Newark New York Trenton Philadelphia Wilmington GNJSHFA Affordable Care Act – Its Here to Stay Christine A. Stearns Counsel, Government Affairs November 19, 2015
Jan 21, 2016
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GNJSHFAAffordable Care Act – Its Here to Stay
Christine A. Stearns
Counsel, Government Affairs
November 19, 2015
Newark New York Trenton Philadelphia Wilmington
Note: 2015 data is for Q1 and Q2 only. Source: CDC/NCHS, National Health Interview Survey, reported in http://www.cdc.gov/nchs/health_policy/trends_hc_1968_2011.htm#table01 and http://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201511.pdf.
Uninsured Rate Among the Nonelderly Population,
1972-2015Share of population uninsured:
Average Annual Worker and Employer Contributions to Premiums and Total Premiums for Family Coverage, 1999-2015
* Estimate is statistically different from estimate for the previous year shown (p<.05).
SOURCE: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2015.
$5,791
$6,438*
$7,061*
$8,003*
$9,068*
$9,950*
$10,880*
$11,480*
$12,106*
$12,680*
$13,375*
$13,770*
$15,073*
$15,745*
$16,351*
$16,834*
$17,545*
Cumulative Increases in Health Insurance Premiums, Workers’ Contributions to Premiums, Inflation, and
Workers’ Earnings, 1999-2015
SOURCE: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2015. Bureau of Labor Statistics, Consumer Price Index, U.S. City Average of Annual Inflation (April to April), 1999-2015; Bureau of Labor Statistics, Seasonally Adjusted Data from the Current Employment Statistics Survey, 1999-2015 (April to April).
* Estimate is statistically different between All Large Firms and All Small Firms estimate (p<.05).
SOURCE: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2015.
Average Annual Worker and Employer Contributions to Premiums and Total Premiums for Single and Family
Coverage, by Firm Size, 2015
$6,163 $6,289 $6,251
Single Coverage Family Coverage
NOTE: Information was not obtained for POS plans in 1988. A portion of the change in plan type enrollment for 2005 is likely attributable to incorporating more recent Census Bureau estimates of the number of state and local government workers and removing federal workers from the weights. See the Survey Design and Methods section from the 2005 Kaiser/HRET Survey of Employer-Sponsored Health Benefits for additional information.
SOURCE: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2015; KPMG Survey of Employer-Sponsored Health Benefits, 1993, 1996; The Health Insurance Association of America (HIAA), 1988.
Distribution of Health Plan Enrollment for Covered Workers, by
Plan Type, 1988-2015
SOURCE: Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group.
U.S. health care spending per capita has risen at historically low rates recently, but is expected to pick up
Average annual growth rate of health spending per capita for 1970’s – 1990’s;Annual change in actual health spending per capita 2000 – 2013 and projected health spending per capita (2014 – 2024)
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The Individual Mandate
Requires most U.S. citizens and legal residents to purchase health coverage or incur a tax penalty of $695 (or 2.5% of adjusted gross income), whichever is greater for 2016.
The fee is calculated monthly for each month with “minimum essential coverage”
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Penalty Calculation
The flat dollar amount was phased in over three years ($95 for 2014; $325 for 2015; and $695 for 2016 and then indexed for inflation).
The applicable percentage is 1% for 2014; 2% for 2015; and 2.5% for 2016 but cannot exceed the premium for the “bronze” level plan offered thru the exchange.
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Effects of the Individual Mandate
Gives all taxpayers, including employees, an incentive to obtain coverage:
• Information sought from employers
• Pressure on employers to provide coverage
• Employees seeking a premium tax credit which may trigger IRS assessments against employers
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Small Employer Tax Credit
Beginning in 2014, the credit refunds up to 50% of health insurance expenses for eligible employers purchasing thru exchange and is available for any two consecutive years (credit was 35% for 2010 – 2013).
The credit is fully available to companies with 10 or fewer full-time employees and average wages below $25,000. The credit phases out as the number of employees increases to 25 and wages grow to $50,000. Tax-exempt organization of maximum credit of 35%.
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Federal Marketplace: The Basics
Each plan’s actuarial value (AV) must fall within the metallic tier (Bronze – 60%, Silver- 70%, Gold – 80% and Platinum – 90%). AV=% of total average costs for covered benefits that a plan will cover.
Rating is now to the member level so a rate is paid for each individual and each member of their family.
In 2015 about 194,000 New Jersey residents chose to enroll in the Marketplace with about 83% receiving a subsidy.
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Marketplace: The Basics
Other rating changes:
No gender rating.
Tobacco use is not a permitted rating factor in NJ, but is permitted in other states.
Plans available “on the exchange” are also available “off the exchange”.
Employers with 1-49 employees: Considered a “small employer”. This is a “new” definition. New Jersey formerly defined small employer as having 2-49 employees.
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The Employer Mandate“Large employers” must offer their workers “affordable” and “minimum essential” health care coverage that has “minimum value” or pay a penalty.
What is minimum essential coverage? No definition yet but we know the broad categories that
What is affordable coverage? An employees contribution may not exceed 9.5 percent of the employees income.
What is “minimum value”? Generally, the plan’s share of total allowed cost of benefits is not less than 60%.
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Who is a large employer?
The mandate applies to employers with 50 or more full-time employees during the previous calendar year.
The law considers an employee who works at least 30 hours a week a full-time employee, as well as two employees who each work 15-hours per week to count as one full-time employee.
The mandate does not apply to employers that exceed 50 employees for 120 days or less, and whose extra employees are considered seasonal workers.
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What is the penalty?
The company could be subject to an annual penalty of $2,000 for each full-time employee that 1) doesn’t offer health coverage and 2) at least one employees receives government subsidized insurance through the marketplace, minus the first 30 employees.
Employers whose coverage is deemed unaffordable or low value could be subjected to a penalty of $3,000 for full-time employees that receives government subsidized insurance through the government insurance exchange.
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The Phase-in: Employers with 50-99 Employees
Required to provide a minimum level of affordable coverage
2015: Must provide information on the number of employees
2016: Penalties are assessed
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The Phase-in: Employers with 100+ Employees
Required to provide a minimum level of affordable coverage
2015: Must cover 70% of employees
2016 (and beyond): Must cover 95% of employees. Penalties are assessed.
NOTES: Current status for each state is based on KCMU tracking and analysis of state executive activity. *AR, IA, IN, MI, MT, NH and PA have approved Section 1115 waivers. Coverage under the PA waiver went into effect 1/1/15, but it has transitioned coverage to a state plan amendment. Coverage under the MT waiver will be effective January 1, 2016. WI covers adults up to 100% FPL in Medicaid, but did not adopt the ACA expansion.SOURCE: “Status of State Action on the Medicaid Expansion Decision,” KFF State Health Facts, updated November 2, 2015.http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/
Current Status of State Medicaid Expansion Decisions
WY
WI*
WV
WA
VA
VT
UT
TX
TN
SD
SC
RI PA*
OR
OK
OH
ND
NC
NY
NM
NJ
NH*
NV NE
MT*
MO
MS
MN
MI*MA
MD
ME
LA
KY KS
IA*
IN* IL
ID
HI
GA
FL
DC
DE
CT
CO CA
AR*AZ
AK
AL
Adopted (31 States including DC)
Adoption Under Discussion (1 State)
Not Adopting At This Time (19 States)
NOTE: The June 2012 Supreme Court decision in National Federation of Independent Business v. Sebelius maintained the Medicaid expansion, but limited the Secretary's authority to enforce it, effectively making the expansion optional for states. 138% FPL = $16,242 for an individual and $27,724 for a family of three in 2015.
The ACA Medicaid expansion fills current gaps in coverage.
Adults
Elderly & Persons with Disabilities
Parents
PregnantWomen
Children
Extends to Adults ≤138% FPL*
Medicaid Eligibility TodayMedicaid Eligibility
in 2014Limited to Specific Low-Income Groups Extends to Adults ≤138% FPL*
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How is the ACA paid for? New taxes …
Health Insurance Tax: Taxes health insurance (not self-funded coverage) and is paid by the carrier.
Generates $8B in 2014 and more then $100B over the next 10 years.
Transitional Reinsurance Fee: A fee of $63 for each covered person which will be collected for three years. The purpose is to offset cost of coverage for people with preexisting conditions.
Cadillac Tax in 2018.
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Cadillac Tax
Permanent annual tax beginning in 2018 on employers that provide “high-cost” benefits through an employer-sponsored group health plan
It is expected to generate $80 billion in revenue over 10 years
The tax is a 40% tax on health care costs that exceed a predetermined threshold ($10,200* individual/$27,500 family)
*Adjusted for inflation
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Key ACA Dates: 2014
Marketplace coverage began
Individual mandate for health coverage
Medicaid expansion
New taxes and fees:
Reinsurance fee: $63 per covered life
Health insurer fee: 2-3% to collect $8 billion
Medicare withholding for high wage earners: individual over $200,000/joint over $250,000 FICA increases from 1.45% to 2.35%
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Key ACA Dates: 2014
Maximum 90-day waiting period
Maximum-out-of-pocket $6,350/$12,700 (all non-grandfathered plans) for 2014. Increases to $6,600 in 2015
No annual dollar limits on essential benefits
Pre-existing condition exclusions are prohibited
(all plans)
Dependent to age 26 (applies to all plans now)
Provider discrimination: All non-grandfathered plans cannot discriminate on covered services based on the provider
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Key ACA Dates: 2015-2018
2015
Employer "play or pay" mandate (delayed from 2014)
Employer information reporting to the IRS on employee coverage
2016
All SHOP exchanges must open to employers with up to 100 FTEs
2017
States may open exchanges to businesses with more than 100 employees
2018
Cadillac Tax – 40% excise tax on high-cost health plans
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Where Are We Headed?
Exchanges: Watch the trend toward private exchanges
Value Based purchasing
Workplace wellness
Self-funding of health benefits (100+)
Changing benefit design (co-pays, reference based pricing)
Consumerism: High-deductible health plans
New Networks: tiered/narrow
Mergers
Among Large Firms Offering Incentives for Workers Who Participate In or Complete Wellness Programs, Maximum Annual Value of the Reward for Wellness and Health Promotion Programs, Including Incentives for Health Risk Assessment and Biometric Screening, 2015
NOTE: Firms with at least one of the listed wellness programs were asked to report the maximum reward or penalty an employee could earn for all of the firm's health promotion activities combined. For some employers, the maximum incentive may include rewards or penalties for activities related to health risk assessments and biometric screening. Listed programs include: “Programs to Help Employees Stop Smoking”, “Programs to Help Employees Lose Weight”, or “Other Lifestyle or Behavioral Coaching”.
SOURCE: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2015.
* Estimate is statistically different between All Small Firms and All Large Firms (p<.05).
NOTE: “Other Lifestyle or Behavioral Coaching” can include health education classes, stress management, or substance abuse counseling.
SOURCE: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2015.
Among Firms Offering Health Benefits, Percentage of Firms Offering Specific Wellness Program to Their Employees, by
Firm Size, 2015
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Thank You!
Christine A. Stearns
Counsel, Government Affairs
(609) 858-2443