Ironically, safety glasses are considered the most optional piece of personal protective equipment (PPE) in the industry. Most employers state that safety glasses are required, but leave it totally up to the employee to determine when to actually wear them. This will not fly with OSHA.

I was working with a company who recognized this issue and posted signs at locations of high particle activity, such as milling machines, that stated: “Safety Glasses Required.” During a site inspection, I observed that the milling machine operator, (who was standing one foot from the sign), was not wearing their safety glasses.

Advice to employers: If you want your employees to follow your safety rules, don’t bother writing up the employee. Write up their supervisor instead. Employees never do anything for anyone unless their immediate supervisor requires it. Next time the supervisor will write up the employee, which is the only way to stop such infractions.

We all know the importance of wellness programs: they lead to healthier employees, better morale, presenteeism, and can help reduce claims and bring insurance costs down.

Once you commit to implementing a wellness program, you need to identify your starting point. Many groups start with Health Risk Assessments, so they’re able to get an idea of where the employees are health wise, and in turn, develop a strategy to target common conditions among the employees. We are seeing more and more carrier investment in starting wellness plans, and for larger groups, carriers will provide the biometric screenings and incentives for employees who complete Health Risk Assessments.

Another starting point is promoting preventive care. In some cases, less than 20% of employees in a group are getting their annual physicals. It takes one hour a year for an employee to get their physical, and they are now covered 100% because of Health Care Reform. Employers can start encouraging their employees to get their annual physical, which will in turn get them in touch with a doctor who can help them improve their health. I’ve had groups who give employees two hours of paid time a year to go complete their wellness visits, or make contributions to premium or HSA/HRA funds if they complete their annual physical.

There are a lot of little steps towards starting your program, and it’s important to remember that different programs work for different companies, so you should assess the culture and demographics of yours to choose a program that will compliment your group and foster wellness within your organization.

The rule requires that insurers and health plans provide a standardized Summary of Benefits and Coverage and Uniform Glossary to consumers “when shopping for coverage, enrolling in coverage, at each new plan year, and within seven business days of requesting a copy from their health insurance issuer or group health plan.” It applies to all fully insured and self insured plans, regardless of grandfathered status. It does not apply to Medicare plans.

The final regulations modify the proposed SBC guidance that was originally issued in August 2011. Plans and issuers must prepare to start providing the SBC. The Department has outline the following revised deadlines to comply with:

• Beginning on the first day of the first open enrollment period that begins on or after September 23, 2012, plans must provide the SBC to participants and beneficiaries who enroll or re-enroll for coverage during that open enrollment period.
• Beginning on the first day of the first plan year that begins on or after September 23, 2012, plans must provide the SBC to participants and beneficiaries who enroll for coverage other than through an open enrollment period, such as newly eligible individuals and special enrollees.
• Issuers must begin providing the SBC to plans on September 23, 2012.

Many of the requirements set forth in the original rule continue to stand. The SBC must be provided in a consistent four-double-sided-page format with 12-point font. Individuals must be informed in writing 60 days ahead of any significant plan changes that affect the SBC (other than in connection with a renewal or reissuance of coverage). And, it must include a customer service phone number and internet address for questions and copies of plan documents.

The Department has provided a final template for the SBC (along with instructions, samples, and a guide for the coverage example calculations to be included in the SBC) and a uniform glossary explaining terms commonly used in health coverage. These are available on the Department of Health and Human Services website at:

 http://cciio.cms.gov/programs/consumer/summaryandglossary/index.html

If you have any questions, or need assistance, please contact Stahl & Associates Insurance.

The lists below outline what is required to be reported on the Forms W-2, and what does not need to be included.

What needs to be included:

• Major Medical
• Medicare Supplemental
• Medicare Advantage
• Mini med plan
• On-site medical clinics
• Employer contributions to health FSA
• Employer contributions to hospital or fixed indemnity plan, or specified disease or illness insurance
• Wellness benefits
• Employee Assistance Plan
• Executive medical coverage

What does NOT need to be included:

• Non- integrated dental or vision
• Long-term care
• HSA
• HRA
• Health FSA coverage funded solely through employee salary reduction elections
• Accident, disability, and AD&D
• Coverage under a self-insured group health plan that is not subject to COBRA (such as a church plan)
• Employer contributions to multiemployer plans
• Commercial insurance including Workers’ Compensation, liability, credit-only, and automobile medical insurance
• Coverage provided by the government for members of the military and their families
• Excess reimbursements of highly compensated individuals
• Health insurance costs for self-employed individuals

The Supreme Court will hear challenges to Health Care Reform Law in March 2012, with a ruling expected in June 2012. Specifically, the justices will make rulings on: 

• Constitutionality of the individual mandate—The court will determine if the provision that requires all individuals to obtain qualified health insurance coverage or pay a tax penalty in 2014 is constitutional.
• Severability—If the individual mandate is found unconstitutional, the court will determine if all or some of the remaining provisions under the Affordable Care Act will be preserved.

In addition to the Supreme Court arguments, there are several other proposed changes you should be aware of:

Summary of Benefits & Coverage, and the Uniform Glossary

Insurers and plans will be required to provide uniform coverage documents, called Summary of Benefits and Coverage (SBC) and a uniform glossary of terms commonly used in the health insurance industry. The SBC is intended to help consumers understand and evaluate their health insurance, and should be a concise document detailing, in plain language, simple and consistent information about health plan benefits and coverage. It should summarize key features of the plan, such as covered benefits, cost-sharing provisions, and coverage limitations and exceptions.

• The proposed deadline for providing the SBC was March 23, 2012, but this deadline has been extended. Plans and issuers now have until after final regulations are issued to begin providing the SBC. It is unknown as to when the final regulations will be issued, but plans and issuers should have sufficient time after they are issued to prepare the SBC.

60 – Day Notice of Plan Changes

Group health plans and issuers are required to provide a 60-day advance notice of a material modification to the plan as reflected in the Summary of Benefits and Coverage. A material modification consists of any change in wording of the SBC. It may be sent as a separate notice, or by providing an updated SBC reflecting the modification. It does not apply to renewals. This will become effective with the timing of the SBC.

Comparative Effectiveness Research Fee

A new research fee will be imposed on self-funded plans in order to fund a nonprofit corporation, which will undertake clinical effectiveness research relating to patient-centered outcomes. It will include research to evaluate risks and benefits of medical treatments, services, procedures, and drugs that treat, manage, diagnose or prevent illness or injury. The fee will start at $1 per covered individual for plan years ending on or after October 1, 2012. It will increase to $2 for plans ending after September 30, 2013.

Medical Loss Ratio

The Health Plan Reporting Requirement will require insurers to report plan costs for the purpose of calculating the insurers’ medical loss ratio. Large group insurers must spend at least 85 percent of premium dollars on claims and activities to improve health care quality. Individual and small group insurers must spend at least 80 percent of premium dollars on claims and activities to improve health care quality. Beginning in August 2012, health plans must provide rebates to enrollees if their medical loss ratio—the percentage of premiums spent on reimbursement for clinical services and activities that improve health care quality– does not meet the minimum standards for a given plan year.

Preventive Care Services

Health insurance plans must now cover women’s preventive services without charging a copayment, coinsurance or a deductible effective for plans beginning or renewing August 1, 2012. The services will continue to include well-women visits, and will add FDA approved contraceptives, as well as breastfeeding support, supplies, and counseling.

W-2 Reporting

Beginning with the 2012 tax year, employers that are required to issue 250 or more W-2 forms must report the aggregate cost of employer-sponsored group health coverage on employees’ W-2 forms. Not all benefits need to be included in the reporting, and a checklist of those to be included will be provided in a separate document.

• The cost must be reported beginning with the 2012 W-2 Forms, which are issued in January 2013.
• The requirement is optional for smaller employers for the 2012 tax year until further guidance is issued.
• The reporting is for informational purposes only and does not affect the taxability of benefits.

If you need additional information about any of the Health Care Reform topics, please contact Stahl & Associates Insurance.

• Workers’ Compensation Worst Case Scenarios & How to Avoid Them
• Cyber Liability Threats
• Employee Benefits Compliance
• Measuring Wellness Success
• Social Media’s Impact on Insurance

Stahl & Associates December Newsletter

The Medicare Part D prescription drug benefit affects Medicare eligible participants and legislation requires employers to take the following action each year:

• Determine whether the prescription drug coverage for each of your medical plans (if more than one) is “Creditable Coverage”, meaning that it is equivalent to or better than the benefits offered to Medicare eligibles under Medicare.
• Inform all Medicare-eligible participants via a notice each year (this includes dependents, as well as employees), that the prescription coverage through the group medical plan is/is not creditable. We recommend that each participating employee is given a notice as this will prevent any oversight in perhaps overlooking a Medicare-eligible dependent. This notice MUST be provided by October 15th of this year. The notices are available on the Centers for Medicare & Medicaid Services “CMS” website: https://www.cms.gov/CreditableCoverage/Model%20Notice%20Letters.asp#TopOfPage (Please note that “Name of Entity” is Employer Name).
• Provide a disclosure statement to CMS regarding the status of whether the group medical plan includes creditable or non-creditable prescription drug coverage. This can be done online via the Disclosure to CMS Form at https://www.cms.gov/CreditableCoverage/45_CCDisclosureForm.asp. The disclosure should be completed no later than 60 days from the beginning of the plan year, within 30 days after termination of the prescription drug plan, or within 30 days after any change in creditable coverage status.

A Medicare-eligible participant (employee or dependent) that is enrolled in a group health plan will only be able to access the new Medicare Part D benefit at the lowest cost if they sign up for the benefit between October 15th and December 7th of the year. If the participant fails to sign up for the benefit by the deadline, or goes 63 days or longer without creditable coverage, they will have to pay higher premiums permanently when they subsequently enroll in Medicare Part D.

Most employers will find that their prescription drug benefit provides “creditable coverage,” meaning that the prescription drug benefit they offer to their Medicare eligibles is as comprehensive as Medicare Part D. Please refer to your current medical carrier for specific clarification of your group’s creditable status. Please note: HSA-compatible High Deductible Health Plans are NOT creditable.

If you have any questions, please contact the Employee Benefits Department here at Stahl & Associates.

Read the latest news on our acquisition:

Lakeland Ledger

Tampa Bay Business Journal

Gulf Coast Business Review

On March 31, several Federal agencies released for public comment various documents regarding Accountable Care Organizations (ACOs). The central document includes the Proposed Rule released by the Centers fo Medicare & Medicaid Services (CMS) on ACOs under the Medicare Shared Savings Program.

The proposed Rule includes several elements impacting the beneficiary experience, including:

• Required ACO-participating providers to notify beneficiaries that they are receiving care in an ACO and that the provider is eligible to receive additional payment or be liable for potential losses, depending on whether the provider delivers high quality, cost-effective care
• Requires each ACO-participating provider to notify the beneficiary with the opportunity to opt-out of those data sharing arrangements.
• Prohibits providers from requiring that a beneficiary obtain services from another provider or supplier in the same ACO.

Participation Requirements

The Proposed Rule elaborates on the statutory requirements provided in the Affordable Care Act concerning participation in the Share Savings Program (SSP), and notes the following:

• ACOs must complete an application in order to participate in the SSP, and must document how the ACO plans to deliver high quality care at lower costs for the beneficiaries it serves. CMS will not automatically accept ACOs into the SSP.
• Each ACO will be responsible for routine self-assessment, monitoring and reporting of the care it delivers.
• The ACO must agree to accept responsibility for at least 5,000 beneficiaries, and agree to participate in the SSP for three years.

Payment

The Proposed Rule establishes quality performance measures and a methodology for linking quality and financial performance that will serve as the foundation for the ACO payment. The Proposed Rule also requires ACOs to publicly report certain aspects of their performance and operations as a condition for participation in the SSP.

Early Retiree Reinsurance Program Application Process to End

Also on March 31, CMS issued a noticed entitled “Early Retiree Reinsurance Program”. This notice announces that the ERRP will no longer accept new applicants after April 30, 2011. The ERRP was provided for by section 1102 of the Affordable Care Act, and was planned to provide early retiree health coverage for enrolling employers through 2014.

With 1,300 employers already enrolled in its first year, the ERRP will exhaust its $5 billion in funding earlier than expected. In order to fund the retiree coverage of current enrollees through 2014 it became necessary to close the application period earlier than expected.

W-2 Guidance

On March 29, 2011, the Internal Revenue Service (IRS) issued interim guidance (Notice 2011-28) on how employers will be required to inform employees of the cost of their “applicable” employer-sponsored group health plan coverage. This informational reporting is required as part of the Affordable Care Act to provide comparable information to employees to inform them of the cost of their health care coverage. This is an informational reporting obligation and does not cause excludable employer provided health care coverage to become taxable. HIPAA “excepted benefits” plans are not subject to the W-2 reporting requirements (E.g., accident, disability income, supplemental liability, workers’ compensation insurance). In addition, amounts contributed to an Archer MSA, FSA, HSA and HRA are not reportable.

Effective Date

The guidance makes clear that the reporting requirements generally apply beginning with the 2012 W-2 forms (required for the calendar year 2012 to be furnished to employees in January 2013). Employers are not required to report the cost of health coverage on any forms required to be furnished to employees prior to January 2013. Employers must provide the written statement before January 31 of the succeeding year. Employees who terminate employment mid-year must receive the report within 30 days after the employee requests a copy. Notice 2010-69, issued last fall, made the reporting requirement optional for all employers for the 2011 Forms W-2 (generally furnished to employees in January 2012). Employers may rely on the guidance provided in this Notice if they voluntarily choose to report the cost of coverage on 2011 Forms W-2.

Using a question-and-answer format, the Notice includes information on how to complete the reporting, what employers are impacted and the coverage that needs to be included, and how to determine the cost of the coverage.

Transition Relief

The Notice also provides additional transition relief for certain employers. This includes smaller employers that are required to file fewer than two hundred and fifty 2011 W-2 forms. These small employers will not be required to report the cost of health coverages on any forms required to be furnished to employees prior to January 2014. This transition relief will continue until the issuance of further guidance. To the extent that future guidance impacts additional employers, or categories of employers, or additional types of coverage, this supplemental guidance will apply prospectively only and will not apply to any calendar year beginning within six months of the date the guidance is issued.

Technical Notice Extends Claims and Appeals Grace Periods

The Departments of Labor (DOL), Health and Human Services (HHS), and Treasury (the Agencies) issued Technical Release 2011-01 (TR 2011-01) on March 18, 2011. TR 2011-01 extends the grace period established last year by the DOL as part of its technical release 2010-02.

Tr 2010-02 was issued by the DOL on September 20, 2010, and establishes an enforcement grace period for compliance with certain new internal claims and appeals provisions. TR 2011-01 now extends the enforcement grace period for most of the same provisions until January 1, 2012. There is also no requirements that plans work in good faith to implement such requirements because more federal guidance is anticipated shortly.

Extension Details

TR 2011-01 extends the enforcement grace period set forth in TR 2010-02 until plan years beginning on or after January 1, 2012 for most bu not all provisions. This extension is being provided to give the Agencies time to publish more detailed regulations in order for plans to implement the internal claims and appeals provisions. The provisions subject to the extension include:

• Notices must be provided in a culturally and linguistically appropriate manner.
• Time frames for making urgent care claims decisions (as soon as possible, taking into account the medical exigencies, but not later than 24 hours after the receipt of the claim).
• Strict compliance requirements or plan participants will be able to initiate certain expedited appeal rights (e.g., to an independent external review agent).
• Automatic disclosure of diagnosis and treatment information.

The enforcement grace period will be extended with respect to the other disclosure requirements until the first day of the first plan year beginning on or after July 1, 2011 (which is January 1, 2012 for calendar year plans). Therefore, enforcement with respect to the following provisions will take effect on a rolling plan year basis, starting on the first day of the first plan year beginning on or after July 1, 2011:

• The disclosure of information sufficient to identify a claim (other than the diagnosis and treatment information as noted above).
• The description of available internal appeals and external review processes.
• The disclosure of the availability of, and contact information for, an office of health consumer assistance program or ombudsman for plans and issuers in States in which one is established.

Next Steps and the Good Faith Effort Requirement

The Agencies intend to issue an amendment to the interim final regulation issued on July 23, 2010 (IFR) in the near future that takes into account comments and other feedback received from the public in response to the requirements set forth in the IFR. Although TR 2010-02 required plans to work in good faith to implement such standards during the enforcement grace period, this requirement was lifted in TR 2011-01. Therefore no such requirement will apply during either the extended or the original enforcement grace period.

Constitutional Challenge Update

To date five U.S. District Courts have ruled on the constitutionality of the individual mandate provision contained within the Affordable Care Act. Two courts ruled the mandate unconstitutional with one finding the entire law must be struck down. The latest court ruling by Judge Roger Vinson in Florida agreed to stay his January 31 ruling that the Affordable Care Act is unconstitutional, while the appeal by the Department of Justice is pending.

The insurance carriers will incorporate many of the required changes into their updated plan documents; however, employers will be required to provide special enrollment opportunities as well as distribute several notices prior to renewal.

At Stahl & Associates Insurance, our entire Employee Benefits Department is thoroughly committed to helping our clients plan ahead. We have compiled this compliance checklist to help our clients review the changes and requirements in advance of the 2010-2011 plan years and open enrollment season.

Click here to download the entire compliance checklist.

Additional Downloads:

• Department of Labor MODEL NOTICE 1
• Department of Labor MODEL NOTICE 2
• Department of Labor MODEL NOTICE 3
• Department of Labor MODEL NOTICE 4