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Healthcare Reform Provisions Provisions
MEBS Employee Benefit Guide
MEBS PPACA guide is for our clients to use in navigating the benefit changes. To download the guide, please select this link - MEBS PPACA Guide.
Reasonable break time
A lesser-known provision of Healthcare Reform requires employers to provide unpaid, reasonable break time, and a private place for nursing mothers as frequently as needed. The space cannot be a bathroom and must be clean and free from intrusion from co-workers and the public. This requirement applies until the child's first birthday.
Possible Exempt Employers
Employers with less than 50 employees are exempt from these requirements, if such requirements would impose an undue hardship by causing the employer significant difficulty or expense when considered in relation to the size, financial resources, nature, or structure of the employer's business.
Awaiting Further Guidance
Rules for enforcement of this rule are not yet in place. Further clarification is expected on the terms "reasonable break time" and "significant difficulty or expense" used in the law. The new federal law will provide at a minimum support for nursing mothers but, it does not override a stringent State law.
Four Page Summary of Benefits and Coverage
Four Page Summary
The four page summary of benefits and coverage must accurately describe the benefits and coverage under the applicable plan or coverage.
Appearance, Language, and Content Requirements
The four-page summary must meet certain appearance, language, and content requirements.
Who must comply with this requirement?
• A health insurance issuer (including a group health plan that is not a self-insured plan) offering health insurance coverage within the United States; OR
• A self-insured group health plan, the plan sponsor, or the designated plan administrator.
Distribution of Four Page Summary
The four page summary must be distributed to all -
1. Applicants (at the time of application);
2. Policyholders or certificate holders (at issuance of the policy or delivery of the certificate); and
3. Enrollees (at initial enrollment and annual enrollment).
The four-page summary can be provided in either paper or electronic form.
Updating the Four-Page Summaries: Notice of Material Modifications
Any material modification of plan terms or coverage that is not included in the most recently provided four-page summary must be issued in a modification notice at least 60 days before the modification becomes effective.
Consequences of Failing to Provide Four-Page Summaries
A penalty of up to $1,000 per failure can be assessed on insurers (for insured health plans) and plan administrators (for self-insured health plans) that do not timely provide the four-page summaries.
Additional Guidance to be Issued
Additional guidance ("standards") addressing the four-page summary requirements will be issued by March 23, 2011. Once developed, these standards are to be periodically reviewed and updated.
The distribution deadline of the four-page summary is 24 months after the enactment of Healthcare Reform (March 23, 2010), which is March 23, 2012.
Early Retiree Reinsurance Program (ERRP)
Overview of the Temporary Program
PPACA established a temporary program to reimburse employment-based plans for a portion of the costs they incur providing health coverage to early retirees. Under this program, a plan sponsor may be reimbursed for 80% of the qualifying retiree health benefit costs paid by its health plan, the plan's insurer, or covered early retirees.
Before they can request reimbursements, plan sponsors, must, among other things, get their plan certified by the Department of Health and Human Services (HHS). The regulations detail the information that must be included in a sponsor's application for certification, along with the rules that certified plans and sponsor must follow to request reimbursement for qualifying expenses.
This program stared on June 1, 2010 and only expenses incurred on or after that date are reimbursable. The program will end no later than January 1, 2014. If the $5 Billion allocated for this program is exhausted before that date, the program will end at that time.
Debit Cards – Health Flexible Spending Arrangements (FSA) and Health Reimbursement Arrangement (HRA)
Over-the-Counter (OTC) Guidance Modified for Debit Cards
The IRS has issued guidance allowing the continued use of FSA and HRA debit cards to purchase prescribed over-the-counter medicines and drugs (OTC drugs). The notice modifies IRS guidance that was issued earlier this year about Healthcare Reform's prescription requirement for OTC drugs and allows the use of Debit Cards to purchase prescribed OTC drugs after January 15, 2011 if certain requirements are met.
Grants for Small Businesses to Provide Comprehensive Workplace Wellness Programs
The Secretary of Health and Human Services (HHS) will be awarding grants to eligible employers to provide their employees with access to a comprehensive workplace wellness program (as described in the Criteria section below). If an eligible employer meets the criteria and requirements below, it can submit an application including the required information to the Secretary for a grant request.
Awaiting Further Guidance
The Secretary of HHS will be developing program criteria for a comprehensive workplace wellness program, required information to be included in an application, and the application itself. We will continue to monitor this area and provide updates as they become available.
Who is an eligible employer?
An eligible employer means an employer, including a non-profit employer that -(1) employs less than 100 employees who work 25 hours or greater per week; and (2) does not provide a workplace wellness program as of March 23, 2010.
The Secretary will develop program criteria for comprehensive workplace wellness programs that are based on and consistent with research and best practices.
A comprehensive workplace wellness program must be made available by an eligible employer to all employees and include the following:
Health awareness initiatives (including health education, preventive screenings, and health risk assessments).
Efforts to maximize employee engagement (including mechanisms to encourage employee participation).
Initiatives to change unhealthy behaviors and lifestyle choices (including counseling, seminars, online programs, and self-help materials).
Supportive environment efforts (including workplace policies to encourage health lifestyles, healthy eating, increased physical activity, and improved mental health).
An eligible employer desiring to participate in the grant program must submit an application to the Secretary, in such manner and containing such information as the Secretary requires. This application must include a proposal for a comprehensive workplace wellness program that meets the criteria and requirements above.
Duration of Grants and Allocated Funds
The grant program is for a five (5) year period (fiscal years 2011-2015). The funds allocated for this program are $200,000,000. The funds are available until expended.
Proposed Rules on Rate Increase Review
Disclosure and review of unreasonable premium increases
Proposed regulations were issued implementing the rules for health insurance issuers regarding disclosure and review of unreasonable premium increases. The proposed regulation will ensure that large rate increases in all States are thoroughly reviewed.
The proposed regulation will help safeguard consumers from unreasonably high rate increases by providing them with detailed information on proposed increases. This new transparency in the health insurance market will promote competition, encourage insurers to do more to control health care costs, and discourage insurers from charging rates which are unjustified.
The rate review process would begin with rate increases filed in a State on or after July 1, 2011 or effective on or after July 1, 2011 in a State that does not require rate increases to be filed.
Additional guidance will be released, which will provide the required formatting and reporting instructions for each of the reporting categories listed in the regulation.
For plan years beginning on or after September 23, 2010, group health plans and insurers are prohibited by Healthcare Reform from rescinding coverage of an enrollee, except in cases of fraud or misrepresentation. A rescission is defined as a retroactive cancellation or discontinuation of coverage.
Mistake in Coverage
Retroactive cancellation of coverage is not permissible, even when a non-eligible individual's coverage was continued by mistake.
30 Days Notice Required
If a rescission is permissible, the group health plan (or the health insurance issuer offering group health insurance coverage), must provide notice to the member(s) 30 days before the cancellation or rescission. If a group is canceled due to nonpayment of premium, their health insurer must notify the group 30 days before cancellation. However, retroactive termination for non-payment of premium is permissible and there is no requirement that premiums be accepted after the original due date.
MEBS has added 100% preventive care benefits without dollar limits. Preventive services may include routine immunizations, certain screenings and preventive services. The plan will maintain this benefit as long as the member sees an in-network provider.
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