HEALTHCARE BENEFITS & ACA REQUIREMENTS SNAPSHOT

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Here we are stepping into January 2014, and the healthcare subject is of a major concern to employees and employers alike. Until now, decisions on eligibility for voluntary benefits has been the employer's prerogative. Health benefits were by essence not a mandated benefit.

The landscape of healthcare regulations has dramatically changed with the Affordable Care Act (ACA). Nothing seems to be really firmly set yet. One thing appears to be certain: the cost is skyrocketing at all levels.

By now, large employers have already rolled out their programs and made necessary addition to their benefits staff. Individuals who wanted coverage to start with the new year have already filed their applications. It is somewhat different for smaller employers since their mandate on Healthcare coverage requirements is being delayed.

In any event, here are a few key points as a reminder or a reference for those of us who still need it.

QUICK REFERENCE CHECK LIST

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What is ACA About?

• Healthcare benefits are not mandated in the same title as FICA or SS. The mandate is "individual." 
• Offered Healthcare benefits  have to cover "Essential Coverage."  
• The Patient Protection and Affordable Care Act provisions offers what is called the Metal Plan
• Small Groups Market: Health care coverage for individual- and small-group markets has only one level

When does it start? Timetable

• It took effect on January 1, 2014.
• Open enrollment closes March 31, 2014
• Proposed date for 2015 open enrollment: November-January 2014
• Since 2013, employers have been required  to provide a notice of coverage options, upon hiring.
• Worth noting: according to DOL, there is no fine for failure to provide information on Exchanges
• Advice: It is best to provide information; This will also ease employees' feeling of uncertainty. Information on subsidy calculator could be helpful, as an example, so that employees could make an informed decision as to opt-out of company coverage or not.

 How Does It Work and Affect Businesses?

• If Healthcare benefits offered are not "affordable", and do not offer "minimum value," employees can go to the Marketplace
• Minimum value: at least 60% of costs should be covered  by the plan
• Affordable: the employee's cost is not to exceed 9.5% of his/her annual, total income
• For calculations of affordability, methodology is strictly based on 30h/week as a FTE. Refer to healthcare.gov or cms.gov  
• Any employer who has an employee choosing to go to the Marketplace will be "taxed" a "shared responsibility payment"

Penalties or Shared Responsibility 

•  Large employers
1.  With 50 or more FTEs and not offering minimum value health benefits to eligible  employees and their adult children up to age 26: the penalty is of $2,000/FTE if at least one full-time employee receives a tax credit/subsidy through the Marketplace.
2.  If employers  provide coverage: the penalty is of $3,000/FTE who obtains coverage through an exchange and receives a premium tax credit/subsidy.
3. Metal plan does not apply (affordability is based on lowest level of coverage offered)

•  Small and individual group markets
  
  1. Small employers of 50 or less: There is no penalty for not offering Health care coverage
  2. Individuals: Healthcare coverage purchase is mandated. Penalty vary from $95/adult and $47.50/child  to $285/family or 1% of annual income- Demystification: Income is defined as total income beyond the filing threshold
  3. Small employers purchasing coverage through Small Business Health Options Programs (SHOP) could be eligible for a tax credit of up to 50% of their premium payments
  4. The SHOP requirement has been delayed until 2015 

  How do SHOP work? 

  1. SHOP were to create  a marketplace of competitive small-group market plans.
  2. The goal:
  • To assist qualified small employers in either purchasing a small-group plan for their employees with up to 50% tax credit on premium paid, or
  •  To give employees the opportunity to select a health plan through SHOP. 
  • Conditions: 
  •  Small Businesses must have 25 or fewer employees
  •  Average annual wage of employees is less than $50,000
  •  Offer all full-time employees coverage and pay at least 50% of the premium.

    SHOP - Guide  

  • Changes: SHOP is delayed and will be limited to one single option versus the originally-intented four
  • Size is set by States: employers of 1-50 or 1-100 FTEs can participate in SHOP until 2016
  • In 2016: participation size requirement is to change to 1-100 FTEs
  • In 2017: States will be able to allow employers of 100+ (defined as large) to buy large group coverage through SHOP
  •  All  full-time employees – (average of 30 hours or +/week) must be offered coverage
  •  At least 70% of FTEs must enroll in the SHOP plan, in many States.
  •  Applying for SHOP between November 15 and December 15 will waive the  employee threshold enrollment requirement.
  • Insurance must cover the "essential health benefits package"

SHOP Channel - Metal Plan

• The metal plan insurance can be provided by an employer or purchased by the employee
• Metal Plans have four levels of coverage:
• Bronze, 60 percent; 
• Silver, 70 percent; 
• Gold, 80 percent; 
• Platinum, 90 percent. 
• Catastrophic:  Available to those under 30, and/or those who cannot afford the bronze level 

• The Metal Plan is also defined as "Essential Health Coverage," which differs from minimum essential coverage, and that includes the following 10 categories (cf. SHRM):

  

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• Ambulatory patient services.
• Emergency services.
• Hospitalization.
• Maternity and newborn care.
• Mental-health and substance-use-disorder services, including behavioral-health treatment.
• Prescription drugs.
• Rehabilitative and habilitative services and devices.
• Laboratory services.
• Preventive and wellness services and chronic disease management.
• Pediatric services, including oral and vision care.

Data for 2013: Kaiser Survey

According to a 2013 Kaiser Family Foundation (Kaiser) and Health Research & Educational Trust (HRET) survey, 57% of employers offer health coverage with 62% of employees being enrolled to the plans.

For healthcare data comparison regarding employer/employee coverage, costs,  premiums and deductibles, click here.


For additional information on ACA, refer to healthcare.gov.

En Synthèse...

 

  Comprendre le Débat sur l'Assurance Santé aux USA 

Ces derniers temps le sujet de sécurité et d'assurance médicale a été d'un débat épineux aux USA. L’idée est de promouvoir une assistance médicale qui serait accessible pour toutes les bourses.

A titre de comparaison et d'information, particulièrement pour les entreprises qui ont des filiales aux USA ou qui considereraient y avoir une implantation ou des échanges avec des entreprises Américaines, voici quelques data qui pourraient donner un aperçu des questions qui constituent tout ce débat.

A noter qu'aux Etats-Unis il est difficile de saisir la notion de "sécurité médicale" qui existe dans d'autres parties du monde, les hopitaux et cliniques medicales étant en grande majorité privés. Quoique certains centres pour l'enfance existent, elles sont rares, et les cliniques gratuites sont gérées par des organisations privées, qui souvent sinon toujours, ou bien taxent les patients, ou exigent des documentations compliquées, ou ont des horaires très restreintes.

Les grandes entreprises (dans ce cas celles de plus de 199 employés) qui offrent une assurance santé comme avantage social ne sont guère plus de 57% en 2013, avec 62% des employés couverts. En principe l'assurance santé est offerte aux employés à plein temps. Entendez par là, ceux qui travaillent plus de 35 ou 40h/semaine, selon les entreprises. La part de l'employé (en sus de la cotisation mensuelle [premium] et du pourcentage à payer par consultation ou par examen [co-pay]), avant prise en charge par l'assurance (dedutible), est d'au moins US $1.000 par individu pour 58% des employés de petites entreprises (moins de 199) et 28% des employés de large entreprises.

Les avantages sociaux sont très rarement offerts aux employés à mi-temps, ou plus, commencent à couper l'assurance pour personnel à mi-temps. Aussi, il faut comprendre qu'aux Etats-Unis, le système de paie est souvent basé par heure de travail, y compris pour certains employés cadres, en particulier suite à la nouvelle définition du terme de personnel d'encadrement (exempt from overtime).

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D’où peut-être l’idée de rendre l'assurance-santé obligatoire pour les individus (individual mandate). Selon cette législation, tout individu doit acheter une assurance-santé. Le gouvernement offre un marché qui serait géré par les Etats (marketplace, exchanges i.e subventionné par les Etats) donnant aux individus qui n'ont pas accès à une assurance dans le cadre d'une entreprise, la possibilité d'avoir une assurance à moindre coût.  Le refus d'adhésion au système est taxé d'une amende de $95/adulte et $47.50/enfant (de la famille) ou 1% des ressources annuelles de la famille. 

Bon à noter aussi est le fait que les entreprises qui auraient des employés qui opteraient pour le marketplace seront pénalisés a raison de US $2.000 à 3.000/employé (participant au marketplace), selon la taille de l'entreprise. Un employé a la possibilité d'opter pour un exchange si l'assurance offerte par l'entreprise est hors de portée (plus de 9.5% du salaire annuel) ou ne couvre pas les besoins médicaux de nécessité. La nouvelle législation considère comme employés a plein-temps ceux qui travaillent avec une moyenne de 30h par semaine.

Pour des data détaillés (enquête Kaiser 2013) sur le sujet cliquer ici.