health care reform rollout - an educatinal seminar
DESCRIPTION
A presentation designed to educate and assist employers regarding the latest information on the new Health Care Reform laws and their implementation.TRANSCRIPT
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TheIXG.com
Health CareReform Rollout
An Educational Seminar
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Developing StrategyManaging Risk
Realizing Your Vision
Health Care ReformRollout
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A presentation designed to educate and assist employers regarding the latest information on the new Health Care Reform laws and their
implementation.
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Alicia GibsonManaging Partner
IXG Consulting Group
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March 23, 2010
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Immediate ChangesQuality Health Insurance for AllAvenues To Obtaining Coverage
Qualified Health PlansHot Topics
Critical Dates - Resources7
Chapters:
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ImmediateChanges
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Pre-Existing Conditions
Annual Lifetime Limits
Patient Protections
Preventative Care
Medical Loss RatioSummary of Benefits
Rescissions
Discriminatory Practices
Immediate Changes
Dependent Coverage
Grandfathered Plans
10Immediate Changes
Grandfathered Plans
Grandfathered status will remain intact unless:• Eliminating benefits
• Increasing the cost-sharing requirement
• Increasing a fixed-amount co-payment
• Certain reductions in employer or employee organization contribution rates
• Changes in annual benefit limits
( March 23, 2010 )
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Grandfathered Plans
Effect of Grandfathered Health Plan StatusEffect of Grandfathered Health Plan StatusEffect of Grandfathered Health Plan Status
PPACA Provision Application to Grandfathered Individual Health Plan
Application to Grandfathered Group Health Plan
Patient Protections Exempt Exempt
Pre-existing Conditions Exclusion
Exempt Must Comply
Annual Benefit Limits Exempt Must Comply
Lifetime Benefit Limits Must Comply Must Comply
Rescission of Coverage Must Comply Must Comply
12Immediate Changes
Pre-Existing Conditions
Coverage for age 19 years of age and younger
Individual grandfathered plans not required to comply
Rates can be based on pre-existing medical conditions
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Immediate Changes
Dependent Coverage
As of September 23, 2010, health insurancecoverage was extended to age 26 for dependents
Dependent status is not reflectiveof enrollment in full-time studies
Applicable to All Plans
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Annual Limits
Research shows that annual benefit limitsare imposed on:
8.2% of Large Employer Plans
14.4% of Small Employer Plans
19% of Individual Plans
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Immediate Changes
Lifetime Limits
Lifetime Limits Are Imposed On:
63% of Large Employer Plans
32% of Small Employer Plans
89% of Individual Plans
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Annual & Lifetime Limits
* 1 in 3 adults suffer from Heart Disease
* 11 Million are affected by Cancer
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Immediate Changes
Annual & Lifetime Limits
10% of cancer patients reached their limit in 2006
Exposure to 101+ million Enrollees
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Three-Year Phase out of annual limitsThree-Year Phase out of annual limits
$750,000 for plan years beginning 9/23/2010 – 9/23/2011
$1.25 Million for plan years beginning 9/23/11 – 9/23/2012
$2 Million for plan years beginning 9/23/2012 – 12/31/2013
Annual & Lifetime Limits
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Immediate Changes
Implementation of unlimited coverage is to prevent the financial stress and loss of needed healthcare for serious medical conditions, leading to worsening medical conditions and potentially early death.
Annual Limits
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As of September 23, 2010, grandfathered plans were not required to comply
Preventative services are now covered at 100% with no cost sharing, deductible, or co-pays
Patient Awareness - Involvement in Health Care Decisions
Preventative Services
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Immediate Changes
Rescission of Benefits
Average of 10,700 rescissions have occurred each year
Retroactive Cancellation
A plan can be rescinded anytime for fraud or intentional misrepresentation of material facts
30 day notice of rescission
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Summary of Benefits( October 1, 2012 and plan year thereafter )
Plans and plan administrators are required to distribute a standardized form that offers a summary of coverage to all enrolled.
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Immediate Changes
Discriminatory Practices
This prohibits the discrimination in favor of highly compensated
employees receiving “Cadillac Plans.”
40% Tax Penalty
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Medical Loss Ratio (MLR)Requires:✴ 85% of premium dollars spent within large
group market✴ 80% of premium dollars spent within small/
individual markets✴ To be spent on clinical services and activities
that improve health care quality.
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Immediate Changes
Patient Protections
• Primary Care Providers are able to be chosen by the insured: Pediatricians and OB/GYNs are now able to be considered a PCP under plans - no referrals required
• New Laws allow insureds to obtain emergency care without prior authorization and without regard to in- or out- of network providers
• Payment from insurance will be based on in-network percentages at a reasonable rate (*not applicable to grandfathered plans)
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Quality Health Insurance for All
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Guaranteed Coverage
Rating Structure Waiting Periods
Tax-Favored Plans
Subsidy Eligibility
Quality Health Insurance
Exclusions
Notification of Changes
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Notification of Exchanges
1.The existence of exchanges2.Eligibility for tax credits or subsidies3.Loss of employer contribution
Employers are required to inform the employee of:
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Quality Health Insurance
Guaranteed Coverage
✴Every employer and every individual that applies for coverage must be accepted by the insurer
✴Open and special enrollment periods may be implemented.
IMPORTANTOpen enrollment is October, 2013 through February, 2014.
“Qualifying Events”
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Pre-Existing Conditions
January 1, 2014
plans may no longer imposepre-existing condition exclusions
As of…
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Quality Health Insurance
Rating Structure
✴Applicable to Small Group and Individual Plans
✴ Large Group where eligible to purchase through the Exchange
Fair Health Insurance Premiums
Monthly Premium Based On:Monthly Premium Based On:• *AGE 3:1• TOBACCO USAGE 1.5:1• FAMILY MAKE-UP• GEOGRAPHY• ACTUARIAL VALUE OF THE BENEFIT
*The maximum increase in premium based on age is3 times the cost of the lowest plan cost.
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Waiting PeriodsSmall & Large
Groups
Large Groups
…cannot impose a waiting period over90 days for new employees or newly eligible employees
✴ Auto enrollment for all employees✴ Can still impose a wait period
(Not to exceed 90 days)
✴ Employee has the option to waive coverage
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Quality Health Insurance
Subsidy Eligibility
Premium CreditAny level plan for those that fall within the 138% - 400% FPL
Cost SharingAvailable for those that fall within 138% - 250% of FPL (Silver Plan Only)
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Subsidy Eligibility
Federal Poverty Level Chart
Federal Poverty Level = $11,490 (single)
Federal Poverty Level = $19,530(for average family size of 3.13)
Above 400%No Reduction
Below 133%Free
133%–400%Reduction
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Quality Health Insurance
Premium AssistanceEmployees Offered Premium Assistance Credit
1 If an employee has access to insurance through work
2 and the cost exceeds 9.5% of the employee income
3 and the employee is within 400% FPL
ThenThe employee is eligible to a subsidy
through the exchange.
Total Allowed benefit costs is less than 60% Actuarial Value.
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Out of Pocket Expenses
For individuals at or below 400% of the FPL, out of pocket expenses will be capped by:
2/3 if income is 100%–200%
1/2 if income is 200-300%
1/3 if income is 300-400%
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Quality Health Insurance
Tax-Favored PlansFSA, HSA, HRA Limits and Rules
• Flexible Spending Account - $2500
• Health Savings Accounts- $3100 max contribution for an individual- $6250 max contribution for a family- $1,000 for each person over the age of 55
• Health Reimbursement Arrangements- No Limit- Self-Employed Individuals not eligible
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Quality Health Insurance
TAX TALK
1. Additional 0.9% Medicare tax imposed on wages, compensation or self-employed income.
Threshold: Married filing joint $250,000, Married filing separate $125,000, all others $200,000.Employers must withhold this tax when wages exceed $200,000 in the current year. There is no employer match.
2. Health flexible spending accounts will be capped at $2,500 a year
Patient Protection & Affordable Care Act: 2013
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TAX TALK Mr. Marty Halloran, [email protected]
3. The 7.5% floor for deducting medical expenses increases to 10% for filers under age 65.
4. Unearned income will be subject to a 3.8% Medicare surtax when modified adjusted gross income exceeds the same thresholds as in #1 above.
Unearned income is defined as interest, dividends, capital gains, annuities, royalties and passive rental income. Tax-free interest or retirement plan income is not included.
Patient Protection & Affordable Care Act: 2013
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Quality Health Insurance
TAX TALK
1. Individuals who remain uninsured will owe a penalty tax equal to the larger of $95 or 1% of income above the filing threshold. For 2015 the minimum penalty is $325 and in 2016 it will be $695 or 2.5% of income above the filing threshold.
2. The family penalty is 3 times the individual amounts without regard to number of family members.
3. Impose a $2,000 per employee penalty on employers with more than 50 employees who do not offer health insurance to their full-time workers.
Patient Protection & Affordable Care Act: 2014
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TAX TALK Mr. Marty Halloran, [email protected]
A “Cadillac Tax” is imposed on employer-sponsored health plans. 40% excise tax charged on the excess benefit of $10,200 for single-only coverage and $27,500 for family coverage.
This is total cost of insurance, not just employee paid premiums.
Other Items:Small Business Health Care Tax Credit – enacted in 2010 with a maximum 35% tax credit through 2013 and expanded to 50% starting 2014. Must have less than 25 full-time equivalent employees with under a $50,000 average salary. File form 8941 with your business tax return.
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Avenues toObtaining Coverage
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Shop Exchanges
Grandfathered Plans Medicare & Medicaid
Employer Coverage
Avenues to Obtaining Coverage
Co-Ops, Non-ProfitsMember Run Plans
Federal/State Run Exchange
46Obtaining Coverage
ExchangesExchanges Are Responsible for:Exchanges Are Responsible for:Exchanges Are Responsible for:
Certification of Qualified Health
Plans
Presenting Plans in Standard
Format
Grant Exemptions from
Individual Responsibility
Operation of Toll Free Phone # and
Website
Eligibility of Medicare/Medicaid
Seamless Communication
Medicaid & CHIP
Rating of All Plans offered
Electronic Calculator for
Plans
Online Enrollment
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Obtaining Coverage
Exchanges1. Who will be able to utilize the Exchange and when? Beginning Oct
2013, open enrollment begins for Small Businesses & Individuals
2. Small Business Health Option Program - “SHOP”
3. Consumer operated & Oriented Plans - “CO-OPs” Co-Ops will be non-profit member run plans.
4. What is a Compact Plan? Plans offered across state lines available in 2016.
5. Keeping Your Coverage Initiative - Grandfathered Plans
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Employer Coverage
Group Employer CoverageGroup Employer Coverage
Small Business Market Under 50 Employees Are Able To Participate in the Exchange
Large Business MarketTwo Sectors
50+ Employees
Large Business MarketTwo Sectors
200+ EmployeesLarge Business MarketTwo Sectors
Unable To Participate in the Exchange Until 2016
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Obtaining Coverage
MedicareCoverage for individuals that are age 65 or older and qualify with 40 quarters OR under age 65 and qualify due to disability or health status
Financing and Increases of Coverage
Preventative Care
Part D$250 reimbursement for those that reach the donut hole
Eliminate the coverage gap in Part D by 2020
Improve coordination of benefits for dual eligible individuals
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MedicaidIndividuals that qualify financially for State and Federally Funded Coverage
Pregnant Women
Children
Elderly
Disabled
Those that fall within 138% or below the FPL
Federally Funded
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QualifiedHealth Plans
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Essential Health Benefits
Qualified Health Plans
Plan Valuation
What Constitutes “Qualified”
54Qualified Health Plans
Definition
Is a plan certified through the Department of Health and Human Services as meeting regulations regarding Essential Health Benefits and Actuarial Value
Qualified Health Plan
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Qualified Health Plans
Definition• 1-100 Small Group Market• Benefits = Typical Employer Plan• Limits >HSA Limits Are Prohibited• Deductibles over 2K (individual) Prohibited• Deductibles over 4K (family) Prohibited• Individual Catastrophic Plans: Under 30• Essential Health Benefits Covered
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Essential Health BenefitsAmbulatory Patient Services
Emergency Services
Hospitalization
Maternity & Newborn Care
Mental Health, Substance Use, & Behavioral Health Disorders
Prescription Drugs
Rehabilitative & Habilitative Services
Laboratory Services
Preventive & Wellness Services Including Chronic Disease
Pediatric Services Including Oral& Vision Care
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Qualified Health Plans
Plan Valuation
Actuarial value accounts for the percentage of coverage a plan offers vs. the out-of-pocket expense of the insured.
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Deductibles, Coinsurance, Co-pays and Cost are all factored in to this valuation.
Plan Valuation
Platinum
Gold
Silver
Bronze
90%
80%
70%
60%
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Hot Topics
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Rewards & Rebates
Penalties Birth Control & Abortions
Exemptions & Safe Harbor Rules
Hot Topics
Wellness Programs
Small Businesses
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Small Businesses
Credits and Incentives to Provide Benefits
• Employers could vary premiums
• Workplace Wellness Grants Offered- Less than 100 workers- Employees must work at least 25 hrs wk- Must meet “wellness” criteria
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Wellness Programs
Mr. Richard ReinholzLowe’s YMCA, Mooresville
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S at workExceptional Programs & ServicesWith over 19 locations and a team of professional health and wellness specialists, the Y can provide countless ways to improve the health of your company. Our programs and services support the athlete to those with medical needs. We customize our approach with a special focus on encouraging teamwork and fun.
Professional StaffThe YMCA has long term success in helping individuals make positive behavior change. Our success is due to our staff. The Y is the only provider who can offer a team of certified professionals in the following specialties to help employees reach their goals:
– Exercise Physiologists – Personal Trainers– Group Exercise & Fitness Instructors– On-site Registered Dietitians in partnership with Carolinas HealthCare System– On-site Registered Nurses in partnership with Carolinas HealthCare System– Lifestyle & Weight Management Instructors– Member Retention Specialists– Yoga & Pilates Instructors– Cycle Instructors– Sport Conditioning coaches
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Additional Benefits to Employees of being a Y Member:
– Free drop-in childcare to ensure your child is in a safe environment while you work out. – Bible studies – Access to 11 outdoor pools and waterparks as well as the Lake Norman YMCA lakefront. – Access to an onsite Registered Nurse or Registered Dietitian through Carolina’s HealthCare
System.– Hundreds of group exercise classes offered weekly including Zumba®, cycle, yoga, Pilates,
BodyPump®, water fitness and more.– Volunteer opportunities that allow you to give back to families & communities.– Member benefits around town.– Nationwide access: more than 2,400 YMCAs across the country will honor your YMCA of
Greater Charlotte membership as part of the YMCA's AWAY program (Always Welcome at the Y).
– Childcare programs that keep kids happy and healthy so parents too can focus on their own health such as:• Swimming programs• Sports• Preschool• Afterschool• Day Camp• Teens
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Additional Benefits to Employees of being a Y Member:
– Free drop-in childcare to ensure your child is in a safe environment while you work out. – Bible studies – Access to 11 outdoor pools and waterparks as well as the Lake Norman YMCA lakefront. – Access to an onsite Registered Nurse or Registered Dietitian through Carolina’s HealthCare
System.– Hundreds of group exercise classes offered weekly including Zumba®, cycle, yoga, Pilates,
BodyPump®, water fitness and more.– Volunteer opportunities that allow you to give back to families & communities.– Member benefits around town.– Nationwide access: more than 2,400 YMCAs across the country will honor your YMCA of
Greater Charlotte membership as part of the YMCA's AWAY program (Always Welcome at the Y).
– Childcare programs that keep kids happy and healthy so parents too can focus on their own health such as:• Swimming programs• Sports• Preschool• Afterschool• Day Camp• Teens
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CHS and YMCA of Greater Charlo3e Carolinas HealthCare System, one of the na8on’s leading and most innova8ve healthcare organiza8ons, provides a full spectrum of healthcare and wellness programs throughout North and South Carolina.Carolinas HealthCare System works to improve and enhance the overall health and wellbeing of its communi8es through high quality pa8ent care, educa8on and research programs, and a variety of collabora8ve partnerships and ini8a8ves. The YMCA, through the partnership with Carolinas HealthCare System, is able to provide the following wellness assessments and services to employers:
Personal Health Survey Online or Paper Ques=onnaire (Vendor: Applied Health Analy=cs)
Biometric Screenings
Lipid Profile & Glucose Screenings
Body Mass Index, Waist Circumference & Blood Pressure Measurements
Finger s=ck (Cholestech LDX) or Venipuncture
One-‐on-‐One Risk Factor Counseling One-‐=me individual counseling session to review results
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Investment Matching Concept
The YMCA of Greater Charlo3e will match a companies investment in their employees health and well-‐being.
• The YMCA will match companies investment in membership up to 40% with centralized billing and up to 30 % without centralized billing.
• The investment matching will come through the following programs / services– Health Coaching– Personal Health Survey– Biometric Screening– Lipid Profile and Glucose Screening– One on One Risk Factor Counseling– Personal Training– On-‐Site Group Exercise Classes– Wellness Challenges– ETC.
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Hot Topics
Wellness Programs
1. Currently cannot exceed 30% cost of employee-only coverage but may increase to 50%
2. Example:• Emily’s Health Coverage Per Month = $300
• Emily is taking steps to become more active by utilizing her gym membership offered through the company wellness program.
• If Emily reports she worked out at least 3 times per week, employer can rebate or discount her premiums by an additional 30%.
• Employer pays 50% of premium - in Emily’s case, $150.
• If Emily works out, employer pays $90+
• Emily’s Monthly Cost = $60
Employers Give Discount or Rebate of Premium
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Hot Topics
Play or Pay: PenaltiesIndividuals failing to carry coverage• Reporting• Penalty Schedule
Flat Fee Phase In$95 in 2014$325 in 2015$695 in 2016 flat fee 1.0% of taxable income in 2014 2.0% of taxable income in 20152.5% of taxable income in 2016
Large Employers (50+ employees)• $2,000-$3,000 per employee (with the first 30 excluded)
• Cadillac Plan = 40% Excise Tax
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Birth Control & Abortions1. This is a State matter2. The primary complaint is that tax-payer dollars and penalty
charges are going to fund abortions and the “morning after” pill
The act has attempted to mitigate this issue by creating two payments for 1 plan premium for subsidized plans
- 1st bucket = Taxpayer $$- 2nd bucket = Insured $$
IF services rendered include birth control measures or abortions, the funding comes from bucket #2.
Many lawsuits have been filed against the ACA for this one issue!
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Hot Topics
Exemptions & Safe Harbor
➡ Granted for financial hardship, religious objections, American Indians…
➡ for those without coverage for less than three months…
➡ including undocumented immigrants, incarcerated individuals, those for whom the lowest cost plan option exceeds 8% of an individual’s income, and those with incomes below the tax filing threshold.
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Resources
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www.TheIXG.com
Health Care Reform Critical Dates
Date Year Action Item
1 Sep 1 2013 Employer Must notify employees of open enrollment and options regarding exchanges
2 Oct 2013 Open Enrollment Begins; Exchanges Available
3 Dec 2013 All-inclusive Health Policies Terminate at Midnight
4 Jan 2014 Affordable Care Act becomes fully active
5 Feb 2014 Last month to obtain insurance without penalties imposed. Open enrollment = Oct 13–Feb 14
6 20162016 Large group market can access insurance plans through exchanges
Resources
ResourcesIXG Consulting Groupwww.TheIXG.com
Utilize our consultancy services to stay on top of the law and implement standards that allow you to be in compliance with Federal and State level requirements
www.Healthcare.gov High level view of the policies and timeline
www.dol.gov US Department of Labor
www.cbo.gov US Congressional Budget Office
www.hhs.gov/ocr Health and Human Services – Office of Civil Rights
Apha.org The American Public Health Association offers reports covering many areas of our nation’s health
NAIC.org National Association of Insurance Commissioners – timeline and commentary on the law
http://healthreform.kff.org Henry J. Kaiser Foundation – Great resource for relatable terms and applicable examples of the law
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Marty HalloranCPA - Cornelius
Richard ReinholzYCommunity Health & Wellness Senior Director
Lowe’s YMCA - [email protected]
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Special Thanks To:
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TheIXG.com
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