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ISPLA: How May the Healthcare Supreme Court Decision Impact You?

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  • Peter Psarouthakis
    The U.S. Supreme Court has issued its decision on the constitutionality of The Patient Protection and Affordable Care Act (PPACA). What will this decision mean
    Message 1 of 1 , Jun 30, 2012
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      The U.S. Supreme Court has issued its decision on the constitutionality of
      The Patient Protection and Affordable Care Act (PPACA). What will this
      decision mean to some of our investigative and security professionals to
      comply with the provisions of this act? Now that we are no longer waiting
      for the court's decision, plan sponsors should be focused on making certain
      their plans and reporting practices comply with the components of the Act.
      There are ERISA implications of making changes to comply with PPACA.
      Fiduciaries, with documentation, are obligated to make certain that required
      changes are made regarding amendments to their health plans.



      Changes required by PPACA, which should already be in effect and amended,
      include the following:



      Auto Enrollment. Employers with more than 200 employees that offer coverage
      must automatically enroll new full-time employees in coverage with the
      opportunity to opt-out.


      Pre-existing Exclusions. No pre-existing exclusions for enrollees under age
      19.


      Dependent Coverage. Extension of coverage of adult children to age 26.


      Coverage Rescissions. Coverage cannot be rescinded absent fraud or
      intentional misrepresentation by the enrollee.


      Lifetime Limits. No annual or lifetime dollar limits on "essential"
      benefits.


      Appeals Procedures. Appeals process required to allow for appeals of
      coverage determinations and claims (includes internal appeals and external
      review).


      External Appeals. The regulations require group health plans and insurers to
      comply with applicable external review process in states that have
      implemented such a process.


      Emergency Services. Must cover emergency services without prior
      authorization and in-network.


      Primary Care Provider. Must allow designation of OB/GYN and pediatrician as
      Primary Care Provider.


      Preventative Care. Must cover preventive care without cost sharing.



      Future compliance issues are as follows:



      For 2012:



      W-2 Reporting - Employers must include aggregate cost of employer-sponsored
      health coverage on annual Form W-2.


      Summary of Benefits Coverage - Insurers and plan sponsors of self-funded
      plans must provide summary of benefits to all participants and applicants,
      based on format set by Secretary, using uniform definitions and stating
      whether the plan provides minimum essential coverage and whether ensures the
      plan's share of costs is at least 60 percent of actuarial value.


      Advance Notice of Mid-Year Changes - Plan must provide 60-days advance
      notice of changes to summary of benefits.


      Quality of Care Reporting - Plans and insurers must report on plan benefits
      and reimbursement structures that provide incentives for the implementation
      of case management, care coordination, chronic disease management and
      medication and care compliance activities for treatment or services under
      the plan or coverage; the implementation of activities to prevent hospital
      readmissions; improving patient safety and reducing medical errors through
      best clinical practices, evidence based medicine and health information
      technology; and the implementation of wellness and health promotion
      activities.


      Nondiscrimination - While originally intended to be effective in 2011,
      nondiscrimination rules will generally apply to fully insured plans just as
      they apply to self-insured plans as soon as guidance is issued. Further
      guidance is expected to be issued in 2012.



      For 2013:



      Flexible Spending Account Changes - Limits FSA contributions to $2,500,
      indexed in future years.


      Employer notice requirements - Effective March 1, 2013, employer requirement
      to provide written notice informing employees about the exchange, and their
      potential eligibility for premium credits if the employer's share of costs
      is less than 60 percent of the allowed total cost of benefits.



      For 2014:



      Penalties to Commence - Businesses having fifty or more employees will be
      subject to a "free rider tax" for those employees obtaining subsidized
      insurance from state health exchanges. For those businesses not offering
      coverage under the minimum requirements for all of their full-time
      employees, and have at least one full-time employee who qualifies for a
      subsidy, such employers will be required to pay $2000 per year for each
      full-time employee, except for the first thirty. Employers who offer
      coverage meeting the minimum requirements for all full-time employees and
      still have at least one full-time employee who qualifies for the subsidy
      will be required to pay $3000 for each employee receiving a tax credit.
      There will certainly be more clarification on these requirements,
      particularly the notice requirement, once the rules related to the exchanges
      are finalized.

      ISPLA thanks the employment law practice of Fox Rothschild, LLP for
      providing this timely and important information for our members.



      Bruce Hulme

      ISPLA Director of Government Affairs

      <http://www.ispla.org/> www.ISPLA.org

      Resource to the Profession, Government, and to the Media







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