2017 Employer-based Premiums Contrast with ACA Increases

By Phil Galewitz, Kaiser Health News

2017 employer-based premiums

Family health insurance premiums rose an average 3% this year for people getting coverage through the workplace, the sixth consecutive year of small increases, according to a study released Tuesday.

Average 2017 Family Premiums: $18,764

The average total cost of family premiums was $18,764 for 2017, according to a survey of employers by the Kaiser Family Foundation and the Health Research & Educational Trust. That cost is generally divided between the employer and workers. (Kaiser Health News is an editorially independent program of the foundation.)

2017 employer-based premiumsWhile overall premium increases remain modest, workers are picking up a greater portion of the tab — this year $5,714 for family coverage, about a third of total cost.

Employer-provided coverage for a single person rose on average 4%, to $6,690. Those individuals pay $1,213 on average.

Still, the employer market looks remarkably stable compared to the price increases seen in the Affordable Care Act’s insurance marketplaces for people who buy their own coverage. Premiums on those plans spiked on average about 20% this year, and many insurers dropped out because of financial concerns.

Average ACA Premiums Up 20% in 2017

For all the media attention and political wrangling over the Obamacare exchanges, their share of the market is relatively small. They provide coverage to 10 million Americans while 151 million Americans get health insurance through their employer.

The continued slow rise of employer health premiums identified in the Kaiser survey surprised some analysts who have expected the trend to end as the economy picked up steam, leading to a jump in use of health services and health costs.

Drew Altman, CEO of the Kaiser Family Foundation, said it’s “health care’s greatest mystery” why health insurance costs have continued their slow pace even as the economy has picked up the past few years. “We can’t explain it.”

2017 employer-based premiums

Employee Deductibles Have Nearly Doubled Since 2010

Another unexpected result was that workers’ deductibles — the health bills that workers must pay before their insurance coverage kicks in — remained stable this year at $1,221. Since 2010, as companies sought to keep premiums in check, deductibles have nearly doubled. Higher deductibles can limit premium increases because costs are shifted to workers and it gives them greater incentive to cut spending.

“Increasing deductibles has been a main strategy of employers to keep premiums down and we will have to watch if this plateauing is a one time thing … or if this portends a sharper increase in premiums in future years,” said Altman. “It could be deductibles are reaching their natural limit or could be the tighter l2017 employer-based premiumsabor market” that’s causing employers to back off, he added.

Meanwhile, a second employer survey released Monday by Mercer, a benefits consulting firm, suggests a modest increase in health costs coming next year, too. Employers said they expect their health costs to increase by an average 4.3% in 2018, according to the survey.

To deal with higher medical costs — notably big increases in the prices of prescription drugs — employers are using multiple strategies, including continuing to shift more costs to workers and paying doctors and hospitals based on the value of the services rather than just quantity of services.

Jeff Levin-Scherz, a health policy expert with benefits consultant Willis Towers Watson, said there is a limit on how much employers can shift costs to their workers, particularly in a tight labor market. “Single-digit increases doesn’t mean health care costs are no longer a concern for employers,” he said.

Trend: Employer-Based Coverage Has Dropped

The 19th annual Kaiser survey also found that the proportion of employers offering health coverage remained stable last year at 53%. But the numbers have fallen over the past t2017 employer-based premiumswo decades.

The survey highlights that the amount workers pay can vary dramatically by employer size. Workers in small firms — those with fewer than 200 employees — pay on average $1,550 more annually for family premiums than those at large firms. The gap occurs because small firms are much more likely than large ones to contribute the same dollar amount toward a worker’s health benefits whether they’re enrolled in individual or family coverage.

More than one-third of workers at small employers pay at least half the total premium, compared with 8% at large employers.

That’s the case at Gale Nurseries in Gwynedd Valley, Pa., where health insurance costs rose 7.5% this year. Its 25 workers are paying nearly half the cost of the premium — at least $45 a week for those who choose the base coverage plan. Employees also have deductibles ranging from $1,000 to $2,500.

A decade ago, the nursery paid the full cost of the premium.

“It’s crazy — we keep paying more and getting less,” said comptroller Candy Koons.

At the Westport (Conn.) Weston Family YMCA, health insurance premiums rose about 7% this year, leaving its 50 full-time employees to pay a $156 premium for individual coverage.

“It’s not problematic, but it’s one of our bigger costs associated with payroll,” said Joe Query, the human resources director.

 

Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.

3 Compliance Areas for Self-Funded Employers (Video)

self-funded employer compliance

WATCH VIDEO NOW

“There are three primary areas that employers should keep in mind when thinking about compliance for their health plan,” said Brad Roehrenbeck, General Counsel and VP of Legal Services and Compliance at MedCost.

1. Employment Retirement Income Security Act 

“The first of those is the Employee Retirement Income Security Act of 1974 (ERISA), which governs employer-sponsored benefit plans. ERISA was a law created in the early 1970s that has been applied to basically set the rules for how an employer that creates their own health plan should do that.”

Michael Berwanger, Director of Quality Management and Compliance, agreed. “ERISA requires several things of plan sponsors and plan administrators. One of those things is to provide notices of what benefits are available to employees. The types of notices that you might expect with the summary plan document are any tax filing notices you might need to be aware of.

self-funded employer compliance“This is to make employees aware of the rights available to them under ERISA. And with the right service provider, employers can feel confident knowing they’re distributing the right notices in the right formats.

2. HIPAA Compliance

“The second area of compliance for self-funded employers is the Health Insurance Portability and Accountability Act of 1996 (HIPAA). HIPAA requires that you safeguard patient data. Employers might find themselves subject to certain HIPAA rules; and with the right service provider, it could be relatively easy to navigate those waters.”

Keeping track of privacy obligations with documents that contain patient information is very important, said Brad Roehrenbeck. “Another thing that HIPAA requires is that anyone who handles that information, particularly if it’s electronic, must keep it secure. That basically means that you have to have systems in place that control who has access to that type of information, if you’re keeping it on your systems.

“HR directors want to make sure that they work with their IT departments to look at what kind of controls are in place, who has access to any folders where patient data is maintained, or anything else in relation to running the health plan. The HR department keeps that sensitive member information for the plan.

3. Internal Revenue Service Compliance

“The third primary area of the law that impacts health plans is tax laws. Like other types of benefit plans, health plans come with a tax benefit to both employees and employers. As dollars go in to support the plan, those dollars are provided on a tax-free basis.”

self-funded employer compliance“There are certainly tax advantages when you’re considering self-funding your health plan,” Michael Berwanger said. “To take advantage of those, you need to be aware of your compliance obligations -things like making sure you’re not discriminating unfairly in favor of your highly compensated employees.”

“There’s one other area of the tax laws that actually provides some additional benefit to employers and employees, and that is this concept of a Health Savings Account (HSA). Health savings accounts are a great vehicle under the tax laws where employees can set aside dollars and employers can contribute dollars on a tax-free basis. Those monies can be used toward deductibles and the payment of claims. Employees can keep that money for the rest of their lives or until such time as they need to use that for their medical expenses.

HSAs are a great asset for employees and a great savings vehicle. More importantly, it’s a great avenue for employers to engage with participants in the health plans to be conscious of where their health plan dollars are spent and to use them in a way that not only promotes their own health, but also the financial stability and viability and strength of both their dollars and the health plan dollars,” Mr. Roehrenbeck said.

self-funded employer compliance“As the markets continue to move towards a consumer-driven economy, it’s important for employees to be mindful of their options and how to best take advantage of the benefits available through their employers,” Mr. Berwanger noted.

“We find ourselves in a challenging environment. It’s important to be able to offer great incentives and great packages to employees. A self-funded health plan is a great opportunity to be able to do that.

“The risk can be worth the reward. Managing those compliance obligations isn’t as complicated as you might think, once you have a good trusted advisor to help you navigate that.”MedCost

(This post is a transcript from the video, “3 Compliance Areas for Self-Funded Employers.”)

 

 

PCORI Fee for Self-Funded Employers: Due July 2017

By Michael Berwanger, JD, Director, Quality Management & Compliance

 PCORI Required by ACA

PCORI due datesThe Affordable Care Act (ACA) includes provisions to promote research by the Patient-Centered Outcomes Research Institute (PCORI) that will provide information on the relative strengths and weaknesses of various medical interventions. This initiative is being funded by a tax that must be paid by insurers and plan sponsors of self-funded health plans. Per IRS Guidance, for self-insured and/or self-funded plans ending in 2016, filing and payment must be submitted to the IRS by July 31, 2017. The fees owed in 2017 are as follows:

  • For plan years* ending on or after October 1, 2015, and before October 1, 2016: $2.17 per covered life
  • For plan years* ending on or after October 1, 2016, and before October 1, 2017: $2.26 per covered life

*’Plan year’ is generally the 12-month period stated in the Summary Plan Description, or for plans filing a Form 5500, the plan year stated in that filing. NOTE: The plan year may be different from the benefit year or the renewal period.

 PCORI Fee Payments

PCORI due dateUnder the Internal Revenue Service (IRS) final rule, plan sponsors are responsible for paying the fee, which is treated as an excise tax by the IRS. A Quarterly Federal Excise Tax Return (Form 720) must be used when reporting liability for the fee. The form can be accessed at http://www.irs.gov/pub/irs-pdf/f720.pdf. Instructions for completing and filing the form can be accessed at http://www.irs.gov/pub/irs-pdf/i720.pdf. Completion of the form is relatively simple.  As described here, only the relevant parts of the form need to be completed, which include:

  • Identifying information at the beginning of the form
  • Part II, line 133 (“Applicable self-insured plans” line)
  • Part III, items 3 and 10
  • The signature section
  • The voucher form, if the form is mailed
  • The form may be filed electronically or mailed to:

Department of the Treasury
Internal Revenue Service
Cincinnati, OH 45999-0009

Additional Tips

The following information may be helpful in determining your tax obligation under the PCORI provision:

  • The plan sponsor must apply a single calculation method in determining the average number of lives covered under the plan for the entire plan year. However, the plan sponsor is not required to use the same method from one plan year to the next.
  • HRA and Self-Insured Plans: A self-insured Health Reimbursement Account (HRA) is not subject to a separate fee if the HRA is integrated with another applicable self-insured health plan that provides major medical coverage. The HRA and the other plan must be established or maintained by the same plan sponsor with the same plan year.
    • However, if a self-insured HRA is integrated with an insured group health plan, then the fee must be paid for both the self-insured product and the insured product.
  • Excepted Benefits: Excepted benefits (as defined under section 9832c of the U.S. Code) are exempt from the fee, as is a health Flexible Spending Account (FSA) that satisfies the requirements of an excepted benefit.
  • All plans that provide medical coverage to employees owe this fee. The insurer/carrier for fully-insured plans will pay the fee (typically, the fee is passed on to the plan). The plan sponsor for self-funded plans will pay the fee. Note, there is no exception for small employers, government, church or not-for-profit plans, nor for grandfathered plans or union plans. The fee is tax-deductible.
  • For more information, see: IRS FAQ or IRS chart that shows which plans owe the fee.

NOTE: MedCost is not a tax preparation company, and you may have additional tax obligations for other benefit plans that you offer to your employees. Please consult with your tax advisor for guidance. This blog post should not be considered as tax or legal advice.MedCost

 

House Republicans Introduce Health Care Reform Legislation

health reformBy Brad Roehrenbeck, General Counsel & VP, Legal Services, Compliance

On Monday, House Republicans unveiled the long-awaited legislation intended to overhaul former President Barack Obama’s signature health care legislation, the Patient Protection and Affordable Care Act (ACA). The bill, titled the American Health Care Act (AHCA), would make major changes to the ACA that impact individuals, employers, insurers, and providers in significant ways, as summarized below.

Provisions Impacting Employer-Sponsored Coverage

The most significant development impacting employers under the proposed law is removal of the employer mandate.

  • Large employers would no longer face penalties for failing to offer coverage that meets the minimum value and minimum essential coverage requirements of the ACA. 
  • Additionally, the proposed bill would repeal the widely unpopular excise tax on high-cost coverage (the so-called Cadillac Tax) and offer tax credits to small businesses for providing coverage to employees. 
  • The law would also require employers to indicate on Form W2 the months of coverage each employee was eligible for coverage. (Note: It appears the legislation is intended also to eliminate the ACA’s annual employer 1094/1095 reporting under Section 6056 of the Code. That would be a natural by-product of the employer mandate repeal, but the bill does not appear to eliminate this obligation expressly. This may be addressed in a future amendment to the bill.) 

Changes to Account-Based Plans

health reformThe AHCA would make some significant changes to the rules governing HSA accounts for the first time since 2004.

  • The bill would increase the annual HSA contribution limit to equal the out-of-pocket maximum amount established for that year under the HSA rules (currently $6,550 for self-only coverage and $13,100 for family coverage).
  • The rules would also be modified to allow both spouses (if over 55) to make “catch-up” contributions to the same HSA account.
  • Also, a new special rule would allow HSA account holders to use HSA funds to pay for health care services performed up to 60 days prior to the account being established.
  • The bill would also reduce the excise tax on distributions not used for medical expenses from 20% to 10%.
  • Finally, the AHCA would remove the ACA’s cap on contributions to health FSA plans.

Changes to the Individual Market

While leaving in place popular provisions of the ACA such as the requirements that insurers cover dependents up to the age of 26 and pre-existing conditions, the AHCA would otherwise significantly redesign the ACA’s changes to the individual market.

  • First, the bill does away with the individual mandate and repeals the cost-sharing subsidies and premium tax credits made available under the ACA to individuals who enroll in coverage on the exchanges.
  • In turn, the AHCA puts in place refundable tax credits that individuals could use to defray the cost of coverage, including coverage outside the exchanges.
  • Like under the ACA, these tax credits are eligible for advance payment. The amount of the credits will vary based on age and income, and excess payments can be deposited directly into an HSA account.
  • Tax credits are not available for any coverage that includes abortion services.

health reformIn place of the individual mandate, to incentivize individuals to maintain coverage, the bill provides for increased premiums (30% for 12 months) for individuals who have had a gap in coverage of at least 63 days.

  • The bill also creates the “Patient and State Stability Fund,” which provides significant payments to states ($10 to $15 billion per year through 2026) to help stabilize the individual and small group insurance markets and to assist high-risk patients.
  • Also, beginning in 2020, the ACA’s requirements around essential health benefits will sunset.
  • Finally, the bill allows carriers greater flexibility to vary premiums based on age by up to a 5:1 ratio, up from 3:1 under the ACA.

Changes in the Medicaid Program

Unsurprisingly, the AHCA would repeal the ACA’s expansion of the Medicaid program.

  • It would also put into place a per-capital allotment of federal Medicaid dollars to the states, which is expected to rein in the future federal financial commitment to the program.
  • Similar to other provisions, the bill would bar Medicaid dollars from being used on abortion providers.
  • It would also require states to disenroll high-dollar lottery winners and incentivize states to assess participant eligibility on a more frequent basis. (Note: The bill will also reverse major cuts to the Medicare Disproportionate Share Hospital program, which provides safety net funding to more than 3,000 hospitals that disproportionately treat indigent patients).

Repeal of ACA Taxes

Finally, the AHCA would repeal numerous taxes—in addition to the Cadillac Tax discussed above—that either have gone into effect or are expected to become effective under the ACA.

  • Among those are:
    • The insurer tax (effectively a federal insurance premium tax),
    • The prescription medication tax,
    • The tax on over-the-counter medications,
    • The medical device tax.
    • It would also eliminate taxes on high-income earners that were levied under the ACA to help pay for the law.

health reformRepublicans have signaled an aggressive timeline for deliberations on the law. Committee hearings are expected to take place immediately, and the bill could reach the floor of the House in as little as one week.

President Trump has forecasted that he would like to sign the bill by Easter. We will continue to monitor developments, including any changes in the bill as it moves through the legislative process.MedCost

This blog post should not be considered as legal advice.

President Trump Orders Pull-Back on ACA

ACA changesBy Brad Roehrenbeck, General Counsel & VP, Legal Services, Compliance

As widely reported over the weekend, within a few hours of his swearing in, President Donald Trump signed his first Executive Order, calling on federal agencies to take immediate steps to curtail aspects of the Affordable Care Act and signaling the new administration’s plans to repeal and replace the Act altogether.

What does the Order say?

The Order itself has little if any tangible impact on the law. The Order states the administration’s official policy of pursuing a complete repeal and replacement of the ACA. It directs the heads of all federal agencies to take steps within their authority to remove or minimize any provision of the ACA that carries fiscal or regulatory burden. As the primary agencies charged with implementing the ACA, that action will likely come from the Department of Health and Human Services, the Department of Labor, and the IRS. The order also directs these agencies to afford greater flexibility to the States in areas impacted by the law. Finally, the order directs federal agencies to take steps to encourage and enable an interstate market for health coverage.

What does the Order mean for employers?

For now, the Order has no real impact on employers, except to signal that federal agencies will be acting quickly to relax various components of the ACA that impact employers, group health plans, and their members. The Senate has yet to confirm those President Trump has nominated to lead the agencies affected by the Order. Once those agency heads are confirmed, we expect to see regulations issued as prescribed by the Order and will be watching closely. Of course, both the Trump administration and members of both houses are said to be working on legislation to repeal and/or replace the ACA. Both the House and the Senate have laid the groundwork for streamlined procedures for repeal of the Act. They face more of an uphill battle to pass legislation to replace the ACA, as a 60-vote majority will be required in the Senate to pass replacement legislation. We will provide updates as details of those efforts become public. Until such legislation passes or further regulations are released, employers should bear in mind that the ACA remains in full force and effect.MedCost

Judge Issues National Injunction Against Certain ACA Rule 1557 Provisions

michael-berwanger-109-by-192By Michael Berwanger, JD, Director, Quality Management & Compliance

On December 31, 2016, Judge Reed O’Connor of the United States District Court for the Northern District of Texas entered a nationwide injunction in Franciscan Alliance v. Burwell. The order prohibited the Department of Health and Human Services (HHS) from enforcing certain provisions of its nondiscrimination rule promulgated under ACA section 1557, namely those that prohibit discrimination on the basis of gender identity or termination of pregnancy.

The remaining provisions of the rule—prohibiting discrimination on the basis of disability, race, color, age, national origin, or sex other than gender identity—are in effect as scheduled, mostly beginning January 1, 2017.

MedCost published a summary of Section 1557 here. HHS has published a summary here and FAQs here. Section 1557 applies antidiscrimination laws to entities receiving assistance under certain federal agencies. These rules have required various plan changes from self-funded plans to implement the protections afforded under the rules.

ACA rule 1557In the December 31 ruling, Judge O’Connor stated that “[w]hile this lawsuit involves many issues of great importance—state sovereignty, expanded healthcare coverage, anti-discrimination protections, and medical judgment—ultimately, the question before the Court is whether Defendants exceeded their authority under the ACA in the challenged regulations’ interpretation of sex discrimination and whether the regulation violates the Religious Freedom Restoration Act as applied to Private Plaintiffs.”

Finding that HHS exceeded its authority under the ACA, he enjoined the agency from enforcing the provisions of Section 1557 regarding plan changes for nondiscrimination on the basis of gender identity and pregnancy termination until further judicial or legislative action.

For more information about Section 1557, consult your broker, legal advisor or the Department of Health and Human Services.MedCost

This blog post should not be considered as legal advice.

ACA Reporting Due Early 2017

ACA DeadlinesBy Michael Berwanger, JD, Director, Quality Management & Compliance

In early 2017, employers and insurance carriers must report information to employees and the IRS about coverage offered to employees under employer-sponsored health plans during calendar year 2016.

Background

The Patient Protection and Affordable Care Act (ACA) requires self-funded employers to satisfy two reporting obligations under Sections 6055 and 6056 of the Internal Revenue Code, relating to health coverage offered to employees and about those employees who are covered under the plan.

The purpose of the reporting obligations is to allow the IRS access to data needed to monitor compliance with both the employer and individual mandates. The reporting also may be used by affected employees in assessing their own compliance with the individual mandate and/or in seeking subsidized coverage on the federal and state exchanges established under the ACA (as described in this blog post).

Section 60ACA reporting55 Reporting Compliance

Under Section 6055 of the Internal Revenue Code, all self-funded employers must annually report information to the IRS and to any individual who is covered under a health plan offered by the employer.

Currently, many employers do not have access to Social Security numbers for non-employed dependents, creating a fairly significant compliance burden to collect that data. The regulations require that employers exercise “reasonable collection efforts” to obtain that information. (Typically, an employer will satisfy that standard by documenting at least two efforts to request the data from those individuals). This same information must be reported to employees, along with basic contact information for the employer.

Section 6056 Reporting Compliance

The second reporting obligation, under Code Section 6056, applies only to “Applicable Large Employers.” Applicable Large Employers are those employers with at least 50 full-time equivalent employees and to whom the ACA’s employer mandate applies.

Unlike Section 6055 reporting, all of this information also must be provided separately to each employee, full-time, part-time, or otherwise. You can read helpful IRS guidance about 6056 reporting here.

IRS Forms 1094 and 1095

The compliance obligations are complex, and the IRS has developed forms (Forms 1094-B, 1095-B, 1094-C, and 1095-C) to provide consistency in reporting and to help simplify the process for employers.

Applicable Large Employers (ALEs) who offer coverage under a self-funded health plan may use Form 1095-C, which combines the reporting obligations of Sections 6055 and 6056 in a single form for reporting to both the IRS and individuals. When the forms are provided to the IRS, the Applicable Large Employer also must submit a transmittal form, Form 1094-C. Forms 1095-C and 1094-C, along with instructions, can be accessed here.

Small employers with fewer than 50 full-time equivalent employees are only required to meet one of the reporting obligations, the Minimum Essential Coverage reporting under Section 6055. Small employers may use Form 1095-B, with transmittal Form 1094-B. These forms, along with instructions, can be accessed onACA reporting the IRS web site here.

Changes from reporting year 2015 to 2016 for forms 1094-C and 1095-C can be found here.

Changes from reporting year 2015 to 2016 for forms 1094-B and 1095-B can be found here.

Compliance Deadline

Filings will begin in early 2017 for the 2016 calendar year.

*Form 1095-C must be provided to all employees (full-time, part-time, or otherwise) by March 2, 2017.

*All Forms 1095-C, along with the transmittal form, 1094-C, must be provided to the IRS by February 28, 2017 (if in paper form), or March 31, 2017 (if filed electronically). 

Note: Employers filing more than 250 information returns (Form 1095-C) must do so electronically.MedCost

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2016 ACA Employer Deadlines Extended

2016 ACA Employer Deadlines

By Michael Berwanger, JD, Director, Quality Management & Compliance

The Internal Revenue Service (IRS) released Notice 2016-70, which extends the due date for furnishing to individuals the 2016 Form 1095-B (titled Health Coverage), and the 2016 Form 1095-C (titled Employer-Provided Health Insurance Offer and Coverage), from January 31, 2017 to March 2, 2017.

Self-funded employers should note that the filing deadlines remain unchanged. The Notice states that the “Treasury and the [Internal Revenue] Service have determined that there is no similar need for additional time for employers, insurers, and other providers of minimum essential coverage to file with the Service the 2016 Forms 1094-B, 1095-B, 1094-C, and 1095-C.”

Employer Deadlines

Therefore, the due dates for filing 2016 Forms 1094-B, 1095-B, 1094-C, and 1095-C with the IRS remain:

February 28, 2017 (for paper filing)

March 31, 2017 (for e-filing)

Employers may obtain a 30-day extension for filing with the IRS by filing Form 8809 on or before the forms’ due date.

The IRS has also extended last year’s good-faith transition relief for inaccurate information on the forms. Recognizing the “challenges involved in developing new procedures and systems to accurately collect and report information in compliance with new reporting requirements,” the IRS has provided relief to incorrect and incomplete information reported on the statement or return.

Please note: The good-faith relief applies only to data on the forms, not failure to comply with due dates.MedCost

 

Some ACA Insurance Markets in Turmoil

NC and SC Could Be Two of the Most Affected States

ACA insuranceSome of the Affordable Care Act’s insurance marketplaces are in turmoil as the fourth open enrollment season approaches this fall, but what’s ahead for consumers very much depends on where they live.

Competition on these exchanges will be diminished next year when three of the nation’s largest health insurers — Aetna, United Healthcare and Humana — will sell individual plans in many fewer markets. So too will several Blue Cross and Blue Shield plans in various states. That’s on top of the 16 nonprofit co-ops that have closed since January 2015.

The announcements, however, apply generally only to the individual market. The much larger market of employer-sponsored insurance is not part of the health law exchanges.

Most hurt will be marketplace consumers in Arizona, North and South Carolina, Georgia and parts of Florida, where only one or two insurers will be left when open enrollment season begins Nov. 1.

(Kaiser Health News, Phil Galewitz, August 18, 2016)
KHN

It’s Time to Plan ACA Reinsurance Payments

By Michael Berwanger, JD, Director, Quality Management & Compliance

 

shutterstock_68891791It is time for employer-sponsored health plans to begin thinking about the process for calculation and submission of enrollment data and payment of fees under the Transitional Reinsurance Program.

As background, this program was established to fund a reinsurance pool to help stabilize premiums in the insurance markets created under the Affordable Care Act (ACA).

The program is being funded by three annual assessments on employer-sponsored health plans. The assessments are for average covered lives in 2014, 2015 and 2016 calendar years.

This year, enrollment data must be submitted by November 15, 2016, and payment must be submitted no later than January 17, 2017.

The 2016 Reinsurance Contribution Rate is $27.00 per covered life.

Online Submission Process

The Centers for Medicare and Medicaid Services (CMS) has implemented a streamlined process for reinsurancethe collection of reinsurance contributions. A contributing entity, or a Third Party Administrator (TPA) on its behalf, can complete all required steps for the reinsurance contributions process online (using the government portal, pay.gov), including registration, submission of annual enrollment count, and remittance of contributions.

A form is available for the contributing entity (or its TPA) to provide basic company and contact information and the annual enrollment count for the applicable year. The form will automatically calculate the contribution amounts, and entities will be required to submit payment information and schedule a payment date for remittance of the contributions.

CMS will not send an invoice to contributing entities. All required action will be completed online at pay.gov.

Options for Payment

There are two options for how a contributing entity can make a payment: (1) a one-time lump sum payment, or (2) a full contribution in two payments. (See chart below.)

Contribution Payment Options for the 2016 Benefit Year

Reinsurance

Source: Centers for Medicare and Medicaid Services

CMS will permit contributing entities to submit each year’s contribution in two separate payments – one larger payment of $21.60 per covered life at the start of the year, and a smaller payment of $5.40 per covered life at the end of the year.

However, when submitting enrollment data, dates must immediately be scheduled for payment of the fees, whether there will be one payment prior to January 17, 2017, or two payments with the later in November 2017.

If You Are Self-funded for a Portion of the Reporting Period

health insurance noticesFor a plan that has moved from a fully insured plan to a self-funded plan during the first nine months of the 2016 calendar year, both plans will be responsible for paying a portion of the fee, using one of the permitted calculation methods.

Since fully-insured plans are not permitted to use the Snapshot Factor Method of calculation, either the Actual Count Method or the Snapshot Method of calculation must be used.

Helpful Resources

This site provides technical assistance and training related to the Marketplace and Premium Stabilization program (which includes the Transitional Reinsurance Program). Webinars are offered that provide entities with information on program and operational guidance, along with live demos of the enrollment count and contributions submission process.

This is the site where the contributing entity, or TPA, will create a profile, and submit the enrollment data and contributions for the Transitional Reinsurance Program.

This website is hosted by the Centers for Medicare and Medicaid to provide information about the Transitional Reinsurance Program.

For more information, consult your broker, legal advisor or cms.gov. MedCost

This blog post should not be considered as legal advice.

 

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