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Frankfort Educational Networking Symposium Health Care Reform Explained May 15, 2013. presented by: Steve Hogan Brian J. Stumm. presented by: Aaron Ruswick Whitney Schmidt. Welcome. Presenters Stumm Insurance, LLC Steve Hogan 773.862.7761 x109

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frankfort educational networking symposium health care reform explained may 15 2013
Frankfort Educational Networking Symposium

Health Care Reform Explained

May 15, 2013

presented by:

Steve Hogan

Brian J. Stumm

presented by:

Aaron Ruswick Whitney Schmidt



  • Presenters
    • Stumm Insurance, LLC
    • Steve Hogan 773.862.7761 x109
    • Brian Stumm 773.862.7761 x102
    • Huck Bouma PC
    • Whitney Schmidt 630.221.1755 x1193
    • Aaron 630.221.1755 x 1254
  • Objective
  • To understand the past and future impact the Affordable Care Act will have on the American public, including both individuals and employers.
  • Synonyms for Today
    • Health Care Reform
    • Obamacare
    • Patient Protection and Affordable Care Act (PPACA)
    • Affordable Care Act (ACA)


  • Timeline of Events
    • 2010
    • 2011-12
    • 2013
    • 2014
    • 2017-18
  • Closer Looks
    • Subsidy (Tax Credit) Examples
    • Marketplace
    • Large Employer Calculation
    • Large Employer Roadmap
    • Bottom Line
  • Question & Answer Session
    • Collect Question Cards


  • Lifetime Maximums
  • Insurance plans prohibited from imposing lifetime benefit limits and restricted annual limits.
  • Dependent Age Limit
  • Insurance plans required to carry dependents up to the age of 26.
  • Preventative Services
  • Insurance plans required to cover preventive services without cost sharing.
  • Pre-Existing Exclusions for Children
  • Insurance plans prohibited from denying coverage to individuals under the age of 19 based on pre-existing conditions.
  • High Risk Pools
  • Temporary (until 2014) high risk pools established for individuals (older than 19) who are denied coverage based on pre-existing conditions.
  • Renewability
  • Insurance plans prohibited from rescinding coverage except in cases of fraud or lack of payment.
  • State Carrier Reviews
  • States begin reviewing premium trends and companies must justify increases over certain thresholds. There is no new power to block rate increases but plans may be excluded from exchanges.
  • Small Business Tax Credit (Phase I)Small businesses with less than 25 employees and average annual wages of less than $50,000 are eligible for tax credits of up to 35% of the employer’s contribution toward the employee’s health insurance premium. Employers must subsidize at least 50% of their employees’ premiums in order to be eligible for the tax credit. Available through 2013 only.
  • Co-Ops Created
  • Create the Consumer Operated and Oriented Plan (Co-Op) program to foster the creation of non-profit, member-run health insurance companies in all 50 states. $6 billion is appropriated to finance the program and award loans and grants to establish Co-Ops by July 1, 2013. Illinois creating Co-Op named Land of Lincoln.


  • Medical Loss Ratio
  • Insurance plans required to comply with new medical loss ratios (MLR):
  • 80% - Individual Plans
  • 80% - Small Groups
  • 85% - Large Groups
  • Companies required to provide rebates to consumers if they fail to comply with the MLRs.
  • Exchange Funding
  • Funding available for states to begin establishing Exchanges until January 1, 2015.
  • Part D Assistance
  • Medicare Part D beneficiaries that fall into the “donut hole” will receive a 50% discount on covered brand-name prescriptions. This will grow to a 75% discount by 2020.
  • OTC MedicationsOver-the-counter drugs not prescribed by a doctor may not be reimbursed through an FSA or HRA, nor on a tax free basis through an Archer MSA or HSA.


W2 Reporting

Employers with 250+ employees are required to report cost of employer sponsored group health coverage on employee W2s for 2012 tax year. This value is not taxable.

  • SBCs
  • Summary of Benefits and Coverages: Beginning with renewals after September 23, 2012, health plans must provide a standardized and easy to understand summary of benefits and coverages as well as a glossary of commonly used insurance terms developed by HHS.


  • Medicare Tax Increase
  • Increase in the Medicare tax rate on wages by 0.9% (from 1.45% to 2.35%) on earnings over $200,000 for individual taxpayers ($250,000 for joint filers).
  • Investment Income Tax Increase
  • 3.8% tax increase on investment income for taxpayers making $200,000 per year ($250,000 for joint filers); however in real estate transactions there is an exemption in current law for $250,000 on the sale of a principal residence ($500,000 for joint filers).
  • National Long Term Care**A national long term care assistance/disability insurance plan (CLASS) is established. The benefit is tied to one’s inability to perform two or three Activities of Daily Living (ADLs) and the benefit amount is varied based on the “scale of functional ability” with a $50-7/day cash benefit. All working adults will be automatically enrolled in the program unless they choose to opt-out.
  • **Implementation of this program halted indefinitely by Department of Health & Human Services
  • FSA Limits
  • Pre-tax contributions to FSAs limited to $2,500 per year.
  • Marketplace Notices
  • Employers required to provide notice to employees of marketplace availability by October 1, 2013.


  • New Rules
  • Insurance plans required to abide by guaranteed issue, minimum benefit standards, revised rate bands (age-based and community-rated) for individual and small group market (2-100 employees).
  • Individual Mandate
  • Individuals required to purchase health insurance or face a tax penalty:
  • 2014 – up to $95 per year (or 1.0% of income, whichever is greater)
  • 2015 - $325 per adult (or 2.0%)
  • 2016 - $695/year (or of 2.5%)
  • 2017 and beyond - indexed to inflation.
  • Subsidies for Individuals
  • Premium tax credits (subsidies for purchase of health insurance) available via exchanges for individuals/families with incomes between 100% and 400% of federal poverty level, who do not receive employer based coverage.
  • Marketplaces (Exchanges)
  • Exchanges are created and open to individuals and small businesses (2-50 employees). Exchanges will include four tiers of private plans:
  • Platinum – 90% actuarial value
  • Gold – 80%
  • Silver – 70%
  • Bronze - 60%
  • (and Catastrophic coverage).

Marketplace (Exchange)


Government-created platform for the sale of health insurance, intended to bring all “qualified” plans into one forum by establishing common rules regarding the offering and pricing of insurance, and providing information to consumers.


Private carriers, State co-ops and government programs such as Medicaid and Children’s Health Insurance Program (CHIP).


Community-rated based on age, geography and tobacco status. Qualified consumers (up to 400% of the poverty level) will receive government assistance to purchase private insurance through the use of premium tax credits.

Congressional Budget Office (CBO) makes clear average premiums could be 27-30% higher because the law demands greater insurance coverage.

**Products and pricing are to be available for viewing in July-August 2013, but coverage is not effective until January 1, 2014.


2014 cont.

  • Large Employer Mandate (Pay or Play)
  • Employers with more than 50 full-time equivalent employees who do not offer their employees health insurance will be subject to a $2,000 tax penalty/full-time employee/year (first 30 employees exempted from calculation) OR they must offer “affordable” insurance coverage meeting minimum coverage requirements.
  • Waiting Periods
  • Waiting periods for coverage cannot exceed 90 days.
  • Health Insurance TaxNew tax is levied on insurance companies based on net premiums written on fully-insured plans. This tax will raise an estimated $8 billion in 2014, reaching $14.3 billion by 2018. The tax does not sunset and is indexed thereafter. Expected to be ~2.3% of premium.
  • Reinsurance TaxNew tax is levied on all policies for the next 3 years. Expected to be ~$5.25 per month of premium for every individual/employee.
  • Medicaid Expansion**States must expand Medicaid to 133% of federal poverty level. States will receive 100% federal financing from 2014-2016, 95% financing in 2017, 94% financing in 2018, 93% financing in 2019, and 90% financing in 2020 and beyond.
  • **The Supreme Court struck down the ability of the federal government to withhold their portion of current Medicaid funds to force states to comply with this expansion.**
  • Women’s Health
  • Insured plans required to expand benefits for Women’s Preventive Health Services
  • Mandatory Enrollment
  • Employers with more than 200 employees would be required to automatically enroll employees into health insurance plans offered by employer (employees may opt-out).
  • Small Business Tax Credit (Phase II)
  • Credit extended for two years, but only available in the SHOP.


Large Employer Roadmap

No Penalty Applies

Does the employer have at least 50 full-time equivalent employees?




Did at least one full-time employee receive a premium tax credit or cost-sharing subsidy through a Marketplace?

A Penalty Applies

The penalty is $2,000 annually times the number of full-time employees minus 30.

Does the employer offer coverage to all full-time employees?



A Penalty Applies

The penalty is the lesser of $3,000 times the number of full-time employees receiving premium tax credits, or $2,000 times the number of full-time employees minus 30.


Marketplace Subsidy

Do any employees purchase coverage in a Marketplace and receive a premium tax credit or cost-sharing subsidy?

Affordability Test

Is the employee’s required premium contribution for single coverage for the employer’s lowest cost plan 9.5% or less of the employee’s gross annual income?






No Penalty Applies

Minimum Value Test

Does the employer sponsored plan provide minimum value?




SHOP Expansion

States are permitted to allow businesses with more than 100 employees to purchase coverage in SHOP Marketplaces.


  • Cadillac Tax
  • A 40% excise tax is levied on insurers of employer-sponsored health plans with aggregate values that exceed $10,200 for individual and $27,500 for family. The tax is applied to the amounts that exceed the threshold and it will be indexed for inflation.

Bottom Line

  • Employer Considerations
  • Does my plan meet minimum requirements?
  • Is my plan grand-fathered?
  • Is my plan affordable?
  • What are my net costs today?
  • Is the penalty cheaper?
  • How will employees react?
  • Will my employees be eligible for subsidies?
  • What are the tax advantages to my business?
  • Are benefits important for talent acquisition?
  • How are we managing plan costs?
  • Employee Considerations
  • Is coverage cheaper on Marketplace?
  • Is cost of insurance tax deductible?
  • Does my spouse have access to insurance?
  • Am I prepared to pay a penalty?
  • How important is my doctor?

What should I do if…

I am a non-working individual?

Go to or seek advice from a Navigator.

I am a full-time employee?

Contact your HR Representative to help you understand and evaluate your options at work.

I am a part-time employee?

Contact your HR Representative to help you understand where the eligibility cut-off is for benefits, go to or seek advice from a Navigator.

I am a business owner?

Consult with your professional team (attorney, accountant and insurance broker) to ensure you are properly positioned for the changes ahead. Compliance will be paramount; make certain your documents are in order (i.e. Ownership documents, ERISA, Business Associates Agreement, Employee Manual, etc.).

I am a Human Resources Professional?

Consult with your insurance professional to help stay informed of changes and understand compliance requirements for your business.


Thank You

  • Stumm Insurance, LLC
  • Steve Hogan 773.862.7761 x109
  • Brian Stumm 773.862.7761 x102
  • Huck Bouma PC
  • Whitney Schmidt 630.221.1755 x1193
  • Aaron 630.221.1755 x 1254