Health Care & Employer Matters - the Blog

This Blog is not legal advice.  Should the content of this Blog create a legal question, please seek counsel from your legal advisor.

  • Employer Mandate Delayed

    The Employer Mandate ("Play or Pay"), arguably one of the largest components of the ACA, has been delayed.  Whereas large employers (defined basically as employers with 50+ full time employees), were to be in compliance with the Employer Mandate by January 1, 2014, the federal government is now telling us that compliance with Play or Pay will now be expected by January 1, 2015.

    The Treasury Department has expressed that this delay is to accomodate the business community, which has expressed significant concern over Play or Pay compliance. 

    In short, this means that large employers no longer face a penalty if the employer fails to provide heath coverage to 95+% of its full time employees and dependents - at least until January 2015.   

    The Treasury Department also tells us that formal guidance on this announcement is to follow. 

    Stay tuned!


  • Individual Exchange Marketplaces

    There have been rumblings that the exchanges, currently scheduled to go online in 2014, have been delayed.  This is partially true.  In short, the "SHOP" exchanges, which are exchange marketplaces set to accommodate small businesses shopping for small-group coverage, have been delayed.  The individual exchange marketplaces, set to go live in 2014, have not been delayed.  This delay is certain for all states where the federal government is currently slated to run that state's exchange (33 states in total), however, states that are set to operate their own exchange in 2014 may proceed with the SHOP exchanges, or they may delay the SHOP exchanges until 2015. 




    Tim Callender

    AmeriBen / IEC Group

    Corporate Counsel

  • Contraceptive Services and Cost Sharing

    HHS (with the help of the DOL and the Treasury Department) has just released proposed rules on contraceptive services and cost sharing.  The ACA requires coverage of certain contraceptive services with no cost to a health plan's participants.  Since the passage of the ACA, numerous religious organizations have objected to this requirement.  The proposed rules have widened the definition of organizations that would be able to claim an exemption from the coverage requirement.  The proposed rules also expand how the contraceptive services might be funded for self-funded religious plans.  Under the proposed rule, it appears that contraceptive services under a self-insured religious group's plan would be funded by the group working with a third-party administrator who will facilitate separate coverage to the group's members, through an insurance carrier, at no cost to the group's members.  Note: this separate, "fully-insured" coverage is only for the contraceptive services with no cost share.  The expenses born by the carriers will be offset by reducing the fees paid by the insurer to assist in the funding of federally run exchanges. 


    The proposed rules also clarify that an insured religious plan would operate similarly as stated above, but would skip the step of involving a third party administrator and would simply notify its insurance carrier of its objection to the mandate.  At that point, the carrier is to notify the plan's members that the covered contraceptive services will be handled at no-cost to the members, through separate, individual insured policies. 


    Student health plans will operate under both scenarios detailed above, depending on whether the plan is self-funded or fully-insured. 


    The proposed rules are open for feedback until April 8, 2013.    


    The HHS publications, including the proposed rules can be viewed here:

  • Comparative Effectiveness Research Fee versus the Patient Centered Outcomes Research Fee (PCOR)

    I've recently seen some confusion over the Comparative Effectiveness Research Fee versus the Patient Centered Outcomes Research Fee (PCOR).  These are the exact same thing, just being labeled differently.  I have gotten into the practice of referring to this fee as the PCOR fee, so don't be alarmed if you hear about the CERF fee and feel that you've missed something. 


    Quick reminder, this PCOR (or CERF) fee is the fee that must be paid by both carriers and self-funded plans and is paid at the rate of $2.00 per average covered life.  The fee will be reported and paid to the IRS using Form 720.


    For more information see:




    Tim Callender

    AmeriBen / IEC Group

    Corporate Counsel

  • Health Care Exchange

    We've just learned that the DOL has postponed the compliance deadline for the health care exchange notice.  If you recall, all employers were originally expected to issue a healthcare exchange notice, in writing, to every employee, no later than March 1, 2013.  Citing to the fact that there is simply not enough information on exchanges to expect employers to assemble a meaningful written notice, the DOL has extended the compliance deadline.  Stay tuned for more details on what the new deadline will be.

  • PCOR - Final Regulations Issued

    The IRS and Treasury Department have just issued the final regulations regarding the Patient Centered Outcomes Research fee.  We've already explored this topic in a webinar a few months back, but with these new regulations a few items have been further defined regarding the PCOR fee.


    1.       In calculating "average number of covered lives" for purposes of paying the fee, you do not have to count the lives in an Employee Assistance Program ("EAP"), the lives in your disease management program, or the lives in your wellness program.

    a.       Caveat: the IRS tells us that we do need to count these lives if the particular EAP, disease or wellness program provides "significant benefits" to the participant in the nature of medical care or treatment.


    2.       If you are an employer, with a self-insured plan, and you also offer fully-insured coverage options, you do not need to factor in the lives covered under the fully-insured options.  The carriers will handle the fees for these lives.


    3.       You must count lives in retiree-only health plans as well. 


    4.       You must count the lives in your health plan that are covered via continuation coverage (COBRA coverage).


    5.       Third-party-administrators are not allowed to calculate the PCOR fee for plans they administer.


    6.       Third-party-administrators are not allowed to pay the PCOR fee for plans they administer. 


    7.       Fees must be reported and paid no later than July 31 of the year following the last day of the policy/plan year, on IRS Form 720.  Use Form 720X to make adjustments to previously filed Forms 720. 




    Tim Callender

    AmeriBen / IEC Group

    Corporate Counsel 

  • Preventive Services

    Had a question recently regarding the August 1, 2012, preventive services for women requirement & the timeline of the requirement.  Basically I've heard the following:


    Becky: "hey, my friend Judy is now receiving well-woman visits at no cost, but I am not.  What gives?" 


    This scenario is likely due to the fact that Judy is on a medical plan with a plan year that just started - for this example let's assume the plan year started September 1, 2012. 


    A common misconception is that the August 1, 2012, preventive services requirement literally became effective on August 1, 2012.  To the contrary, the 8 new services must be covered, with no cost-sharing to plan participants, in plan years starting on or after August 1, 2012.  In short, if your plan year is July 1, 2012, through June 30, 2013, then the plan is not required to cover these new items until the new plan year starts in 2013.  But, in the example above, Judy's plan year started just after August 1st, hence the new preventive services coverage in her plan. 


    As an aside, the 8 preventive services required to be covered, with no cost-sharing to eligible participants are:


    1.       Breastfeeding: comprehensive support and counseling from trained providers, as well as access to breastfeeding supplies, for pregnant and nursing women;

    2.       Contraception: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, not including abortifacient drugs;

    3.       Domestic and interpersonal violence screening and counseling for all women;

    4.       Gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk of developing gestational diabetes;

    5.       Human Immunodeficiency Virus (HIV) screening and counseling for sexually active women;

    6.       Human Papillomaviurs (HPV) DNA test: high risk HPV DNA testing every three years for women with normal cytology results who are 30 or older;

    7.       Sexually transmitted infections (STI) counseling for sexually active women; and

    8.       Well-woman visits to obtain recommended preventive services for women under 65 years of age.


    So there is no confusion - Becky and Judy are fictional plan participants. 

  • 90 Day Requirement

    In a recent webinar that I presented regarding SBCs, I provided some information regarding the requirement to provide the SBC to a special enrollee within 90 days of his/her enrollment of the plan (this would typically be a new employee becoming eligible in the middle of the plan year).  The 90 day requirement is confusing and warrants clarification. 


    DOL Regulation 29 CFR 2590.715-2715(f) is where we are instructed to apply the "first open enrollment after September 23, 2012" or "first plan year following September 23, 2012" logic.  Regarding the special enrollees requirement of providing an SBC within 90 days from the date of the enrollment date, this is coming from 29 CFR 2590.715-2715(a)(1)(ii)(D), stating that "the plan or issuer must provide the SBC to special enrollees no later than the date by which a summary plan description is required to be provided under the timeframe set forth in ERISA section 104(b)(1)(A) and its implementing regulations, which is 90 days from enrollment."


    The trick is determining whether the 90 day requirement applies only after regulations from -2715(f) kick in, or whether the 90 day requirement is operational within the same timeframe as the -2715(f) regulation.  You can see the conundrum here. 


    I believe the way this should be interpreted then would be this:


    -2715(f) gives us the initial SBC implementation timeline requirement.  Then, once a plan has had its first SBC actually occur - then the rest of the regulations kick in, for example, requiring the 90 day turnaround for new enrollees.  Which, at that point, shouldn't be a big deal b/c the plan in question would have a pile of SBCs sitting around from their most recent open enrollment and/or plan year. 
  • Medical Loss Ratio (MLR) Requirements

    Recently had a number of people inquiring about whether the MLR requirements apply to self-funded plans.  Short answer: no.  Now, if you do offer some fully-insured benefits, make sure you are communicating with the carrier/issuer about MLR requirements pertaining to those products.  But, as a basic rule, the MLR requirement does not apply to self-funded plans - only to health insurance "issuers" that offer a coverage product on the individual or group market. 

  • Summary of Benefits & Coverage

    Here are some extremely useful links to some great information on the SBC requirement.  It's coming soon - so get ready!

  (general SBC information from the Department of Labor - scroll down once you get there)

  (general SBC information from the Centers for Medicare & Medicaid Services)

  (recent FAQs published by the Department of Labor)


  • ACA (Affordable Care Act)

    The Supreme Court has upheld the ACA (Affordable Care Act).  There are many requirements that you must be sure you are aware of.  The Summary of Benefits & Coverage (SBC) requirement is coming up, in a hurry!  Join me on August 7th, at 10 AM Mountain Time, for a webinar covering SBCs and what you need to know to prepare you for the September 23rd implementation deadline.  To register:


     Tim Callender

    AmeriBen / IEC Group

    Corporate Counsel