It’s seems like only yesterday that the Affordable Care Act (aka ACA, ObamaCare) was signed into law.   In fact, the law will celebrate it’s 8th anniversary on March 23, 2018…….and it was a big deal.   Yet, in all of this time and all of the front page conversations, so much is still not clear to so many.

Many misunderstandings are creating frustration for individuals, employees and employers.   Insurance and Benefit professionals spend countless hours providing service and guidance to those caught up in this ongoing learning curve.   I would like to take some time to highlight the most common, and often costly misunderstandings.

For Employers

The Employer Mandate to provide Affordable Coverage is in effect

Employers (and Controlled Groups) with 50 or more Full Time Equivalents must offer their eligible full-time employees health insurance that provides minimum essential coverage that is both affordable and provides minimum value.   Just this week, the IRS has released information to remind employers that they are going to be collecting penalties.   The Wall Street Journal (2-13-18) is reporting here that:

The financial impact on businesses could be significant. The nonpartisan Congressional Budget Office estimated in 2014 that companies would owe about $139 billion in penalties from fiscal 2016 to 2024.

“There are penalties of three, four, five million dollars,” said Alden Bianchi, an attorney at the firm Mintz Levin. “There is a smaller group of employers that really didn’t understand how the rules applied and didn’t offer coverage or sufficient coverage in 2015. … To a smaller company, a half-million is an existential threat.”

Employers need to offer coverage to at least 95% of their eligible full-time employees.  Penalties apply for non-compliance.  For additional information on affordability,  minimum value and penalties please contact Paula Wilson at paula@paulawilson.com.     (IRS Employer Mandate Penalties)

The Individual Mandate is still  in effect

Employers should remind their employees that the individual mandate is still in effect as well as the penalties for non-compliance through the end of calendar year 2018.  Employees declining coverage in 2018 should be warned.  Employers accepting employee declinations without proper counsel should provide time for employees to meet with your benefit advisor/agent.  We are always happy to provide this time to our clients.

Overwhelmed by 1095-C Tracking and Reporting on your Age Rated plan?

Employers subject to 1095 reporting in an age rating environment can often make their life easier with a bit of planning.    Employers offering more generous plans can often offer a Bronze level plan at no copay to the employees.   This would allow the 1095-C to be easily completed as the cost to the employee for a qualified plan would always be $0.  Because California considers groups from 1-100 to be small group, this reporting nightmare is a reality for employers with 51-100 employees.

Employers can make this reporting easier with thoughtful benefit planning and the advice of experienced benefit agents.

Plan Documents (WRAP) Documents

Employers must update and distribute a complete set of Plan Documents to all employees per ERISA.  These important Plan Documents will include but are not limited to Summary Plan Descriptions, Summaries of Benefits and Coverage as well as other documents needed based on your employee benefit package.   Simply offering an Employer Sponsored medical insurance plan constitutes an Employee Welfare Plan and you must comply with ERISA.  Be sure to ask your agent or administrator about these documents.

For Individuals and Employees

Preventive Care is covered at 100%. 

I am still shocked at the number of people who are not taking advantage of this benefit, if not for themselves….for their children.  As a society, we are living in a time when lifestyle related diseases can be caught and dealt with if you just know your numbers.  Make time to know your numbers.

Surprisingly, we spend a good part of our customer service hours explaining uncovered expenses that many thought were covered under this important benefits.   Blue Shield recently provided an excellent illustration to understand the coverage.  You can find that link here.

Even if you’re feeling fine, scheduling an appointment with your doctor for preventive care services is important. Through a preventive exam and routine health screenings, your doctor can determine your current health status and detect early warning signs of more serious, costly problems.

What’s covered in a preventive care visit

During your visit, your doctor will determine what tests or health screenings are right for you based on factors such as your age, gender, health status, and health and family history.  Plus, your medical plan covers 100% of the costs for preventive health services when care is provided through network providers. Be sure your physician understands your expectations of the free visit and testing.   IF the physician orders tests that are not covered within the limitations of ACA YOU WILL BE responsible for the charges.

What’s not considered a preventive care visit

If you discuss new medical concerns or a current illness, the entire visit may be considered a medical treatment visit and would not be covered as preventive care.  Copayments, Deductibles and Coinsurance will apply. You will be required to pay the plan’s physician office copayment or coinsurance.

The complete definition and detail of what is covered under the Preventive Benefits can be found at  the Healthcare.gov website here.

If your employer offers you Affordable and Minimum Value Coverage you cannot go to the State or Federal Exchange and receive a subsidy.

Employers may charge the employee up to 9.69% of his pay as a contribution to the employee only coverage.   Employees often look to the State Exchanges for lower cost coverage when employers require employee contribution.

You will be asked to make repayment if you are receiving subsidies in error.   This often occurs when:

The Employee does not disclose the offer of the employer based coverage at the time of application to the Marketplace, or,

The Employee does not advise the Marketplace in which they are already enrolled of any change of income or employment status to justify continued eligibility.

It is important that employers utilize their benefits professional/agent at the time of open enrollment to review needs and address these issues with the employee.

Paula Wilson, RHU, REBC is a insurance agent specializing in benefits for employers in the Southern California area.