MACPA PPACA Health Care Act - 2014 Business impact - Town Hall

111
The Affordable Care Act:
2014 Business Impact
A special town hall for members
Presented by:
Tom Hood, CPA, CITP, CGMA
CEO
Maryland Association of CPAs
Business Learning institute

335 Clubhouse Road • Hunt Valley, MD www.rjpassociates.com 800.618.2600
THE AFFORDABLE CARE ACT
BUSINESS IMPACT – 2014

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Discussion Topic
Affordable Care
Act Provisions –
Current, Ongoing,
and Delayed

ACA Provisions applicable to Employers
Many of the provisions required to be implemented by 2014 already
in effect or remain scheduled for implementation, including:
Exchange Notices
Individual Mandate
Implementation of Insurance Exchanges
Employees’ access to premium subsidies
Reporting minimum waiting period and essential coverage
(including minimum value and affordability on SBC)
Insurance Mandates (e.g., no pre-existing condition exclusion,
premium rating, minimum essential benefits, medical loss ratio)
Payment of reinsurance and PCORI fees

2014 ACA Provisions - Delayed
IRS Notice 2013-45 issued July 9, ,2013 provided a one-year
enforcement delay for:
The information reporting requirements applicable to insurers
and self-insured plans who provide minimum essential
coverage under IRC § 6055
The information reporting requirements for large employers
under IRC § 6056
The Employer Shared Responsibilities under IRS § 4980H
(“Play or Pay”)

Certain enforcement provisions previously delayed pending
further guidance continue to be delayed, including:
W-2 reporting of employer-provided health coverage cost for
small employers (<250 W-2s) issued in prior calendar year
Automatic enrollment of employees in employer-provided
health coverage – 200+ FTE Employers
Application of Code § 105(h) nondiscrimination rules to non-
grandfathered fully insured health plans

Insurance
Exchanges

State Exchanges:
California, Colorado, Connecticut, District of Columbia, Hawaii,
Idaho, Kentucky, Maryland, Massachusetts, Minnesota, Nevada,
New Mexico, New York, Oregon, Rhode Island, Utah, Vermont and
Washington
State Partnership Exchanges:
Arkansas, Delaware, Illinois, Iowa, Michigan, New Hampshire and
West Virginia
Remaining states to default to Federally Facilitated Exchanges
More info at CMS.gov: http://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-
FAQs/state-marketplaces.html

Maryland Health Benefit Exchange
and SHOP Discussion
Michele Eberle
Executive Director
Maryland Health Insurance Plan

A service of Maryland Health Benefit Exchange
Maryland Health Benefit
Exchange
The Affordable Care Act:
2014 Business Impact
Michele Eberle
Executive Director, MHIP
August 27, 2013

The Patient Protection and Affordable Care Act of
2010 (ACA)

Why It’s Important to Maryland
Expands access to health insurance for 730,000 Marylanders
(13% of Maryland) currently without health insurance
– Gives individuals access to primary care physicians, preventive services
Lowers uncompensated care costs in the healthcare system
– lower insurance premiums across the state
Provides federal subsidies for individuals up to 400% of FPL to pay for health
insurance premiums
– Infuses $600 million in federal subsidies into the State of Maryland by 2015
 NEW funds in health care system
Requires each state to establish a “health insurance exchange” by 2014

A marketplace where individuals and small businesses explore, compare and
enroll in private health insurance and public assistance programs, as well as
access federal tax credits and cost-sharing subsidies
States had a choice to establish a state-based exchange, join a partnership or
the federally-facilitated exchange; Maryland opted to establish a state-based
health insurance exchange
What it is NOT:
The state-based health insurance exchange is NOT an insurer or issuer of
health insurance plans.
What is a State-Based Health Insurance
Exchange?
4

Maryland ACA Related Legislation

Establishment of Maryland’s State-Based
Health Insurance Exchange
Health Benefit Exchange Act of 2011
– April 12, 2011: Establish Maryland’s state-based exchange as a
public corporate and independent unit of state government
– June 3, 2011: Nine-member Board of Trustees held its first
meeting
– September 2011: Exchange appointed Executive Director (first
Executive Director appointment in the U.S.)

Stakeholder Engagement
Policy decisions were made through an open, public and transparent
process with over 60 stakeholders representing Maryland’s diversity from
across the state (Fall 2011)
Four Advisory Committees studied six topics:
– Navigator and Consumer Assistance / Advertising
– Market Rules and Risk Selection / Operating Model
– SHOP Exchange
– Financing the Exchange
Executive Director and Board Liaisons attended all 22 meetings
Stakeholder representation included: health insurance industry, providers
and associations, community members, advocates, community-based
organizations, academia, business owners and leaders, local chamber
officials, consumers, consultants
Continued through 2012 – Tenet of the Exchange

Health Benefit Exchange Act of 2012
Options laid out in the stakeholder advisory committee process
provided recommendations from the Exchange Board to the
General Assembly
“Recommendations for a Successful Maryland Health Benefit
Exchange” Legislation Report (December 23, 2011) provided
recommendations for SB238/HB443
Maryland Health Benefit Exchange Act of 2012 signed by
Governor O’Malley (May 2, 2012) outlines the implementation
policies for operating the state-based exchange

Guiding Principles of Policy Decisions
Informed by public input seven principles guide the policy decisions of MHBE to
ensure that the state-based health insurance exchange serves the health care
needs of Maryland individuals, families, employers and employees:
Accessibility: reduce the number of Marylanders without health insurance and
improve access for all Marylanders.
Affordability: the affordability of coverage, within the Exchange and within the
state, is essential to improving Maryland’s health care system and economy.
Sustainability: The Exchange will need to be sustainable in order to succeed
in the long run.
Stability: promote solutions that respect existing strengths of our state’s
health care system and promote stability
Health Equity: The Exchange should work to address longstanding, unjust
disparities in health access and health outcomes in Maryland.
Flexibility: be nimble and flexible in responding to the quickly changing
insurance market, health care delivery system, and general economic
conditions in Maryland, while being sensitive and responsive to consumer
demands.
Transparency: MHBE is accountable to the public, and its activities should be
transparent, its services easily available, and its information easily
understandable by the populations it assists
9

Maryland Health Progress Act of
2013
Dedicated funding stream to finance the MHBE
Gradual transition of MHIP enrollees into Exchange
Flexibility for State reinsurance wrap-around program
SHOP Exchange rules for employer premium contributions
Continuity of care for Marylanders
Consolidated Services Center employee function
Plan certification appeals process
MCO/carriers permitted to offer plans in Exchange only
Creation of application counselors and captive producers
Medicaid expansion
10

Small Business Health Insurance
Options Program (SHOP)

The Small Business Health Options Program (SHOP) is a competitive private
health insurance marketplace where small businesses and their employees will
have access to affordable coverage and a choice of insurance plans
Employer Benefits
– Employers can offer employees choice of insurer and qualified health plan
– Employers can continue to use their brokers
– Online tools available to employers and their brokers will help employers predict costs
– Many small employers will qualify for tax credits
– Simple, online administration
• Online Adds & Drops
• Online Billing & Payment
• Phone & Online Support
Employee Benefits
– Employees have a choice of plans that suit their individual needs
– Standardized plans and online tools help employers make meaningful comparisons
between health plans
– Employees can enroll online
– Employees can manage their accounts online
– Other benefits due to small group market reforms
SHOP Overview

Maryland Health Connection will have a Small Business Health Options
Program (SHOP) dedicated portal for small businesses and their employees
Small businesses (including non-profits) with up to 50 employees may
participate
In 2016, the ACA modifies the definition of small group to 100 employees
SHOP supports the existing market (does not replace it), small employers
will still be able to purchase insurance outside of the SHOP
Carriers above a minimum threshold must offer products in the SHOP; all
catastrophic plans be offered in the SHOP
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SHOP in Maryland

Meets the requirements of the Affordable Care Act (ACA) as it pertains to SHOP
set-up and management;
Encourages small business to purchase coverage on the SHOP Exchange;
Provides minimum disruption to the existing small group health insurance market in
Maryland while promoting innovation;
Leverages the knowledge and expertise of current market players (e.g. carriers,
benefit administrators, etc.) for key technical and business functions;
Minimizes duplicative development effort among Maryland stakeholder through
the development of common service components that can be leveraged equitably by
the broadest number of market players;
Provides a SHOP solution that satisfies the needs of employers, employees, and
health plans in an efficient and consumer-friendly manner;
Ensures that operations are transparent and managed with effective oversight
whereby the Exchange and the State of Maryland meet all their management
oversight and fiduciary responsibilities to the state’s small employer community.
SHOP Guiding Principles

SHOP Plan Set-Up & Enrollment
Employer
Plan Set-up
Estimated
Quote
Employee
Enrollment
Eligibility
Determination
Validate
Group
Notify
Carriers
Employer is evaluated
for eligibility to
purchase QHP based
on demographic
information
Employer selects a
metal level (Employee
Choice) or a carrier
(Employer Choice)
and sets defined
contribution amount
SHOP provides an
estimated quote
based on employer
choices and employee
census (age, income,
etc.)
Employees make
plan selections
with information
on employer
contribution and
their expected
cost
Validate that all
requirements for
the employer (e.g.
minimum
participation) have
been met
Notify carriers to
contract with
employer and
start coverage
for employees
SHOP Administration
• Premium aggregation and billing
• Carrier payment
• On-going eligibility / enrollment management
(employee adds, deletes, life changes, etc.)
• Enrollment and funds flow reconciliation

16
Two Options for Small Employers:
Employer v Employee Choice
Gold
Bronze
Platinum
Carrier
A
Carrier
C
Carrier
D
Carrier
E
Carrier
F
Employee Choice
EmployerChoice
Carrier
B
Silver

17
Employee Counting Methodology
The employee counting methodology impacts whether a group will be eligible to
purchase on the SHOP – Maryland Exchange Board approved the FTE aggregation
method consistent with federal rules for tax subsidies
Employers can decide whether to offer coverage to full time employees or all employees
Seasonal employees can be excluded from the employer count under certain conditions (e.g. the
employer only exceeded the 50 employee count for four or less months in the year).

Tax Credits for Health Insurance will only be available through
MarylandHealthConnection.gov beginning October 1, 2013
The SHOP will provide employers:
– Innovative plan options that are easy to administer
– Access to tax credits to cover employee premiums
– Employee choice model
Streamlined application, and customer service through
statewide Call Center
Ability to continue to work with brokers and third party
administrators
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Why Consider the SHOP?

Employee Choice Features:
– Employer selects a metal level with multiple
carriers offering different plans
– Employees are free to choose between plans
that best meet individual needs
– Broader selection
– Ability to stay with carrier and providers as
jobs change  portability
– Allows employers to recruit and retain in
competitive environment
In 2014, small employers will have the same
purchasing power with health insurance as large
employers
Small employers can continue to work with their
brokers in the SHOP
Aggregated billing (single list bill) will be available
Employee Choice Model
19

2010-2013: Maximum tax credit for small
employers is 35% of the qualified premium for
health insurance for employees
– Maximum tax credit for small tax-exempt
employers (charities) is 25%
January 1, 2014, rate increases to:
– 50% tax credit for small employers
– 35% for small tax-exempt employers
(charities)
Can be carried back and forward to other tax
years
Tax Credit Eligibility
20

Fewer than 25 full-time equivalents, with average
wages of less than $50,000 per year
Provide 50% of single (not family) coverage for each
employee
Calculations are made on a sliding scale
Tool available on IRS website
Tax Credit Eligibility Examples
21
* Source: Internal Revenue Service

Small Business Tax Scenarios
Example*: Auto Repair Shop with 10 Full-Time Employees
– Wages: $250,000 total, or $25,000 per worker
– Employee Health Care Costs: $70,000
– 2010 Tax Credit: $24,500 (35% credit)
– 2014 Tax Credit: $35,000 (50% credit)
Scenario #2: Restaurant with 40 Part-Time Employees (the
equivalent of 20 full-time workers)
– Wages: $500,000 total, or $25,000 per full-time equivalent
worker
– Employee Health Care Costs: $240,000
– 2010 Tax Credit: $28,000 (35% credit with phase-out)
– 2014 Tax Credit: $40,000 (50% credit with phase-out)
22

Online Resources
23
Sign Up for Email Updates
Sign Up for Text Updates: Text
“Connected” to 69302
Get information on resources available to
help now
Link to details on meetings and reports
MarylandHealthConnection.gov
MarylandHBE.com

2014 Small Group and Individual
Insurance Premium Rate Setting
Richard J. Princinsky
President
Richard J. Princinsky
& Associates, Inc.

Current Rating Structure for Small Groups
(2 – 50 Employees)
Based on average age of all employees enrolled in the
health insurance plan
Rates are established for each tier level of coverage
(individual, individual plus spouse, family )
All employees pay the same tier rate, regardless of their
age
Get ready
This is about to change

New Member Level Rating Structure
effective January 1, 2014 (PHSA § 2701)
New rating structure will be based on the state-specified
geographic rating area and on the age of each individual
employee and dependents being enrolled.
Every employee and their dependents with different ages will
have a unique rate
Employee + Spouse = sum of the two individual rates based on
their ages
Family plan = sum of each member’s rate based on their age
- Age of the employee, the spouse and the oldest three children
under the age of 21 and all adult children between the ages of
21 and 26

Rate Structure Ratios
Will move from 5:1 to 3:1
5:1 implies if individual group rate was $100/month for the
lowest average age group in the state, then the group with
the highest average age could not be charged more than
$500/month for the individual rate
The compression of a 3:1 ratio creates less of a gap in cost
between the younger person and older person
– The change from the current rates may be greater for the
younger person than the older

Individual
Mandate

Individual Shared Responsibility
Annual penalty assessment against any individual that does not have
monthly minimum essential health coverage – specific exceptions apply.
Individual is taxpayer (or spouse/dependent).
Minimum Essential Coverage is health coverage under a:
– Government plan; e.g., Medicare Part A, Medicaid, CHIP, Tri-Care
– Eligible employer-sponsored plan
– Individual market plan
– HHS recognized plan; i.e., State health benefits risk pool
Exceptions:
- Cannot afford coverage (premium share >8% of household income)
- No federal income tax return filing requirement based on income threshold
- Hardship exemption deemed by HHS
- Members of certain Indian tribes
- Gap in coverage for less than a continuous three-month period – one time per year

Annual Penalty Amount is the greater of:
– Flat dollar amount per individual
• 2014 - $95/individual; $47.50 for individual 18 years or younger
• 2015 - $325/individual; $162.50 for
• 2016 - $695/individual; $327.50 for
Annual cap amount = 3 x individual rate
– Percentage of income amount
• 2014 – 1% of combined household income (after exemptions and standard
deductions)
• 2015 – 2% of combined household income
• 2016 – 2.5% of combined household income
Penalty capped at the national average of the annual cost of a bronze level health
insurance plan, for the applicable family size, offered through the state health care
exchanges.

Individual Tax Credit/Premium Subsidy
Available to individuals and families who do not qualify for
Medicare or Medicaid and are not offered health insurance
through an employer.
Taxpayers with household income between 100% and 400% of
federal poverty line (FPL) who purchase insurance through an
Exchange
– Based on modified adjusted gross household income – includes social
security benefits that are not included in taxable year gross income
– Some individual may additionally qualify for cost-sharing reduction
subsidy to help with deductibles and co-payments
– Exchanges to determine eligibility for premium tax credit and cost-sharing
reductions

Premium Cost Share Assistance Illustration
% of Fed
Poverty
Level
(FPL)
Annual
Income1
(Individual)
Premium
(% of
Income)
Monthly
Premium
Share
Reduction
in Max
OOP Limit
Reduced
Cost-
Sharing
Limit
Required
Actuarial
Value of Plan
138% $15,856 Financial eligibility for Medicaid enrollment in Maryland
150% $17,430 4.0% $58 66.7% $2,250 87%
200% $23,240 6.3% $122 20% $5,200 73%
250% $29,050 8.05% $195 N/A $6,400 70%
300% $34,860 9.5% $276 N/A $6,400 70%
400% $46,480 9.5% $368 N/A $6.400 70%
1Based on 2012 individual FPL ($11,170) trended two years at 2% annual trend (rounded).

Required
Employee
Disclosure

Notice of Exchange Availability
Employers must provide written notice to employees of
availability of health coverage through the 2014 Exchange
Notice deadline October 1, 2013
Provide to all W-2 employees of the Employer
– FT, PT, seasonal, on-call
– Regardless of eligibility for Employer’s health plan
– Provided free of charge
New hires must receive notice within 14 days of hire
DOL model notice template available at:
www.dol.gov/ebsa/healthreform/index.html

Employer offering
Health Coverage Notice
PDF fillable template to
customize notice
Part B (2nd page) –
employer and group
health plan info
Part B (3rd page) –
optional info
Distribution to all
current W-2 employees
by October 1st; new
employees at time of
hire (October 1st and
forward)

Notice Template – Employer does not offer Health
Coverage

Non-calendar year plan Section 125 Plan nonqualified mid-
year status change event – transition rule
– 2014 Exchange open enrollment is not a qualified status
change event or special enrollment right for Section 125
Plans
– Employer is permitted to amend Plan to allow either one or
both of the following salary reduction elections:
– Employees currently participating (and enrolled in Health plan
option) to change current election to opt out
– Employees not currently enrolled in health plan through the
Plan to elect to participate (and enroll in Employer health plan)

– Important Note: insurance carrier must also agree to allow
health plan election change for this reason
– Plan amendment only applies to 2013 Plan year renewing on
or after February 2014
– Transition rule allows retroactive Plan amendment until
December 31, 2014
Recommendation: inform employees of ability/inability to change
current election or newly enroll in employer plan

Revised COBRA notice released – DOL Technical Release
2013-02 (http://www.dol.gov/ebsa/newsroom/tr13-02.html )
– Revised model notice advises of alternative health coverage
availability through the Exchange
HIPAA Certificate of Creditable Coverage – notice requirement
eliminated effective 12/31/2014
Summary of Benefits and Coverage (SBC)
Grandfathered Plan assertion or Patient Protections notice
W-2 reporting cost of employer provided health coverage –
large employer (250 or more W-2s issued in prior year)
– Small employer transition rule still applicable

Rebate for failure to meet MLR standards
Insurers must meet medical loss ratio standards each year, report to
HHS, and issue premium rebates to policy holder reflecting portion that
did not meet applicable ratio.
– Large Group Market = 85%
– Small Group/Individual Market = 80%
– Not applicable to self-insured health plans
– Rebate issued in form of premium credit or lump sum payment to
policy holder – employer for group plan
– Insurer must provide notice of rebate to employer and enrollees
– Employer responsibility to distribute any insurance rebate received
according to pro-rata share of premiums paid by employer and plan
participants

Group plans subject to Title I of ERISA must follow those
requirements for distribution of the rebate; Non-ERISA plans (e.g.,
non-Federal government plans and Church plans) must follow CMS
guidance.
ERISA covered plans distribution guidelines – DOL guidance
issued (Technical Release 2011-04)
• No requirement under ERISA to include or exclude prior plan
participants
• “Ordinary notions of property rights” application to pro-rata distribution
• ERISA trust requirements for plan assets avoided if rebate distributed
within 3 months
• May apply “de minimus” amount rebate to plan enhancement that
benefits all plan participants

– ERISA group plan participant rebate distribution:
• Lump sum cash
• Premium holiday/reduction
• Plan enhancement benefiting all participants
– Participant rebate distribution may be made to:
• Participants of plan that rebate applies
• Current plan participants that were also plan participants in prior
year
• Current plan participants only, regardless of prior year
participation

Non-Federal Government group plan (e.g., state/local
government) participant rebate distribution may be made only
to current plan participants.
(HHS/CMS guidance – 76 Fed Reg. 76596 Dec. 7, 2011)
– Policy holder may apply participant rebate:
• Reduce future premium contribution to all current plan
participants (covered under any option of the policy)
• Reduce future premium contribution to only current plan
participants who were covered in prior plan year (year rebate
applies)
• Cash rebate to current participants of plan that were covered
under the plan option/policy rebate applies

– Policy holder may distribute rebate:
• Divide participant rebate equally among all participants
• Divide it based on each participant’s actual contribution
• Apportion as reasonable reflection of participant’s contribution
Non-ERISA Plan, e.g., Church
– Entire rebate returned to participants of plan rebate applies,
unless policy holder provides written assurance that rebate
will be apportioned according to rules for non-Federal Gov’t
plans.
– Without written assurance, insurer required to divide entire
rebate equally among participants of plan rebate applies and
distribute

Tax consequences for participant rebates (lump
sum or premium reduction) – IRS guidance
– Pre-tax insurance premium contributions – rebate is
taxable, subject to Federal /state income tax and
employment taxes
– After-tax premium contribution – rebate not taxable
– Distribution to COBRA participants – rebate treated
as after-tax contribution
IRS Medical Loss Ratio (MLR) FAQs:
http://www.irs.gov/uac/Medical-Loss-Ratio-(MLR)-FAQs

Disclosure Requirements - Delayed
Reporting of Health Insurance Coverage (Insurers and Employers
that Self-insure) [Code § 6055(c)]
– One-year implementation delay to January 1, 2015; first report due
by January 31, 2016
– Report to IRS showing any individual with “minimum essential
coverage during prior calendar year; reporting form and additional
guidance required of IRS
– Written notice to covered individual with same information provided
to IRS
– Possible coordination of reporting with large employer reporting
requirement – awaiting additional guidance

Reporting of Health Insurance Coverage (Large Employers
and “Offering Employers”) [Code § 6056(c)]
– Large employers (50+ FTEs) to report to the IRS whether they
offer their full-time employees and their employees' dependents
the opportunity to enroll in “minimum essential coverage and
certain other information
– Reporting employers must also provide a related written
statement to their full-time employees
– Purpose is to enable IRS to verify needed information related to
Employer Shared Responsibility provisions (“Play or Pay” penalty
assessment)
– Same reporting time as Insurer Reporting requirement – January
31st for prior calendar year, effective January 1, 2015 (first
reporting by January 2016)

Employer
Mandate

Employer Shared Responsibility
Small Employer – fewer than 50 (average) full-time equivalent
employees (FTE’s) in preceding calendar year*
- If offering group health coverage, must meet essential health
benefits package requirements (Grandfathered Plan exception)
- No Employer Shared Responsibility Payment assessment
liability
Large Employer – 50+ (average) FTE’s in preceding calendar
year*
- Employer Shared Responsibility Payment liability starting 2015
- Penalty liability effective plan renewal month in 2015 for non-
calendar year health plans – Transition Rules application
*Preceding Calendar Year = any consecutive 6-month period

Proposed Rules issued January 2, 2013
– Transition Rule for non-calendar year plans/large employer
provisions
• Controlled Group and Affiliated Service Group application –
Code § 414 (b), (c), (m) and (o)
– Full-time Equivalent Employee (FTE) –
• Common-law employee (W-2 wages)
• Average of 30 service hours/week (130 hours/month)
• Service Hours = all paid hours + unpaid hours for reason of
vacation, holiday, illness, incapacity (including disability), layoff,
jury duty, military duty or leave of absence (e.g., FMLA)
• Seasonal worker exception – meets statutory definition
application and works no more than 120 business days

Employer Size Determination Example:
65 employees: 7 FT; 58 PT and seasonal
employees
6-month calculation period : July 1 – Dec 31
1. FT ee’s (7 x 6) ÷ 6 = 7
2. Total service hours of all other ee’s:
Jul: 7540
Aug: 7600
Sep: 7580
Oct: 7000
Nov: 5800
Dec: 5500
Total: 41020 ÷ 6 ÷ 130 = 52.59 FTE’s
3. 7 + 52.59 = 59.59 = 59 FTE’s
Large Employer in 2014
1. Total number of full time employees
(employees classified as FT by employer)
employed on any business day during
each month of 6-month calculation period
/ 6 = average FT employees
If average number of FT employees is at
least 50 no need for further calculation –
Large Employer
2. Total all service hours for all other
employees employed on any business
day during 6-month calculation period
(PT, seasonal, temporary)/ 6 / 130 =
average number of FTE’s
3. Add FT number to FTE number = total
average FTE; if 50 or greater (disregard
any fraction) – Large Employer
Note: if 50+ total is solely attributable to
seasonal workers – not a Large Employer

“Play or Pay” Penalty Assessment
Beginning in 2015, certain large employers may be subject to a
penalty assessment for either of the following:
1) Failing to offer health care coverage to substantially all full-time
employees.
$2,000/year ($166.67/month) for every FT employee (minus the first 30)
2) Offering less than “minimal value” plan – the plan's share of the
total allowed benefits is less than 60%, or
Offering minimum essential coverage that is deemed unaffordable.
(>9.5% of W-2 wages for cost of individual coverage).
$3,000/year ($250/month) for each FT employee enrolled in Exchange
plan and receiving premium assistance

Additional ACA Provisions and Fees/Taxes
90-Day Maximum Waiting Period
- Effective plan year beginning on or after January 1,
2014
- Applies to small/large employer, fully-insured/self-
insured; no Grandfathered Plan exclusion – all health
plans
- Offer of coverage (enrollment) must occur by 91st day of
eligibility for coverage
- From date of hire for FT employees
- From first day of FTE eligibility determination for all others

Patient-Centered Outcomes Research Institute (PCORI) Fee
– The fee applies from 2012 to 2019, based on plan/policy years ending on or after
Oct. 1, 2012, and before Oct. 1, 2019
– The fee is due by July 31 of the year following the calendar year in which the
plan/policy year ended
– The first fee was due July 31, 2013, for November, December 2012 and January
2013 plans
– The first fee is not due until July 31, 2014, for plan years that start February through
December 2013
– The fee will be calculated and paid by:
• Insurer for fully-insured plan (probably passed thru to plan sponsor)
• Plan sponsor (generally employer) for self-funded plans, including HRA’s. Health FSA’s
generally excepted. Not applicable to HSA’s (not a health plan)
– Fee reported on IRS Form 720. Revised form and instructions just released.
Download form and instructions: www.irs.gov/uac/Affordable-Care-Act-Tax-
Provisions
– $1 per covered life (plans ending before Oct. 1, 2013); $2 per covered life
(subsequent years, adjusted for medical inflation)

Transitional Reinsurance Fee
– Purpose is to stabilize premiums in the individual market during the initial
phase of Exchange operation (2014 – 2016)
– Applicable to fully insured and self-insured health plans that are “major
medical coverage”
• Does not apply to HRA’s integrated with group health plan, HSA’s or Health FSA’s
• Medicare Secondary Payer rules apply; e.g. retiree plans
– Fee is $63/year per covered life ($5.25/month); COBRA (or other
continuation) participants included in count
– Fee calculated and paid to HHS by:
• Insurer for fully-insured plans
• Plan Sponsor (or TPA) for self-funded health plans
– Info provided to HHS by Nov. 15th (plan data from Jan – Sep); HHS will
notify entity within 30 days (or Dec. 15th ) of amount due within 30 days
– Per IRS, Plan Sponsors and Insurers may deduct cost of fee as ordinary
and necessary business expenses – (considered an expense of the Plan)

Health Insurer Fee
– Effective starting each calendar year after 2013; first fee due
September, 2014
– Applicable only to insurers (fully-insured health plans)
• Does not apply to self-funded health plans
• Governmental entities and certain nonprofit entities are also
excluded
– IRS to calculate each covered entity's portion of the
aggregate fees for each fee year
– Controlled group application – regs apply 50% ownership
standard
– IRS proposed regulations, that information would be
provided on Form 8963 (Report of Health Insurance Provider
Information)

DOMA
Decision
Impact

Marriage (spouse) Definition Impact on Employee
Welfare Benefit Plans
ERISA – state insurance and benefits regulations override
ERISA preemption; e.g., Maryland’s Civil Marriage
Protection Act
– Insured health plans – state insurance regulations apply
– Self-insured health plans – plan document defines
spouse/dependent – caution
Other Federal laws impacted:
– Family and Medical Leave Act (FMLA)
– COBRA continuation

Tax Issues
– Federal tax – depends on spousal status and dependent status
under federal law
• Questions still exist on whether non-DOMA definition of spouse will be applied
retroactively for federal tax purposes
– DOMA Section 2 – residency provision still intact – states can define
spouse
• Awaiting guidance regarding whether states and employers will be
required to recognize same sex spouses who are legally married in one
state move to another that does not recognize same sex marriage
– Section 125 Plan – pre-tax contributions for spouse
– “Gross up” policy review

There are currently 13 jurisdictions that recognize same-sex
marriage (plus the District of Columbia), and 9 states
recognize some form of same-sex union recognition (being
either civil unions or domestic partnerships):
Same-sex Marriage: Connecticut, District of Columbia, Delaware,
Iowa, Maine, Maryland, Massachusetts, Minnesota, New
Hampshire, New York, Rhode Island, Vermont, Washington
(legal Domestic Partnerships will convert automatically 1/1/2014)
Civil Union Recognition: Colorado, Hawaii, Illinois, Oregon
Domestic Partnership legal status: California (carries same
rights as other states Civil Union laws), Maine (same-sex and
opposite sex), Nevada, New Jersey, Wisconsin

Today’s Presenter
Richard J. Princinsky & Associates, Inc.
RJP & Associates, Inc. was founded in 1976 to help employers develop, understand and manage their group insurance and
employee benefits. RJP continues to partner with companies to deliver effective group benefit programs, helps to control
insurance costs, and provides strategic insight for health care legislation. Our client groups are comprised of a variety of
industries and multi-state locations. RJP has developed a specialty focus in non-profit and social service agencies, being
recognized as the preferred employee benefits provider for many association groups, such as the MACS, MARFY, as well as
professional organizations including the MACPA.
Sandra C. Krauer, Director, Client Risk Management Services
Sandy brings 27 years multi-state human resources management and employee welfare benefit plan regulatory compliance
expertise to the RJP management team. Sandy’s professional career has included oversight of the HR function for Maryland-
based employers encompassing strategic planning, company reorganization and acquisition integration; company policy and
procedure design and implementation; employee welfare benefit plan regulatory compliance under ERISA, COBRA, HIPAA, IRC
§125 and the Affordable Care Act. In addition to providing ongoing technical expertise and compliance tools to our staff and
client groups, the CRM Services team provides employee welfare benefit and HR education through the development and
presentation of in-person and web-based seminars focusing on Health Care Reform, Cafeteria Plans, Sexual and Other
Workplace Harassment and other topics relevant to employer groups.
Sandy graduated (summa cum laude) from the University of Baltimore, Robert G. Merrick School of Business, and is a longtime
member of the national Society for Human Resource Management (SHRM).
skrauer@rjpassociates.com / 410-773-4300 ext. 4337

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