Time to Implement!Moving Forward with

Reform

By Michael Bertaut, Healthcare Economist and Exchange Coordinator

BCBSLAMarch 2013

2

All information in this presentation INCLUDING THE OPINIONS OF THE PRESENTER are solely for illustrative purposes. The information is based on certain assumptions, interpretations, and calculations that are not necessarily accurate with regard to provisions of PPACA, HCERA, HIPAA, COBRA, ERISA, and other rules, regulations, guidance and all other documents issued by relevant state and federal agencies with regard to these laws and any other relevant laws. The information provided should not be considered as legal, financial, accounting, planning, or tax advice. You should consult your attorneys, accountants, and other employees or experts of this type of this type of advice based on their own interpretations, calculations, and determinations of applicable laws, rules, regulations, guidance, and any other documents and information that they determine may be relevant. The authors make guarantees or other representations as to the accuracy or completeness of the data in this presentation.

BCBSLA expressly disclaims any liability for information obtained from use of this presentation by any BCBSLA employee or by any other person. No warranty of any kind is given with regard to the contents of the presentation.

Disclaimer

How many benefit eligible Employees do I have?

Am I an Applicable Large Employer (ALE)? ALE Yes, or No, What do I do? To be or not to be Grandfathered?

As an Employer, What 4 Questions Must I Answer?

Any employee who averaged 30 hours of service per week or more in the previous look-back period (3 to 12 months.)

Any new hire who, after 90 days, is REASONABLY EXPECTED to work more than 30 hours/week

If a REASONABLY EXPECTED determination cannot be made after 90 days, then another 90 day period may be used to make the call.

If eligibility determination is made, and then hours change, coverage must continue for the LONGER of the look-back period or 6 months.

Who is benefit eligble?

FOR THE ALE COMPUTATION, the common law definition of employee must be used:

“Under common-law rules, anyone who performs services for you is your employee if you can control what will be done and how it will be done. This is so even when you give the employee freedom of action. What matters is that you have the right to control the details of how the services are performed.” (www.irs.gov)

What is a Common Law Employee?

Month Benefit Eligible

Common Law Hours

/120 FTE Total FTE AVERAGE

JAN 2013 22 3300 27.5 49.5

FEB 2013 23 2800 23.3 46.3

MAR 2013 23 3250 27.1 50.1

APR 2013 23 3450 28.8 51.8

MAY 2013 24 3105 25.9 49.9

JUNE 2013

22 3271 27.3 49.3

JULY 2013 23 3655 30.5 53.5

AUG 2013 24 3705 30.9 54.9

SEPT 2013

25 3000 25.0 50.0

OCT 2013 26 3800 31.7 57.7

NOV 2013 27 3950 32.9 59.9

DEC 2013 30 4250 35.4 65.4 53

How Do I Know if I have to Provide Coverage?Controlled Groups and Associated Groups Must

be COMBINED for this computation!!!

No obligations to provide affordable coverage

No obligations to provide valuable coverage

No obligations to offer coverage

No danger of fines under 4980H

Note: ANY GROUP may offer affordable coverage and lock their employees out of Advanced Tax Credits in the Exchange.

Ok, I’m not an ALE, what now?

8

You have many new Federal Obligations that can be condensed into 3 major options:

1. AVOID FINES--Must offer “affordable”, “minimum value” health coverage to 95% of all eligible employees. Must offer coverage to children under age 26 (but not spouse and subsidy not required).

2. RISK SOME FINES—Offer coverage that fails one of the tests in #1 above. Employer is fined $250 per month per employee who “leaks” to the Exchange. Max fine is total fine computed under “3” below.

3. PAY THE FINES –Offer no coverage at all, employer must pay $2,000 per year per uncovered employee minus first 30 lives.

Ok, I’m an ALE, What Do I do now?

Federal Poverty Line:◦ Use 100% of FPL x 9.5% = affordable premium for all

employees.◦ In 2012, would be $11,170 x 9.5% = $1,061.15

Rate of Pay:◦ Use hourly rate times 130/month to determine wages x 9.5% to

compare to premium.◦ At $10/hour, $1,300/month x 12 x 9.5% = $1,482.00

9.5% of Employee Box 1 W-2 income in premiums for employee-only coverage. ◦ Determined at end of calendar year, and on an employee-by-

employee basis.◦ Partial-year adjustments allowed for new employees who work

part of a year.◦ At $20,800/year ($10/hr, 40 hrs/week) = $1,976.00

What Does “Affordable” Mean?

Scenario 1: I offer coverage but it fails the affordability or AV Test.◦ Every employee who shops on the Exchange and draws an

Advanced Tax Credit becomes a $3,000/year fine in 2015 ◦ The Fine is NOT tax deductible

Scenario 2: I fail to offer coverage at all to a block or all of my employees.◦ I must pay a fine computed by the following:◦ (# of eligibles – 30) x $2,000/year)◦ Fine is NOT tax deductible

What Happens if I fail the Test in 2014?

In general, an ALE must comply with the new rules or face fines by his RENEWAL DATE in 2014, not necessarily 1/1/2014

BUT……

If a group today has a fiscal year plan, and offers it to less than 33% of their employees (part timers AND full timers) or currently cover less than 25% of employees, then they MUST comply with the new ALE standards for affordability/actuarial value/offer to 95%

or fines will start on 1/1/2014, not on their renewal date.

When do ALE’s have to comply?

Grandfathering: Current Benefits to Groups

“You’re Darn Tootin’ Listen to your Grandfather!!”

• Not required to add USPTF Schedule B Tests and screenings to the Plan at zero dollar• Not required to add new women’s coverage to the Plan at zero dollar • Not required to add new coverage for FDA clinical experimental trials • Not required to reimburse ER docs at higher rates, especially out of network docs• Will not be charged transitional reinsurance fees• Will be pooled for rates (2-50) with much healthier groups • Avoid sharing cost of exchange fee on premiums.• Will not be subject to rate compression due to Age Rating, or dissolution of State UW Laws (+40% to -18%)

Who Pays? Sample Rate Compression Scenario for Louisiana

50% Below50%

Above

Average Rate$200 $300$100

A$125

B$150

C$175

D$200

E$225

F$250

G$275

Today, State Law allows a +/- 50% Spread in Small Group Rates

In 2014, no Underwriting is

allowed in Groups 2-50

20% Above

20% Below

+40%!

-18%!

Michael R. BertautHealthcare Economist

LINKED-IN Recommendations WELCOME!!!

Michael.bertaut@bcbsla.com

Office: 225-297-2719Cell: 225-573-2092

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Appendix and Additional Material Including non-business audience slides

What Will We Talk About?

What are the Rules? New Requirements for

Businesses New Requirements for

Health Insurance Companies.

New Requirements for Consumers.

Partner/Agent/Broker web site maps.

Financial Impacts of the Act on all stakeholders.

17

Yes. The Individual Responsibility Requirement mandates all Americans to have health insurance policy

Starts 1/1/2014 Exemptions for unaffordable

coverage (above 8% of income), certain religious groups, native Americans.

Failure to comply means confiscation of tax refund starting at $95 for first year and rising to $695 or 2.5% of income by 2017.

Do I as an Individual HAVE to have Health Insurance?

18

Exchanges are designed to remove the two most common barriers to entry for health insurance coverage:◦ COST-through the use of federal advanced tax credits◦ UNDERWRITING-by making all coverage guaranteed issue with

no medical questions or underwriting on the application. Who Qualifies?

◦ Non-Medicaid eligibles from 100% to 400% of federal poverty level projected Income who are NOT offered affordable coverage at work.

Who Runs It?◦ In Louisiana the Federal Government will operate our exchange.

In some other states, Exchanges will be locally operated.

◦ WHEN DOES IT OPEN? 10/1/2013 with open enrollment through 3/31/14 Coverage effective 1/1/14.

Where Do I Buy It?

19

WHAT’S THE PLAN?◦ To create a streamlines, easy to use, consumer friendly,

health neutral, gender neutral, FEDERALLY REGULATED market for health insurance.

HOW’S IT GOING?◦ Lots of bugs to work out. Test applications appear to take

over an hour and seem more complex than expected. Many unanswered questions.

WHO PAYS FOR IT?◦ Hospitals, Doctors, Insurance companies, Medical Device

Manufacturers, Large Employers, Drug Companies.◦ In other words, we all will pay for it.

HOW MANY PEOPLE WILL USE IT?◦ CBO estimates 6 million families in 2014 (low).

What’s an Exchange?

Risk Factor

Pre-2014 Post-2014

Rate Changes by

ClassAGE OF

INSUREDRATE MAY VARY UP TO 10X BETWEEN 19 AND

64 YEAR OLD

RATE MAY VARY ONLY 3X

BETWEEN 21 YEAR OLD AND 64

YEAR OLD

YOUNGER

OLDER

GENDER WOMEN CHARGED MORE DURING

CHILDBEARING YEARS. MEN CHARGED MORE

POST AGE 55

GENDER MUST BE IGNORED FOR RATE SETTING

MEN

WOMEN

HEALTH STATUS

MEDICAL RECORDS, CLAIMS DATA,

PHARMACY RECORDS, ALL USED TO

DETERMINE RATE OR OUTRIGHT EXCLUDE

APPLICANT FROM COVERAGE

HEALTH INFORMATION CANNOT ALTER

RATES OR EXCLUDE ANYONE

HEALTHY

SICK

From this grid we can see the big winners are older women with health conditions, and the biggest losers the young, healthy males.

How Will That Insurance Be Priced?

0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60 63$100.00

$200.00

$300.00

$400.00

$500.00

$600.00

$700.00

$800.00

Age Rating Effects: Sample Current Moving to 3:1, Remove Gender

PPACA Age CurveMale CurrentFemale Current

Age of Member

Standard Premium

Dramatic decrease in

Newborn Rates (-67%)

Males Age 22-42 get

rate increases up

to 38%!

Females get rate decreases at ages 22 through 54, peaking at (-35%) at age 40.

Males get small rate decreases at ages 56-64, peaking at (-11%)

22

Family Adult 1 Adult 2 Child 1 Child 2Ages 40 36 6 4

Issuer B B(Benchmark) B BMetal Level Bronze Silver Gold Platinum

Typical Sample Premium $10,908 $12,120 $13,332 $15,350

Family Income $35,000/year (149% of FPL)Premium Tax Subsidy$10,734 $10,734 $10,734 $10,734

Family pays: $174 $1,386 $2,598 $4,616 Payment % of Income 0.4% 4.0% 7.4% 13.2%

Family Income $88,000/year (375% of FPL)Premium Tax Subsidy $3,760 $3,760 $3,760 $3,760

Family pays: $7,148 $8,360 $9,572 $11,590 Payment % of Income 8.1% 9.5% 10.9% 13.2%

How Will Insurance Be Priced?

Incarcerated. Income above 400% of FPL. Offered coverage at work that is affordable

and at least 60% AV. Medicaid or CHIP eligible (income <138% fpl

in states that have agreed to expand). Claimed as a dependant on someone’s taxes. Unable to attest to residency in a single

state. In the country unlawfully.

23

Who Can’t Get Help?

Once a Subsidy is Accepted, Individual MUST file Tax Return for

That year.

Children (LIH)713k58%

Blind/ Disabled, 160k13%

Pregnant Females, 196k16%

Dual Eligibles, 161k 13%

Would Add new Category of Low Income Healthy

Adults Up to 138% of FPLPotentially 550k new

Can I Qualify for Free Insurance?

Who Gets Left Out?

The Healthcare Income Continuum (PPACA)

PPACA when fully enforced provides coverage and assistance for most Americans from 0 to 400% of Federal Poverty level Income

Coverage Gap

Without Medicaid expansion Louisiana will have no insurance help for citizens between 11% and 100% of FPL unless they

have employer coverage.

Around 200,000 people considered “Working Poor” will be without insurance.

0-11% Existing Medicaid

11% to 138% New Medicaid

Expansion139% to 400% Exchange

Subsidy Eligible

401% of FPL and above, you are on your own!

Federal Poverty Level Income0%

27

27

Should Louisiana Expand Medicaid?

Yes EXPAND! No, Don’t EXPAND!

100% FMAP for First 3 years, settling at 90% FMAP going forward.

DiSH money reduced by 50% by 2016, eventually eliminated

PPACA built with expansion in mind, covers working poor.

500,000+ will get access to no-premium health insurance

Fed does not fund administration of new population

La. Budget already $1.0B in the red

90% match may not be permanent

180k+ of expansion population already has private insurance.

Another 90k will be Exchange eligible.

Medical Capacity?

What Will We Talk About?

What are the Rules? New Requirements for

Businesses New Requirements for

Health Insurance Companies.

New Requirements for Consumers.

Partner/Agent/Broker web site maps.

Financial Impacts of the Act on all stakeholders.

29

Yes. The Individual Responsibility Requirement mandates all Americans to have health insurance policy

Starts 1/1/2014 Exemptions for unaffordable

coverage (above 8% of income), certain religious groups, native Americans.

Failure to comply means confiscation of tax refund starting at $95 for first year and rising to $695 or 2.5% of income by 2017.

Do I as an Individual HAVE to have Health Insurance?

30

Exchanges are designed to remove the two most common barriers to entry for health insurance coverage:◦ COST-through the use of federal advanced tax credits◦ UNDERWRITING-by making all coverage guaranteed issue with

no medical questions or underwriting on the application. Who Qualifies?

◦ Non-Medicaid eligibles from 100% to 400% of federal poverty level projected Income who are NOT offered affordable coverage at work.

Who Runs It?◦ In Louisiana the Federal Government will operate our exchange.

In some other states, Exchanges will be locally operated.

◦ WHEN DOES IT OPEN? 10/1/2013 with open enrollment through 3/31/14 Coverage effective 1/1/14.

Where Do I Buy It?

31

WHAT’S THE PLAN?◦ To create a streamlines, easy to use, consumer friendly,

health neutral, gender neutral, FEDERALLY REGULATED market for health insurance.

HOW’S IT GOING?◦ Lots of bugs to work out. Test applications appear to take

over an hour and seem more complex than expected. Many unanswered questions.

WHO PAYS FOR IT?◦ Hospitals, Doctors, Insurance companies, Medical Device

Manufacturers, Large Employers, Drug Companies.◦ In other words, we all will pay for it.

HOW MANY PEOPLE WILL USE IT?◦ CBO estimates 6 million families in 2014 (low).

What’s an Exchange?

Risk Factor

Pre-2014 Post-2014

Rate Changes by

ClassAGE OF

INSUREDRATE MAY VARY UP TO 10X BETWEEN 19 AND

64 YEAR OLD

RATE MAY VARY ONLY 3X

BETWEEN 21 YEAR OLD AND 64

YEAR OLD

YOUNGER

OLDER

GENDER WOMEN CHARGED MORE DURING

CHILDBEARING YEARS. MEN CHARGED MORE

POST AGE 55

GENDER MUST BE IGNORED FOR RATE SETTING

MEN

WOMEN

HEALTH STATUS

MEDICAL RECORDS, CLAIMS DATA,

PHARMACY RECORDS, ALL USED TO

DETERMINE RATE OR OUTRIGHT EXCLUDE

APPLICANT FROM COVERAGE

HEALTH INFORMATION CANNOT ALTER

RATES OR EXCLUDE ANYONE

HEALTHY

SICK

From this grid we can see the big winners are older women with health conditions, and the biggest losers the young, healthy males.

How Will That Insurance Be Priced?

0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60 63$100.00

$200.00

$300.00

$400.00

$500.00

$600.00

$700.00

$800.00

Age Rating Effects: Sample Current Moving to 3:1, Remove Gender

PPACA Age CurveMale CurrentFemale Current

Age of Member

Standard Premium

Dramatic decrease in

Newborn Rates (-67%)

Males Age 22-42 get

rate increases up

to 38%!

Females get rate decreases at ages 22 through 54, peaking at (-35%) at age 40.

Males get small rate decreases at ages 56-64, peaking at (-11%)

34

Family Adult 1 Adult 2 Child 1 Child 2Ages 40 36 6 4

Issuer B B(Benchmark) B BMetal Level Bronze Silver Gold Platinum

Typical Sample Premium $10,908 $12,120 $13,332 $15,350

Family Income $35,000/year (149% of FPL)Premium Tax Subsidy$10,734 $10,734 $10,734 $10,734

Family pays: $174 $1,386 $2,598 $4,616 Payment % of Income 0.4% 4.0% 7.4% 13.2%

Family Income $88,000/year (375% of FPL)Premium Tax Subsidy $3,760 $3,760 $3,760 $3,760

Family pays: $7,148 $8,360 $9,572 $11,590 Payment % of Income 8.1% 9.5% 10.9% 13.2%

How Will Insurance Be Priced?

Incarcerated. Income above 400% of FPL. Offered coverage at work that is affordable

and at least 60% AV. Medicaid or CHIP eligible (income <138% fpl

in states that have agreed to expand). Claimed as a dependant on someone’s taxes. Unable to attest to residency in a single

state. In the country unlawfully.

35

Who Can’t Get Help?

Once a Subsidy is Accepted, Individual MUST file Tax Return for

That year.

Children (LIH)713k58%

Blind/ Disabled, 160k13%

Pregnant Females, 196k16%

Dual Eligibles, 161k 13%

Would Add new Category of Low Income Healthy

Adults Up to 138% of FPLPotentially 550k new

Can I Qualify for Free Insurance?

Who Gets Left Out?

The Healthcare Income Continuum (PPACA)

PPACA when fully enforced provides coverage and assistance for most Americans from 0 to 400% of Federal Poverty level Income

Coverage Gap

Without Medicaid expansion Louisiana will have no insurance help for citizens between 11% and 100% of FPL unless they

have employer coverage.

Around 200,000 people considered “Working Poor” will be without insurance.

0-11% Existing Medicaid

11% to 138% New Medicaid

Expansion139% to 400% Exchange

Subsidy Eligible

401% of FPL and above, you are on your own!

Federal Poverty Level Income0%

39

39

Should Louisiana Expand Medicaid?

Yes EXPAND! No, Don’t EXPAND!

100% FMAP for First 3 years, settling at 90% FMAP going forward.

DiSH money reduced by 50% by 2016, eventually eliminated

PPACA built with expansion in mind, covers working poor.

500,000+ will get access to no-premium health insurance

Fed does not fund administration of new population

La. Budget already $1.0B in the red

90% match may not be permanent

180k+ of expansion population already has private insurance.

Another 90k will be Exchange eligible.

Medical Capacity?