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Insurance Updates

Group Health Insurance Enrollment | ACA Healthcare Updates | Providence Insurance Group - Atlanta Broker

FAQ on Mental Health Parity and the ACA

By | HealthCare Reform, Insurance Updates, Providence Updates

 

Healthcare Reform Updates: Mental Health Parity in ACA Requirements | Providence Insurance Group

In October 2015, the Department of Labor (DOL) provided an informational FAQ relating to the Mental Health Parity and Addiction Equity Act (MHPAEA) and ACA market reform provisions.

Non-grandfathered group health plans and individual or group market health insurance must cover a variety of preventive services without any cost-sharing requirements. Required preventive services include “breastfeeding comprehensive support and counseling from trained providers, and access to breastfeeding supplies,” obesity screening and weight management services for certain individuals, colonoscopies for certain age groups, and contraception coverage for women.

ACA Auto-Enrollment Requirement Repealed

The ACA initially required employers with more than 200 full-time employees and that offer employees one or more health benefit plans to automatically enroll (and re-enroll existing) full-time employees into one of the health plans (subject to any waiting period authorized by law), in accordance with DOL regulations.

Following delays in the DOL regulation, the “Bipartisan Budget Act of 2015,” which was signed by President Obama on November 2, 2015, repealed the auto-enrollment requirement.

Employers are still free to use default or negative elections for employee enrollment, but employers with more than 200 employees are not longer required to do so.

EEOC Proposes Rule Relating to GINA and Wellness Programs

On October 30, 2015, the Equal Employment Opportunity Commission (EEOC) issued a proposed rule to amend the regulations implementing Title II of the Genetic Information Nondiscrimination Act (GINA) as they relate to employer wellness programs that are part of group health plans. The proposed rule would allow employers to offer financial incentives and inducements to spouses who offer information about current or past health status as part of a wellness program.

 

Final Rule on Grandfathered Health Plans

On November 13, 2015, federal agencies issued a final rule that essentially combined a variety of interim final rules and non-regulatory guidance on a variety of ACA initiatives such as grandfathered health plans, preexisting condition exclusions, internal and external appeals, rescissions of coverage, lifetime and annual limits, emergency care access and dependent coverage. The final rule was very similar to the previous guidance it consolidated. The final rule goes into effect on January 1, 2017. At that time all of the prior interim rules will be superseded.

The final rule also noted that various transitional rules are now void, such as the allowance of grandfathered health plans to exclude children under age 26 who were eligible for other group health plan coverage, and rules that provided a special enrollment period for children under age 26 who had been excluded from coverage.

PACE Act Clarifications from CMS

The Providing Affordable Coverage for Employees (PACE) Act amended the ACA and redefined small employers as those with 50 or fewer employees; it also gives states the option to expand the definition to include employers with up to 100 employees (or, practically speaking, those with 51 to 100 employees, also called “mid-size employers”). Prior to the ACA, all states defined small employers as those with 1 to 50 or 2 to 50 employees; however, many have passed legislation redefining the group size up to 100 employees beginning in 2016. States are now in the process of determining what they define as “small employer.”

The Centers for Medicare & Medicaid Services (CMS), in response to the PACE Act, issued an FAQ on the impact of the PACE Act on small group expansion. CMS clarified that states that choose to expand the definition up to 100 employees beginning January 1, 2016, were required to notify CMS of the decision by October 1, 2015. States with other effective dates should notify CMS of the decisions as soon as is practical. A state’s definition is legally binding on health insurance issuers.

Question of the Month

  1. May an employer fill out 1094-B, 1095-B, 1094-C, and 1095-C forms by hand or must they be typewritten?
  2. Although handwritten forms will be accepted, the IRS prefers that filers type or machine print data entries.
Providence Insurance Group: Atlanta Group Benefits Insurance Broker

Agencies Issue Final Rule on Grandfathered Health Plans and Other Initiatives

By | HealthCare Reform, Insurance Updates, Providence Updates

 

Healthcare Reform Updates: Grandfathered Health Plans | Providence Insurance Group

On November 13, 2015, federal agencies issued a final rule that essentially combined a variety of interim final rules and non-regulatory guidance on a variety of Patient Protection and Affordable Care Act (ACA) initiatives such as grandfathered health plans, preexisting condition exclusions, internal and external appeals, rescissions of coverage, lifetime and annual limits, emergency care access and dependent coverage. The final rule was very similar to the previous guidance it consolidated. The final rule goes into effect on January 1, 2017. At that time all of the prior interim rules will be superseded.

The final rule also noted that various transitional rules are now void, such as the allowance of grandfathered health plans to exclude children under age 26 who were eligible for other group health plan coverage, and rules that provided a special enrollment period for children under age 26 who had been excluded from coverage.

Grandfathered Health Plans

The final rule reaffirmed that grandfathered status applies separately with respect to each benefit package. For example a group health plan with a preferred provider organization (PPO) plan, a point of service (POS) arrangement, and a health maintenance organization (HMO) option would each carry grandfathered status (or not) separately. Requirements for grandfathered status notification remain the same — plans must include a statement that the plan or health insurance coverage believes it is a grandfathered health plan in any summary of benefits provided under the plan. The model disclosure notice remains the same.

Grandfathered plans have been governed by anti-abuse rules, to prevent plans from maintaining grandfathered status when employees transferred into the plan are from a transferee plan that would have caused the transferor plan to lose grandfathered status if its terms were adopted. There is an exception for bona fide reasons for employee transfers, such as a plan being eliminated by the carrier.

The final rule noted that a plan that eliminated substantially all benefits needed to diagnose a condition would cause a plan to lose its grandfathered status, but purposefully declined to provide a bright line rule to interpret the requirement. Excessive increases to a single or limited number of copayments would cause a plan to lose grandfathered status, even if the remaining copayments remained the same.

Plans that add additional tiers (such as individual plus one, individual plus two) will not lose grandfathered status if the contribution rate for the new tiers is not below the previous non-self-only tier by more than five percent. Employers with grandfathered health plans that offer wellness programs should take great caution if the wellness program imposes penalties for failing to meet standards, this could put the plan’s grandfathered status at risk. Finally, grandfathered health plans may move brand-name versions of drugs that become generic to a higher cost-sharing tier.

Preexisting Conditions

The final rule clarifies that a carrier can bar coverage for a specific condition if it does so regardless of when the condition arose. Caution should be exercised to take other requirements into account, such as essential health benefit requirements.

Lifetime and Annual Coverage Limits

Carriers and group health plans are prohibited from imposing lifetime and annual limits on coverage. Because health reimbursement arrangements (HRAs) cannot meet this requirement and are a group health plan, HRAs must be integrated with a group health plan in order to meet the requirements of the ACA. HRAs are still prohibited from being used to purchase individual plan premiums.

There are two sets of requirements for HRA and other account-based plan integration. An HRA that does not need to meet minimum value requirements is considered integrated if:

  1. The plan sponsor offers a group health plan (other than the HRA or other account-based plan) to the employee that does not consist solely of excepted benefits;
  2. The employee receiving the HRA or other account-based plan is actually enrolled in a group health plan (other than the HRA or other account-based plan) that does not consist solely of excepted benefits, regardless of whether the plan is offered by the same plan sponsor (referred to as non-HRA group coverage);
  3. The HRA or other account-based plan is available only to employees who are enrolled in non-HRA group coverage, regardless of whether the non-HRA group coverage is offered by the plan sponsor of the HRA or other account-based plan (for example, the HRA may be offered only to employees who do not enroll in an employer’s group health plan but are enrolled in other non-HRA group coverage, such as a group health plan maintained by the employer of the employee’s spouse);
  4. The benefits under the HRA or other account-based plan are limited to reimbursement of one or more of the following — co-payments, co-insurance, deductibles, and premiums under the non-HRA group coverage, as well as medical care that does not constitute essential health benefits; and
  5. Under the terms of the HRA or other account-based plan, an employee or former employee) is permitted to permanently opt out of and waive future reimbursements from the HRA or other account-based plan at least annually and, upon termination of employment, either the remaining amounts in the HRA or other account-based plan are forfeited or the employee is permitted to permanently opt out of and waive future reimbursements from the HRA or other account-based plan.

An HRA or other account-based plan will meet integration requirements and minimum value if:

  1. The plan sponsor offers a group health plan (other than the HRA or other account-based plan) to the employee that provides minimum value pursuant to IRS Code (and its implementing regulations and applicable guidance);
  2. The employee receiving the HRA or other account-based plan is actually enrolled in a group health plan that provides minimum value pursuant to IRS Code (and applicable guidance), regardless of whether the plan is offered by the plan sponsor of the HRA or other account-based plan (referred to as non-HRA MV group coverage);
  3. The HRA or other account-based plan is available only to employees who are actually enrolled in non-HRA MV group coverage, regardless of whether the non-HRA MV group coverage is offered by the plan sponsor of the HRA or other account-based plan (for example, the HRA may be offered only to employees who do not enroll in an employer’s group health plan but are enrolled in other non-HRA MV group coverage, such as a group health plan maintained by an employer of the employee’s spouse); and
  4. Under the terms of the HRA or other account-based plan, an employee (or former employee) is permitted to permanently opt out of and waive future reimbursements from the HRA or other account-based plan at least annually, and, upon termination of employment, either the remaining amounts in the HRA or other account-based plan are forfeited or the employee is permitted to permanently opt out of and waive future reimbursements from the HRA or other account-based plan.

Rescissions

Rescissions of coverage, or cancelling coverage retroactively or with a retroactive effect, have been prohibited since 2010, unless there is fraud or misrepresentation of material fact. The final rule did not provide a definition of “material fact.”

The rescission rules do not apply when an employee fails to or delays informing its employer that he or she has divorced a covered spouse, or a COBRA-qualified beneficiary fails to pay for COBRA coverage.

Rescissions are subject to internal and external appeal. Coverage must remain effective until an internal appeal is completed, and enrollees must be given 30 days notice prior to rescission to allow them time to appeal.

Adult Children

Group health plans and carriers must cover all children up to age 26, regardless of financial dependency or shared residence, student status of the child, employment status, or marital status. They must also be covered even though they do not live in a plan’s service area. Plans are not required, however, to cover out-of-network services for adult children, and the rule does not extend to grandchildren or other relatives.

Appeals

The final rule finalized additional requirements for internal appeals for individual plans. The final rule clarified that non-grandfathered fully insured group health plans and individual insurers must comply with the state’s external review processes if the state process offers the same consumer protections offered by the National Association of Insurance Commissioner’s Uniform Health Carrier External Review Model Act. Self-insured plans and insurers in states without this requirement must use a process that meets the Department of Health and Human Services (HHS) standards, which were narrowed in regard to adverse benefit determinations. Originally all final adverse benefit determinations were permitted to be reviewed. The final rule determined that only final review of adverse benefit decisions involving medical judgment and rescission may be reviewed. Examples of medical judgment claims were provided. Coding decisions may involve medical judgment and are appealable.

The final rule also provided the federal review process rules which were previously found in guidance. Group health plans have five days to complete a review of an appeal to determine if it is eligible for an external review, and then assign the appeal to an accredited independent review organization. That organization, or IRO, notifies the claimant, who has 10 days to provide additional information. Decisions must be issued, in writing, within 45 days, unless the situation involves serious jeopardy to life or health, in which case decisions must be made within 72 hours. Group health plans must contract with three accredited IROs and assign them claims through unbiased means.

The regulations discourage filing fees for claimants, but in states that are required to charge a filing fee, it must not exceed $25, and must be waived if it would cause hardship.

Designation of a Primary Care Provider

Plans that require or provide for designation of a primary care provider must allow the participant (or beneficiary or enrollee) to designate any available in-network primary care provider. Women do not need authorization for care from an obstetrician or gynecologist, who must be treated as primary care providers for purposes of ordering and authorizing services.

Similarly, plans that require the designation of a participating primary care provider for a child must permit the designation of a physician who specializes in pediatrics if they are in-network.

Access to Emergency Care

Plans and carriers may not impose administrative hurdles or requirements to limit access to emergency care, or charge additional copayments or coinsurance for out-of-network emergency care. Out-of-network emergency providers may balance bill, and plans or carriers are not required to pay a balance bill. Plans and carriers must pay a reasonable amount for out-of-network emergency care, which is:

  1. The median amount it pays for in-network-providers;
  2. The amount it usually pays out-of-network providers; or
  3. The Medicare rate.

Federal agencies indicated they might prohibit balance billing in the future.

IRS Health Insurance Reporting: 6055 and 6056 | Providence Group Health Insurance Broker

IRS Provides Major Delay in 6055 and 6056 Reporting

By | HealthCare Reform, Insurance Updates, Providence Updates

Healthcare Reform Updates: Atlanta Health Insurance Compliance | Providence Insurance Group

Under the Patient Protection and Affordable Care Act (ACA), individuals are required to have health insurance, while applicable large employers (ALEs) are required to offer health benefits to their full-time employees. In order for the Internal Revenue Service (IRS) to verify that (1) individuals have the required minimum essential coverage, (2) individuals who request premium tax credits are entitled to them, and (3) ALEs are meeting their shared responsibility (play or pay) obligations, employers with 50 or more full-time or full-time equivalent employees and insurers will be required to report on the health coverage they offer. Final instructions for both the 1094-B and 1095-B and the 1094-C and 1095-C were released in September 2015, as were the final forms for 1094-B, 1095-B, 1094-C, and 1095-C.

 

Reporting will first be due in 2016, based on coverage in 2015. All reporting will be for the calendar year, even for non-calendar year plans. On December 28, 2015, the IRS issued Notice 2016-4, delaying the reporting deadlines.

 

The reporting requirements are in Sections 6055 and 6056 of the ACA. The 1094-C, 1095-C, 1094-B, and 1095-B were originally due to the IRS by February 28 if filing on paper (February 29, in 2016, because February 28 falls on the weekend), or March 31 if filing electronically. The 1095-C form was due to employees by January 31 of the year following the year to which the Form 1095-C relates (February 1, in 2016, because January 31 falls on a weekend). The 1095-B was due to the individual identified as the “responsible individual” on the form by January 31 (February 1, in 2016, because January 31 falls on a weekend).

 

The transition relief provided by Notice 2016-4 extended the due date for furnishing Form 1095-B and 1095-C to individuals to March 31, 2016. The due date for filing all forms (1094-C, 1095-C, 1094-B, and 1095-B) to the IRS is moved from February 29, 2016, to May 31, 2016, if filing by paper. If filing electronically, the date is moved to June 30, 2016.

 

Employers that have difficulty meeting the extended reporting deadlines are encouraged to file late, as the IRS will take late filing into consideration when determining whether to reduce penalties for reasonable causes. The IRS will also take into account if an employer made reasonable efforts to prepare for reporting, such as gathering or transmitting necessary information to a reporting service.

 

Impact on Individuals

 

The IRS has determined that individual taxpayers may be affected by the extension, as employees are not eligible for the premium tax credit for any month, which an employee is eligible for an employer plan that provides minimum value, affordable coverage. However, the IRS has determined most individuals offered employer-provided coverage will not be affected by the extension.

 

Employees who enrolled in Marketplace coverage, but did not receive a determination from the Marketplace regarding whether their employer-sponsored coverage was affordable, could be affected by the extension if they do not receive their 1095-C form prior to filing their individual income tax returns. As a result, for 2015 only, individuals who rely on other information received from employers about their offers of coverage for purposes of determining eligibility for the premium tax credit when filing their income tax returns need not amend their returns once they receive their Forms 1095-C or any corrected Forms 1095-C. Individuals do not need to send this information to the IRS when filing their returns, but should keep it with their tax records.

 

Some individuals might also be affected by the extension because they will use the forms in determining whether they had minimum essential coverage. Individuals may not have received this information before they file their income tax returns, so for 2015 only, individuals who rely on other information received from their coverage providers about their coverage, for purposes of filing their returns, need not amend their returns once they receive the Form 1095-B or Form 1095-C or any corrections. Individuals need not send this information to the IRS when filing their returns, but should keep it with their tax records.

 

The extensions of due dates provided in the Notice apply only to section 6055 and section 6056 information returns and statements for calendar year 2015 filed and furnished in 2016 and do not require the submission of any request or other documentation to the IRS.

 

Extension Process

 

In September 2015, the IRS provided information on the Form instructions on applying for extensions. Generally, an automatic 30-day extension will be given to entities filing Form 8809, and no signature or explanation is needed. Form 8809 must be filed by the due date of returns in order to be granted the 30-day extension. Waivers may be requested with Form 8508, and are due at least 45 days before the due date of the information returns. This extension relates to the deadline to provide the IRS with the forms, not providing individuals with the forms.

 

However, because of the transition relief, for 2015, no extension requests will be granted. Employers must utilize the transition relief guidelines provided in Notice 2016-4.

Providence Welcomes New Team Leader Zach

By | Insurance Updates
Providence Insurance Group is excited to bring on the very newest member of the team, Zach Bertram!Zach Bertram has been in the insurance industry since January 2015. Prior to this, Zach attended Kennesaw State University where he graduated in 2009 with a Bachelor of Science in Sports Management and Marketing. After college, he began five years of camp ministry at Camp Highland, which is located in the North Georgia mountains. During his time at Camp Highland, he took on many different roles including that of Marketing Director, where he helped reinvent the camp’s brand and served as first contact for all guests. An avid outdoorsman, Zach enjoyed his time at Camp Highland, but what he enjoyed most about the experience was forming personal relationships with guests. Camp Highland’s mission is to connect kids and adults on a deeper level by meeting them where they are in life. This gives a greater opportunity for authentic relationships to be formed. After leaving Camp Highland, Zach joined the Providence team where he looks forward to continuing the same mission- to create authentic, personal relationships with clients. Zach truly believes that life is about creating meaningful business and personal relationships because everyone desires genuine care and trust. Zach chose to be a Team Lead at Providence Insurance Group because they strive to create deeper relationships that set their company apart from their competitors. Though Zach has just begun his journey at Providence, he has big goals. He hopes to progress within the company by creating lasting relationships with clients and providing trustworthy information in an industry where there is often chaos and confusion.In his spare time, Zach enjoys being outdoors. He likes to mountain bike, rock climb, kayak, backpack and enjoy nature with his girlfriend Emily. He also enjoys taking trips back to Camp Highland as often as possible where he enjoys reconnecting with campers and is passionate about sharing the gospel.

Providence Promotes Grant Thomas

By | Insurance Updates
Starting the new year with exciting news!  Providence’s Grant Thomas has been promoted to full time.Grant has been in the insurance industry for four years.  He started at Providence Insurance Group in 2011.  Grant’s current role at Providence is in Inside Sales. Despite how much he loves this industry and enjoys sales, Grant makes it a point to genuinely listen to everyone he interacts with on a daily basis and not allow himself to be driven strictly by making the sale.  He’s a strong team player that has a unique voice no one would ever forget.  In his free time Grant enjoys golf, basketball, and ping pong.  He won the State Championship in golf & basketball in 2005 & 2006.  In his busy schedule, Grant also finds time to work with Miles for Maria, a non profit organization that raises money for epilepsy research.

Mandatory Employer Notices

By | Insurance Updates

Disregard the notices that do not apply to your situation.  You should also review each notice you do need to give, modify it as needed to describe your plan, and fill in any blanks or highlighted areas.

  • Important Notice About Your CREDIBLE Prescription Drug Coverage and Medicare – Provide this notice by October 14 to all participants and dependents who are or may become eligible for Medicare Part D in the next 12 months if the prescription drug coverage provided by the plan is “creditable.”  (Providence Insurance Group can tell you if the coverage is creditable.)
  • Important Notice About Your NON-CREDIBLE Prescription Drug Coverage and Medicare – Provide this notice by October 14 to all participants and dependents who are or may become eligible for Medicare Part D in the next 12 months if the prescription drug coverage provided by the plan is not “creditable.”  (Providence Insurance Group can tell you if the coverage is not creditable.)
  • Women’s Health and Cancer Rights Act Notice – Provide this notice at least once a year to all participants
  • Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP) – Provide this notice before the start of the plan year if you have any employees in a state listed in the notice. (These states provide premium assistance for CHIP and/or Medicaid coverage.)  Caution:  This notice is updated regularly. Check at www.dol.gov/ebsa/chipmodelnotice.doc for the most current version if you do not promptly distribute this notice.
  • Wellness Program – Notice of Reasonable Alternatives – Provide this notice only if you have a wellness program that considers health status
  • Notice to Enrollees Regarding Opt-Out – Provide this notice only if the plan is a self-funded nonfederal governmental group health plan that has opted out of some or all of HIPAA; tailor as needed to describe what the plan has opted out of

ADDITIONAL NOTICES FOR NEW ENROLLEES

  • Notice of Special Enrollment Rights – Give this notice to all new enrollees
  • ** Continuation Coverage Rights Under COBRA** – Give this notice to all new enrollees – including new spouses – if you employ 20 or more people
  • New Health Insurance Marketplace Coverage – Provide this notice to all new employees (even if they are part-time/temporary/not eligible for the plan) within 14 days after their hire date if you offer coverage to any employee.  Note that completing questions 13 – 16 is optional.  At this time, providing information on minimum value and affordability is required.  
  • New Health Insurance Marketplace Coverage – Provide this notice to all new employees (even if they are part-time or temporary) within 14 days after their hire date if you do not offer coverage to any employee.