allied™ pay or play solutions cost-effective options for the employer shared responsibility...
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Allied™ Pay or Play Solutions Cost-effective options for the Employer Shared Responsibility provisions of the Affordable Care Act
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Allied Pay or Play Solutions•Employer Shared Responsibility (Pay or Play)
•Impacts, Requirements & Penalties
•Product Solutions for Large Employers
•Sample Cases
•Submissions and Underwriting
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Allied National
InnovationStabilityService
Allied NationalOperational Profile•Underwriting
•Claims Administration
•Policy Service
•Actuarial
•Compliance
•Product Development
•Case Management
•Sales & Marketing
•Legal
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What you need to know and learn to understand Pay or Play
ACA Pay or Play Regulations and Language:• What is an applicable large employer?• What is an FTE? How to count FTEs?• How do the penalties work?• PMEC/Skinny Plans/MVP/Narrow Plans• Affordability• 2015 rules vs 2016 rules – group size, penalties• Transition relief rules - All employee test/All FT
employee testThese are the high points -THIS IS NOT
ALL!!!! Expect the rules to change5
For the Individual - Employee
What does ACA mean for an individual?
1. Individual Mandate says individuals must have health insurance or pay a penalty.• Penalty starts at $95 for 2014 then in 2016
escalates to $695 or 2.5% of taxable income (which ever is greater).
2. Insurance can be employer provided or an individual plan.Must be qualifying Minimum Essential Coverage.
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For a Business – Employer
What you need to know about ACA for businesses . . .
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Do I have to offer health insurance to my employees on January 1, 2015?
less than 100 more than 100
Based on full-time equivalent employee counts.Part-timers count!
In 2016, the employer size drops to 50!
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What type of coverage must I offer?
Employer coverage must meet TWO levels of tests under Section 4980H
“A” test – “The Sledgehammer”
• Must provide Minimum Essential Coverage to 95% of full-time eligible employees (70% in 2015)
• The Penalty? $2,000 per full-time eligible employee less the first 30 (80 in 2015)
• Penalty triggered by employee going to the Exchange and receiving subsidy
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What type of coverage must I offer?
Employer coverage must meet TWO levels of test under Section 4980h
“B” test – “The Tackhammer”
• Must provide Minimum Value Coverage to 95% of employees
• Coverage must be Affordable (no more than 9.5% of household income).
• The Penalty? $3,000 per employee who receives subsidized coverage on the Exchange 10
What If I don’t Play?PENALTY EXAMPLES
Employer with 180 full-time eligible employees(A) Failure to provide MEC: $2,000 (180 - 80*) = $200,000 non tax deductible penalty ($300,000 in 2016!)(B) Failure to provide Minimum Value affordable coverage:$3,000 per employee with subsidized coverage
* less 80 is 2015….less 30 in 2016 11
What are an Employer’s Options?
1. Pay the penalty?
2. Find the cheapest way to avoid penalties?
3. Provide a major medical health plan to everyone?
4. Provide an affordable alternative in the middle?
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Allied Pay or Play Solutions• Creative suite of products to meet any
employer’s needs
• Uses a mix of self-funded and fully insured options
• Low-cost Alternatives
• Meets Current Minimum Essential Coverage (MEC) and Minimum Value standards
• Four plan levels
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Allied Pay or Play SolutionsOffering four plan levels to manage the expense of this mandate:
Plan Level 1 – Self Funded PMEC•Preventive Services Only Minimum Essential Coverage (PMEC)•Meets MEC requirement and avoids the employer sledgehammer penalty•Meets individual mandate and covered employees avoid that individual penalty•Lowest cost way to avoid penalties
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Allied Pay or Play Solutions
Plan Level 2 – Fully Insured Limited Benefit PlansFixed Indemnity plan on top of PMEC
• Allows employer to provide additional benefits on top of a PMEC plan
• Employer paid or voluntary• Benefits for hospitalization, office visits, Rx
drugsGap Plan
• Supplement for high deductible plans• Employer paid or voluntary
Allied Pay or Play Solutions
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Plan Level 3 – Self-funded Minimum Value PlansAllied Minimum Value Plan (MVP)
• Low Cost Narrow MVP plan – one size fits all• Guaranteed Issue – No Medical Underwriting• First dollar benefits - $0 deductible with
copays• Eliminates In-Patient, Surgery and Specialty
Drugs• Adds indemnity benefits for In-Patient &
Surgery• Currently Satisfies Minimum Value 60%
standard
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Allied Pay or Play Solutions
Plan Level 3 – Self-funded Minimum Value PlansAllied MediPay Plan
• Comprehensive Major Medical - Controls costs by basing provider reimbursement on Medicare
• Physicians reimbursed at 125%• Facilities at 125-200% as selected.• Lowers monthly costs 10% to 30% below traditional
PPO reimbursement• Members subject to balance bill
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Allied Pay or Play Solutions
Plan Level 4– Self Funded Traditional Plans•Allied Funding Advantage Plans
• Premium Advantage – traditional PPO plans• Provider Freedom – no network, see any
provider, protection from balance bills• MediPay Plan – no network, Medicare
reimbursement - Employee is responsible for all balance bills under MediPay
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Allied Pay or Play Solutions
Sample PMEC CaseAssumptions• Employer Contribution 100% of PMEC Plan• 90% Participation combined required
Type of Risk Restaurant Chain
FT employees 425
Management - Group Major Medical 75
Penalty Exposure (After tax) $986,000
Penalty Exposure per FT employee $2,817
PMEC Cost (350 FT employees) $210,000
PMEC Cost per employee (annually) $600
Sample MVP CaseAssumptions
• 75% participation required
Type of Risk Construction Company
FT Employees 130
Management - Group Major Med 25
Penalty Exposure (After tax 2015) $142,857
Penalty Exposure (After tax 2016) $285,714
Penalty Exposure per FT Employee (All 2015 -80) $1,099
Penalty Exposure per FT Employee (All 2016 -30) $2,857
Minimum Value Plan Participants 85
Minimum Value Plan Costs (estimate) $2,400
Minimum Value Plan Annual Costs - Total $204,000
Fully Insured Structure•Limited Benefit•Gap Plans
Self Funded Structures•Funding Advantage, PMEC, MVP, MediPay•12-21 contracts
• Plan run out period ends the last day of month 21
• Refunds calculated in month 22• Refunds disbursed in month 23
•Monthly accounting summary•Quarterly claims reports•Renewal offers on all groups
Plan Structures
Claims PaymentBalance Bill Obligations
ID cards for PMEC/MVP/MediPay will show Medicare reimbursement levels.
Members receive Advocacy help in balance bill situations.
Underwriting Time Frame
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Time Frame: Medically Underwritten Cases
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Time Frame: PMEC - MVP
Agent’s Compensation
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Funding Advantage
& MVP
Default 2-6% adjustable as required
Limited Benefit & Gap TBD
PMEC 10%
Our Sales TeamContact Us
Email or fax data to “Sales” [email protected]
888-767-7133Fax: 913-945-4390
Our Team•Dan Meylan: National Sales Director; 913-945-4253•Bill Ringhofer: Regional Sales Manager; 913-945-4266•Randy Wehner: Sales Manager; 913-945-4267•Matthew Bryon: Account Executive; 913-945-4255•Cheryl Knight: Account Executive; 913-945-4261
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Questions?Allied Sales Support
888-767-7133
www.alliednational.com
[email protected]/alliednational
Fax: 913-945-4396
Allied National, Inc.4551 W. 107th St. #100Overland Park, KS 66207
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