in employer
contribution rates (assuming the issuer is not aware of the
change) if the issuer and plan sponsor complete the following
actions:



Copyright 2010
Upon renewal, the issuer requires the plan sponsor to clearly
indicate both its contribution rate for the new plan year and its
rate as of March 23, 2010.
The issuer’s policies, certificates, or contracts of insurance
clearly disclose that plan sponsors must notify the issuer if they
change contribution rates during the plan year.
Multiemployer plans may follow similar steps and the same
relief will apply unless or until the multiemployer plan knows
that the contribution rate has changed.
37
Recent Guidance

Copyright 2010
Plan can make various changes
without losing its grandfathered status,
other than changes previously
discussed under “Loss of
‘Grandfathered’ Status,” i.e., not every
change will cause a loss of
grandfathered status.
38
Recent Guidance

Copyright 2010
Plans with Multiple Benefit Options.
Grandfather status is determined on a
benefit package-by-benefit package basis.
Therefore, if a plan has three options among
which participants may choose, such as a
point-of-service option, a preferred provider
option, and a health maintenance option,
the loss of grandfathered status under one
benefit package would not affect the
grandfather status of the other two.
39
Recent Guidance


Copyright 2010
Changes in Tiers of Coverage. If a plan eliminates
or modifies any of the tiers of coverage it had on
March 23, 2010 (e.g., changes from self-only and
family to a multi-tiered structure of self-only, selfplus-one, self-plus-two, etc.), the employer
contribution rate for any new tier would be tested by
comparing it to the contribution rate for the
corresponding tier in effect on March 23, 2010.
For example, if the employer contribution rate for
the family tier on March 23, 2010 was 50%, the
employer contribution rate for any new tier of
coverage other than self-only could not be less than
45%.
40
Recent Guidance

Copyright 2010
A plan can add new coverage tiers for
classes of individuals not previously
covered under the plan without losing
grandfather status, as long as it does
not eliminate or modify a tier of
coverage in existence on March 23,
2010.
41
Recent Guidance

Copyright 2010
Changes in Cost-Sharing. Each
change in cost-sharing is tested
separately and an increase in
employee cost-sharing in even one
category of services (e.g., such as a
change in an office visit co-payment)
will result in a loss of grandfather
status if the increase exceeds the
applicable standard.
42
Recent Guidance


Copyright 2010
Cost-Sharing. If a policy holder had an option
under an individual health insurance policy to pay a
reduced premium in exchange for higher cost
sharing available on March 23, 2010, he/she can
exercise the option after that date without affecting
the plan's grandfather status.
Thus, the cost-sharing level that would apply under
this option would be grandfathered as part of the
policy in place on March 23, 2010, even if the level
did not apply for the particular individual at that
time.
43
Recent Guidance

Copyright 2010
Wellness Programs. Plans may continue to
provide incentives for wellness programs
but penalties under a wellness program,
such as cost-sharing surcharges, “may
implicate” the standards discussed earlier
and should be examined carefully. In
addition, Plans should take steps to ensure
they do not run afoul of HIPAA
nondiscrimination rules regarding penalties
based on health status.
44
Recent Guidance

Copyright 2010
Disclosure Requirement for
Grandfathered Plans. Plans can
comply with the grandfathered
disclosure requirement if they include
the model disclosure language
whenever a summary of the benefits
under the plan is provided to
participants and beneficiaries.
45
Recent Guidance


Copyright 2010
The interim final regulations, by their terms,
provide that if an employer enters into a
“new policy, certificate, or contract of
insurance” after March 23, 2010, then the
new policy, certificate, or contract is not a
grandfathered health plan.
Regulators have said in two sets of FAQs
that they will be addressing circumstances
under which plans may change insurers
without endangering their grandfathered
plan status.
46
Contact Information
Robert Browning
rbrowning@spencerfane.com
913-327-5192
Chadron Patton
cpatton@spencerfane.com
913-327-5137
Copyright 2010
47
Thank you for your participation in the Employer Webinar Series. You
may receive HRCI credit of 1.5 hours for your participation.
This Employer Webinar Series program
is presented by Spencer Fane Britt & Browne LLP
in conjunction with United Benefit Advisors
To receive your HRCI credit information, obtain a recording, or to
register for future presentations, contact your local UBA Member Firm.
Kansas City = Omaha = Overland Park
St. Louis = Jefferson City
www.spencerfane.com
www.UBAbenefits.com
Download