Health Plan – Setnor Byer Insurance & Risk

Gender Identity and Sex Stereotyping Under the Affordable Care Act

Did you know that the Affordable Care Act (ACA) contains a civil rights provision? The ACA prohibits discrimination on the basis of race, color, national origin, sex, age or disability in certain health programs and activities. Despite becoming law in 2010, final implementation rules were not issued by the Department of Health and Human Services (HHS) until May 2016. On July 18, 2016, the Nondiscrimination in Health Programs and Activities final rule went into effect.

Under the ACA, individuals cannot be excluded from participation in, be denied the benefits of, or otherwise be subjected to discrimination under any covered health program or activity on the basis of race, color, national origin, sex, age or disability. Though the final rule generally incorporates existing federal nondiscrimination laws and policies , provisions dealing with sex discrimination, primarily gender identity and sex stereotyping, are getting the most attention.

The final rule states that sex discrimination includes discrimination based on sex, pregnancy, childbirth and related medical conditions. Individuals cannot be denied health care based on their sex and women and men must be treated equally in terms of health care and insurance coverage. However, the final rule also prohibits discrimination on the basis of gender identity and sex stereotyping.

Gender identity is an individual’s internal sense of gender. It may be male, female, neither, or a combination of both. An individual’s gender identity may be different from the sex they were assigned at birth. A transgender individual is an individual whose gender identity is different from the sex assigned to that person at birth.

Sex stereotypes are stereotypical notions of masculinity or femininity. They include expectations of how individuals represent or communicate their gender to others and that individuals will consistently identify with and conform to stereotypes associated with their assigned gender. Sex stereotypes also include gendered expectations related to the appropriate roles of a certain sex.

According to HHS, categorical coverage exclusions or limitations for all health care services related to gender transition are discriminatory. Individuals must be treated in a manner consistent with their gender identity. Providers may not deny or limit treatment that is ordinarily or exclusively available to individuals of one gender because the person seeking treatment identifies as belonging to another gender.

The manner in which the final rule expanded the traditional scope of sex discrimination to include gender identity and sex stereotyping represents a fairly significant policy shift. However, HHS admits that the final rule does not resolve whether discrimination on the basis of an individual’s sexual orientation alone violates the ACA’s nondiscrimination provision. Nevertheless, HHS states that allegations of sexual orientation discrimination will be evaluated by the Office for Civil Rights to determine whether they involve the sorts of stereotyping that violate the ACA’s nondiscrimination provision.

Despite not being directly covered by the ACA’s nondiscrimination rules, many employers will be affected indirectly. Employers providing fully insured group health plans may be affected because their insurance companies are covered by the rule. Employers using a covered third-party administrator to manage their self-fund group plan may also be affected by the rule. Consequently, employers should have at least a basic understanding of the ACA’s nondiscrimination rules.

At Setnor Byer Insurance & Risk, we are committed to guiding you through the constantly changing health care landscape and offer a number of valuable risk management solutions to help you properly and efficiently manage your employee benefits, group health and business insurance programs.

Please contact us if you would like more information about complying with the Affordable Care Act or subscribe to our weekly risk mangement newsletter.

Is Telemedicine Right for Your Business?

Industry experts estimate that 80% of employers will offer telemedicine by 2018. So what exactly is this trending health care benefit? Well, telemedicine generally refers to the practice of using telecommunications technologies (phone, Internet, etc.) to diagnose and treat patients, and in case you haven’t noticed, it’s come a long way.

If you ask a Group Benefits Manager at Setnor Byer Insurance & Risk you’ll discover:

The Centers for Medicare & Medicaid Services describes telemedicine as a cost-effective alternative to providing medical care.

The American Medical Association says telemedicine is a key innovation that can maintain patient safety, improve access to health care and control costs.

Industry analysts expect significant growth in the telemedicine market over the next few years.

You’ll also learn that employers are increasingly relying on telemedicine. According to a recent survey, a third of U.S. employers currently offer telemedicine services to employees as a low-cost alternative to doctor office visits for non-serious medical issues. In 2014, only 22% offered telemedicine services.

A primary benefit of telemedicine is fewer unscheduled absences by employees needing to see or take their child to a doctor for non-serious medical issues. Research shows that a majority of doctor visits are unnecessary. A cough, for example, can often be treated safely and effectively with telemedicine. (According to the Centers for Disease Control and Prevention, the most frequent reason for going to the doctor is, ahem…a cough.)

Employers offering telemedicine services also benefit from:

Healthier employees

Fewer employee sick days

Increased productivity

Measureable reduction in health care (insurance) costs

Telemedicine service plans are typically structured as discount card programs. These plans are not insurance and should not be considered a substitute for health insurance. Employers considering a telemedicine program should work with a reputable broker to not only find the right plan, but to also avoid those trying to take advantage of a rapidly growing market.

At Setnor Byer Insurance & Risk, we can help you:

Evaluate options

Find the best solution

Obtain competitive pricing

Implement and integrate a new plan into existing benefit programs

If you would like more information, please contact a Group Benefits Manager at Setnor Byer Insurance & Risk.

For more information about group health and other benefits, you can subscribe to our weekly risk management newsletter.

Automatic Deadline Extensions Now Available for Affordable Care Act Information Reports

For the first time, all applicable large employers must comply with the Affordable Care Act’s annual healthcare reporting requirements. Employers that averaged at least 50 full-time or full-time equivalent employees in 2014 must report specific 2015 healthcare information to the Internal Revenue Service. Reports for the calendar year 2015 are due in early 2016, so time is running out. Or is it?

The IRS recently amended Form 8809–Application for Extension of Time to File Information Returns–so applicable large employers can now request an automatic 30-day extension to file the following forms with the IRS:

Form 1095-C (Employer-Provided Health Insurance Offer and Coverage); and
Form 1094-C (Transmittal of Employer-Provided Health Insurance Offer and Coverage Information Returns).

The deadline to request an extension is the due date of the ACA form for which an extension is being requested. In other words, employers cannot request an extension after missing the original IRS filing deadline. For the calendar year 2015, the deadline to file Forms 1095-C and 1094-C with the IRS is February 29, 2016 (March 31st if filed electronically), so this is also the deadline to request an IRS filing extension. To avoid missing the deadline, employers should request an extension as soon as they realize more time is needed.

However, Form 8809 only extends IRS filing deadlines, not deadlines to furnish copies to recipients. Applicable large employers must furnish the calendar year 2015 Form 1095-C to each full-time employee by February 1, 2016. Form 8809 cannot be used to extend this deadline. Instead, employers must request an extension by submitting a letter to the IRS. These extension requests are not automatically approved and must include an explanation.

There are other nuances to requesting an IRS filing extension, such as:

Form 8809 can be filed on paper, online or electronically through the IRS’s FIRE system.

No explanation is necessary.

The automatic extension is 30 days from the original due date.

Employers may request a second 30-day extension before the end of the first extension period by submitting a second Form 8809; however, these requests are not automatically granted and generally require a showing of extenuating circumstances.

IRS previously stated that employers making a good faith effort to comply with the ACA’s information reporting requirements for the calendar year 2015 will not be penalized for incomplete or incorrect information reports filed with the IRS or furnished to employees in 2016. However, employers will not be able to show a good faith effort if they fail to timely file information returns with the IRS or furnish statements to employees. Though incorrect reports may be forgiven by the IRS, late reports will not.

In addition to other valuable resources, Setnor Byer Insurance &Risk has an online tool to help clients complete their ACA information reports. If you have any questions or would like to discuss how we can help you navigate the constantly changing healthcare landscape, please contact us.

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Is Telemedicine Right For You?

Telemedicine generally refers to the practice of using telecommunications technologies (phone, Internet, etc.) to diagnose and treat patients, and in case you haven’t noticed, it’s come a long way. Consider this:

The Centers for Medicare & Medicaid Services describes telemedicine as a cost-effective alternative to providing medical care.
The American Medical Association says telemedicine is a key innovation that can maintain patient safety, improve access to health care and control costs.
Industry analysts expect significant growth in the telemedicine market over the next few years.

Employers are taking notice of the benefits of telemedicine. According to a recent survey, 22% of large U.S. employers currently offer telemedicine services to employees as a low-cost alternative to doctor office visits for non-serious medical issues; 37% expect to begin doing so in 2015.

Employers offering telemedicine services also benefit from:

Healthier employees
Fewer employee sick days
Increased productivity
Measureable reduction in health care (insurance) costs

Telemedicine service plans are typically structured as discount card programs. These plans are not insurance and should not be considered a substitute for health insurance. Employers considering a telemedicine program should work with a reputable broker to find the right plan and avoid those trying to take advantage of a rapidly growing market.

At Setnor Byer Insurance & Risk, we make it easy to:

Evaluate options
Find the best solution
Obtain competitive pricing
Implement and integrate a new plan into existing benefit programs

If you would like more information, please contact us.

Are You Ready for the New Affordable Care Act Reporting Requirements?

The Affordable Care Act (ACA) requires Applicable Large Employers (ALEs) with 50 or more full-time or full-time equivalent employees to file information returns with the Internal Revenue Service and provide statements to their full-time employees about employer-offered health insurance coverage. This information will be used to administer the ACA’s employer shared responsibility provisions (employer mandate) and to determine whether an employee is eligible for the premium tax credit.

Filing Forms (Drafts)

In 2014, the IRS released non-final draft versions of two forms that ALEs can use to satisfy these reporting requirements.

Form 1095-C (Employer-Provided Health Insurance Offer and Coverage)
Form 1094-C (Transmittal of Employer-Provided Health Insurance Offer and Coverage Information Returns)

Filing Deadlines

ALEs must file these forms with the IRS on or before February 28 (March 31 if filed electronically) of the year immediately following the calendar year for which the offer of coverage information is reported. For calendar year 2014, there is no filing requirement. For calendar year 2015, these forms must be filed by February 29, 2016 (or March 31, 2016 if filed electronically).

ALEs must also furnish a Form 1095-C to each full-time employee by January 31 of the following year. The first Forms 1095-C are due to these individuals by February 1, 2016.

Form 1095-C

ALEs must file a Form 1095-C (or a substitute form) for each employee who was a full-time employee for any month of the calendar year. This form is used to report specific health insurance coverage information for each full-time employee to the IRS, such as:

which months the employee was a full-time employee
any offers of health coverage that meet the minimum value standard made to the employee and family members each month
the employee’s share of the monthly premium for the lowest-cost insurance that offers minimum value health coverage
whether any safe harbors are applicable to the employee
whether the employee was enrolled in the plan

Form 1094-C

ALEs must use Form 1094-C to transmit its Forms 1095-C to the IRS. A Form 1094-C must be attached to any Forms 1095-C filed by an ALE. One transmittal form can be used to cover all Forms 1095-C filed by an ALE or multiple transmittal forms can be used. The information reported with this form includes:

the total number of Forms 1095-C submitted with this particular transmittal
the total number of Forms 1095-C that will be filed by the ALE
whether the ALE is a member of an aggregate group (multiple employers treated as a single employer)
whether special rules or transition relief apply to the ALE

Though these ACA reporting forms are not due until 2016, large employers cannot wait until the last minute. Given the technical nature and complexity of the new ACA reporting requirements, legal and tax professionals should be consulted when preparing any forms filed with the IRS.

At Setnor Byer Insurance & Risk, we are committed to guiding you through the health care reform process. Check back with us periodically for future informational updates about the Affordable Care Act. If you have specific questions about the Act or if you are ready to take action and would like to see how Setnor Byer Insurance & Risk can help, contact us.

If you’d like to subscribe to our weekly newsletters please click here.

Understanding Excepted Benefits Under the Affordable Care Act

Many employers offer benefits packages that provide employees with more than just health insurance coverage. Though some of these benefits, like pre-paid legal service plans, are clearly not health-related, others may provide employees with some health-related benefits. Does this mean they are subject to the Affordable Care Act’s health insurance market reforms? Not necessarily.

Certain types of benefits, due to their nature, are not subject to a number of health-related laws, including the Affordable Care Act, the Health Insurance Portability and Accountability Act, the Mental Health Parity Act and the Genetic Information Nondiscrimination Act. These are known as excepted benefits.

There are four categories of excepted benefits.

Benefits Excepted In All Circumstances

The following benefits, or any combination thereof, are considered excepted benefits in all circumstances:

Coverage only for accident (including accidental death and dismemberment)
Disability income coverage
Liability insurance, including general liability and automobile insurance
Coverage issued as a supplement to liability insurance
Workers’ compensation or similar coverage
Automobile medical payment insurance
Credit-only insurance (for example, mortgage insurance)
Coverage for on-site medical clinics

Limited Excepted Benefits

A number of benefits may be considered excepted benefits if they are provided under a separate policy, certificate or contract of insurance. They can also qualify as a limited excepted benefit if they are not an integral part of a group health plan, which means that participants may decline coverage or that claims for benefits are administered under a separate contract than claims for any other benefits under the plan.

One or more of the following benefits may qualify as a limited excepted benefit:

Limited-scope dental benefits
Limited-scope vision benefits
Long-term care benefits
Health flexible spending arrangements
Employee assistance programs (EAPs)

Noncoordinated Excepted Benefits

Coverage for only a specified disease or illness, such as a cancer-only policy, may qualify as a noncoordinated excepted benefit. Hospital indemnity or other fixed indemnity insurance may also qualify if it pays a fixed dollar amount per day (or per other period) of hospitalization or illness regardless of the amount of expenses incurred.

To qualify as a noncoordinated excepted benefit:

Benefits must be provided under a separate policy, certificate or contract of insurance;
There is no coordination between the benefits provided and an exclusion of benefits under any group health plan maintained by the same employer; and
Benefits are paid regardless of whether benefits are provided under any group health plan maintained by the same employer.

Supplemental Excepted Benefits

The following benefits may qualify as supplemental excepted benefits if they are provided under a separate policy, certificate or contract of insurance:

Medicare supplemental health insurance (Medigap or MedSupp insurance);
Coverage supplemental to the managed health care program established by the Department of Defense (TRICARE); and
Similar supplemental coverage specifically designed to fill gaps in primary coverage, such as coinsurance or deductibles, but which does not include coverage that becomes secondary or supplemental only under a coordination-of-benefits provision.

Excepted benefits must satisfy a number of specific requirements set forth in the federal regulations. Employers should consult a knowledgeable and licensed professional before taking action or making changes to their benefits packages.

If you would like more information about excepted benefits or would like to see how Setnor Byer Insurance & Risk can help with your employee benefits package, contact us.

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Employee Assistance Programs under the Affordable Care Act

Employee Assistance Programs (EAPs) are designed to help employees prevent, identify and resolve various personal issues and matters. Many employers include EAPs in their benefits packages to enhance employee effectiveness and maintain workplace productivity. In addition to providing benefits like pre-paid legal, crisis intervention or professional development services, EAPs commonly provide health-related benefits, such as mental health, substance abuse and wellness services. Does this mean that they must comply with the Affordable Care Act?

According to final regulations issued by the Departments of Labor, Treasury and Health & Human Services on October 1, 2014, the answer is…maybe.

If an EAP qualifies as an excepted benefit, it will generally be exempt from the ACA’s requirements. Otherwise, the EAP must incorporate the market reforms mandated by the ACA, such as no lifetime or annual limits. Under the final regulations, an EAP must satisfy four requirements to qualify as an excepted benefit.

The EAP cannot provide significant benefits in the nature of medical care.

The amount, scope and duration of services are considered when determining whether an EAP meets this requirement. For example, an EAP that provides only limited, short-term outpatient counseling to substance abusers without requiring prior authorization or review for medical necessity, will not be considered an EAP that provides significant benefits in the nature of medical care. Alternatively, EAPs providing disease management services (lab testing, counseling, prescription drugs, etc.) for chronic conditions, such as diabetes, do provide significant benefits in the nature of medical care.

The Departments may provide additional clarification in the future regarding when a program provides significant benefits in the nature of medical care.

Benefits provided by the EAP cannot be coordinated with benefits under another group health plan.

This requirement has two elements:

Participants in the other group health plan must not be required to use and exhaust benefits under the EAP (making the EAP a “gatekeeper”) before becoming eligible for benefits under the other group health plan.
Eligibility for EAP benefits must not be dependent on participation in another group health plan.

Employee premiums or contributions cannot be made a condition of participation in the EAP.
The EAP cannot impose any cost-sharing requirements (co-pay, etc.).

These final regulations apply to group health plans with plan years beginning on or after January 1, 2015. Until then, the Departments will consider EAP benefits meeting the conditions of the 2013 proposed regulations or these final regulations to qualify as excepted benefits.

At Setnor Byer Insurance & Risk, we are committed to guiding you through the ACA’s market reforms. Check back with us periodically for future informational updates about the Affordable Care Act.

If you have specific questions about the ACA or if you are ready to take action and would like to see how Setnor Byer Insurance & Risk can help, contact us.

If you’d like to subscribe to our weekly newsletters please click here.