Employer Notices From the Marketplace - What to do

Many employers received notices last week about employees who are receiving subsidies on the individual exchange. This matters if you are classified as an ALE "Applicable Large Employer" as penalties may be assessed.

1. If the employee is receiving a subsidy because you did not offer them coverage, then there is nothing you need to do.
2. If the employee is receiving a subsidy because you did not offer a plan that met minimum essential coverage or affordability, then there is nothing you need to do.
3. If you did offer coverage that was affordable and met minimum essential coverage, then you have 90 days within which to appeal.

Here is a link to that form: https://www.healthcare.gov/downloads/marketplace-employer-appeal-form.pdf

If you are an ALE and don't know what I am talking about in the above 3 points, then you ABSOLUTELY need to talk to me, your current broker, or your Employment Attorney.

Below is a newsletter about this from a very good Employment Attorney (if you need one). Larry Grudzien (larry@larrygrudzien.com, 708-717-9638).

From the Desk of Larry Grudzien

What's up with the Notice from the Marketplace?        

July 3, 2016

Last week, many employers received notice from the Marketplace indicating one of their employees was qualified for advance premium tax credits. Many are asking what  is this notice and how should deal with it. The following explains what the notice is and what steps an employer should take.

What is this Notice?

Under Section 1411(e)(4) of the Affordable Care Act, a Marketplace must notify an employer if any of its employees is determined to be eligible for a premium assistance credit (or the cost-sharing subsidy) because the employer does not provide minimal essential coverage through an employer-sponsored plan, or the employer does offer such coverage but it is not affordable.

Under 45 CFR Section 155.310(h), the notice must:

• identify the employee, providing the minimum necessary personally identifiable information;
• state that the employee has been determined eligible for advance payments of the premium tax credit, listing the potential reasons for the determination (instead of the actual reason) and without providing tax return information;
• indicate that, if the employer has 50 or more full-time employees, the employer may be liable under the employer responsibility rules of Code Section 4980H; and
• notify the employer of its right to appeal the determination.

Under Section 1411(e)(4)(B)(iii) of the Affordable Care Act, a Marketplace must provide this notice regardless of the size of the employer even though the employer mandate penalties only apply to applicable large employers (ALEs).

In addition to the above notice, a Marketplace may also contact the employer to determine whether its employees are enrolled in or are eligible for affordable, minimum value coverage under an eligible employer-sponsored plan, as provided in 45 CFR Section 155.320(d)(3)(iii)(D).

What should an employer do after it receives this notice?

The employer may appeal a determination that an employee is eligible for advance payments of the premium tax credit based in part on a finding that the employer did not offer qualifying coverage to the employee, as provided in 45 CFR Section 155.310(h). While a Marketplace's determination does not itself trigger the employer mandate penalties (those penalties are assessed by the IRS), employers offering coverage that should not result in the receipt of advance payment of premium tax credits may wish to use the appeals process to ensure, as much as possible, that their employees are not mistakenly receiving such payments.

The appeal may be conducted by either a Marketplace or by HHS if a Marketplace has not established an appeals process.

A Marketplace must allow employers to request an appeal within 90 days from the date of the notice from the Marketplace and permit employers to submit relevant evidence to support the appeal, as provided in 45 CFR Section 155.555(c). An employer may request an appeal by completing an appeal request form. Click on link below to obtain a copy of the request form:

https://www.healthcare.gov/downloads/marketplace-employer-appeal-form.pdf

An employer may mail or fax an appeal request.

Under 45 CFR Section 155.555, this appeals process must give employers the opportunity to:

• present information to a Marketplace for review of the determination, including evidence of the employer-sponsored plan and employer contributions to the plan; and
• have access to the data used to make the determination to the extent allowable by law.

Under 45 CFR Section 155.555(d), once a Marketplace receives a valid appeal request, it must:

• timely acknowledge the receipt of the request,
• provide an explanation of the appeals process,
• inform the employee of the appeal, and
• provide the employee with instructions for submitting any additional evidence for consideration by the appeals,

Under 45 CFR Section 155.555(i)(3), the standard of this review is a de novo review. A de novo review means a review of an appeal without deference to prior decisions in the matter.

Under 45 CFR Section 155.555(g), as part of the review process, the employer must be given the opportunity to:

• provide relevant evidence for review of the determination of the employee's eligibility for advance payments of the premium tax credit or cost-sharing reductions;
• review the information identifying the employee, information regarding whether the employee's income is above or below the threshold by which the affordability of employer-sponsored minimum essential coverage is measured, and other data used to make the determination, to the extent allowable by law.

The Marketplace's decision is required to be provided to both the employer and employee generally within 90 days of the date the appeal request is received, as provided in 45 CFR Section 155.555(k).

If the employer's appeal is successful, a Marketplace will send a notice to the employee encouraging the employee to update his or her Marketplace application to reflect that the employee has access to or is enrolled in other coverage. Under 15 CFR Section 155.555(k), the employee has the right to appeal the decision.

This appeal decision does not foreclose any future appeal rights the employer may have under the Internal Revenue Code for excise tax liabilities. While an appeal of a notice by the Exchange may be beneficial, employers are not necessarily required to make this appeal to preserve their rights against the later potential assessment of Code Section 4980H liability, as provided under 45 CFR Section 155.555(k)(1)(ii).

For a copy of the employer appeals process regulations, please click on the link below:

https://www.law.cornell.edu/cfr/text/45/155.555

Predicting Health Insurance Rates for 2016 in Illinois

Predicting Health Insurance Rates for 2016 in Illinois

By Robert Slayton

One good thing that came out of the Affordable Care Act is that any insurance company that is going to raise premiums more than 10 percent for individual or small group medical plans is required to file with the Federal Government. This information is made public so we can review it.
Unlike other states, Illinois has no authority to prevent the increases from being implemented as requested (this isn’t necessarily a bad thing, but just the way it is in Illinois). Based upon those rate increase requests, we have a pretty good idea of who will be the competitive players in the market for 2016.

BCBS of IL has requested increases from 12.83% to 38.24% for ACA plans. As a result, BCBS of IL is eliminating the Blue PPO (large PPO network) option in 2016 for ACA plans. All members on this plan will be migrated to the smaller Blue Choice network (which has about 40% of the doctors/hospitals as the larger network). This will impact approximately 173,000 people. Also expect BCBS to eliminate other plans that have been unprofitable.

If you are on a transitional plan, (plans written after 3/23/2010 to 12/31/2014) you may see increases of over 46%.

Coventry, Humana, and Health Alliance have also requested increases. If you look at the table below, it shows, generally, which increase impacts which plan. If you are on a subsidized plan, you will not see as dramatic of an increase if your income has stayed the same. Subsidies are based upon the second lowest silver plan. The assumption is that this plan will be more expensive in 2016 therefore providing you with a bigger subsidy. For everyone else, it will be a choice of paying the increase or keeping cable.

Aetna (who owns Coventry), Land of Lincoln Health, and IlliniCare are not listed as requesting a rate increase even though I’ve heard rumblings that some have. If we go with the assumption that they will increase rates less than 10%, then these will be some of the players who will win business away from BCBS.

One unknown is Land of Lincoln Health. I’ve had conversations with a board member who says the financials look good (doesn’t mean that they made a profit as it is difficult for any start up to make a profit in the first several years). If they continue to perform as they have, I’d say they will be the company most move to.

Expect all insurance companies to modify the plans they offer. We probably won’t know what these will look like until open enrollment begins on 11/1.

Below are the rates increase requests for ACA compliant plans.

For Transitional plans, here’s the rate table.

Individual Health Insurance Exchange (Marketplace) Subscribers and the 90 Day Grace Period to Pay Your Premium

Below is how BCBS of IL will handle claims for those people who have gotten a health insurance plan on the Exchange (Marketplace) AND receive a subsidy (Advance Premium Tax Credit).

It is my understanding that most other insurance carriers will be following a similar methodology, hence why I am posting this.

This is NOT for Small Group SHOP plans.

Blue Cross and Blue Shield of Illinois Providers Notified of ACA Grace Period Provision Providers will be receiving information in the Blue Cross and Blue Shield of Illinois (BCBSIL) provider newsletter about the Affordable Care Act (ACA) provision that allows Health Insurance Marketplace enrollees who receive the advance premium tax credit (APTC), a three-month grace period to pay their premium — provided they have already paid at least one month’s premium in full. It is important to note that not all members who purchase coverage on the Marketplace will receive the tax credit. During the three-month grace period, members are eligible for covered services under their plan.

The provision requires all payers to complete claims (for covered services rendered) in the first month of the grace period. For covered services rendered during months two and three, payers must either pay or hold claims for processing once the payments have been received. Notification of Eligibility Providers will be informed through eligibility and benefits verification when a member has entered into a grace period during months two and three of the grace period. All preauthorization letters will encourage providers to confirm whether the member is in a grace period prior to providing services. Claims Processing Payment for all allowable services provided during the first month of the grace period will be the responsibility of BCBSIL, subject to member cost sharing. During the second and third months of the grace period, BCBSIL will pend the claims the member incurs during this period. If the member pays all outstanding premium payment(s) in full, claims incurred during this period will process according to the member’s benefits. If the member has not paid premiums in full by the end of the grace period, BCBSIL will terminate the member’s policy retroactive to the first day of month two of the grace period. BCBSIL will deny any claims pended in months two and three of the grace period. Pharmacy Claims A member’s pharmacy claims will be denied during months two and three. If the member retroactively pays the premium in full, they may submit claims for prescriptions dispensed during this time to BCBSIL. If a member elects to receive a 90-day supply of a prescription during month one of the grace period, the member will receive the full 90-day prescription and BCBSIL will pay this claim. Member Responsibility for Payment We are encouraging providers to notify their patients that they will be responsible for payment of any outstanding claims for the full cost of provided services, if their health care coverage terminates at the end of the grace period.