2015 Open Enrollment Checklist

Grandfathered Plan Status


□    If you have a grandfathered plan, determine whether it will maintain its grandfathered status for the 2015 plan year. Grandfathered plans are exempt from some of the ACA’s requirements. A grandfathered plan’s status will affect its compliance obligations from year to year.


□    If your plan will lose grandfathered status for 2015, confirm that the plan has all of the additional patient rights and benefits required by the ACA. This includes, for example, coverage of preventive care without cost-sharing requirements.


Cost-sharing Limits


□    Review your plan’s out-of-pocket maximum to make sure it complies with the ACA’s limits for the 2015 plan year ($6,600 for self-only coverage and $13,200 for family coverage).


□    If you have a health savings account (HSA)-compatible high deductible health plan (HDHP), keep in mind that your plan’s out-of-pocket maximum must be lower than the ACA’s limit. For 2015, the out-of-pocket maximum limit for HDHPs is $6,450 for self-only coverage and $12,900 for family coverage.


□    If your plan uses multiple service providers to administer benefits, confirm that the plan will coordinate all claims for EHB across the plan’s service providers, or will divide the out-of-pocket maximum across the categories of benefits, with a combined limit that does not exceed the maximum for 2015.


□    Be aware that the ACA’s annual deductible limit no longer applies to small insured health plans.


US Insurance Exchage 2015 Open Enrollment ChecklistHealth FSA Contributions


□    Work with your advisors to monitor IRS guidance on the health FSA limit for 2015.


□    Once the 2015 limit is announced by the IRS, confirm that your health FSA will not allow employees to make pre-tax contributions in excess of that amount for 2015. Also, communicate the 2015 health FSA limit to employees as part of the open enrollment process.


Transition Policy for Small Group Health Plans


□    Pre-existing Condition ExclusionsThe ACA prohibits health plans from imposing pre-existing condition exclusions (PCEs) on any enrollees. (PCEs for enrollees under 19 years of age were eliminated by the ACA for plan years beginning on or after Sept. 23, 2010).


□    Coverage for Clinical Trial ParticipantsNon-grandfathered health plans cannot terminate coverage because an individual chooses to participate in a clinical trial for cancer or other life-threatening diseases or deny coverage for routine care that would otherwise be provided just because an individual is enrolled in a clinical trial.


□    Comprehensive Benefits PackageInsured plans in the individual and small group market must cover each of the essential benefits categories listed under the ACA. Each state has a specific benchmark plan for determining the essential health benefits for insurance coverage in that state.


Employer Penalty Rules


□    Determine ALE status for 2015, including eligibility for the one-year delay for medium-sized ALEs;


□    For sponsors of non-calendar year plans, determine whether you qualify for the transition relief that allows you to delay complying with the pay or play rules until the start of your 2015 plan year;


□    Establish a system for identifying full-time employees (those working 30 or more hours per week);


□    Document plan eligibility rules; and


□    Test your health plan for affordability and minimum value.


HSA Limits for 2015


If you offer a high deductible health plan (HDHP) to your employees that is compatible with a health savings account (HSA), you should confirm that the HDHP’s minimum deductible and out-of-pocket maximum comply with the 2015 limits. Also, the 2015 increased HSA contribution limits should be communicated to participants. The following table contains the HDHP and HSA contribution limits for 2015.


HDHP Minimum Deductible Amount

Individual                                                         $1,300

Family                                                              $2,600


HDHP Maximum Out-of-Pocket Amount

Individual                                                         $6,450

Family                                                              $12,900


HSA Maximum Contribution Amount

Individual                                                         $3,350

Family                                                              $6,650


Catch-up Contributions (age 55 or older)    $1,000


For more information please contact The Benefits Firm.

Ph: (502) 451-4560


620 S. 3rd Street, Suite 102 Louisville, KY 40202

Health Care Reform: Common Acronyms

There are a growing number of acronyms used in health care reform-related materials today. Use this handy reference to view the different acronyms and the definitions for each.

health insurance 300x147 Health Care Reform: Common Acronyms


ACA: The Affordable Care Act. Used to refer to the final, amended version of the health care reform legislation.


CDC: The Centers for Disease Control and Prevention.


CHIP: The Children’s Health Insurance Program. Program that provides health insurance to low-income children, and in some states, pregnant women who do not qualify for Medicaid but cannot afford to purchase private health insurance.


DOL: United States Department of Labor.


EBSA: Employee Benefits Security Administration. A division of the DOL responsible for compliance assistance regarding benefit plans.


EPO Plan: An exclusive provider organization plan. A managed care plan that only covers services in the plan’s network of doctors, specialists or hospitals (except in an emergency).


ERRP: The Early Retiree Reinsurance Program. A temporary program created under health care reform to provide coverage to early retirees.


FPL: Federal poverty level. A measure of income level issued annually by HHS and used to determine eligibility for certain programs and benefits.


FLSA: The Federal Fair Labor Standards Act. Amended by PPACA to incorporate health care reform-specific provisions.


FSA: Flexible spending account.


HCERA: The Health Care and Education Reconciliation Act of 2010. Enacted on March 30, 2010, to amend and supplement PPACA.


HCR: Health care reform.


HDHP: High deductible health plan.


HHS: United States Department of Health and Human Services.


HMO: Health maintenance organization. A type of health insurance plan that typically limits coverage to care from medical providers who work for or contract with the HMO.


HRA: Health reimbursement arrangement or account.


HSA: Health savings account.


IRO: An independent review organization. An organization that performs independent external reviews of adverse benefit determinations.


MLR: Medical loss ratio. Refers to the claims costs and amounts expended on health care quality improvement as a percent of total premiums. This ratio excludes taxes, fees, risk adjustments, risk corridors and reinsurance.


NAIC: The National Association of Insurance Commissioners.


OCIIO: The Office of Consumer Information and Insurance Oversight. A division of HHS responsible for implementing many of the health care reform provisions.


OOP: Out-of-pocket limit. The maximum amount you have to pay for covered services in a plan year.


PCE: Pre-existing condition exclusion. A plan provision imposing an exclusion of benefits due to a pre-existing condition.


PCIP: The Pre-Existing Condition Insurance Plan. A temporary high-risk insurance pool to provide coverage to eligible individuals until 2014.


POS Plan: Point-of-service plan. A type of plan in which you pay less if you go to doctors, hospitals and other health care providers that belong to the plan’s network. POS plans require a referral from your primary care doctor to see a specialist.


PPACA: The Patient Protection and Affordable Care Act. Enacted on March 23, 2010, as the primary health care reform law.


PPO: Preferred provider organization. A type of health plan that contracts with medical providers (doctors, hospitals) to create a network of participating providers. You pay less when using providers in the plan’s network, but can use providers outside the network for an additional cost.


QHP: Qualified health plan. A certified health plan that provides an essential health benefits package. Offered by a licensed health insurer.


SHOP Exchange: The Small Business Health Options Program. A program that each health insurance exchange must create to assist eligible small employers when enrolling their employees in qualified health plans offered in the small-group market.

Check Your Group Health Plan Compliance for 2015

The Affordable Care Act (ACA) has made a number of significant reforms to group health plans since it was enacted in 2010. Many of these changes became effective in 2014, including health plan design changes, increased wellness program incentives and reinsurance fees. More changes will take effect in 2015 for employers that sponsor group health plans. To prepare, review the new requirements and develop a strategy for compliance.


First, do you have a grandfathered plan? It must be one that existed when the ACA was enacted on March 23, 2010. If so, determine whether it will maintain its grandfathered status for the 2015 plan year. If you make certain changes to your plan that go beyond permitted guidelines, your plan is no longer grandfathered. If your plan will lose its grandfathered status for 2015, confirm that it has all of the additional patient rights and benefits required by the ACA.


Next, review your plan’s out-of-pocket maximum to make sure it complies with the ACA’s limits for the 2015 plan year: $6,600 for self coverage and $13,200 for family coverage. Also, make sure your plan limits an employee’s annual pre-tax salary reduction contributions to a health flexible spending account (FSA) to $2,500. Watch for an announcement later this year from the IRS on what the health FSA limit will be for 2015.


Review the health coverage you provide to your employees to determine if it is subject to reinsurance fees for 2015. Both health insurance issuers and self-funded group health plans must pay fees to a transitional reinsurance program for the first three years of the Exchanges’ operation (2014-2016). The fees will be used to help stabilize premiums for coverage in the individual market. Fully insured plan sponsors do not have to pay the fee directly, and certain types of coverage are excluded.


The Benefits Firm Check Your Group Health Plan Compliance for 2015Make sure your health plans files a statement with the Department of Health and Human Services certifying compliance with HIPAA’s electronic transaction and operating rules. The ACA has extended the first deadline to Dec. 31, 2015, although small health plans may have additional time to comply.


Determine your status as an applicable large employer (ALE). ALEs that do not offer health coverage to their full-time employees and dependents will be subject to “employer shared responsibility” or “pay or play” penalties if any full-time employee receives a government subsidy for health coverage through an Exchange. The IRS has delayed the penalties and related reporting until Jan. 1, 2015.


To count your employees, determine whether you will use the entire 2014 calendar year or an acceptable period of at least six consecutive calendar months during 2014. Calculate the number of full-time employees or full-time equivalents (FTEs) for each calendar month in the period using either a monthly measurement method or look back method. If your result is 50 or more, you are likely an ALE for 2015.


If you have a non-calendar year plan, determine whether you qualify for the transition relief that allows you to delay complying with the pay or play rules until the start of your 2015 plan year. Also confirm whether all full-time employees are covered by the transition relief.


Finally, review your health plan design. Confirm that health plan coverage will be offered to all full-time employees and their dependent children in 2015. Review the cost of your health plan coverage to determine whether it’s affordable for your workers.


To learn more about compliance for group health plans in 2015, please contact The Benefits Firm.


Ph: (502) 451-4560


620 S. 3rd Street, Suite 102 Louisville, KY 40202

ObamaCare Premiums to Rise by an Average of 7.5%

According to a new analysis, premiums on ObamaCare’s health insurance exchanges will rise by an average of 7.5% next year.


The Health Research Institute (HRI) at PricewaterhouseCoopers compiled data and found modest changes in premiums for 27 states and the District of Columbia.


The Benefits Firm2 ObamaCare Premiums to Rise by an Average of 7.5%The national increase average of 7.5% is “well below the double-digit increases many feared,” HRI Managing Director Ceci Connolly wrote in an email.


Indiana has the highest average price increases under ObamaCare, some consumers will see prices rise by 15.4%.


The average individual monthly premium for next year, before any subsidies are applied, is $384,” Connolly wrote. “And insurance commissioners get a chance to weigh in on rates before fall enrollment.”


For the insurance industry the healthcare law’s first enrollment period was a big test. Premium prices were set with little information about who might sign up for coverage.


2015 rates shed light on how well insurance company’s guesses will pan out.


Prices are generally being raised by companies if their new customers will use more medical care than projected, are older or sicker.


On the other hand, firms with a healthier pool have an incentive to lower premiums.


ObamaCare’s second enrollment period begins Nov. 15.
For more information please contact The Benefits Firm.
Ph: (502) 451-4560


620 S. 3rd Street, Suite 102 Louisville, KY 40202

California’s Healthcare Premiums Increased by 22%-88% Over the Past Year, Kentucky’s Only 9.9%

According to an annual report detailing the rise of healthcare premiums in the state, the four largest insurers in California raised individual’s premiums between 22% and 88%. These numbers are determined by factors such as age and location.
In Kentucky, the highest filed rate increase On-Exchange was 9.9% with the Kentucky Co-Op. Humana’s increase is roughly 5.7% On-Exchange, Bluegrass Family Health On-Exchange for SHOP is 5.1%, and Anthem On-Exchange is -5%. Anthem now has Norton and Kosair as part of their network and will also offer new products with out-of-state coverage beginning January 2015.
The Benefits Firm California’s Healthcare Premiums Increased by 22% 88% Over the Past Year, Kentucky’s Only 9.9%

What we anticipate going into Open Enrollment 2015…
There will also be at least two new carriers offering plans On-Exchange in Kentucky for the 2015 year. With this change consumers will have more options to choose from, creating a more competitive market compared to the last Open Enrollment.


We predict that due to their familiarity and decrease in premium costs, Anthem may acquire more business among shoppers. Humana, whose rates are similar to the Kentucky Co-Op, may take the lead in the cheapest rates of the three carriers. And lastly, the newly state funded carrier, the Kentucky Co-Op thrived this year taking approximately 75% of the business but with new competition only time will tell if they will continue to lead the market.
For more information please contact The Benefits Firm.
Ph: (502) 451-4560


620 S. 3rd Street, Suite 102 Louisville, KY 40202