Boca Benefits Consulting Group Inc.

If you are an employer or senior management person trying to keep up with the provisions of PPACA, you are likely very frustrated as are many others. It is a moving target with interpretations and interim rules emerging almost daily. I noted in today’s St. Pete Times comments made following a seminar hosted by the Tampa Chamber on the details of PPACA. Even the normally informed “experts” are a little behind the curve and major employers are struggling with decisions due to incomplete guidance.

CIGNA has been holding a series of web meetings hosted by both their own employees and outside experts. The last one had two attorneys who specialize in PPACA as presenters and who were excellent in terms of their level of knowledge and current information. Following the presentation, a web conference operator moderates individual telephone questions directly to the presenters for specific questions and answers.

You do not need to be a CIGNA client to take advantage of this resource. Even if you just “lurk” without asking any questions, you will be brought up to speed on many details that might not otherwise be available to you. BBCG encourages you to register via the below link and join the web meeting at 2 P.M. June 17, 2010.

Click here for the CIGNA registration web page and link to additional health reform information available from CIGNA.


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Below is link to excellent National Association of Insurance Commissioners “Frequently Asked Questions” resource relative to the specfics of PPACA (i.e., 2010 health care reform statute). It is segmented by Consumers, Employers and Seniors.

Click here for link.

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CIGNA is hosting an educational teleconference on the subject of early implementation of the “To Age 26” provision of PPACA. Valuable for all employers sponsoring employee health plans (i.e., both insured and self-funded). Possibly broker and CIGNA client oriented. However, pertinent to all regardless of present carrier and/or TPA.

CIGNA teleconference registration link.

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Below are two links to resources provided by the U.S.  Department of Health and Human Services in regard to the new “To Age 26” provisions of PPACA. Important reading for graduating college seniors, parents and other adult children less than 26 years of age.

HHS Frequently Asked Questions

HHS fact sheet

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United Healthcare announced that it has agreed to the White House’s request to provide coverage for graduating college seniors under the “To Age 26” provision of PPACA (i.e.,  2010 health reform act). See below excerpt from announcement. Click here for full broker announcement.

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On April 19 we (sic) announced that we will work with customers that wish to extend the health coverage that graduating college students currently have under their parents’ plans. As a result, we are mailing letters beginning May 5 to all fully insured customers* regarding our graduate coverage initiative.  The mailing includes the Customer Notice, Letter and FAQ and Opt-Out form posted above.

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Following on CIGNA’s earlier announcement this week regarding early implementation of the PPACA “to age 26” provision, CIGNA has announced today that they will also implement early the “anti-rescission” provisions of PPACA prior to the statutory requirement of 9/23/2010. CIGNA has announced they will make the policy change effective 5/1/2010.

It would appear that CIGNA is attempting to capture the public relations high ground on these decisions relative to their healthcare insurance competitors. However, these are relatively easy changes to effect and will not substantially alter the competitive balance as other major carriers make similar decisions to implement certain PPACA provisions early.

Below Excerpt from CIGNA Press Release:

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CIGNA’s business practices are already compliant with the suggested reforms that are to be implemented on September 23, 2010. CIGNA is confirming that it will not rescind the coverage of any premium-paying customer except in cases of deliberate fraud or intentional misrepresentations of material facts. CIGNA will also institute a policy of third party review if a rescission is to be made.

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Click here for full press release.


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Below from The White House Blog. See http://www.whitehouse.gov/blog/2010/04/27/more-support-young-adults for a list of carriers voluntarily accelerating the “age 26” provision to make in coincide with 2010 college graduation dates as of the date of this posting. BBCG expects that most all carriers will ultimately agree to this timeline.

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But we knew that some young adults graduating from college this spring could risk losing their health insurance before the provision takes effect, only to be added back onto their parents’ policy the next time their parents’ plan comes up for renewal on or after September 23rd.  That was bad news for families and bad news for insurance companies too.  Removing an individual from a health insurance plan and then adding them back on a few months later takes time, and it costs money.

That’s why on April 19, Health and Human Services Secretary Kathleen Sebelius called on leading insurance companies to begin covering young adults voluntarily before the September 23 implementation date required by the new health reform law.  Early implementation would avoid gaps in coverage for new college graduates and other young adults and save on insurance company administrative costs of dis-enrolling and re-enrolling them between May 2010 and September 23, 2010.   Early enrollment will also enable young, overwhelmingly healthy people who will not engender large insurance costs to stay in the insurance pool.

And we’re pleased to report that the following insurance companies are doing just that:

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We have received communications from both CIGNA and Aetna that they will each be implementing the “to age 26” provisions of the Patient Protection and Affordable Care Act earlier than required by statute (9/23/2010).  The concern stated is the potential for a gap in coverage for those in the 21-26 age group who may be graduating from college and who would otherwise lose eligibility once full-time student status was eliminated.

Both companies are making their eligibility changes effective 6/1/2010.

Although we have not seen announcements from either Blue Cross/Blue Shield or United Healthcare, BBCG is surmising that the changes announced by Aetna and CIGNA have become the new de facto eligibility standard and that the other major healthcare insurers will follow.

Click here for CIGNA announcement. 

Click here for Aetna announcement.

Health Care Reform Impact on Employer-Sponsored Health Plans

Excerpted from Various Insurance and Benefits Industry Sources

(impact on self-insured plans is annotated in bold text below)

• Prohibition of lifetime limits – Prohibits all plans from establishing lifetime limits. Only applicable to self-insured plans established after 6 months from date of enactment.
• Prohibition of annual limits – Prohibits all plans from establishing annual limits on the dollar value of benefits starting in 2014. Prohibits plans from setting limits that would “impair essential health benefits” in subsequent years. Only applicable to self-insured plans established after 6 months from date of enactment.
• Prohibition on rescissions – Prohibits all plans from rescinding coverage except in instances of fraud or misrepresentation. Only applicable to self-insured plans established after 6 months from date of enactment.
• Coverage of preventive health services – Requires all plans to cover preventive services and immunizations, recommended by various Federal agencies, also specifically includes certain child preventive services and women’s preventive care. Plans are prohibited from imposing any cost-sharing requirements. Only applicable to self-insured plans established after 6 months from date of enactment.
• Dependent coverage – Requires all plans offering dependent coverage to make coverage available to dependents that are under the age of 26 and unmarried. Plans are not required to cover dependents of dependents. Only applicable to self-insured plans established after 6 months from date of enactment.
• Prohibition of preexisting conditions – No group health plan or insurer offering group or individual coverage may impose any pre-existing condition exclusion or discriminate against those who have been sick in the past. Only applicable to self-insured plans established after 6 months from date of enactment.
• Prohibiting discrimination based on health status – No group health plan may set eligibility rules based on health status, medical condition, claims-experience, receipt of healthcare, medical history, genetic information or evidence of insurability – including acts of domestic violence or disability. Permits employers to vary insurance premiums by as much as 30 % for employee participation in certain health promotion and disease prevention programs. Only applicable to self-insured plans established after 6 months from date of enactment.
• Prohibition on waiting periods – Prohibits any waiting periods for group or individual coverage that exceed 60 days. Employers are penalized $600 per full-time employee for each employee required to wait beyond 60 days. Only applicable to self-insured plans established after 6 months from date of enactment. 
• Required Plan Information Disclosure
  • Requires plans to issue a summary of benefits and explanation of coverage to beneficiaries with the following criteria:
    • In uniform format
    • In “easily understood” language
    • Inclusion of uniform definitions of standard insurance and medical terms
    • Explanation of cost-sharing exceptions, reductions and limitations on coverage
    • Provide common benefits scenarios 
• Expanded Beneficiary Appeals Availability
  • Requires plans to implement a process for external appeals of coverage determinations and claims
  • Requires self-insured plans to comply with minimum standards to be established by the Secretary of DOL
  • Only applicable to self-insured plans established after 6 months from date of enactment.
• Health Information Technology Standards and Plan Requirements
  • Adoption of uniform standards and operating rules for the electronic transactions that occur between providers and health plans that are governed under HIPAA (such as benefit eligibility verification, prior authorization and electronic funds transfer payments)
  • Establishes a process to regularly update the standards and operating rules for electronic transactions and requires health plans to certify compliance or face financial penalties collected by the Treasury Secretary
• “Young Invincibles” Plan
  • Allows health insurers to offer a catastrophic, high-deductible plan as an exchange option
  • To be eligible for plan, individuals must be either
    • Under the age of 30
    • Exempt from the individual responsibility requirement because coverage is unaffordable to them
    • Individuals with access to employer-sponsored plans who meet criteria may join
  • Plan must
    • Cover essential health benefits
    • Cover at least 3 primary care visits
    • Require cost-sharing up to the HSA out-of-pocket limits
• Allowable Prevention and Wellness Incentives
  • Allows employers to discount up to 30% of the premium or cost-sharing requirements for participants in a workplace wellness program
  • Provides discretion to HHS to permit discounts up to 50%
• Low-Income Tax Subsidies Effects on Employer-Sponsored Health Plans
  • Employees with access to employer-sponsored coverage are eligible for credit (for use in an Exchange only), if:
    • Plan covers less than 60% of total coverage cost
    • The premium exceeds 9.8 of total income
• Employer Responsibility
  • Requires an employer with more than 50 full-time employees that offers coverage, but has employees receiving the “premium assistance” tax credit, to pay the lesser of $3,000 for each employee receiving the credit, or $750 for each full-time employee – adjusted annually and non-deductible
  • An employer with more than 50 full-time employees that maintains an enrollment waiting period would be required to pay
    • $600 for any full-time employee subjected to longer than a 60 day waiting period – adjusted annually and non-deductible
• Employee “Free Choice” Voucher
  • Allows employees with access to an employer-sponsored plan, under certain income eligibility, to receive a voucher from their employer, equal to their employer’s contribution (“free choice” voucher), to purchase coverage through an Exchange participating plan.
  • To be eligible for a voucher, an employee would have to meet both of the following criteria:
    • The cost of the employee’s coverage needs to be between 8% and 9.8 percent of the employee’s household income
    • Employee has a household income below 400% FPL
  • The contribution amount to the voucher must be equal to the amount the employer contributes to their own health plan
  • If the employee chooses coverage that costs less than the voucher, the employee keeps the remainder amount
  • Vouchers cannot be taxed as income
• Automatic Employee Enrollment
  • Requires employers with more than 200 employees to automatically enroll new full-time employees in coverage
  • Requires employers to provide adequate notice and the opportunity for an employee to opt out of any coverage the individual or employee was automatically enrolled in 
• Reporting Requirements for Employer-Plan Sponsors
  • Requires large employers (over 200 employees) to report the following
    • Whether it offers to its full-time employees (and their dependents) the opportunity to enroll in minimum essential coverage under an eligible employer-sponsored plan
    • The length of any applicable waiting period
    • The lowest cost option in each of the enrollment categories under the plan
    • The employer’s share of the total allowed costs of benefits provided under the plan
    • The number and names of full-time employees receiving coverage
    • Disclose the value of the benefit provided by the employer for each employee’s health insurance coverage on the employee’s annual Form W-2 
• Requirement to Disclose Coverage Options
  • Requires that an employer provide notice to their employees informing them of the existence of an exchange
• Excise Tax on Generous Plans
  • Levies an excise tax of 40% on insurance companies and plan administrators for any health coverage plan that is above the threshold of:
    • $8,500 for single coverage
    • $23,000 for family coverage 
• Fees on Self-Insured Plans
  • In 2013, the plan sponsor of a self-insured plan is required to pay $2 multiplied by the average number of covered lives
  • From 2013-2019 the previous year’s fee is multiplied by projected per-capita amount of National Health Expenditures
  • Plans are not required to pay fees beyond 2019 
• Termination of Deductibility of Medicare Prescription Drug Subsidies
  • Elimination of the deductibility of Federal subsidies for Medicare Rx programs 
• Limitation on Health Flexible Spending Arrangements
  • Limits the amount of contributions to health FSAs to $2,500 per year indexed by CPI 
• Annual Report on Self-Insured Plans
  • Requires the Secretary of DOL to prepare an annual report, using information obtained from submitted Form 5500, on various aspects of self-insured, group health plans. Report will include:
    • Plan type
    • Number of participants
    • Benefits offered
    • Funding arrangements
    • Benefit arrangements
    • Data from the financial filings including:
      • Information on assets
      • Liabilities
      • Contributions
      • Investments
      • Expenses 
• Indirect Health Industry Fees Likely to Increase Plan Costs 
  • Fees on Pharmaceuticals
    • Imposes an annual flat fee of $2.3 billion on the pharmaceutical manufacturing sector beginning in 2010
  • Fee on Medical Devices
    • Imposes an annual flat fee of $2 billion on the medical device manufacturing sector in years 2011 – 2017
    • Imposes an annual flat fee of $3 billion on the medical device manufacturing sector in years after 2017

BBCG did not spend a lot of time massaging the below linked file to make it aesthetically pleasing. It summarizes the implications for employer sponsored health plans (i.e., both insured and self-insured). We opted to expedite the posting. Although the House was forced to revisit the reconciliation procedures, the actual gist of the legislation is unlikely to change.

See http://bocabenefits.com/reform_as_passed.pdf for the summary.