October 2013
NFP Golden & Cohen Newsletter
In This Issue
ACTION ITEM: Medicare Part D
The Exchanges Are Open!
FAQs on FF-SHOP Premiums &
Contributions
Excise Tax Form Revised
Bicycle Commuting Benefits
Department of Labor Exchange
Notices
Same-Sex Marriage & Tax Credits
Carrier-Specific News
New Census Data Needed
A New Way to See Your Doctor
Human Resources Corner
Training & Education: Upcoming
Event and Webinar Schedule
Ask the Expert
Page 1
ACTION ITEM: Medicare Part D Creditable/
Non-Creditable Coverage Notice Due
The Centers for Medicare & Medicaid Services (CMS) requires
that a Medicare Part D Creditable/Non-creditable Coverage
notification be provided to Medicare-eligible plan participants on
an annual basis prior to Oct. 15, which is the first day of the
Medicare enrollment period.
This important notice assists eligible individuals in deciding
whether to enroll in Medicare Part D prescription drug coverage.
Because an individual can be eligible for Medicare due to age or
disability, or an employee's spouse or dependent can be eligible
for Medicare, it might be difficult for an employer to identify plan
participants who are Medicare-eligible (and therefore must
receive the Creditable/Non-creditable Coverage notice). To avoid
this difficulty (and for purposes of administrative simplicity), the
recommended approach is for the notice to be distributed to all
employees who are eligible to participate in the plan. The
preferred method of delivery is first-class mail, although it is
possible to distribute the notice electronically as long as certain
conditions are met.
CMS has provided both creditable and non-creditable basic
model notices in English and in Spanish. These notices are
updated from time to time, so it is essential that you use the most
current version. The most current model notice is available for
use on or after April 1, 2011. CMS did not update the model
notice for 2012 or 2013. Four model notices may be reviewed
and downloaded here.
The Exchanges Are Open!
704 Quince Orchard Rd.
Suite 200
Gaithersburg, MD 20878
www.golden-cohen.com
P: 866.330.0195
F: 301.330.0507
On Oct. 1, 2013, the health care exchanges, established under
PPACA, opened for business and began taking applications. HHS
has provided that the initial open enrollment period will run from
Oct. 1, 2013, through Mar. 31, 2014. This is the same for all
states. Coverage must be offered effective Jan. 1, 2014, for
qualified individuals whose qualified health plan selections are
received by the exchange on or before Dec. 15, 2013. For
selections received between the first and 15th day of January,
February or March 2014, coverage must be provided effective the
first day of the following month. For those received between the
16th day of the month and the last day of the month of December,
January, February or March, the exchange must ensure coverage
effective the first day of the second following month.
The paper application contains an employer coverage form to
assist individuals with gathering the requested information on
employer-sponsored coverage from their employees. Now that the
exchanges are open, some employees will be coming to their
human resources department to get information they need to
complete the application. The application includes a one-page
employer coverage tool that an employer can fill out to help an
individual complete their portion.
October 2013
NFP Golden & Cohen Newsletter
Page 2
FAQs on the Federally-Facilitated
SHOP Premium Calculations and
Employer Contributions
On Oct. 2, 2013, Centers for Medicare & Medicaid
Services (CMS) released technical guidance in the form
of frequently asked questions (FAQs) on the Federallyfacilitated SHOP (FF-SHOP). The questions addressed
in the FAQs largely pertain to premium rates and
contribution determinations. Specifically, how premiums
will be calculated in the FF-SHOPs, whether composite
premiums may be used in the FF-SHOPs, how
employers will contribute to employee and dependent
premiums, whether an employer may contribute
different amounts based on employee classifications
(part-time vs. full-time) and how employees will
contribute toward their coverage in an FF-SHOP,
among other FAQs. The technical guidance also
includes examples depicting the various ways in which
an employer may determine its contribution amounts.
The guidance clarified that employers in all FF-SHOPs
will be able to have their employees contribute the
same amount toward premiums (i.e., composite rating)
for employee-only coverage, subject to the imposition of
a tobacco surcharge, as applicable. In addition, in most
FF-SHOP states, employers will have the option to
have employees contribute to premiums based on age,
also subject to the imposition of a tobacco surcharge,
as applicable. When a state allows both methodologies,
the FF-SHOPs will make both options available to
employers. However, employees in the FF-SHOPs will
always contribute to dependent coverage on a permember basis. Thus, dependent contributions will not
be based on a composite dependent rate.
The full set of FAQs can be found here.
Excise Tax Form Revised to Include
Upcoming 2014 Mandates
The IRS recently released a new version of Form 8928 and
the accompanying instructions, both of which reflect a
revision date of December 2013.
Employers sponsoring group health plans complete and
submit this form for payment of applicable excise taxes for
compliance failures relating to COBRA, HIPAA and other
group health plan mandates. Importantly, the form also
references many important health care reform requirements.
A number of health care reform mandates with the potential
to trigger excise taxes generally become applicable for plan
years beginning on or after Jan. 1, 2014, including the
required coverage of expenses in connection with clinical
trials; cost-sharing limitations; prohibition on excessive
waiting periods; nondiscrimination against health care
providers; and complete prohibition of annual dollar limits on
essential health benefits and pre-existing condition
exclusions. Employers needing assistance to complete this
tax form in the event of a compliance failure should work with
their accountant or legal counsel.
IRS Web page
Form 8928
Form 8928 Instructions
October 2013
NFP Golden & Cohen Newsletter
Page 3
Department of Labor
Exchange Notices
Under the Patient Protection and Affordable Care Act
(PPACA), employers are mandated to provide a Model
Notice to all current employees and new hires explaining
the options available to them for health coverage. This
Notice was to be sent to all current employees by
October 1, 2013 and is to be distributed to all new hires
within 14 days of the date of their employment.
IRS Issues Guidance Related to
Bicycle Commuting Benefits
On July 26, 2013, the IRS provided guidance on
qualified bicycle commuting reimbursement as a
transportation
fringe
benefit.
Under
Section
132(f)(1)(D), a qualified transportation fringe benefit
includes
any
"qualified
bicycle
commuting
reimbursement." The regulations define "qualified
bicycle commuting reimbursement" as any employer
reimbursement during the 15-month period beginning
with the first day of such calendar year for reasonable
expenses incurred by the employee during the
calendar year for the purchase of a bicycle or bicycle
improvements, if the bicycle is regularly used for travel
to work. The IRS clarified in Chief Counsel Memo
2013-0032 that expenses incurred in using a bicycle
share program, however, are not allowed expenses.
The guidance further clarified that unlike other qualified
transportation fringe benefits, qualified bicycle
commuting reimbursements cannot be excluded from
the employee's gross income if the employer provided
them in place of pay. Therefore, Section 132(f)(4), the
provision which permits employees to reduce their
taxable
compensation
in
order
to
receive
reimbursement for transit expenses on pretax basis,
does not apply to qualified bicycle commuting
reimbursements.
The law is very clear that businesses subject to the Fair
Labor Standards Act must notify their employees about
the Exchange and that the notice should inform
employees:
 About the Health Insurance Marketplace;
 That, depending on their income and what
coverage may be offered by the employer,
they may be able to get lower cost private
insurance in the Marketplace; and
 That if they buy insurance through the
Marketplace, they may lose the employer
contribution (if any) to their health benefits.
The Department of Labor released Model Notice
templates for employer use.
The penalty for not issuing these Notices has been
delayed. However, the Notice should still be sent to
all employees, regardless of eligibility, under the
law.
If you have not already distributed this Notice, you
should complete the Notice and distribute to all
employees as quickly as possible. Model Notices can
be found through the Department of Labor’s website,
and through the links below.
Model Notice for employers who offer a health plan
to some or all employees
Model Notice for employers who do not offer a
health plan
The Model Notices can be found in Spanish at this site:
http://www.dol.gov/ebsa/healthreform/
IRS Chief Counsel Memo 2013-0032
NFP Golden & Cohen Newsletter
October 2013
Page 4
Guidance on Same-Sex Marriage and
Exchange Determinations for Premium Tax
Credits
On Sept. 27, 2013, CMS published guidance relating to same-sex
marriage and eligibility for advance payments of the premium tax
credit and cost-sharing reductions that are available through the
health insurance exchanges (also referred to as “marketplaces”). As
background, following the U.S. Supreme Court decision in U.S. v.
Windsor, 133 S. Ct. 2675 (2013), which held as unconstitutional the
Defense of Marriage Act’s (DOMA) prohibition on same-sex
marriage, the IRS issued guidance recognizing same-sex marriage
for federal tax purposes so long as the marriage is validly performed
in a state or country that recognizes same-sex marriage (regardless
of laws of the state in which the couple is domiciled). The IRS ruling
is relevant in determining eligibility for premium tax credits and costsharing reductions because a taxpayer’s spouse is included in
determining family size and household income. Also, married couples generally must file a joint federal income tax return to
qualify for premium tax credits.
According to the CMS guidance, CMS generally requires exchanges to evaluate marital status based on the law of the state or
country where the marriage was performed, even if the state of residence (i.e., the state in which the exchange is located)
does not recognize same-sex marriage. Federally facilitated exchanges will recognize same-sex marriages based on the
married couple’s attestations that they expect to file a joint federal income tax return for the 2014 tax year. State-based
exchanges are given time to adjust their systems to reflect this guidance (but must implement a workaround where they can).
In separate but similar guidance, CMS also explained how the Windsor decision affects Medicaid and Children’s Health
Insurance Program (CHIP) eligibility (these are both need-based programs run jointly by the federal and state governments).
For income-based eligibility determinations for both Medicaid and CHIP, CMS will permit states to apply their own choice-oflaw rules in deciding whether a couple is lawfully married. Thus, in states that do not recognize same-sex marriage, Medicaid
and CHIP programs may still use the state of residence rule — potentially denying income-based eligibility for those programs
for same-sex couples married in other states. For other eligibility determinations, CMS indicates that the Social Security
Administration’s (SSA) eligibility rules will apply; SSA has not yet issued post- Windsor guidance.
The CMS guidance does not directly affect employers. But employers should be aware of the new guidance, as it affects
employees interested in the exchanges and potential penalties under PPACA’s employer mandate.
CMS Exchange Guidance
CMS Medicaid and CHIP Guidance
NFP Golden & Cohen Newsletter
October 2013
Page 5
Carrier-Specific News
CareFirst Plan Offerings Change
Please note that you or your employees may receive a letter from
CareFirst stating that your plan is no longer available. For those of you
who renewed early, you will not need to worry about changes to your
plan until your next renewal cycle.
Should you have additional questions, please call us at 301.330.5300.
A
CareFirst Changes – Effective January 1, 2014

Effective January 1, 2014 there are no more
A keyrenewal caps on your increases.

Full-Time Equivalents (FTEs) count will determine group size. MD Parity is going away. Groups currently in
MD Small Group but with more than 51 FTEs will NOT be required to move from MD Small Group.

All self-employed contracts will receive termination notices.

If you have a group that is currently renewing under the wrong jurisdiction (i.e., MD group moved to VA but is
still renewing under MD) you will NOT be allowed to do that in 2014.

1099 Employees will be offered coverage in ALL states.

Only RX on the shop - $10/20%/40%/50% (specialty) with no caps.

OFF Shop – 42 total plans in MD.

OFF shop – 52 total plans in VA.

ON & OFF shop – 54 total plans in DC.

There will be a new Healthy Blue HMO in 2014.

RX off shop $10/$45/$65/50% with no cap (thus the advantage of buying off the Shop).

11/15-12/15 groups can be written for 1/1 without participation requirements each year.

If an employee leaves your group plan and qualifies for a subsidy they will be considered a valid waiver.
Continued on page 6
NFP Golden & Cohen Newsletter
October 2013
Page 6
Carrier-Specific News (continued)
CareFirst Replaces Drug Card Effective January 1, 2014
Existing members with drug coverage are getting new ID cards due to CareFirst partnering with a new Pharmacy Benefits
Manager (PBM), CVS Caremark - Effective 1/1/2014.
If a member currently uses Mail Order or Specialty Pharmacy services they will be contacted by CareFirst with instructions on
pharmacy procedural changes.
It is important to start using this new card when visiting your pharmacy on or after January 1, 2014 to ensure your
prescription claims are paid correctly.
There will be no change in CareFirst’s network of approximately 60,000 pharmacies. The CareFirst formulary will continue to
be used -- no change to existing formulary.
Cards will have new BIN/PCN numbers. Used much like a bank routing number, these numbers route prescription claims to
the correct PBM (CVS Caremark).
 Commercial:
Rx BIN: 004336 Rx PCN: ADV
Cards will also have a new Group (Grp) number. This number identifies the claim as CareFirst.
 Commercial:
Grp: Rx7546
SAMPLE 2014 FACETS ID Cards (CD & SLMD)
Continued on page 7
NFP Golden & Cohen Newsletter
October 2013
Page 7
Carrier-Specific News
Important Changes from Aetna
Two new policies affecting members with out-of-network benefits recently went into effect.
Starting July 1, if members are admitted to an out-of-network hospital through the emergency room, clinicians from our
Utilization Management area will confirm that the admission was clinically necessary before we will cover it at the network rate.
If our Utilization Management professionals determine the admission was not a true emergency, we will cover it at the out-ofnetwork benefit level. This means the member will have to pay a larger portion of the bill at the out-of-network hospital.
Examples of admissions that might not qualify as emergencies are elective detoxification from alcohol, or a member admitted
with back pain who undergoes a scheduled back procedure the next day.
Doctors encouraged to transfer members to network hospitals
After a member’s admission is verified as an emergency and the member is medically stable, we will ask the attending
physician to write a transfer order to have the member sent to a network hospital for ongoing care. We will identify a network
hospital and a doctor at that hospital to treat the member.
If the doctor does not agree to the transfer, we will continue to cover the hospitalization at a network benefit level. If the doctor
agrees to transfer the member, we will tell the member about the transfer. We will explain that if the member does not agree to
the transfer, his or her hospital stay will be covered at the out-of-network benefit level, beginning the next business day.
With these policies we are taking steps to reduce and control costs and eliminate inefficiencies in handling claims for members
who admitted to out-of-network hospitals through emergency rooms.
Coverage for observation now limited to 48 hours
Beginning August 1, we are also changing the way we pay for observations at out-of-network emergency rooms. Members
brought to the emergency room are not always admitted, but placed under observation. We will pay for only the first 48 hours
of observation (except in New Jersey, where their state requirement is 24 hours) at out-of-network hospitals.
Members who stay longer without being either discharged or admitted could be balance billed for the remainder of their stay.
We are taking this step to counter a growing trend of hospitals holding patients for long periods without having to notify the
insurer of an admission.
Aetna will contact the member when the member is considered stable enough for transport, notifying the member that his or
her in-network coverage will be ending. Members will be asked to sign the notification letter and indicate whether they agree to
be transferred to another facility or if they'd prefer to stay at the out-of-network hospital and have the ongoing stay benefited at
the out-of-network rate.
New Census Data Needed
Due to PPACA changes, new census data is necessary. Be on the lookout for our up dated census at your renewal! We’ll
now be required to ask for more dependent information (date of birth or age), employees’ home zip code and county, and
the employee’s status (COBRA, Retired, Waiver, etc.).
NFP Golden & Cohen Newsletter
October 2013
Page 8
A New Way to See Your Doctor
Access Health Group offers immediate, video-based access to US board-certified and licensed doctors 24/7/365. Check
out www.accesshealthgroup.com for more information about all these benefits:
1. Doctor Choice: Employees can pick their own doctor based on educational background and ratings from other
patients.
2. It's face-to-face in real time: Through video, employees literally see the doctor and interact, just like at an inperson visit.
3. Employees can talk to the doctor whenever they want: Healthcare has never been this convenient -- 24/7/365
from any web or mobile device.
4. Employers and employees save money -- there are no co-pays ever: Employers can offer the plan as 100%
paid or voluntary. For one low monthly rate, employees can see the doctor as often as they like.
5. Employees save time: No leaving work for appointments, sitting in a crowded waiting room, or juggling work and
family responsibilities to see the doctor.
Offer telehealth to your employees: you'll save money, boost productivity, and get some needed control over spiraling
healthcare costs.
Fact # 1: Telehealth can help employers lower overall healthcare expenditures.
Fact # 2: Telehealth can deliver the same outcomes as in-person visits.
Fact # 3: Telehealth saves time and reduce absenteeism by giving employees access to care right from work.
Fact # 4: Telehealth can reduce utilization and claims for more expensive office care.
Fact # 5: Telehealth is a benefit used by more than 6 million Americans.
To learn more about partnering with Access Health Group, contact Geoff Walker, Managing Director, 610-21202112, or
gwalker@accesshealthgroup.com.
Visit us today at www.campusmd.net or www.accesshealthgroup.com.
NFP Golden & Cohen Newsletter
Page 9
October 2013
Human Resources Corner
Frequently Asked Question’s
Q: How long do I need to obtain our personnel files?
A: The short answer – it depends on the size of the
company and what the record is. For example, under the
FLSA (Fair Labor Standards Act), all employers must
maintain records about the employee and data about the
hours worked and wages earned for a period of three
years. These records include payroll records, collective
bargaining agreements, and sales and purchase records.
However, records on which wage computations are based
(i.e., time cards, work and time schedules, additions and
deductions of wages, and wage rate tables) should be
kept for a period of two years. For employers with 50 or
more employees, under the Family and Medical Leave Act
(FMLA), records such as payroll, FMLA leave requests
and notices, etc. should be kept for three years. To help
navigate through record retention, we’ve attached a
guideline to this newsletter.
Q: How do I keep my employees motivated?
A: Every employee is motivated by something different so
get to know your employees! If you learn what interests
and challenges your employees, you can better align them
in their position and within your company. Recognize
employees’ achievements by personally thanking them for
doing a great job. Create opportunities for social
interaction among team members – when people like their
colleagues, they are happier at work! If an employee
wants to develop and you can’t promote them – consider
lateral moves to help develop their skills and knowledge
base!
In the long run, if your employees are motivated –
everyone wins! But, not everyone is created equal so what
is important to one employee, may not be important to
another!
It’s Flu Season!
Did you know that flu shots can be free at
participating vendors? Check with your insurance
carrier or call our customer service line at
301.330.5300 to see if your vendor participates!
NFP Golden & Cohen Newsletter
Page 10
October 2013
TRAINING AND EDUCATION:
UPCOMING EVENT AND WEBINAR SCHEDULE
WEBINARS:
NFP Training & Education does not currently have any training webinars scheduled for October but will have some exciting
webinars coming in November! A note about our webinars: at registration, you will need to enter NFP Golden & Cohen’s
name in the “NFP Representative” field. An email confirmation will be sent once you have completed your registration.
Access to the webinar will be available approximately 10-15 minutes prior to the start time.
November 6 at 2:30pm EST: HIPAA Privacy and Security for Employers. HIPAA is an area of compliance that
continues to be confusing for employers. We will discuss an employer’s privacy and security obligations under HIPAA’s
administrative simplification rules, which vary based on whether the employer sponsors a fully insured or self-insured group
health plan and their access to protected health information. We will help employers of all sizes understand their
requirements related to Business Associate Agreements, the Notice of Privacy Practices, authorization forms, safeguarding
of information and written policies and procedures.
November 12 at 2:30pm EST: Top Ten Benefits Compliance Requirements an Employer Should Know. NFP Benefits
Compliance answers hundreds of questions every month from employers seeking information related to their employee
benefit plans. Join us for a discussion of the top ten compliance issues, which include Section 125 qualifying events, ERISA
plan documents, COBRA, Medicare and, of course, health care reform.
November 19 at 2:30pm EST: A PPACA Update. The exchanges are open and the Notice of Exchange has been
distributed to the employees. Now what? Employers are finding themselves on the receiving end of employee questions
regarding health care reform. Specifically, employees want to know if they are eligible to purchase coverage through the
exchange and what that coverage will cost. This discussion will help employers to understand the eligibility provisions of the
exchange, how premium tax credits work and whether employees will be able to make changes under the employer’s plan
because of the availability of the exchange. We will also discuss the recently proposed regulations related to employer
reporting requirements, which would begin in 2015 related to the individual and employer mandate.
November 20 at 1:00pm EST: Wellness Call. Additional information will be available here soon!
You can also check out our “On Demand” selection of past webinars by visiting our Client Learning Portal.
Out & About in Our Community
Thursday, October 31, 2013: Join us for the Beyond Mask Expressions Masquerade Ball at the Strathmore Music Hall.
Beyond Mask Expressions is a not-for-profit offering transpersonal and other training, performances, recordings, and
exhibits in the field of Intellectual Disabilities and the Creative Arts. Tickets are $65.00 per person; if you cannot attend, you
can also donate tickets to family members of the choir, ensemble, and Therapeutic Noh Theatre cast members.
Tuesday, November 12, 2013: The Greater Washington Hispanic Chamber of Commerce is hosting, in partnership with
Fiesta Travel, an informative session on the Affordable Care Act for local Hispanic small businesses. Golden & Cohen’s
very own Stephanie Cohen will be presenting.
Wednesday, December 4, 2013: We will be participating in World AIDS Day 2013 in Silver Spring. This event is open to
the community and Golden & Cohen’s team will have a table! Stop in and see us!
For additional information on our events, please contact Michele at Michele@golden-cohen.com.
NFP Golden & Cohen Newsletter
October 2013
Page 13
Ask the Expert
Q: An employer offers full-time employees the opportunity to enroll in coverage that is affordable and meets
minimum value. The employees’ spouses and children are also eligible for coverage, but the employer pays nothing
toward the cost of the family coverage. Would a spouse or child be eligible for a premium tax credit through the
exchange?
A: No. The spouse and child would be eligible to purchase coverage through the exchange, but would not be eligible for a
premium tax credit.
Generally, an individual is eligible for a premium tax credit if he/she: a) has household income between 100 percent and
400 percent of federal poverty level; b) is not eligible for Medicare or TRICARE; and c) is not eligible for qualified
employer-sponsored coverage. "Qualified employer-sponsored coverage" means that the coverage is affordable and
meets minimum value. "Affordable" means that the employee’s cost for self-only coverage does not exceed 9.5 percent
of income.
If an employer offers minimum value coverage to a spouse, child and employee, and the cost of self-only coverage is
affordable, the spouse and child will not be eligible for a premium tax credit. The spouse and child would still be eligible
to purchase coverage from the exchange, but it would be at full cost. The result would be the same no matter what the
employer paid toward family coverage. The determining factors are whether the spouse and child are eligible for
coverage and whether the cost of the self-only tier is affordable.
If the employer excludes spouses from eligibility under the group health plan, the spouse would be eligible for a premium
tax credit through the exchange (providing that the household income was within the proper levels and the spouse was
otherwise eligible). Further, the employer would not pay a penalty for excluding spouses. In other words, if the spouse is
not eligible for the employer-sponsored coverage, the spouse would maintain their eligibility for a premium tax credit
(and the employer would not suffer a penalty related thereto).
The same is not true for children. If a large employer does not make an offer of coverage to substantially all full-time
employees and their children, then the employer would be subject to Penalty A under the employer mandate, which is
$2,000 per each full-time employee (minus the first 30).
Newsletter provided by:
NFP Golden & Cohen, LLC
704 Quince Orchard Rd., Suite 200, Gaithersburg, MD 20878 • 301.330.5300 • www.golden-cohen.com
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