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

 

IRS Announces 2017 FSA Limits

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

The Internal Revenue Service recently announced the tax year 2017 annual inflation adjustments for more than 50 tax provisions.

Notably, for the first time in two years and consistent with industry expectations, the IRS has increased the dollar limitation under § 125(i) on voluntary employee salary reductions for contributions to health Flexible Spending Accounts (FSA) from $2,550 to $2,600.

The Revenue Procedure 2016-55 provides details about these annual adjustments. The tax year 2017 adjustments generally are used on tax returns filed in 2018.

2017 FSA

 

 

 

For guidance on FSAs, please review the IRS Frequently Asked Questions page.

 

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Got Employees? 5 Tips for a Smooth Open Enrollment

open enrollmentIt’s that time of the year that presents headaches for HR professionals and admin staff—open enrollment. But your company’s benefits administration doesn’t have to resemble a Halloween Fright Night. Here are five best practices to streamline your employees’ enrollment period and leave you with a basket of sweet candy:

1. Create a realistic schedule for open enrollment by beginning with the end in mind.

Your open enrollment period should end no later than 30 days prior to the end of your plan year or renewal date. Once you determine the ending date of open enrollment, back up from there to schedule open enrollment meetings, print forms or materials, distribute or mail open enrollment packets, etc.

2. Collect all required information for each plan participant (employee or dependent).

This may include information for each plan participant such as:

  •  Last Name, First Name and Middle Initial (exactly as provided in previous enrollments)
  •  Social Security Number (unique and accurate identifying information for each dependent)
  •  Address
  •  Date of Birth (unique and accurate identifying information for each dependent)
  •  Gender
  •  Hire Date (if an employee)
  •  Coverage Effective Date
  •  Product Coverage (Medical, Dental, Flex)
  •  Date of Termination, if applicable, and Reason for Term
       (especially needed for COBRA)
  •  E-mail address (useful to promote programs and services available through benefits plan)

3. Remind employees that “good data in equals good data out.”

open enrollmentStress the importance of completing all fields on any enrollment or waiver forms. It’s in every plan participant’s best interest to review and verify new and existing data during open enrollment since it directly affects coverage for the upcoming plan year. Decisions regarding participants’ eligibility and coverage under the health plan—as well as that of their dependents—are made based on the information provided during open enrollment.

4. Educate employees about the “not-so-flexible” guidelines of flexible spending accounts (FSAs), if available through your plan.

In addition to the advantages of flexible spending accounts, make sure your employees also know about the guidelines for FSAs. The most important thing for employees to remember is that FSAs are “use it or lose it” accounts. Contributions made to an FSA during a calendar year can be used only for eligible expenses incurred during the same year—unless your plan provides for either a grace period or a carryover. If your plan doesn’t provide for a carryover, employees need to be aware that any money remaining in an FSA account after the claim filing period at the end of the year (and after the grace period, if applicable) is forfeited in accordance with IRS regulations.

5. If your employees have flex debit cards, remind them to save all receipts for purchases made with the card.

open enrollmentSince a flex debit card deducts payment for an eligible health care expense directly from an FSA account, employees may think that saving health care receipts is unnecessary. Some claims for reimbursement, however, may require substantiation. Encourage employees to save all receipts for flex debit card purchases in case they receive a substantiation request or their tax return is audited by the IRS. Employees should hold on to their cards even if the allocated FSA total amount has already been used.

Our next blog will contain five more tips to plan and prepare for open enrollment like a pro. Subscribe to our blog to receive it automatically!*

 

*To sign up for the blog, go to the left margin under “STAY UP TO DATE.” The only requirement is your email address. 

 

A Pharmacist Looks at the Opioid Epidemic

By Zafeira Sarrimanolis, PharmD, MedCost Clinical Consultant

The statistics prove it — more Americans die from accidental drug overdoses each year than from traffic accidents. Data from 2014 showed more deaths from drug overdoses than any other year on record.[i]  Approximately six out of 10 of those deaths involved opioids.[ii]

opioid epidemicSource: Centers for Disease Control and Prevention[iii]

The week of September 18-24 was designatedPrescription Opioid and Heroin Epidemic Awareness Week.”[iv] As a pharmacist, I know that opioid medications can be beneficial in controlling certain types of pain. However, this benefit must be weighed against the risks associated with these medications.

The Epidemic

The number of opioid prescriptions in the US quadrupled from 1999 to 2014, while the number of American reporting chronic pain remained constant.[v]

Opioid pain medications like Opana, OxyContin and Percocet were originally used to treat short term-pain, such as after a surgery or accident, and for long-term pain associated with cancer. Today, we see these medications prescribed and utilized more commonly for all forms of pain and over longer periods of time.

The diagram below highlights opioid prescribing patterns in the US. In some states, including NC, the number of painkiller prescriptions per 100 people is equal to or exceeds 100.[vi]

opioid epidemicThere are many sources of misused opioid prescriptions. The majority, approximately 60%, of misusers obtain opioid medications from a friend or relative, either for free, by stealing or by buying them.[vii] 

 

The Dangers

Imagine you are in a car accident and have persistent back pain that makes it difficult for you to sit and stand

comfortably. The doctor prescribes an opioid medication used regularly to control your pain.  Soon you find that you have become dependent on this medication—even after your back feels better.

This scenario happens more often than we think. The danger of opioids is that they can become addictive to any user. For this reason, they should only be prescribed in appropriate cases.

In addition to risk for addiction, these medications are dangerous because of side effects like sedation and respiratory depression. These effects can be compounded when combined with other medications. For example, a common drug interaction with Xanax (a medication used for anxiety) can lead to slowed breathing, oversedation and possible death.

Action Steps

The fight against the opioid epidemic requires action from everyone. Prescribers and pharmacies are more regularly monitoring those taking opioid medications. In North Carolina, the Board of Medicine and Board of Pharmacy have strategies to control these medications to decrease utilization and death from opioid abuse and overdose.

The opioid reversal agent, naloxone, is more readily available from retail pharmacies. Efforts are being made to increase access to treatment for addiction. Communities are educating the public on the dangers of opioids and offeopioid epidemring “take-back” programs for disposal of unused opioid medications.

In July, the US Senate passed the Comprehensive Addiction and Recovery Act, the first major federal legislation on addiction in 40 years. The purpose of this law is to expand education, strengthen state monitoring programs and create new treatment programs.

Real progress can only result when doctors, nurses, pharmacists, patients, government officials, community leaders and the family and friends of those affected work together to put an end to the opioid epidemic.

Pharmacist on Staff for Clients

As the new MedCost Pharmacist, I discuss pharmacy management strategies with clients and brokers to control the explosion of drug costs. Prior authorizations, step therapy programs and quantity limits can be frustrating and disruptive. But we know that these utilization management strategies are key in controlling costs. 

Our partnership with OptumRx, ensures that members take safe, effective medications appropriate for their conditions, while implementing cost-saving strategies.

Opioid epidemic

 

 

 

 

 

 

 

 


Source: 
Mercer National Survey of Employer-Sponsored Health Plan -2015l[i]

Our goal at MedCost is to help ensure that our clients’ covered members are being treated appropriately and safely, without the risk of exorbitantly high costs. This will not only be the most cost-effective strategy, but it can result in members with healthier, happier lives.MedCost

 

[i] “The Opioid Epidemic: By the Numbers,” US Health & Human Services, June 15, 2016, http://www.hhs.gov/sites/default/files/Factsheet-opioids-061516.pdf (accessed September 26, 2016)

[ii] “Injury Prevention & Control: Opioid Overdose,” Centers for Medicaid and Medicare Services, https://www.cdc.gov/drugoverdose/data/index.html (accessed September 22, 2016).

[iii] Ibid.

[iv]Office of the White House Press Secretary, September 16, 2016, https://www.whitehouse.gov/the-press-office/2016/09/16/presidential-proclamation-prescription-opioid-and-heroin-epidemic (accessed September 22, 2016).

[v] Guideline for Prescribing Opioids for Chronic Pain, Centers for Medicaid and Medicare Services, March 16, 2016, http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm (accessed September 22, 2016).

[vi]  “Injury Prevention & Control: Opioid Overdose,” Centers for Medicaid and Medicare Services, http://www.cdc.gov/drugoverdose/data/prescribing.html (accessed September 22, 2016).

[vii] Ibid.

[viii] Bruce Lee, “With the Excise Tax in Their Sights, Employers Hold Health Benefits Cost Growth to 3.8% in 2015,” Mercer, November 19, 2015, http://www.mercer.com/newsroom/national-survey-of-employer-sponsored-health-plans-2015.html (accessed September 22, 2016).

Employee Deductibles Rise Faster Than Wages

ks110111-medEmployer health insurance expenses continued to rise by relatively low amounts this year, aided by moderate increases in total medical spending but also by workers taking a greater share of the costs, new research shows.

Average premiums for employer-sponsored family coverage rose 3.4% for 2016, down from annual increases of nearly twice that much before 2011 and double digits in the early 2000s, according to a survey by the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

But 3.4% is still faster than recent economic growth, which determines the country’s long-run ability to afford health care.

And the tame premium increases obscure out-of-pocket costs that are being loaded on employees in the form of higher deductibles and copayments. Another new study suggests those shifts have prompted workers and their families to use substantially fewer medical services.

For the first time in Kaiser’s annual survey, more than half the workers in plans covering a single person face a deductible of at least $1,000. Deductibles for family plans are typically even higher.

Deductibles are what consumers pay out of pocket before the insurance kicks in. Employers sometimes contribute to pre-tax accounts to help workers pay such costs.

Employers have been flocking to high-deductible plans in recent years, arguing that exposure to medical costs makes consumers better shoppers.wingeddollar-sm

It also saves employers money. Having workers pay more out of pocket shaved half a percentage point off premium increases of employer-sponsored plans in each of the past two years, Kaiser researchers calculated.

Since 2011, the average deductible for single coverage has soared 63%, according to the survey, while workers’ earnings have gone up by only 11%.

Microsoft PowerPoint - 20160825 Cumulative Slides [Read-Only]

 

 

(Kaiser Health News, Jay Hancock and Shefali Luthra, September 14, 2016)

 

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

The Life-Saving Resource Ignored After Heart Attacks

childrens hospital readmissionsCHARLOTTESVILLE, Va. — Mario Oikonomides credits a massive heart attack when he was 38 for sparking his love of exercise, which he says helped keep him out of the hospital for decades after.

While recovering, he did something that only a small percentage of patients do: He signed up for a medically supervised cardiac rehabilitation program where he learned about exercise, diet and prescription drugs.

“I had never exercised before,” said Oikonomides, 69, who says he enjoyed it so much he stayed active after finishing the program.

Despite evidence showing such programs substantially cut the risk of dying from another cardiac problem, improve quality of life and lower costs, fewer than one-third of patients whose conditions qualify for the rehab actually participate. Various studies show women and minorities, especially African Americans, have the lowest participation rates.

“Frankly, I’m a little discouraged by the lack of attention,” said Brian Contos, who has studied the programs for the Advisory Board, a consulting firm used by hospitals and other medical providers.

ManWithHeartNow, though, advocates say cardiac rehab may gain traction, partly because the federal health care law puts hospitals on a financial hook for penalties if patients are readmitted after cardiac problems. Studies have shown that patients’ participation in cardiac rehab cut hospital readmissions by nearly a third and saved money.

The law also creates incentives for hospitals, physicians and other medical providers to work together to better coordinate care.MedCost

(Kaiser Health News, Julie Appleby, August 31, 2016)

KHN

 

 

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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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