Navigating ACA: What Attorneys Need to Know...Mental Health Parity and Addiction Equity Act • On June 1, 2016, HHS and DOL issued guidance about what terms or practices would constitute

The opinions expressed in this presentation are those of the speaker. The International Foundationdisclaims responsibility for views expressed and statements made by the program speakers.

Navigating ACA:What Attorneys Need to Know

Louise F. (Wendy) PongraczPartnerWillig, Williams & DavidsonPhiladelphia, Pennsylvania

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Essential Information Tools

• For daily updates (regulations, agency actions, court cases)– IFEBP—Today’s Headlines– BenefitsLink.com

• Health & Welfare Plans Newsletter

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Essential Information Tools

• Deeper Dives:– National Coordinating Committee for Multiemployer

Plans: http://www.nccmp.org/resources/index.html– Health Affairs Blog: Following the ACA

http://healthaffairs.org/blog/topics/following-the-aca/

In-depth analysis by Tim Jost, Esq.– Harmon on Health Care Law

http://www.healthplanlaw.com/

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DOL Compliance Audits

• Conducted under the DOL’s Health Benefits Security Project

• Audits triggered by:– Participant complaints;– Advocacy group inquiries;– Form 5500 filings (reporting prohibited transactions;

financial difficulty (e.g., reduction in contributions; investment losses; losses of participants).

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• DOL will request plan documents (trust, plan document, SPD); vendor agreements including Business Associate Agreements; contribution payment schedules and rosters; financial documents for funded plans; claims data.– NOTE: Take the opportunity to ensure that all plan

documents as well as vendor agreements are all properly executed. This apparently has been of interest to the auditors.

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• Compliance audits are not just “desk audits,” requiring a plan to provide documents.– Compliance audits may also entail on-site

interviews and observation of plan operations.– Cooperation with the audits is certainly

encouraged, but fund staff should be prepared in the same manner as, for example, a deposition or other interview.

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• DOL provides a Compliance Guide on its website.

• In addition to the detailed questions in the Compliance Guide, the Guide includes a “Required Documents and Notices” Appendix.– This is a good opportunity to review required

documents and notices (e.g., creditable coverage, WHCRA, special enrollment notices, etc.) Are these timely provided? Recently updated?

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Mental Health Parity and Addiction Equity Act

• The Mental Health Parity and Addiction Equity Act (MHPAEA) as amended by the ACA prohibits group health plans and insurers from imposing financial requirements or treatment limits on treatment for mental health or substance use disorders that are more restrictive than those imposed on medical or surgical treatments.

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Mental Health Parity andAddiction Equity Act

• On June 1, 2016, HHS and DOL issued guidance about what terms or practices would constitute violations of the MHPAEA:

“Warning Signs: Plan or Policy Non-Quantitative Treatment Limitations (NQTL’s) that Require Additional Analysis to Determine Mental Health Parity Compliance”

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Mental Health Parity andAddiction Equity Act

• This guidance includes not only general guidance about potential violations but also a check list plans can use to check for potential violations in plan provisions, including, inter alia:– Preauthorization and pre-certification notification

requirements;– Fail-first protocols;– Probability of improvement;– Written treatment plan requirements;– Geographic limitations.

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ACA Section 1557Nondiscrimination Regulations

• On May 18, 2016, the U.S. Department of Health & Human Services (HHS) added 45 CFR part 92 to implement the nondiscrimination requirements of Section 1557 of the Affordable Care Act (ACA).

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ACA Section 1557Nondiscrimination Final Rule

• The Final Nondiscrimination Rule prohibits covered entities, including funds, from discriminating on the basis of race, color, national origin, sex, age, disability or association with an individual in any of these protected categories, including individuals of the same gender.– Funds will want to pay special attention to the rules

regarding transgender individuals.

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ACA Section 1557 Nondiscrimination Final Rule

(1) Deny, cancel, limit, or refuse to issue or renew a health insurance plan or policy, or other health coverage, or deny or limit coverage of a claim, or impose additional cost sharing or other limitations or restrictions, on the basis of an enrollee's or prospective enrollee’s race, color, national origin, sex, age, or disability;

(2) Employ marketing practices or benefit designs that discriminate on the basis of race, color, national origin, sex, age, or disability in a health-related insurance plan or policy, or other health-related coverage;

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(3) Deny or limit coverage, deny a claim, or impose additional cost sharing or other limitations or restrictions, on any health services that are ordinarily or exclusively available to individuals of one sex, based on the fact that an individual's sex assigned at birth, gender identity, or gender otherwise recorded by the plan or issuer is different from the one to which such health services are ordinarily or exclusively available;

45 CFR 92.207(b)(1)-(3).

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(4) Categorically or automatically exclude from coverage, or limit coverage for, all health services related to gender transition; or

(5) Otherwise deny or limit coverage, or deny a claim, for specific health services related to gender transition if such denial or limitation results in discrimination against a transgender individual.

45 CFR 92.207(b)(4)-(5)

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ACA Section 1557Nondiscrimination Regulations

• The Final Rule requires affected entities to take steps including (but not limited to!):– Adopt certain nondiscrimination standards (including ensuring

that certain coverage is provided, e.g., for certain gender transition services);

– notify their beneficiaries of these new standards; – Ensure that beneficiaries can access these services without

barriers attributable to language or disability; and– Implement a grievance procedure for employees whose rights

under these regulations have been compromised.

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Is Your Plan Affected?

• These regulations apply to “every health program or activity, any part of which receives Federal financial assistance provided or made available by the Department . . . ” 45 CRF 92.2.

• A “health program or activity” means the “provision or administration of health-related services, health related insurance coverage, or other health-related coverage.”

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• “Federal financial assistance . . . means any grant, loan, credit, subsidy, contract (other than a procurement contract but including a contract of insurance), or any other arrangement by which the Federal government provides or otherwise make available assistance in the form of . . . [f]unds . . .”

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• Therefore, your plan is covered if it receives Medicare Part D subsidies from HHS or amounts for a self-insured employer group waiver plan (EGWP). (See Footnote 273 of the Regulations.)

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• Where a health fund uses a TPA, OCR will determine whether the fund or the TPA is liable for discriminatory conduct.

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Transgender Rules• The Final Nondiscrimination Rule prohibits:

– Discrimination against transgender individuals. Funds must take steps to ensure that these individuals are not denied eligibility or services because the service they are seeking is not consistent with the gender assigned at birth.

– Exclusions that would prohibit coverage for individuals based on gender identity or related issues;

– A blanket exclusion for transition-related care; and – An exclusion for transgender individuals that would not apply to

non-transgender or non-transitioning individuals.

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Gender Identity• The Final Rule specifically defines “gender identity”:

Gender identity means an individual’s internal sense of gender, which may be male, female, neither, or a combination of male and female, and which may be different from an individual’s sex assigned at birth. The way an individual expresses gender identity is frequently called “gender expression,” and may or may not conform to social stereotypes associated with a particular gender. A transgender individual is an individual whose gender identity is different from the sex assigned that person at birth.

• 45 CFR 92.4 (Definitions)

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Gender Identity

• The definition of discrimination “on the basis of sex,” now includes “gender identity”:

On the basis of sex includes, but is not limited to, discrimination on the basis of pregnancy, false pregnancy, termination of pregnancy, or recovery therefrom, childbirth or related medical conditions, sex stereotyping, and gender identity.

• 45 CFR 92.4(Definitions)

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ACA Section 1557 Nondiscrimination Final RuleOverview of Required Action

• Modify or amend any plan termsinconsistent with these rules. For example, plans frequently include terms that exclude benefits for gender transition or gender dysphoria;

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• Implement a grievance process for individuals who believe the covered entity has acted in a discriminatory fashion and appoint a “responsible employee” charged with processing grievances in accordance with these rules;

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• Adopt procedures ensuring that the covered entity does not engage in discrimination in violation of these rules, including procedures to ensure that individuals with disabilities or limited English proficiency can be accommodated and can access the services;

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• Post notice of these procedures on the covered entity’s website and in any significant communication or publication;

• Post “taglines” on the covered entity’s website and in any significant communication or publication.

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ACA Section 1557Nondiscrimination Final Rules

Notice Requirements

• Each covered entity must take certain actions as well as “appropriate initial and continuing steps” to notify not only Fund Participants and Beneficiaries but also “members of the public.”– The regulations include a model notice.

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ACA Section 1557 Nondiscrimination Final Rules

Notice Requirements

Notice must be: • In a conspicuously-visible format;• In “significant publications and significant

communications” which include, but are not limited to, all plan documents, summary plan descriptions, patient handbooks, outreach publications, or written notices pertaining to rights or benefits or requiring a response from an individual;

• In conspicuous physical locations; and • In a conspicuous location on the home page of a covered

entity’s website.

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Notice Requirement—Limited English Proficiency

• Covered entities must provide notice of nondiscrimination and taglines alerting limited English proficiency individuals that language assistance services are available.– The Census Bureau provides a listing of the top non-English

languages spoken in a state here: http://www.census.gov/data/tables/2013/demo/2009-2013-lang-tables.html .

– OCR will provide the translations for the notices and taglines at: http://www.hhs.gov/civil-rights/for-individuals/section-1557/translated-resources/index.html

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• For significant communications, the plan must provide taglines in the top 15 languages in the state in which the entity is located or does business;

• For smaller communications (postcards, tri-fold mailers, and presumably explanations of benefits (EOBs), entities must provide taglines in at least the top two non-English languages spoken in the state in which the entity is located or does business.

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• Take reasonable steps to provide meaningful access to each individual with limited English proficiency eligible to be served or likely to be encountered in its health programs and activities; and

• Develop an “effective written language access plan” appropriate to its particular circumstances to be prepared to meet its obligations.

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ACA Section 1557 Nondiscrimination Final RuleIndividuals with Disabilities

• Important to note that the rules for services for individuals with disabilities refer to existing regulations dealing with individuals with disabilities and require that covered entities make “reasonable modifications” to implement the Rule’s requirements.– The term “reasonable modification” is to be interpreted very broadly.

The Final Rule incorporates the standard from the ADA regulations (28 CFR 35.130(b)(7)):

A [covered] entity shall make reasonable modifications in policies, practices, or procedures when the modifications are necessary to avoid discrimination on the basis of disability, unless the [covered] entity can demonstrate that making the modifications would fundamentally alter the nature of the service, program, or activity.

45 CFR 92.202

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ACA Section 1557 Nondiscrimination Final RuleIndividuals with Disabilities

• Covered entities must ensure that communications with individuals with disabilities are “as effective as communications with others in health programs and activities,” in accordance with 28 CFR 35.160–35.164.– In order to comply with this provision, covered entities must

provide appropriate “auxiliary aids and services” to persons with impaired sensory, manual, or speaking skills,” where necessary to provide the individual with “an equal opportunity to benefit from the service in question.”

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Electronic and Information Technology

• Electronic and IT communications and tools used by covered entities must comply with the requirements of Title II of the ADA.

The DOJ Civil Rights Division ADA website includes the following “tool kit” for ensuring that organization’s websites comply with ADA Title II. This “toolkit” explains modifications that must be made for websites to be able to accommodate text readers (e.g., no pictures without captions).

45 CFR 92.204

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ACA Section 1557Litigation

• Current Litigation: In Franciscan Alliance et al. v. Burwell, the plaintiffs allege that the regulations require practitioners to provide coverage for abortion and gender transition services against their professional judgment and religious beliefs. – Originally filed in August 2016, the case is still in its

preliminary stages. An amended complaint was filed on October 17, 2016

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• The regulations do not require any provider or organization to provide abortion services. As noted in the preamble:– . . . nothing in Section 1557 displaces the ACA

provisions regarding abortion . . . No [Marketplace QHP] may discriminate against an individual health care provider or health care facility because of its unwillingness to provide, pay for, provide coverage of, or refer for abortions . . .”

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• The regulation protects providers from claims of discrimination if they decline to provide gender transition services:

Insofar as the application of any requirement under this part would violate applicable federal statutory protections for religious freedom and conscience, such application shall not be required.

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“Pay or Play” Reporting

• These forms (1094-B and -C; 1095-B and -C) are provided by employers and plans to covered individuals and are used for reporting coverage in order to determine whether individuals or employers owe “shared responsibility” penalties under IRC 6055 or 6056.

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• Quick refresher on forms:– Form 1095-B: Provided to individuals by the

provider of health coverage (small employers, health insurance issues and multiemployer plans) so individuals can demonstrate whether they had “minimum essential coverage” and therefore could avoid the “individual mandate” penalty; Form 1094-B: Transmittal form used to file the Form 1095-Bs with the IRS.

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• Quick refresher on forms:– Form 1095-C: Provided to individuals by “applicable

large employers” informing them whether the employer provided “affordable” coverage offering “minimum value,” to be used for determining whether the individual was eligible for subsidized coverage and whether the employer was liable for a “shared responsibility” payment; Form 1094-C: transmittal form used to file the Form 1095-Cs with the IRS.

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• Penalties: For the initial year, penalties were not assessed for missing or incorrect information. However, the leniency for “good faith” compliance is unlikely to be extended to future years.– Persons required to file Form 1095 are subject to

penalties up to $250 for each return, to a total of $3,000,000 annually. (Penalties can be reduced for prompt correction, within 30 days of the original deadline for submission.)

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• New proposed regulations and guidance:– On July 29, 2016, proposed regulations

regarding IRC Section 6055 reporting were published;

– On September 30, 2016, new instructions were issued for the 2016 Forms 1094 (B and C) and 1095 (B and C).

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• Multiemployer Plans:Note that under the new guidance, employers contributing to multiemployer plans may provide data on Form 1094-C and 1095-C for 2016 in the same manner they used for 2015 reporting.

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Opt-Out PaymentsProposed Rule

• On July 8, 2016, the IRS issued proposed rules on “opt-out payments,” that is, cash payments given to employees who opt-out of their employer-sponsored health insurance, under which an unconditional opt-out payment will be treated as a salary reduction for the purpose of determining health insurance “affordability.”– Unconditional opt-out arrangements are those under which the

employee declines employer-sponsored health insurance without satisfying any other requirements.

– Conditional arrangements are those under which the opt-out payment is conditioned on the employee obtaining minimum essential coverage from another source. Under a conditional arrangement, the opt-out payment will not be included in determining the affordability of the health coverage offered to the employee. These arrangements are “eligible opt-out arrangements.”

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Why do these opt-out rules matter?They affect the determination of whether a plan is “affordable.” Under an unconditional opt-out arrangement, the employee’s cost for the coverage (whether or not the employee opts out) equals the amount of the opt-out payment added to any salary reduction elections that the employee must make as required premium contribution.

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EXAMPLE: The Generous Company requires all employees electing self-only coverage to pay $250 per month for health coverage and has established a Section 125 plan to facilitate these employee premium payments through salary reduction elections. The Company also provides $125 per month in taxable wages to each employee who declines the coverage. The $125 per month payment is not subject to any conditions.

Here, the monthly cost to an employee for the employer-provided coverage (whether or not the employee takes or declines the health coverage) would be $375 ($250 + $125): the employee electing coverage must pay the $250 premium copayments through the salary reduction election as well as give up $125 per month in compensation from the opt-out.

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• If the opt-out payment is made under an “eligible Opt-Out arrangement,” the payment will not be included in determining the cost of the coverage.

• “Eligible Opt-Out Arrangement” means an arrangement that requires the following:– The employee must provide, at least annually, reasonable evidence that

the employee and all those for whom the employee reasonably expects to claim a personal exemption (employee’s tax family) will have minimum essential coverage (MEC) that was not obtained in the individual market (on or off the Exchange) during the period of the opt-out arrangement.

For example, if an employee's expected tax family consists of the employee, the employee's spouse, and two children, the employee would meet this requirement by providing reasonable evidence that the employee, the employee's spouse, and the two children, will have coverage under the group health plan of the spouse' s employer for the period to which the opt-out arrangement applies.

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What is “reasonable evidence that those opting out have minimum essential coverage (MEC) that was not obtained in the individual market”?The preamble to the regulations explains that “reasonable” really does mean “reasonable”: it can include “the employee’s attestation that the employee and all other members of the employee’s expected tax family, if any, have or will have minimum essential coverage (other than coverage in the individual market, whether or not obtained through the Marketplace) or other reasonable evidence.” (81 FR 44564)

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• When must the evidence of coverage be provided?– At least every plan year for the applicable period,– Not any earlier than a reasonable period before the

coverage begins– Examples:

• During the regular annual open enrollment period; or• After the plan year starts, so the employee and family would

already have the alternative coverage.

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New Summary of Benefits and Coverage

• CMS has released a new summary of benefits and coverage (SBC) template, which is available on its website, including both forms and detailed instructions.

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• When must the new SBC template be used?– For plans with open enrollment periods: No later

than the first day of an open enrollment period that begins on or after April 1, 2017;

– For plans with no open enrollment period: No later than the first day of the first plan year beginning on or after April 1, 2017.

– $$$ penalties: If revised SBCs not timely provided, could result in penalties of $1,000 each violation.

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• Major Changes:– The template reduces the number of pages from

eight to five;– Additional coverage example (simple fracture);– Must provide information on “core” limitations, i.e.,

where cost sharing on a covered service does not accumulate to the OOP limit, visit limits, etc.

– If electronic distribution, can hyperlink to uniform glossary.

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Form 5500—Revised

• DOL issued proposed rules in the Federal Register on July 21, 2016 (but no proposed forms as of yet).

• New forms designed to facilitate, inter alia, the enhanced reporting requirements as set forth in ACA Section 2717.

• Comment period closes December 5, 2016.

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Form 5500—Revised

• New Form 5500 applies to ALL group health plans governed by Title I of ERISA:– Now includes GHP’s regardless of:

• Size (no exemption for small plans);• Funding structure; or• Insured status.

– Also includes certain plans providing certain HIPAA-excepted benefits (e.g., dental, vision, health FSAs).

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Form 5500—Revised

• The most significant changes will be reflected on a new Schedule J. – Although plans will continue to be required to report

the number of participants and beneficiaries, type of benefits and funding arrangement on Schedule J (currently on Schedule A), they will be required to provide significant additional information.

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Form 5500—Revised

• Plans will be required to report (not a comprehensive list):– Number of COBRA beneficiaries;– Coverage options: employee only; spouses;

dependent children;– Late ER or EE contributions;– Grandfathered plan status;– Plan features: HDHP; Health FSA; HRA;– Stop Loss Coverage: premium paid, individual and

aggregate attachment points; (continued)

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Form 5500—Revised

• Plans will be required to report (not a comprehensive list):– Pre- and post-service claims: number of claims,

appeals, denials and appeals allowed;• Must report appeals that were not timely processed;

– Plan rebates, refunds, and reimbursements from service providers (e.g., TPA, PBM, issuers), including the amount received and how the monies were used; (continued)

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Form 5500—Revised

• Plans will be required to report (not a comprehensive list):– Plan inability to pay claims and, if so, the number of

claims;• Late payments to insurance carriers and whether the late

payment resulted in lapse of coverage for participants and beneficiaries;

– Compliance with SPD, SBC, and SMM rules;– Compliance with HIPAA, WHCRA, Newborns &

Mothers, GINA; MHPAEA; and ACA.(continued)

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Form 5500—Proposed

• Plans will be required to report (not a comprehensive list):– Termination of any service provider, not just

accountants and enrolled actuaries as is now required, when termination caused by vendor contract breaches and failure to remedy breach in service provider agreement.

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Cadillac Tax

• Cadillac Tax– The excise tax on high-cost health plans—referred to

as the “Cadillac tax”—is set forth in Section 9001 of the ACA, as modified by Section 1401 of the Health Care and Education Reconciliation Act of 2010.

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Cadillac Tax

• Implementation delayed to 2020. At that time, health insurance issuers and sponsors of self-funded group health plans will be assessed a nondeductible excise tax on a “high-cost” health plan.

• Purpose is to raise revenue (generous health benefits are viewed as untaxed compensation) and to force employers and consumers (employees) to control health care costs by curbing overutilization.

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Cadillac Tax

• A high-cost plan is defined by the total cost of premiums, rather than what the plan covers or how much the patient has to pay for a doctor or hospital visit.

• All employer-sponsored health care plans are potentially subject to the excise tax. Applies to both insured and self-insured plans and to grandfathered and non-grandfathered plans.

• The statute does not include an exception for plans negotiated as part of a collective bargaining agreement.

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Cadillac Tax

• Applicable Limitation– The excise tax will be 40% of the amount that

exceeds the applicable threshold.– The initial threshold in the statute is:

• $10,200 for individual coverage• $27,500 for employee plus spouse or family

coverage

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Cadillac Tax

• It is the excess that is subject to the excise tax: – For example, if employer-sponsored family coverage

for an employee has an annual value amount of $28,500, the excess of $1,000 ($28,500 minus the $27,500 limit) would be subject to the 40% excise tax, and the amount due with respect to that employee is $400.

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Cadillac Tax

• Applicable Limitation– Special rule for multiemployer plans:

• For multiemployer plans, each employee shall be treated, for purposes of the applicable threshold, as if they have spouse or family coverage even if they have only single coverage.

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Cadillac Tax Adjustments to Threshold Amount

• The initial threshold amounts may be increased depending on actual inflation between 2010-2018 using a measure that looks to the Blue Cross Blue Shield standard benefit option under the Federal Employees Health Benefits Plan (FEHBP).

• If the cost of this FEHBP coverage goes up by more than 55% between 2010 and 2018, the initial threshold for 2018 would increase by the percentage of premium growth over 55%).

• This adjustment is called the “health cost adjustment percentage.”

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• After 2018, the threshold amounts will be further increased as follows:– For 2019, by the Consumer Price Index for All Urban

Consumers (CPI-U) plus one percent.– For 2020 and later, by the Consumer Price Index

for All Urban Consumers (CPI-U)

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• The ACA takes some of these issues into account by increasing the threshold amounts ($11,850 and $30,950) for certain individuals:– Individuals who are retirees age 55 and older who are

not eligible for Medicare– Individuals in a plan sponsored by an employer the

majority of whose employees covered by the plan are engaged in high-risk professions or employed to install or repair electrical or telecommunications lines

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Cadillac Tax “High Risk” Professions

“High-risk” professions include:• Law enforcement• Firefighters• First responders • Employment in certain industries (e.g., construction,

mining, certain agriculture, forestry and fishing)• Longshoremen

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Cadillac TaxWhat Could Go Wrong?

• Economists LOVE the Cadillac Tax:

“[The Cadillac tax] is perhaps the single biggest leverage we have on health costs in the private sector.”

Jason Furman, chair of the Council of Economic Advisors.

• Consumers—both employers and employees: not so much.

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Cadillac TaxProblems with the Tax

• If the CPI-U index grows more slowly than medical inflation and medical premiums, then more plans will become subject to the excise tax over time.

• Plan sponsors may simply try to increase deductibles in order to keep the premiums low. But, what if the premiums are high because your group is sick or old and not because the plan provides “Cadillac” benefits?

STAY TUNED!

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Website Resources

https://www.ifebp.org/news/featuredtopics/hcrc/Pages/default.aspx

http://www.ifebp.org/inforequest/ifebp/0167445.pdf

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2017 Educational ProgramsFund Advisors—Attorneys

63rd Annual Employee Benefits Conference October 22-25, 2017Las Vegas, Nevadawww.ifebp.org/usannual

Washington Legislative UpdateMay 22-23, 2017Washington, D.C.www.ifebp.org/washington

Fraud Prevention Institute for Employee Benefit PlansJuly 17-18, 2017Chicago, Illinoiswww.ifebp.org/fraudprevention

Collection Procedures InstituteNovember 15-16, 2017Santa Monica, Californiawww.ifebp.org/collections

Related Reading

Trustee Handbook: A Guide to Labor-Management Employee Benefit Plans, Seventh Edition | Item #7068 Visit one of the on-site Bookstore locations or see www.ifebp.org/bookstore for more books.

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