HHS Warns Insurers, TPAS Complete ACA Reinsurance & Risk Adjustment Edge Server Pre-Registration Steps By 9/27

August 8, 2014

The Department of Health & Human Services (HHS) is warning group health insurers third party administrators (TPAs) of self-insured group health plans and to get moving on their preparations to register and conduct required interactions with the EDGE Server that HHS plans to use to collect and administer the data necessary to administer the temporary reinsurance fee and risk adjustment provisions of the Patient Protection & Affordable Care Act (ACA).  HHS says insurers and TPAs have work to complete by 9/27 to prepare to comply with the EDGE system data reporting that HHS will require them to conduct as part of ACA’s reinsurance premium and risk adjustment risk sharing provisions.

The temporary reinsurance fee and risk adjustment provisions of ACA are intended to generate $25 billion in revenues from assessments on insured and self-insured group health plans that the federal government plans to use to partially reimburse commercial insurers writing policies in public exchanges for individuals with high health care costs.

ACA provides that the reinsurance fee applies in 2014, 2015, and 2016. Under Final Rules published March 5, 2014, the insurer pays the fee for insured plans but where a group health plan is self-insured, the plan itself pays the fee.   Final Rules published March 5, 2014 provide that self-insured and self-administered plans are exempt from the fees in 2015 and 2016, however.

The reinsurance fee equals the yearly rate times the number of plan participants. The yearly rate is $63 for 2014, $44 for 2015, and to be announced for 2016.

The Centers for Medicare and Medicaid Services (CMS) plans to run the first risk adjustment and reinsurance calculation estimates in mid-December, 2014 using data to be collected from insurers and TPAs on the EDGE system.

In an August 7, 2014 webinar, HHS gave issuers and TPAs an overview of the EDGE server implementation schedule and guidance on the key pre-registration tasks that must be completed prior to the start of the EDGE server registration process scheduled to begin on September 27, 2014.

HHS warned issuers and TPAs must be ready to start the EDGE registration process on September 27, 2014 in order to have sufficient time to set-up their servers and test their data submissions prior to the mid-December estimate calculations.

In the webinar, HHS outlined a series of key pre-registration activities that issuers and TPAs of self-insured health plans impacted by the new requirements need to complete between now and September 26, 2014, in order to prepare for EDGE implementation.

Review the pre-registration checklist, timeline and other information shared by CMS in the 90-minute presentation here.

For Advice, Training & Other Resources

If you need assistance monitoring these and other regulatory policy, enforcement, litigation or other developments, or to review or respond to these or other workforce, benefits and compensation, performance and risk management, compliance, enforcement or management concerns, the author of this update, attorney Cynthia Marcotte Stamer may be able to help.

Board Certified in Labor & Employment Law, Past Chair of the ABA RPTE Employee Benefit & Other Compensation Arrangements Group, Co-Chair and Past Chair of the ABA RPTE Welfare Plan Committee, Vice Chair of the ABA TIPS Employee Benefit Plans Committee, an ABA Joint Committee On Employee Benefits Council representative, Past Chair of the ABA Health Law Section Managed Care & Insurance Section, a Fellow in the American College of Employee Benefit Counsel, ABA, and State Bar of Texas, Ms. Stamer has more than 25 years’ experience advising health plan and employee benefit, insurance, financial services, employer and health industry clients about these and other matters. Ms. Stamer has extensive experience advising and assisting health plans and insurers about ACA, and a wide range of other plan design, administration, data security and privacy and other compliance risk management policies.  Ms. Stamer also regularly represents clients and works with Congress and state legislatures, EBSA, IRS, EEOC, OCR and other HHS agencies, state insurance and other regulators, and others.   She also publishes and speaks extensively on health and other employee benefit plan and insurance, staffing and human resources, compensation and benefits, technology, public policy, privacy, regulatory and public policy and other operations and risk management concerns. Her publications and insights appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications.

You can review other recent human resources, employee benefits and internal controls publications and resources and additional information about the employment, employee benefits and other experience of the Cynthia Marcotte Stamer, PC here. If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information – including your preferred e-mail – by creating or updating your profile www.cynthiastamer.com or by registering to participate in the distribution of these and other updates on our HR & Employee Benefits Update distributions here including:

If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information including your preferred e-mail by creating or updating your profile here. For important information about this communication click here

NOTE:  This article is provided for educational purposes.  It is does not establish any attorney-client relationship nor provide or serve as a substitute for legal advice to any individual or organization.  Readers must engage properly qualified legal counsel to secure legal advice about the rules discussed in light of specific circumstances.

The following disclaimer is included to ensure that we comply with U.S. Treasury Department Regulations.  The Regulations now require that either we (1) include the following disclaimer in most written Federal tax correspondence or (2) undertake significant due diligence that we have not performed (but can perform on request).

ANY STATEMENTS CONTAINED HEREIN ARE NOT INTENDED OR WRITTEN BY THE WRITER TO BE USED, AND NOTHING CONTAINED HEREIN CAN BE USED BY YOU OR ANY OTHER PERSON, FOR THE PURPOSE OF (1) AVOIDING PENALTIES THAT MAY BE IMPOSED UNDER FEDERAL TAX LAW, or (2) PROMOTING, MARKETING OR RECOMMENDING TO ANOTHER PARTY ANY TAX-RELATED TRANSACTION OR MATTER ADDRESSED HEREIN.

©2014 Cynthia Marcotte Stamer. Limited, non-exclusive right to republished granted to Solutions Law Press, Inc. All other rights reserved.


House Hearings Consider Authorizing House Lawsuit Challenging Consitutionality of Obama’s Health Care Reform Actions

July 16, 2014

House Republicans are continuing to challenge President Obama’s failure to enforce and other discretionary actions in his Administration’s implementation of the sweeping health care reforms of the Patient Protection & Affordable Act (ACA) by holding with two key hearings this morning (July 16, 2014).

At 10 a.m. Eastern Time, the U.S. House of Representatives Rules Committee began its hearing on a draft House Resolution available here, which if passed by the House of Representatives, will authorize Speaker of the House Republican John Boehmer to sue President Obama for alleged violations of the Constitution in his implementation and administration of various provisions of the Patient Protection & Affordable Care Act (ACA). See Legislative hearing on a Committee Discussion Draft of H. Res. ____, Providing for authority to initiate litigation for actions by the President inconsistent with his duties under the Constitution of the United States.

Meanwhile, the House Committee on Energy and Commerce Subcommittee on Health is simultaneously is holding a hearing on “Failure to Verify: Concerns Regarding PPACA’s Eligibility System,” which is investigating concerns about the Obama Administration’s failure to timely establish and implement processes and procedures to verify eligibility of individuals slated to quality for subsidies for enrolling in health care coverage through the Health Insurance Exchanges established under ACA. Written testimony of Department of Health & Human Services Assistant Inspector General, Office of Audit Services, Kay Daly, and Regional Inspector General, Office of Evaluations and Inspections, Joyce Greenleaf is available for review here.

The hearings reflect a growing emphasis by House Republicans on highlighting and challenging the Constitutionality of discretionary decisions made by President Obama to waive or delay enforcement or implementation of major provisions of the law and other exercises of discretion and executive license when implementing the guidance and enforcement practices which Republicans charge exceed his authority and violate his duty to faithfully administer the laws passed by Congress.

For Advice, Training & Other Resources

If you need assistance monitoring these and other regulatory policy, enforcement, litigation or other developments, or to review or respond to these or other workforce, benefits and compensation, performance and risk management, compliance, enforcement or management concerns, the author of this update, attorney Cynthia Marcotte Stamer may be able to help.

Board Certified in Labor & Employment Law, Past Chair of the ABA RPTE Employee Benefit & Other Compensation Arrangements Group, Co-Chair and Past Chair of the ABA RPTE Welfare Plan Committee, Vice Chair of the ABA TIPS Employee Benefit Plans Committee, an ABA Joint Committee On Employee Benefits Council representative, Past Chair of the ABA Health Law Section Managed Care & Insurance Section, a Fellow in the American College of Employee Benefit Counsel, ABA, and State Bar of Texas, Ms. Stamer has more than 25 years’ experience advising health plan and employee benefit, insurance, financial services, employer and health industry clients about these and other matters. Ms. Stamer has extensive experience advising and assisting health plans and insurers about ACA, and a wide range of other plan design, administration, data security and privacy and other compliance risk management policies.  Ms. Stamer also regularly represents clients and works with Congress and state legislatures, EBSA, IRS, EEOC, OCR and other HHS agencies, state insurance and other regulators, and others.   She also publishes and speaks extensively on health and other employee benefit plan and insurance, staffing and human resources, compensation and benefits, technology, public policy, privacy, regulatory and public policy and other operations and risk management concerns. Her publications and insights appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications.

You can review other recent human resources, employee benefits and internal controls publications and resources and additional information about the employment, employee benefits and other experience of the Cynthia Marcotte Stamer, PC here. If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information – including your preferred e-mail – by creating or updating your profile www.cynthiastamer.com or by registering to participate in the distribution of these and other updates on our HR & Employee Benefits Update distributions here including:

If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information including your preferred e-mail by creating or updating your profile here. For important information about this communication click here

NOTE:  This article is provided for educational purposes.  It is does not establish any attorney-client relationship nor provide or serve as a substitute for legal advice to any individual or organization.  Readers must engage properly qualified legal counsel to secure legal advice about the rules discussed in light of specific circumstances.

The following disclaimer is included to ensure that we comply with U.S. Treasury Department Regulations.  The Regulations now require that either we (1) include the following disclaimer in most written Federal tax correspondence or (2) undertake significant due diligence that we have not performed (but can perform on request).

ANY STATEMENTS CONTAINED HEREIN ARE NOT INTENDED OR WRITTEN BY THE WRITER TO BE USED, AND NOTHING CONTAINED HEREIN CAN BE USED BY YOU OR ANY OTHER PERSON, FOR THE PURPOSE OF (1) AVOIDING PENALTIES THAT MAY BE IMPOSED UNDER FEDERAL TAX LAW, or (2) PROMOTING, MARKETING OR RECOMMENDING TO ANOTHER PARTY ANY TAX-RELATED TRANSACTION OR MATTER ADDRESSED HEREIN.

©2014 Cynthia Marcotte Stamer. Limited, non-exclusive right to republished granted to Solutions Law Press, Inc. All other rights reserved.


Use Care Before Using “Skinny Plan” Option As Code Section 4980H Tool

March 9, 2014

Employers considering skinny plans and the brokers, third party administrators (TPAs), insurers and consultants recommending the use of these arrangements alone or as part of a broader health plan design should seek qualified legal advice for help with structuring and implementing these arrangements to avoid potential traps and missteps that could trigger unanticipated benefits, costs and/or tax consequences.  While offering some potential for certain employers, employers must carefully evaluate the potential suitability, benefits, risks and resultant responsibilities of including skinny plan options in their group health benefit offerings and ensure that any such arrangements are properly designed and administered to comply with applicable requirements.

Why Code Section 4980H Has Fueled Growing Skinny Plan Option Hype

Over the past year, many brokers and consultants have advocated that employers adopt a “preventive only” or “skinny plan” to low paid or other groups of employees as a means of avoiding liability for the potential $165 per month “employer shared liability payment” now scheduled to take effect for employers of more than 100 employees on January 1, 2015 and later for employers of more than 50 employees under Internal Revenue Code (Code) Section 4980H(a) (the “A Penalty”).

The Code Section 4980H rules are only one of a plethora of federal mandates and rules applicable to group health plans and their employers under federal law as a result of the health care reforms of the Patient Protection & Affordable Care Act (ACA) as well as a host of previously enacted federal laws.

Enthusiasm for the skinny plan option has been fueled by IRS guidance originally in IRS Notice 2013-54 and its subsequent publication in February 2014 of its final regulations implementing Code Section 4980H that reflect that most plans that pay or provide for reimbursement of medical care costs might qualify as the “minimum essential coverage” necessary to avoid triggering the penalty under Code Section 4980H(a) as long as the arrangement is not an “excepted benefit plan” for purposes of ACA.

While a properly implemented “skinny plan” option may work for many employers with self-insured health plans, getting past the Code Section 4890H(a) employer shared responsibility payment doesn’t necessarily mean that the employer won’t face liability under Code Section 4980H.  Furthermore, getting past Code Section 4980H isn’t all that employers, insurers, brokers and consultants need to consider when designing group health plans.  In fact, an improperly designed skinny plan that avoids triggering liability under Code Section 4980H could trigger much greater liability than the penalty that the employer hoped to avoid by using the skinny plan.

While a full understanding of all the potential implications that may affect a decision to offer a skinny plan is beyond the scope of this short article, it often is helpful to begin by understanding first the mechanics of Code Section 4980H and its employer-shared responsibility payments.

Code Section 4980H Employer Shared Responsibility Penalty Basics

The A Penalty is one of two potential employer shared responsibility payments that Code Section 4980H may impose against a “large employer” that fails to provide the necessary coverage mandated to avoid triggering liability under Code Section 4980H.  Under Code Section 4980H, there are two potential penalties that could be triggered:  the penalty under Code Section 4980H(a) commonly called the “A Penalty” or the penalty under Code Section 4989H(b) commonly called the “B Penalty.”  Understanding the skinny plan hype starts with understanding the basics and applicability of these two potential penalties.

First, the Code Section 4980H penalty doesn’t apply as long as the employer either doesn’t have 50 or more full-time employees or non of its full-time employees enroll in subsidized health coverage through a health insurance exchange.  Also, neither penalty under Code Section 4980H applies to any employer until at the earliest, January 1, 2015, when under the delayed effective date announced by the Obama Administration, employers with 100 or more full-time employees will become subject to Code Section 4980H.  Employers of 50 to 99 full-time employees enjoy an even further delayed effective date and employers of fewer than 50 full-time employees are exempt.

The A Penalty under Code Section 4980H(a) results when a large employer fails to offer employee and dependent coverage providing “minimum essential coverage” to is full-time employees.  The month A-Penalty amount generally will equal the result of the total number of all full-time employees of the employer minus 30, multiplied by $165 per month.

Just because an employer avoids the A Penalty by offering a plan providing minimum essential coverage to all employees does not necessarily mean it avoids liability under Code Section 4980H.  An employer offering the minimum essential coverage under a group health plan to all employees needed to get past the A Penalty generally still risks liability under Code Section 4980H to pay the “B Penalty” of $250 per month for any employee who actually enrolls in health care coverage through a Health Insurance Exchange whose family adjusted gross income is less than 400% of the Federal Poverty Level (approximately $98,000), unless the skinny plan or another group health plan offered to the employee by the employee both:

  • Provides both minimum essential coverage and the required “minimum value” within the meaning of Code Section 4980H; and
  • Doesn’t require the full-time employee to contribute more than 9.5% of his family adjusted gross income to qualify for the coverage offered under the group health plan.

Thus, while offering a skinny plan to all full-time employees may allow an employer to avoid liability for the A Penalty, an employer offering a skinny plan risks liability for the B Penalty of $250 per month for each employee whose family adjusted gross income is less than 400% of the Federal Poverty Level who actually choses to enroll in the richer health care coverage offered through the Health Insurance Exchanges rather than the skinny plan offered by the employer.

Since ACA provides subsidies for many employees with family adjusted gross incomes of less than 400% of the Federal Poverty Level, offering only a skinny plan alone creates a risk for employers that employ a significant number of these lower paid employees that employees will choose to enroll in health insurance coverage offered through the Health Insurance Exchange with subsidies rather than the skinny plan.  To the extent that this occurs, the offering of the skinny plan actually may increase the liability under Code Section 4980H of that employer for that employee from $165 per month to $250 per month.  Some skinny plan proponents may pooh-pooh this risk, arguing that the cost for an employer that incurs the B Penalty will not be higher because See Code § 4980H(b)(2) caps the amount of the B Penalty at the amount of the A Penalty.  While it technically is true that this means that the amount of the B Penalty will not exceed the amount of the A Penalty that the employer would have incurred had it not provided any coverage, the fact remains that the cost to the employer could still be greater because in addition to the B Penalty, the employer also will have incurred the cost of coverage and compliance to provide the skinny plan in addition to the B Penalty incurred.  Accordingly, employers considering this approach need to carefully evaluate their workforce to assess the potential exposure to B Penalties before assuming that avoiding the A Penalty is the best option for their organization and options to mitigate their downside exposures.

To reduce this risk, many consultants and brokers may suggest that the employer adopt a group health plan that offers all full-time employees the option to choose either to enroll in a skinny plan, to enroll in a group health plan coverage option that provides minimum essential coverage offering minimum value at a higher cost than the cost of the skinny plan coverage, or to forego coverage under the group health plan.  Since current IRS guidance states that offering group health plan coverage under a group health plan providing both minimum value and minimum essential coverage with an employee premium of less than 9.5 percent of family adjusted gross income will avoid liability under for the B Penalty for an employee even if an employee who otherwise would qualify for a subsidy choses to enroll in health insurance coverage through the Health Insurance Exchange, this design, properly implemented, may allow the employer to avoid liability under Code Section 4980H.  However, this is not all that an employer needs to worry about.  In fact, unless the group health plans including the skinny plan meets other rules and the discrimination rules applicable to the group health plan and the cafeteria plan through which the enrollment choices are offered meet applicable nondiscrimination requirements, the employer may create unanticipated exposures equal to or greater to the Code Section 4980H liability that the employer seeks to avoid.

Other Traps To Step To Beyond Code Section 4980H May Carry Bigger Risks

Code Section 4980H is only one of several issues that employers contemplating offering skinny plan designs alone or along with an alternative minimum essential coverage, minimum value group health plan coverage option must consider a plethora of other applicable laws and regulations, some of the most significant of which are highlighted in the following paragraphs.

First, when deciding the skinny plan or other group health plan design, employers and their insurers, brokers, administrators and consultants need to ensure that the benefit plan coverage, benefits and other terms meet all applicable mandates of applicable federal, and in the case of insured, multiple employer welfare arrangements (MEWAs) and certain staffing and leasing company arrangements, ACA’s insured plan mandates and other applicable state insurance rules.  Federal law imposes a wide range of mandates on group health plans beyond the requirements of Code Section 4980H.  These include additional coverage, benefit, and nondiscrimination rules added to the Employee Retirement Income Security Act (ERISA), the Code, the Public Health Services Act and other provisions of the Social Security Act, by laws like the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), the Health Insurance Portability & Accountability Act (HIPAA), Code health and cafeteria plan nondiscrimination rules, federal laws mandating coverage for breast cancer, newborns and mothers, mental health and substance abuse, ACA’s coverage, benefit, non-discrimination, procedural and other reforms and various other requirements.  Where a group health plan is or is treated as insured, ACA, as well as state insurance regulations impose additional mandates.  Any group health plan must be designed to meet these rules.  Because ACA and state insurance requirements for insured, MEWA and other arrangements subject to regulation as insured group health programs generally mandate that the arrangement meet ACA’s essential health benefit requirements as well as other ACA and state insurance mandates, current federal and state regulations generally make it unlikely that a skinny plan option that qualifies as minimum essential coverage plans can be offered through an insured, a MEWA or other arrangement subject to regulation as an insured program.  Even where the arrangement is self-insured, ACA and other the inclusion of prescription drug or wellness benefits covering a wide range of conditions and treatments along with an otherwise skinny plan design many trigger mental health parity or other mandates often overlooked by brokers and consultants promoting these arrangements. While guidance is still evolving, there also exists a risk that the scope of mandates also can be greater than expected if the skinny plan is offered with an insured “limited benefit” or other insurance benefit arrangement in a manner that is considered integrated with the skinny plan. Furthermore, regardless if the arrangement is insured or self-insured, failure to comply with these mandates can trigger significant liability including in the case of many of these rules, the obligation to self-identify, self-report, self-assess, and pay penalties under Code Section 6039D of a minimum penalty of the greater of $2500 or $100 per day, as well as any other liability as otherwise applies under ERISA and the Code to participants, the IRS and DOL, or both.

Second, even if the arrangement is self-insured, employers, their administrators, brokers, consultants and advisors need to monitor whether the arrangement is discriminatory under the group health plan nondiscrimination rules or cafeteria plan discrimination rules of the Code.  Particularly where it is possible that highly compensated or key employees will enroll in coverage or a richer coverage option, while lower paid workers will forego enrollment or chose the skinny plan over enrolling in a richer minimum value, minimum essential coverage option, an employer must test to determine if the arrangement discriminates in favor of key or highly compensated employees for purposes of Code Section 125.  If so, at minimum, the employer will want to ensure that its cafeteria plan is drafted to require and that discriminatory contributions are recharacterized and reported to highly compensated and key employees as after-tax, taxable contributions.  It also is equally important that the discriminatory status of the arrangement under Code Section 105(h) be considered for a self-insured program and to the extent that the arrangement is discriminatory that income be reported to highly compensated employees as well.  It should be noted that the harsh nondiscrimination rules and draconian liabilities that can result from offering a discriminatory insured group health plan would add nondiscrimination concerns to the challenges of designing an insured skinny plan that could comply with applicable mandates discussed earlier.

Use Care When Considering Or Using Skinny Plan Design

Accordingly, while some employers may benefit from including a properly designed and implemented skinny plan option in their group health plan design, employers need to act carefully to ensure that the design is appropriate and properly integrated and administered. Those considering these plans should use care (a) to ensure that the plan is self-insured and not an insured plan or MEWA subject to ACA’s insurance reforms and/or state mandates; (b) meet all required federal and state mandates; (c) are tested for potential discrimination issues under Code sections 125 and 105(h); (d) are not paired with insurance contracts considered to be excepted insurance policies in a way that is considered integrated to trigger unexpected mandates and costs; and (e) when an employer group has a large group of subsidy-eligible employees, that the offering of a skinny plan doesn’t result in an increase in the employer’s Code Section 4980H liability by triggering the larger Code Section 4980H(b) penalty of $250 per month instead of the smaller Code Section 4980H(a) penalty of $165 per month.

For Advice, Training & Other Resources

If you need assistance monitoring these and other regulatory policy, enforcement, litigation or other developments, or to review or respond to these or other workforce, benefits and compensation, performance and risk management, compliance, enforcement or management concerns, the author of this update, attorney Cynthia Marcotte Stamer may be able to help.

Board Certified in Labor & Employment Law, Past Chair of the ABA RPTE Employee Benefit & Other Compensation Arrangements Group, Co-Chair and Past Chair of the ABA RPTE Welfare Plan Committee, Vice Chair of the ABA TIPS Employee Benefit Plans Committee, an ABA Joint Committee On Employee Benefits Council representative, Past Chair of the ABA Health Law Section Managed Care & Insurance Section, a Fellow in the American College of Employee Benefit Counsel, ABA, and State Bar of Texas, Ms. Stamer has more than 25 years’ experience advising health plan and employee benefit, insurance, financial services, employer and health industry clients about these and other matters. Ms. Stamer has extensive experience advising and assisting health plans and insurers about ACA, and a wide range of other plan design, administration, data security and privacy and other compliance risk management policies.  Ms. Stamer also regularly represents clients and works with Congress and state legislatures, EBSA, IRS, EEOC, OCR and other HHS agencies, state insurance and other regulators, and others.   She also publishes and speaks extensively on health and other employee benefit plan and insurance, staffing and human resources, compensation and benefits, technology, public policy, privacy, regulatory and public policy and other operations and risk management concerns. Her publications and insights appear in the Health Care Compliance Association, Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, the Dallas Morning News, Modern Health Care, Managed Healthcare, Health Leaders, and a many other national and local publications.

You can review other recent human resources, employee benefits and internal controls publications and resources and additional information about the employment, employee benefits and other experience of the Cynthia Marcotte Stamer, PC here. If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information – including your preferred e-mail – by creating or updating your profile www.cynthiastamer.com or by registering to participate in the distribution of these and other updates on our HR & Employee Benefits Update distributions here including:

If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information including your preferred e-mail by creating or updating your profile here. For important information about this communication click here

NOTE:  This article is provided for educational purposes.  It is does not establish any attorney-client relationship nor provide or serve as a substitute for legal advice to any individual or organization.  Readers must engage properly qualified legal counsel to secure legal advice about the rules discussed in light of specific circumstances.

The following disclaimer is included to ensure that we comply with U.S. Treasury Department Regulations.  The Regulations now require that either we (1) include the following disclaimer in most written Federal tax correspondence or (2) undertake significant due diligence that we have not performed (but can perform on request).

ANY STATEMENTS CONTAINED HEREIN ARE NOT INTENDED OR WRITTEN BY THE WRITER TO BE USED, AND NOTHING CONTAINED HEREIN CAN BE USED BY YOU OR ANY OTHER PERSON, FOR THE PURPOSE OF (1) AVOIDING PENALTIES THAT MAY BE IMPOSED UNDER FEDERAL TAX LAW, or (2) PROMOTING, MARKETING OR RECOMMENDING TO ANOTHER PARTY ANY TAX-RELATED TRANSACTION OR MATTER ADDRESSED HEREIN.

©2014 Cynthia Marcotte Stamer. Limited, non-exclusive right to republished granted to Solutions Law Press, Inc. All other rights reserved.


Essential Health Benefit Definition Built On Expensive Mandated Benefit Plan Likely To Be Expensive For Employers, States & Individuals

July 20, 2012

Learn More & Get A 2012 Health Plan Compliance Checkup at 7/24 Health Plan Update WebEx Workshop!

Concerned about how the mandates and costs of  the Patient Protection & Affordable Care Act will impact your corporate and family finances following the Supreme Court’s June 28, 2012 National Federation of Independent Business v. Sebelius ruling upholding the constitutionality of the individual mandate of the Patient Protection & Affordable Care Act (ACA)? Businesses, individuals, states and federal and state Congressional and regulatory leaders others looking for opportunities to manage these costs should carefully scrutinize how the Department of Health & Human Services (HHS) plans to define “essential health benefits” (EHBs).

Essential Health Benefit Determinations Impact Program Designs and Costs

The definition of EHBs is pivotal to determining the benefits required to be offered by payers and purchased by individuals under the Affordable Care Act now as well as when full Affordable Care Act implementation happens in 2014. Of course, the already effective Affordable Care Act’s restrictions on lifetime and annual dollar limitations on EHBs provided under covered health plans and insurance policies already have impacted the plan designs and costs of existing coverages.

Beginning in 2014, the Affordable Care Act will require that all non-grandfathered health plans in the insured individual and small group market and certain covered state and federal programs will cover at least the EHB as defined by HHS. Although the Affordable Care Act does not directly obligate self-insured group health plans, large group market health plans, and grandfathered health plans to design their plan to provide the coverage included in the required EHB package after 3014, the EHB package design also will affect the costs of these plans by prohibiting these plans from imposing annual and lifetime dollar limits on EHBs even though the final process for determining what is an EHB for these employer-sponsored health plan purposes has yet to be finalized.

Furthermore, since the Affordable Care Act currently restricts both insured and self-insured health plans of all sizes from imposing lifetime and annual dollar limits on benefits and services listed in the Affordable Care Act as required EHBs, the statutory list of EHBs already is having significant cost implications for employers and health plans and their health plan designs. These implications will only grow as full implementation of the Affordable Care Act reform occurs in 2014. Thus, the definition of EHB and how it is a key determinant of the ultimate cost of the Affordable Care Act mandates for individuals, employers, insurers, states, the federal government and ultimately taxpayers.

HHS Guidance Promotes Benefit-Rich EHB Program Mandate For States & Individual & Small Group Insured Programs & Policies

The current approach of the HHS to determining the services and benefits for non-grandfathered individual and small group market insured plans and covered state and federal benefit programs will be skewed toward the benefit rich plan design of federal and state employee health plans and benefit mandate-laden small group insurance plans even though the majority of employer sponsored health plans are self-insured plans that contain more limited benefit packages.

The Affordable Care Act directs that the EHB reflect the scope of benefits covered by a “typical employer plan” and cover at least the following general categories of items and services: categories of items and services: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care (Listed EHB).

An overly-rich EHBs definition will require that individual and insured small group employer health plans, insurers, state Medicaid and Exchanges and the federal exchanges provide, and individuals in these programs purchase, a much richer set of benefits than is currently provided to the majority of employees under the self-insured, employer-sponsored health plans under which they are covered when most are struggling to deal with already over-extended budgets.

Although 60% or more of all employer-sponsored health plans nationwide and 82% of plans sponsored by companies employing more than 200 workers are “self-insured” health plans exempt from the obligation to provide the state mandated benefits that apply to insured plans under state insurance regulations, HHS is largely ignoring the practices of these self-insured health plans for purposes of defining the EHBs package that plans and other payers must offer as EHBs.

Unlike insured health plans, self-insured health plans generally are exempted from the obligation to comply with mandated benefits requirements of state insurance laws pursuant to the preemption provisions of the Employee Retirement Income Security Act (ERISA).   Avoidance of the cost of providing state mandated benefits typically is one of the primary reasons that an employer chooses to offer health plan coverage on a self-insured rather than insured basis. Consequently, the care and services covered by self-insured health plans typically are less generous in many respects than those provided by state and federal employee health plans or individual or group health insurance policies regulated by state insurance law.

Even knowing that the majority of employer-sponsored coverage is provided on a self-insured basis and that federal, state, employer and individual budgets are already strained, HHS nevertheless set up the process so that practices of the government employee health programs and state-regulated insurance policies subject to a wide range of state benefit mandates will determine the EHBs package.

Both state-regulated insured health plans and federal and state employee plans generally are loaded with a long list of mandated benefits that self-insured health plans don’t provide or provide only on a more limited basis. Because self-insured plans are exempt from the duty to comply with state insurance mandated benefit regulations, the benefit package provided under a self-insured plan typically is not as extravagant as the benefit package offered by insurance plans required to comply with state benefit mandates or by the federal or state employee health insurance programs paid for with taxpayer dollars, the process ensures a richer EHB package.

More required benefits means more required costs and the required EHB package determines the benefits required.  Thus, HHS’s decision to model the Affordable Care Act’s definition of EHBs upon federal and state employee health plans and insured state policies when the sponsors of those programs already are struggling to pay for the costs of the plush benefit packages dictated by law merely promises to overburden the fiscal resources of these sponsors and the individuals required to participate and contribute to these programs.

Nevertheless, driven by an administration firmly entrenched in the utopian delusions that money is no object when it comes to promising health care benefits, HHS is diligently proceeding on a path to ensure that the benefit-rich, more expensive government employee health plan/state regulated insured plan model determines the required EHBs.

Under the intended process announced by HHS Center for Consumer Information and Insurance Oversight (CCIIO) on December 16, 2011, HHS announced that it would allow each state to decide the EHBs package on a state-by-state by choosing a “benchmark health plan” that meets HHS standards. While HHS touted the decision as allowing states significant choice, as outlined in more detail in the paragraphs that follow, in reality the parameters within which HHS will require states to exercise this choice provides little flexibility for states to control costs by adopting a limited EHB package. Furthermore, final regulations published in the July 20, 2012 Federal Register that define the data that HHS will rely upon to define and update the EHB definition going forward also layout a process that will almost certainly result in a much richer package of EHBs than what most employees covered by self-insured employer or union-sponsored health plans enjoy today.

In December 2011, HHS announced its intention to allowing states the “flexibility” to define EHB on a state by state basis provided that the state’s EHB definition meets minimum standards required by HHS. Under this approach, the benefits and services included in the benchmark health insurance plan selected by the state would be the EHBs package. States in deciding the required EHB package could modify coverage within a benefit category so long as they do not reduce the value of coverage.

To set the EHBs package for its state, HHS intend that a state will decide the benefits and services required in the EHBs package by choosing one of the following programs, (supplemented as necessary to ensure that the benchmark health plan covers each of the 10 categories of benefits listed in the Affordable Care Act) as the benchmark health insurance plan for that state:

  • One of the three largest small group plans in the state by enrollment;
  • One of the three largest state employee health plans by enrollment;
  • One of the three largest federal employee health plan options by enrollment; or
  • The largest HMO plan offered in the state’s commercial market by enrollment.

None of these options would allow for a state to elect for the EHBs package that more closely tailors the more cost-effective, less mandated benefit heavy designs more typically used in the self-insured employer-sponsored programs sponsored by more than 60% of U.S. employers offering employee health insurance coverage. Therefore, individuals covered by individual health insurance and small employers providing coverage through small group market insurance policies can expect to be required to offer a rich benefit package regardless of the state in which they are based.

Concerning which EHB package will apply when a small employer has employees or operates in multiple states, existing guidance specifies that the EHB benchmark for the State in which the insurance policy is issued would determine the EHB for all participants, regardless of the employee’s State of residence.

Individual and small group insurance plans and policies and government benefit programs required to provide essential benefits also should not anticipate that required scope of the required EHB package will narrow over time if HHS proceeds as planned.

The final rule on “Patient Protection and Affordable Care Act; Data Collection To Support Standards Related to Essential Health Benefits; Recognition of Entities for the Accreditation of Qualified Health Plans” (EHB Data Rule) published on July 24, 2012 also does not take into account the practices of self-insured health plans for purposes of defining and updating EHB package.

The EHB Data Rule outlines the data that health insurers offering coverage under qualified health plans pursuant to Health Care Exchanges will be required to collect and report to HHS for HHS to use to determine the definition and update the EHBs package. This final rule also establishes a process for the recognition of accrediting entities for purposes of certification of qualified health plans.

The EHB Data Rule ignores and excludes reference to any data based on self-insured health plan coverage. Instead, in its current form the EHB Data Rule relies only collects data reported by insured plans. Reliance only upon data collected under the EHB Data Rule will further skew the plan design for all plans – insured or self-insured – to be designed in accordance with the more benefit rich mandates of governmental employee plans funded by taxpayer dollars and fully-insured group health plans forced to include a broad range of state benefit mandates in their programs. Consequently, it appears that HHS intends that self-insured employee health plans will be required to provide the same extremely benefit rich EHBs package as required in a fully-insured health plan even though ERISA section 514 bars the states from enforcing state mandates against self-insured plans.

By disregarding the practices of self-insured plans in the current process of setting expectations for the EHB package the planned HHS process for determining the EHB package provides for a much richer and more expensive benefit package than what is provided in the typical self-insured health plan offered by 60% of U.S. employers nationwide.

Implications & Action Items For Employer Plan Sponsors, Insurers, Employers, Individuals & States Concerned About Costs

Because the determination of the EHB package plays such a significant role in determining the premiums and other amounts that employers, individuals, states and taxpayers will have to expend to fund promised benefits, all parties concerned with the need to appropriately manage these and other related costs should push for HHS and the other Departments, as well as members of Congress to insist that the benefits and services treated as EHBs be carefully tailored.

As the history of state mandated benefits already demonstrates, the cost of funding the benefits promised in the program for all parties will increase the more services included in the definition of EHB. With state, employer, individual and the federal government budgets already strained in a tight economy, a utopian definition of EHBs that results in overburdening costs is a luxury that no one can avoid.

Taken together, the final regulations and HHS’s intended approach to allowing states to define essential health benefits on a state-by-state basis promises under the process established by HHS will result in the imposition of a much richer and more expensive required EHB package on individuals that is richer and more expensive than would result if the self-insured group health plan practices and data were included. As a result, states, small group market insurers and their employer customers and the individuals participating in these plans can expect to be required to pay for a more costly package of benefits than might apply if HHS had elected to use a more holistic approach to defining the EHB package that took into account the practices of self-insured employer and union-sponsored health plans.

This outcome certainly is not dictated by the language of the statute. A more balanced definition of EHBs tailored to meet the economic and budget realities of the times certainly is attainable within the current statutory framework without the need for legislative action. Indeed, given that the majority of group health plans are self-insured, many question the appropriateness of HHS’s reliance upon the practices and data of state regulated, mandated benefit laden insured health plans to define the EHB of a “typical employer plan.”  Concerned employers, insurers, and individuals should urge HHS to reconsider its approach and adopt an alternative definition of EHB focused on defining essential in light of the cash-strained times. 

To the extent that the existing regulators are unwilling to temper the zealousness of idealism to meet today’s budget and economic realities, employers, insurers and the individuals who will be required to bear the burden of the resulting costs should pressure Congress to act to clarify the EHB definition so as not to overburden the system.

Self-insured group health plans, large group market health plans, and grandfathered health plans also need to recognize the need to participate in the dialogue. These programs and their employer and union sponsors are still in limbo, awaiting guidance from HHS about what standards HHS will impose for purposes of determining what constitutes an EHB and how this decision will impact their costs and plan design and other implications even as the Affordable Care Act requires them to decide without guidance what EHBs are for purposes of complying with its lifetime and annual dollar limit prohibitions. 

According to a “Frequently Asked Questions on Essential Health Benefits Bulletin” published by HHS earlier this year, the Departments of Labor, Treasury, and HHS still are deciding how they will determine if a self-insured group health plan, a large group market health plan, or a grandfathered group health plan used a permissible definition of EHB for purposes of meeting their responsibilities under the Affordable Care Act. HHS as indicated they are considering deeming the plan’s definition of EHB appropriate if the plan uses “a definition authorized by the Secretary of HHS (including any available benchmark option, supplemented as needed to ensure coverage of all ten statutory categories).

Regardless, until that additional guidance is forthcoming, the need to administer their group health plans in accordance with the already-effective Affordable Care Act restrictions on lifetime and annual dollar limits on EHBs means all affected group health plans that contain any annual limits on benefits, their sponsors and fiduciaries should take steps to ensure that these provisions are supported and administered using an appropriate definition of EHB supported by the necessary analysis and documentation to position the health plan to demonstrate this effort at good faith compliance until HHS issues further clarifying guidance.

Get Health Plan Compliance Check up at 7/24 Health Plan Update

Health plans, their employer and other plan sponsors, fiduciaries, administrators, brokers and consultants and other service providers are invited to get a 2012/2013 Health Plan Compliance Checkup by participating in the Health Plan Update Workshop Solutions Law Press, Inc. is hosting on July 24, 2012 as part of its 2012 Health Plan-U Coping with Health Care Reform Workshop Series beginning with the kickoff program, “2012 Health Plan Update” on July 24, 2012. 

The Workshop offers the opportunity for employer and union health plans, their sponsors, fiduciaries, insurers, administrators and service providers to catch up on the latest requirements and guidelines impacting employer and union sponsored group health plans under ACA and other federal health plan regulations.

The 2012 Health Plan Update Workshop is scheduled for July 24, 2012 from 12:30 P.M.-2:30 P.M. Eastern, 11:30 A.M.-1:30 P.M. Central, 10:30 A.M-12:30 P.M. Mountain and 9:30 A.M-11:30 A.M. Pacific Time.

Participants may choose to attend the live briefing in Addison, Texas or take part via WebEx for a registration fee of $125.00. Texas Department of Insurance Continuing Education Credit and other professional certification credit may be requested by qualifying participant for an added charge.

The Coping With Healthcare Reform: 2012 Health Plan Update Workshop will cover the latest guidance on Affordable Care Act and other federal health plan regulatory changes impacting employment-based group health plans and other key information employer and other group health plan sponsors, group health plans, insurers, plan administrators, fiduciaries, brokers and advisors and others working with these plans need to understand and cope with 2012-2013 ACA and other health plan requirements including:

  • ACA Summary of Benefits And Communications Mandates & Their Implications On Plan Documents, SPDs & Administration
  • ACA Culturally and Linguistically Appropriate Mandates
  • ACA External & Internal Review, ERISA Claims & Appeals, & Other Federal Claim Handling Requirements: What rules apply to which plans? What to do to minimize the impact of changing requirements?
  • ACA “Essential Health Benefit” Rules & Their Implications For Health Plans & Their Sponsors Now & After 2014
  • ACA, ADA & Other Federal Health Plan Nondiscrimination Rules
  • ACA W-2 & Other Federal Reporting, Notice & Disclosure Requirements
  • ACA grandfathered plan status: Do you have it? How do you lose it? What it does for your program?
  • ACA, COBRA, HIPAA, GINA, FMLA, Military Leave, Michelle’s Law & Other Federal Eligibility Mandates
  • Preventive care coverage & wellness program rules under Affordable Care Act, GINA, ADA & other federal regulations
  • Mental health & substance abuse, provider choice & other benefit mandates under ACA, Mental Health Parity & other federal rules
  • Federal Health Plan Notice & Communication Rules
  • ERISA Fiduciary Responsibility, Reporting & Disclosure & Other Rules
  • New HIPAA Privacy Rules & Audits & How Plans & Plan Sponsors Should Respond
  • Consumer Driven Health Plan Communication Strategies
  • Tips To Help Review & Update Plans, Communications, Vendor Agreements & Processes
  • Expected & Proposed ACA & Other Federal Health Plan Rules
  • Practical Strategies For Monitoring & Responding To New Requirements & Changing Rules
  • Participant Questions
  • More

The Supreme Court’s June 28, 2012 National Federation of Independent Business v. Sebelius ruling upholding the health care reform law means health plans, their employer and other sponsors, fiduciaries and administrators, and insurers must quickly update their health plan documents, summary plan descriptions and other communications, administrative procedures, contracts, reporting and other arrangements to meet Affordable Care Act and other federal rules that have, or by plan year end will, take effect pending the full rollout of the law in 2014.  The 2012 Health Plan Update Workshop on July 24, 2012, kicks off a series Solutions Law Press, Inc. is offering to help health plans and their leaders quickly and cost-effectively get up to speed with and respond to these requirements.   Other upcoming programs offered as part of the Health Plan-U 2012 Coping With Health Care Reform Series include:

Claims & Appeals Bootcamp*
July 31, 2012
12:30 P.M.-2:00 P.M. Eastern | 11:30 A.M.-1:00 P.M. Central | 10:30 A.M-12:00 P.M. Mountain | 9:30 A.M-11:00 A.M. Pacific

HIPAA Bootcamp*
August 14, 2012
12:30 P.M.-2:30 P.M. Eastern | 11:30 A.M.-1:30 P.M. Central | 10:30 A.M-12:30 P.M. Mountain | 9:30 A.M-11:30 A.M. Pacific

Health Plan Communications Bootcamp: SBCs, SPDs & Beyond*
August 28, 2012
12:30 P.M.-2:00 P.M. Eastern | 11:30 A.M.-1:00 P.M. Central | 10:30 A.M-12:00 P.M. Mountain | 9:30 A.M-11:00 A.M. Pacific

The Workshops are designed to help health plans, their employer and other sponsors, fiduciaries, administrators, brokers and consultants and others with responsibilities for these plans quickly learn key steps that they may need to take to update and administer their health plans to meet existing and emerging ACA, Employee Retirement Income Security Act (ERISA), Internal Revenue Code (Code) and other federal mandates.

Attorney Cynthia Marcotte Stamer Leads Workshops

The 2012 Health Plan Update and other Coping With Healthcare Reform Workshops in the Solutions Law Press, Inc. Health Plan-U Coping With Health Care Reform Series will be lead by attorney Cynthia Marcotte Stamer. 

A Fellow in the American College of Employee Benefits Counsel, recognized in International Who’s Who, and Board Certified in Labor & Employment Law, Ms. Stamer has 25 years experience advising and representing private and public employers, employer and union plan sponsors, employee benefit plans, associations, their fiduciaries, administrators, and vendors, group health, Medicare and Medicaid Advantage, and other insurers, governmental leaders and others on health and other employee benefit. employment, insurance and related matters.

Also a well-known and prolific author and popular speaker Board Certified in Labor & Employment Law, Ms. Stamer presently serves as Co-Chair of the ABA RPTE Section Welfare Plan Committee, Vice Chair of the ABA TIPS Employee Benefit Committee, an ABA Joint Committee on Employee Benefits Representative, an Editorial Advisory Board Member of the Institute of Human Resources (IHR/HR.com) and Employee Benefit News, and various other publications.

A primary drafter of the Bolivian Social Security privatization law with extensive domestic and international regulatory and public policy experience, Ms. Stamer also has worked extensively domestically and internationally on public policy and regulatory advocacy on health and other employee benefits, human resources, insurance, tax, compliance and other matters and representing clients in dealings with the US Congress, Departments of Labor, Treasury, Health & Human Services, Federal Trade Commission, HUD and Justice, as well as a state legislatures attorneys general, insurance, labor, worker’s compensation, and other agencies and regulators.

A prolific author and popular speaker, Ms. Stamer regularly authors materials and conducts workshops and professional, management and other training on employee benefits, human resources and related topics for the ABA, Aspen Publishers, the Bureau of National Affairs (BNA), SHRM, World At Work, Government Institutes, Inc., the Society of Professional Benefits Administrators and many other organizations. She also regularly serves on the faculty and planning committees of a multitude of symposium and other educational programs.

For more details about Ms. Stamer’s services, experience, presentations, publications, and other credentials or to inquire about arranging counseling, training or presentations or other services by Ms. Stamer, see http://www.CynthiaStamer.com.

Registration, Continuing Education & Other Details

Register Now! The Registration Fee per course is $125.00 per person (plus an additional $10 service fee for each individual seeking Texas Department of Insurance Continuing Education Credit). Registration Fee Discounts are available for groups of three or more. Payment required via website registration required 48 hours in advance of the program to complete registration. Payment only accepted via website PayPal. No checks or cash accepted. Persons not registered at least 48 hours in advance will only participate subject to system and space availability.
Texas Department of Insurance and Other Continuing Education Credit.

All Health Plan-U Coping With Health Care Reform programs are approved to be offered for general certification credit by the Texas Department of Insurance, World At Work and HRCI education credit for the time period offered subject to fulfillment all applicable Texas Department of Insurance requirements, completion of required procedures and payment of the additional service processing fee of $10.00. The HIPAA Bootcamp program is Texas Department of Insurance-approved for 1.5 hours of General Credit and .5 Hours of Ethics Credit. The Texas Department of Insurance possesses the final authority to determine whether an individual qualifies to receive requested continuing education credit. Neither Solutions Law Press, Inc., the speaker nor any of their related parties guarantees the approval of credit for any individual or has any liability for any denial of credit. Special fees or other conditions may apply.

Cancellation & Refund Policies

In order to receive refund credit, written cancellation (either fax or e-mail) must be received at least 48 hours in advance of the meeting and are subject to a $10.00 refund processing fee. Refunds will be made within 60 days of receipt of written cancellation notice.

About Solutions Law Press, Inc.™

Solutions Law Press, Inc.™ provides business and management information, tools and solutions, training and education, services and support to help organizations and their leaders promote effective management of legal and operational performance, regulatory compliance and risk management, data and information protection and risk management and other key management objectives. Solutions Law Press, Inc.™ also conducts and assists businesses and associations to design, present and conduct customized programs and training targeted to their specific audiences and needs. For additional information about upcoming programs, to inquire about becoming a presenting sponsor for an upcoming event, e-mail your request to info@Solutionslawpress.com These programs, publications and other resources are provided only for general informational and educational purposes. Neither the distribution or presentation of these programs and materials to any party nor any statement or information provided in or in connection with this communication, the program or associated materials are intended to or shall be construed as establishing an attorney-client relationship, to constitute legal advice or provide any assurance or expectation from Solutions Law Press, Inc., the presenter or any related parties. If you or someone else you know would like to receive future Alerts or other information about developments, publications or programs or other updates, send your request to info@solutionslawpress.com.

CIRCULAR 230 NOTICE: The following disclaimer is included to comply with and in response to U.S. Treasury Department Circular 230 Regulations. ANY STATEMENTS CONTAINED HEREIN ARE NOT INTENDED OR WRITTEN BY THE WRITER TO BE USED, AND NOTHING CONTAINED HEREIN CAN BE USED BY YOU OR ANY OTHER PERSON, FOR THE PURPOSE OF (1) AVOIDING PENALTIES THAT MAY BE IMPOSED UNDER FEDERAL TAX LAW, OR (2) PROMOTING, MARKETING OR RECOMMENDING TO ANOTHER PARTY ANY TAX-RELATED TRANSACTION OR MATTER ADDRESSED HEREIN. If you are an individual with a disability who requires accommodation to participate, please let us know at the time of your registration so that we may consider your request

©2012 Cynthia Marcotte Stamer. Non-exclusive right to republish granted to Solutions Law Press, Inc. All other rights reserved.

 

Coping With Health Care Reform: 2012 Health Plan Update Workshop July 24, 2012: Register Now!

July 2, 2012

Coping With Health Care Reform: 2012 Health Plan Update

A Solutions Law Press HR & Benefits Workshop

July 24, 2012

10:30 A.M.-Noon Eastern | 11:30 A.M.-1:00 P.M. Central | 9:30 A.M-11:00 A.M. Pacific

Register Now!

Get a 2012/2013 Health Plan Compliance Checkup! 

 Learn Latest About What Your Health Plan Must Do To Meet Patient Protection & Affordable Care Act  (ACA) Summary of Benefits & Communications (SBC), External Review,  Culturally & Linguistically Appropriate, Nondiscrimination,  Mandated Coverage & Benefit & Other Affordable Care Act, As Well As The Latest On ERISA & Other Federal Health Plan Rules!

The June 28, 2012 Supreme Court National Federation of Independent Business v. Sebelius ruling rejecting constitutional challenges to the ACA health care reform law means most health plans, their employer and other sponsors, fiduciaries and administrators, and insurers must rush to update their health plan documents, summary plan descriptions and other communications, administrative procedures and contracts, reporting and other arrangements to meet the requirements of ACA that have, or by year end will, take effect pending the full rollout of the law in 2014.  

Solutions Law Press, Inc. invites you to catch up on the latest requirements and guidelines impacting employer and union sponsored group health plans under ACA and other federal health plan regulations by participating in “Coping With Health Care Reform:  2012 Health Plan Update Workshop on Tuesday, July 24, 2012.   Participants may choose to attend the live briefing in Addison, Texas or take part via WebEx for a registration fee of $125.00.  Texas Department of Insurance Continuing Education Credit and other professional certification credit may be requested by qualifying participant for an added charge.

Learn Latest On 2012/2013 Federal Health Plan Requirements

 The Coping With Healthcare Reform: 2012 Health Plan Update Workshop will cover the latest guidance on Affordable Care Act and other federal health plan regulatory changes impacting employment-based group health plans and other key information employer and other group health plan sponsors, group health plans, insurers, plan administrators, fiduciaries, brokers and advisors and others working with these plans need to understand and cope with 2012-2013 ACA and other health plan requirements including:

  • ACA Summary of Benefits And Communications Mandates & Their Implications On Plan Documents, SPDs  & Administration
  • ACA Culturally and Linguistically Appropriate Mandates
  • ACA External & Internal Review, ERISA Claims & Appeals, & Other Federal Claim Handling Requirements:  What rules apply to which plans?  What to do to minimize the impact of changing requirements.
  • ACA “Essential Health Benefit” Rules & Their Implications For Health Plans & Their Sponsors Now & After 2014
  •  ACA, ADA & Other Federal Health Plan Nondiscrimination Rules
  • ACA W-2 & Other Federal Reporting, Notice & Disclosure Requirements
  • ACA grandfathered plan status:  Do you have it?  How do you lose it?  What it does for your program?
  • ACA, COBRA, HIPAA, GINA, FMLA, Military Leave, Michelle’s Law & Other Federal Eligibility Mandates
  • Preventive care coverage & wellness program rules under Affordable Care Act, GINA, ADA & other federal regulations
  • Mental health & substance abuse, provider choice & other benefit mandates under ACA, Mental Health Parity & other federal rules
  • Federal Health Plan Notice & Communication Rules
  • ERISA Fiduciary Responsibility, Reporting & Disclosure & Other Rules
  • New HIPAA Privacy Rules  & Audits & How Plans & Plan Sponsors Should Respond
  • Consumer Driven Health Plan Communication Strategies
  • Tips To Help Review & Update Plans, Communications, Vendor Agreements & Processes
  • Expected & Proposed ACA & Other Federal Health Plan Rules
  • Practical Strategies For Monitoring & Responding To New Requirements & Changing Rules
  • Participant Questions
  • More

About The Speaker

A Fellow in the American College of Employee Benefits Counsel, recognized in International Who’s Who, and Board Certified in Labor & Employment Law, attorney and health benefit consultant Cynthia Marcotte Stamer has  25 years experience advising and representing private and public employers, employer and union plan sponsors, employee benefit plans, associations, their fiduciaries, administrators, and vendors, group health, Medicare and Medicaid Advantage, and other insurers, governmental leaders and others on health and other employee benefit. employment, insurance and related matters. A well-known and prolific author and popular speaker Board Certified in Labor & Employment Law, Ms. Stamer presently serves as Co-Chair of the ABA RPTE Section Welfare Plan Committee, Vice Chair of the ABA TIPS Employee Benefit Committee, an ABA Joint Committee on Employee Benefits Representative, an Editorial Advisory Board Member of the Institute of Human Resources (IHR/HR.com) and Employee Benefit News, and various other publications.  A primary drafter of the Bolivian Social Security privatization law with extensive domestic and international regulatory and public policy experience, Ms. Stamer also has worked extensively domestically and internationally on public policy and regulatory advocacy on health and other employee benefits, human resources, insurance, tax, compliance and other matters and representing clients in dealings with the US Congress, Departments of Labor, Treasury, Health & Human Services, Federal Trade Commission, HUD and Justice, as well as a state legislatures attorneys general, insurance, labor, worker’s compensation, and other agencies and regulators. A prolific author and popular speaker, Ms. Stamer regularly authors materials and conducts workshops and professional, management and other training on employee benefits, human resources and related topics for the ABA, Aspen Publishers, the Bureau of National Affairs (BNA), SHRM, World At Work, Government Institutes, Inc., the Society of Professional Benefits Administrators and many other organizations. She also regularly serves on the faculty and planning committees of a multitude of symposium and other educational programs.  For more details about Ms. Stamer’s services, experience, presentations, publications, and other credentials or to inquire about arranging counseling, training or presentations or other services by Ms. Stamer, see http://www.CynthiaStamer.com.

Registration, Education Credit & Other Details

REGISTRATION FEE:  Registration Fee $125.00 per person (plus an additional $10 service fee for parties seeking Texas Department of Insurance Continuing Education Credit).  Registration Fee Discounts available for groups of three or more.  Payment required via website registration required 48 hours in advance of the program to complete registration.  Payment only accepted via website PayPal.  No checks or cash accepted.  Persons not registered at least 48 hours in advance will only participate subject to system and space availability.   Register Now!

TEXAS DEPARTMENT OF INSURANCE CONTINUING EDUCATION CREDIT:  This program has been approved to be offered for general certification credit by the Texas Department of Insurance subject to fulfillment all applicable Texas Department of Insurance requirements, completion of required procedures and payment of the additional service processing fee of $10.00.  The Texas Department of Insurance possesses the final authority to decide whether an individual qualifies to receive requested continuing education credit.  Neither Solutions Law Press, Inc. , the speaker or any of their related parties shall have any liability therefore.

OTHER PROFESSIONAL CERTIFICATION OR CONTINUING EDUCATION CREDIT:   HRCI and World At Work certification credit requested and pending.  If you have special continuing education credit needs that you wish us to consider, please let us know.  We are happy to visit with you about our ability to accommodate your request.  Special fees or other conditions may apply. 

CANCELLATION   & REFUND POLICY:  In order to receive credit, cancellation (either fax or mail) must be received at least 48 hours in advance of the meeting and are subject to a $10.00 refund processing fee.  Refunds will be made within 60 days of receipt of written cancellation notice.. DISABILITIES ACCOMMODATION:  If you are an individual with a disability who requires accommodation to take part, please let us know when registering so that we may consider your request.

About Solutions Law Press, Inc.™

Solutions Law Press, Inc.™ provides business and management information, tools and solutions, training and education, services and support to help organizations and their leaders promote effective management of legal and operational performance, regulatory compliance and risk management, data and information protection and risk management and other key management objectives. Our resources include a broad range of   legal, regulatory, compliance, risk management, internal controls and other key information and support to aid management generally as well as industry and discipline specific resources on Management Compliance, Operations & Risk Management; Human Resources, Employee Benefits & Compensation, Health Plans & Insurance; Investigations, Audits & Assessments; Internal & External Controls & Policies; Officer, Directors & Owner Risk Management; Privacy & Other Information Security; Public Policy & Regulatory Oversight; Quality & Process Management; Vendor & Customer Relationship; Event Management; and Other Management & Operations Needs. 

Solutions Law Press, Inc.™ also conducts and assist businesses and associations to design, present and conduct customized programs and training targeted to their specific audiences and needs.  For additional information about upcoming programs, to inquire about becoming a presenting sponsor for an upcoming event, e-mail your request to info@Solutionslawpress.com.

Save The Date & Register For These Upcoming  HR & Benefits Workshops

Solutions Law Press, Inc sponsors many valuable Human Resources and Employee Benefits Workshops. Register or get more information on the following upcoming Health Plan Workshops  Here:

July 24, 2012, Coping With Health Care Reform: 2012 Health Plan Update Workshop

 July 31, 2012, Claims & Appeals Bootcamp

August 14, 2012, HIPAA Bootcamp

 Sponsorships & Other Partnering Opportunities

Solutions Law Press, Inc. offers many sponsorship and other opportunities for consultants, brokers, associations and other organizations to offer our training and other resources to groups and others on preferred terms.  To explore these opportunities, please E-mail cindy@solutionslawpress.com.

Important Information

Solutions Law Press, Inc.™  programs, publications and other resources are provided only for general informational and educational purposes. Neither the distribution or presentation of these programs and materials to any party nor any statement or information provided in or in connection with this communication, the program or associated materials are intended to or shall be construed as establishing an attorney-client relationship,  to constitute legal advice or provide any assurance or expectation from Solutions Law Press, Inc., the presenter or any related parties. If you or someone else you know would like to receive future Alerts or other information about developments, publications or programs or other updates, send your request to info@solutionslawpress.com.  If you would prefer not to receive communications from Solutions Law Press, Inc. send an e-mail with “Solutions Law Press Unsubscribe” in the Subject to support@solutionslawyer.net.  CIRCULAR 230 NOTICE: The following disclaimer is included to comply with and in response to U.S. Treasury Department Circular 230 Regulations.  ANY STATEMENTS CONTAINED HEREIN ARE NOT INTENDED OR WRITTEN BY THE WRITER TO BE USED, AND NOTHING CONTAINED HEREIN CAN BE USED BY YOU OR ANY OTHER PERSON, FOR THE PURPOSE OF (1) AVOIDING PENALTIES THAT MAY BE IMPOSED UNDER FEDERAL TAX LAW, OR (2) PROMOTING, MARKETING OR RECOMMENDING TO ANOTHER PARTY ANY TAX-RELATED TRANSACTION OR MATTER ADDRESSED HEREIN. 

©2012 Solutions Law Press, Inc.  All rights reserved.


HHS Credits Health Reform For Getting Health Coverage For Added 1 Million Young Adults

September 22, 2011

The Department of Health & Human Services is touting the Affordable Care Act as helping 1 million young adults get health coverage.  On September 21, 2011, HHS announced that data from the National Center for Health Statistics at the Centers for Disease Control and Prevention (CDC) showed that the  Affordable Care Act has helped increase the number of young adults who have health insurance.  According to HHS, data from the National Health Interview Survey (NHIS) shows that in the first quarter of 2011, the percentage of adults between the ages of 19 and 25 with health insurance increased by 3.5 percentage points, representing approximately 1 million additional young adults with insurance coverage compared to a year ago.

Under the Affordable Care Act, most group health plans and insurance contracts offering dependent coverage must continue to offer dependent child coverage for children up to age 26.  The obligation to offer dependent child coverage to age 26 generally applies regardless of whether the child is married or otherwise dependent upon the parent for support.  Implementing regulations required group health plans and insurers to notify covered persons of these rights and where applicable, offer opportunities to enroll or re-enroll qualifying adult children not enrolled when the law took affect.  As the implementation of these rules and the governing guidance continues to evolve, employer and other health plan sponsors, plans, insurers, fiduciaries and administrators need to review and update plan documents, contracts, communications and practices to meet new responsibilities and mitigate risks.

For Help With These Or Other Health Plan Or Employee Benefit Matters

If you would like help reviewing or defending your organizations health plan or other insurance or employee benefit, employment, health care or other practices in light of these or other laws, please contact attorney Cynthia Marcotte Stamer.

Immediate past Chair of the American Bar Association (ABA) RPTE Employee Benefits & Other Compensation Group and current Co-Chair of its Welfare Benefit Committee, Vice-Chair of the ABA TIPS Employee Benefits Committee, a council member of the ABA Joint Committee on Employee Benefits, and past Chair of the ABA Health Law Section Managed Care & Insurance Interest Group, Ms. Stamer is recognized, internationally, nationally and locally for her more than 24 years of work, advocacy, education and publications on health and other employee benefit and related workforce, insurance and health care matters. 

A board certified labor and employment attorney widely known for her extensive and creative knowledge and experienced with health benefit and insurance matters, Ms. Stamer continuously advises and assists employee benefit plans, their sponsoring employers, fiduciaries, insurers, administrators, service providers, insurers and others to monitor and respond to evolving legal and operational requirements and to design, administer, document and defend medical and other welfare benefit, qualified and non-qualified deferred compensation and retirement, severance and other employee benefit, compensation, and human resources programs and practices.  She works extensively with plan sponsors, insurers, administrators, technology and other service providers and others to develop and operate legally defensible programs, practices and policies that promote the client’s human resources, employee benefits or other management goals.  Ms. Stamer also is a widely published author and highly regarded speaker on these and other employee benefit and human resources matters who is active in many other employee benefits, human resources and other management focused organizations. 

You can learn more about Ms. Stamer and her experience, review some of her other training, speaking, publications and other resources, and register to receive future updates about developments on these and other concerns from Ms. Stamer here. For important information concerning this communication click here.

About Solutions Law Press

Solutions Law Press™ provides business risk management, legal compliance, management effectiveness and other resources, training and education on human resources, employee benefits, compensation, data security and privacy, health care, insurance, and other key compliance, risk management, internal controls and other key operational concerns. If you find this of interest, you also be interested reviewing some of our other Solutions Law Press resources available at www.solutionslawpress.com

THE FOLLOWING DISCLAIMER IS INCLUDED TO COMPLY WITH AND IN RESPONSE TO U.S. TREASURY DEPARTMENT CIRCULAR 230 REGULATIONS.  ANY STATEMENTS CONTAINED HEREIN ARE NOT INTENDED OR WRITTEN BY THE WRITER TO BE USED, AND NOTHING CONTAINED HEREIN CAN BE USED BY YOU OR ANY OTHER PERSON, FOR THE PURPOSE OF (1) AVOIDING PENALTIES THAT MAY BE IMPOSED UNDER FEDERAL TAX LAW, OR (2) PROMOTING, MARKETING OR RECOMMENDING TO ANOTHER PARTY ANY TAX-RELATED TRANSACTION OR MATTER ADDRESSED HEREIN.

©2011 Cynthia Marcotte Stamer, P.C.  Non-exclusive license to republish granted to Solutions Law Press.  All other rights reserved.


Health Plans, Insurers Get Limited & Imperfect Relief From Grace Period Extension For Some New Affordable Care Act Health Claims & Appeals Rules

March 24, 2011

 The Departments of Labor, Health & Human Services and Internal Revenue Service are extending a previously announced enforcement grace period under which the agencies will not take enforcement against health plans or health insurers that attempt to operate in good faith compliance with, but fail to meet certain new requirements for handing medical claims and appeals enacted as part of the Patient Protection and Affordable Care Act (Affordable Care Act).  While health plans and insurers working in good faith to comply with the new requirements may find the enforcement relief helpful for dealing with some areas of uncertainty about the interpretation of certain requirements, it is important to keep in mind that the enforcement grace period provides only limited and somewhat imperfect relief.  As a result, health plans, health insurers and those responsible for their design and administration are encouraged to continue to move forward on efforts to comply with the new requirement in thoughtful and well-documented manners despite the announced grace period extension.

New Claims & Appeals Requirements & Enforcement Grace Period

As signed into law on March 23, 2010, the Affordable Care Act generally requires that health plans and health insurance policies that are not “grandfathered” to begin complying with a series of new requirements by the first day of the first plan year that begins after September 22, 2010.  These new requirements include a number of new requirements about the way that nongrandfathered health plans and health insurance policies handle medical claims and appeals.  For instance, the Affordable Care Act as construed by the agencies in interim final regulations published by the agencies on July 23, 201 will require that non-grandfathered group health plans and insurers issuing non-grandfathered health insurance plans and policies:

  • Implement specified internal and external review procedures that among other things mandate independent external review of medical judgment based decisions in accordance with the regulations for reviews of appeals of medical judgment based denials;
  • Provide a broad range of new information in notices regarding claims and do so in a culturally and linguistically appropriate manner;
  • Provide continued coverage pending the outcome of an internal appeal; and
  • Comply with a laundry list of additional criteria for ensuring that a claimant receives a full and fair review in addition to complying with the requirements of existing Labor Department claims and appeals procedures.

After the agencies jointly published interim final regulations defining and implementing these requirements on July 23, 2010, last September the agencies announced that they would not enforce certain elements (but not all) of the new requirements set forth in the interim final regulations against covered health plans or health insurers seeking to comply in good faith with the new requirements through July 1, 2011.  In the March 18, 2011 announcement, the Department of Labor said that the agencies now have agreed to extend this reprieve from agency enforcement of the requirements listed in the guidance against plans seeking to comply in good faith with the new requirements until plan years beginning on or after January 1, 2012.

While offering welcome relief, covered health plans and insurers, their sponsors and issuers should not over-estimate the reach and protection provided by this new guidance.  For instance:

  • First, in order to qualify for the enforcement grace period, efforts must be made to administer the health plan or health insurance policy in good faith compliance with the new requirements during the enforcement grace period. 
  • Second, the enforcement grace period provides only limited relief.  The extension to 2012 only four of a series of new requirements set forth in the interim final regulations.  Nongrandfathered plans and their administrators and insurers remain accountable for prudently administering claims and appeals in accordance with all other requirements of the Affordable Care Act as well as pre-existing claims and appeals regulations set forth in 2000 claims regulations issued by the Department of Labor pursuant to the Employee Retirement Income Security Act.
  • Third, the enforcement grace period guidance only means that the agencies will not exercise their power to take action against a non-compliant plan.  It does not prevent plan members, health care providers with benefit assignments or other plan beneficiaries from bringing lawsuits against health plans, health insurers or their administrators for failing to comply with the new requirements during post- September 22, 2010 plan years even if the enforcement grace period otherwise protects the plan or insurer from agency enforcement action.  This means that health insurers and health plans may still run the risk that plan members or beneficiaries will ask courts to reverse claims or appeals denials or impose other penalties and sanctions against plans or their fiduciaries for failing to meet the new requirements for post-September 22, 2010 plan years.
  • Finally, and perhaps most significantly, the grace period guidance requires nongrandfathered plans and insurers to make “good faith” efforts to comply with the requirements covered by the relief during the grace period in order to be eligible to claim the relief offered by the enforcement grace period guidance.

Consequently, despite the relief announced March 18, nongrandfathered health plans still have significant work to do to comply with the new Affordable Care Act claims and appeals requirements even during the announced enforcement grace period.

For Help With Affordable Care Act or Other Employee Benefits or HR Needs

If you have any questions or need help responding to the Affordable Care Act or other any other health plan or insurance employee benefit, compensation, workforce or internal control concerns, please contact the author of this update, Cynthia Marcotte Stamer here or at (469)767-8872.

About Solutions Law Press

Solutions Law Press™ provides business risk management, legal compliance, management effectiveness and other resources, training and education on human resources, employee benefits, data security and privacy, insurance, health care and other key compliance, risk management, internal controls and operational concerns. If you find this of interest, you also be interested reviewing some of our other Solutions Law Press resources including:

If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information – including your preferred e-mail – by creating or updating your profile at here or e-mailing this information here.

©2011 Cynthia Marcotte Stamer.  Non-exclusive right to republish granted to Solutions Law Press.  All other rights reserved.


Affordable Care Act Grandfathered Plan Rules Loosened To Allow Insured Plans Making Some Insurance Changes To Qualify

November 17, 2010

A change to regulations implementing the “grandfathered plan” rules of the Patient Protection and Affordable Care Act (Affordable Care Act) announced yesterday has opened up the possibility that some insured group health plans changing insurers may continue to qualify as “grandfathered health plans” exempted from certain health care reform mandates.  Because policy or insurer changes can create challenges in meeting other conditions required to get grandfathered plan status, however, sponsors and administrators of insured group health plans should prepare to timely comply with all applicable Affordable Care Act mandates unless they have verified their ability to prove that their program meets all requirements to qualify for grandfathered plan status will need to confirm that with or without the insurance-related change.

The Affordable Care Act generally requires that insured and self-insured group health plans and group and individual health insurance policies comply with many new federal mandates beginning with the first day of the plan or contract year that begins after September 22, 2010.  If a group health plan or health insurance policy existed on March 23, 2010 and otherwise qualifies as a “grandfathered health plan,” however, it may qualify as exempted or for a delayed effective date from some but not these new mandates. By shaping the mandates applicable to group health plans, the grandfather rules will impact both the cost and the design of affected group health plans. 

Original Rule About Insurance Changes

Interim Final Regulations issued by jointly by the Departments of Labor, Health & Human Services and Treasury (Agencies) last June established a series of detailed requirements that a group health plan or health insurance policy must meet to qualify as a grandfathered health plan or policy beyond merely existing on March 23, 2010.  As part of these requirements, the Interim Final Regulations identified a number of changes and other events that would disqualify a group health plan or insurance policy as a grandfathered plan. 

In the case of insured group health plans, changing insurance policies or insurers was not an allowable change for a plan desiring to qualify as grandfathered.  As originally interpreted by the Agencies in the Interim Final Regulations, self-insured group health plans were permitted to change third-party administrators without forfeiting grandfathered health plan status as long as the change did not otherwise change the plan terms or design in a way that would disqualify the plan for grandfathered status.  In contrast, however, the Agencies original interpretation stated that entering into a new policy, certificate, or contract of insurance for an insured non-collectively bargained group health plan in and of itself would disqualify the group health plan as a grandfathered health plan.  The modified rule published on November 16, 2010 (Amended Rule) eliminates this distinction in response to public comments received since its publication of the original guidance.

Amended Rule About Insurance Changes

Under the Amended Rule, the same standards now will determine the effect of a change in vendor or contract on the grandfathered health plan status of a group health plan whether the plan is insured or self-insured.  Accordingly, with respect to changes in group health coverage contracts, the Interim Regulations, as modified by the Amended Rule, now provides where insured or self-insured, a group health plan (including a group health plan that was self-insured on March 23, 2010) or its sponsor that enters into a enters into a new policy, certificate, or contract of insurance after March 23, 2010 that is effective before November 15, 2010 generally will cease to be a grandfathered health plan unless the plan meets certain specified conditions.  The group health plan must provide to the new health insurance issuer (and the new health insurance issuer must require) documentation of plan terms (including benefits, cost sharing, employer contributions, and annual limits) under the prior health coverage sufficient to demonstrate that except for the contract change, the group health plan otherwise has not been modified or experienced any other event that would otherwise result in its disqualification for grandfathered health plan status under the Interim Final Regulations as modified by the Amended Rule.

As currently drafted, the relief provided in the Amended Rule does not expressly apply to a change in insurer or insurance contract made by a non-collectively bargained group health plan after November 14, 2010 regardless of whether the change in made before deadline for the group health plan to begin complying with the Affordable Care Act (i.e., the first day of the first plan year beginning after March 22, 2010).  Additionally, the relief set forth in the Amended Rule does not apply to individual health insurance policies.  Where insured coverage is provided not through a group health plan but instead in the individual market, a change in issuer still remains a change in the health insurance coverage after March 22, 2010 that disqualifies the new individual policy, certificate, or contract of insurance for status as a grandfathered health plan for purposes of the Affordable Care Act.

For a more detailed discussion of the grandfathered plan rules and the changes made this week, see here.

For More Information Or Assistance

If you need help reviewing or responding to the grandfather regulations or other health benefit regulations or other related matters please contact Cynthia Marcotte Stamer here or (469) 767-8872. 

About Ms. Stamer

Board Certified in Labor and Employment Law by the Texas Board of Legal Specialization, Chair of the American Bar Association (ABA) RPTE Employee Benefit & Other Compensation Group, a Council Member of the ABA Joint Committee on Employee Benefits, Past Chair of the ABA Health Law Section Managed Care & Insurance Interest Group, management attorney and consultant Cynthia Marcotte Stamer has more than 23 years experience advising and representing employers, health and other employee benefit plans, their sponsors, fiduciaries and plan administrators, consultants, vendors, outsourcers, insurers, governments and others about employment, employee benefit, compensation, and a wide range of other performance, legal and operational risk management practices and concerns.  As a part of this work, Ms. Stamer has worked extensively with clients on health care reforms and regulations under the Affordable Care Act and other federal and state laws.  A prolific author and popular speaker, Ms. Stamer also publishes, conducts client and other training, speaks and consults extensively on GINA and other employment and employee benefit risk management practices and concerns for the ABA, World At Work, SHRM, American Health Lawyers Association, Institute of Internal Auditors, Society for Professional Benefits Administrators, HCCA, Southwest Benefits Association and many other organizations.  Her insights on these and related topics have appeared in Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, Managed Healthcare, Health Leaders, various ABA publications and a many other national and local publications. To learn more about Ms. Stamer, her experience, involvements, programs and publications, see here or contact Ms. Stamer.

Other Resources & Developments

If you found this information of interest, you also may be interested in reviewing other recent Solutions Law Press updates including:

About Solutions Law Press

Solutions Law Press™ provides business risk management, legal compliance, management effectiveness and other resources, training and education on human resources, employee benefits, compensation, data security and privacy, health care, insurance, and other key compliance, risk management, internal controls and other key operational concerns. If you find this of interest, you also be interested reviewing some of our other Solutions Law Press resources available for review here. If you or someone else you know would like to receive future updates and notices about other upcoming Solutions Law Press events, please be sure that we have your current contact information – including your preferred e-mail- by creating or updating your profile at here. For important information concerning this communication click here.

©2010 Cynthia Marcotte Stamer PC.  Reprint Permission Granted To Solutions Law Press. All other rights reserved.


2010 Health Plan Update: Learn What You Must Do Now To Meet Key 2010/2011 Affordable Care Act & Other Federal Health Plan Deadlines

July 23, 2010

August 24, 2010

10:00 A.M.-12:30 P.M. Eastern ¨ 11:00 A.M.- 1:30 P.M. Central ¨ 9:00 A.M-11:30 A.M. Pacific

Solutions Law Press invites you to catch up on the latest guidance about the new group health plan mandates imposed under the Patient Protection and Affordable Care Act (Affordable Care Act) and other federal health plan regulations by participating in a live 2010 Health Plan Update” internet[*] broadcast briefing on Tuesday, August 24 2010.  The briefing will be conducted via live video broadcast from 11:00 A.M.-1:30 P.M. Central Time.  Register here for a registration fee of $150.00[†] per participant.   

Affordable Care Act Requires Prompt Action By Group Health Plans, Sponsors, Fiduciaries & Administrators

The Affordable Care Act and other impending federal health plan changes will require employment-based group health plans, their employer and other plan sponsors, plan fiduciaries, plan administrators and other service providers and insurers to make quick decisions and to act quickly to meet impending federal compliance deadlines while preserving flexibility.  All employer and other group health plan sponsors, fiduciaries, insurers and administrators must act quickly to update their health plan documents, communications, insurance and vendor agreements and other practices to comply with new federal requirements that become effective under the Affordable Care Act on the first day of the plan year beginning after September 22, 2010 and various other changes in federal health plan rules effective or scheduled to take effect during 2010 or 2011 plan years.  Many plan sponsors also may need to act quickly to cancel or revise plan design or vendor changes planned or already implemented since March 23, 2010 to position their health plan to qualify for grandfather status.  Quick action also may be needed to claim small employer tax credits, retiree medical subsidies or other benefits. 

August 24 Live Briefing Provides Key Information By Internet Broadcast

The August 24, 2010 “2010 Health Plan Update” briefing will cover the latest guidance on Affordable Care Act and other federal health plan regulatory changes impacting employment-based group health plans and their sponsors for plan years beginning between September 23, 2010 and September 22, 2011 and other key information to help employers, group health plans, insurers, plan administrators, fiduciaries, broker and others working with these plans to understand and respond to these new requirements.  The briefing will include:

  • How to qualify your health plan as a grandfathered plan under Affordable Care Act
  • How to decide if maintaining grandfathered plan status is worthwhile
  • Claims & appeals requirements for grandfathered & non-grandfathered plans
  • Preventive care coverage mandates & wellness program requirements & rules under Affordable Care Act & other federal regulations
  • Updated dependent child eligibility, pre-existing condition & other requirements for grandfathered & non-grandfathered plans
  • Special enrollment, preexisting condition & other eligibility mandates for grandfathered & non-grandfathered plans under new Affordable Care Act, new FMLA, COBRA, Michelle’s Law, HIPAA & other federal regulations
  • Mental health & substance abuse, provider choice & other benefit mandates under Affordable Care Act, Mental Health Parity & other federal rules
  • Update on other recent & pending Affordable Care Act group health plan rule guidance
  • Tips to review & update your plans, vendor agreements & processes to meet Affordable Care Act & other federal group health plan dictates
  • Expected future Affordable Care Act & other federal rule changes & tips for preparing
  • Practical strategies for responding to new requirements & changing rules
  • Participant questions

About The Presenter

The program will be conducted by attorney Cynthia Marcotte Stamer. With more than 23 years of experience advising employers, group health plans, plan fiduciaries, plan administrators and vendors, insurers and others about health plan and managed care matters, Ms. Stamer is nationally known for her work, publications and presentations on health plan and other employee benefit, health care and insurance matters. 

Current Chair of the American Bar Association (ABA) RPTE Employee Benefit & Other Compensation Committee, a Council Member of the ABA Joint Committee on Employee Benefits and Past Chair of the ABA Health Law Section Managed Care & Insurance  Interest Group, Ms. Stamer continuously advises employers, health plans, plan sponsors, fiduciaries, plan administrators, plan vendors, insurers and others about health program related legal, operational, documentation, public policy, enforcement, privacy, technology, litigation and risk management and other concerns. Ms. Stamer also publishes and speaks extensively on these and other health and managed care program concerns and practices.  Her insights on these and related topics have appeared in Atlantic Information Service, Bureau of National Affairs, World At Work, The Wall Street Journal, Business Insurance, Managed Healthcare, Health Leaders, various ABA publications and a many other national and local publications.  To contact Ms. Stamer or for additional information about Ms. Stamer, her experience, involvements, programs or publications, contact Ms. Stamer at (469) 767-8872 or via e-mail here, or see here.

About Solutions Law Press

Solutions Law Press™ provides business risk management, legal compliance, management effectiveness and other resources, training and education on human resources, employee benefits, compensation, data security and privacy, health care, insurance, and other key compliance, risk management, internal controls and other key operational concerns. If you find this of interest, you also be interested reviewing some of our other Solutions Law Press resources available for review here. If you or someone else you know would like to receive future updates and notices about other upcoming Solutions Law Press events, please be sure that we have your current contact information – including your preferred e-mail- by creating or updating your profile at here. For important information concerning this communication click here.  If you do not wish to receive these updates in the future, send an e-mail with the word   ©2010 Solutions Law Press.   All rights reserved. 


[*] A limited number of participants on a space available basis will have the opportunity to participate in the briefing as a member of the live studio audio audience in Plano, Texas.  Interested persons should e-mail support@solutionslawyer.net.

[†] Discounts available for groups registering three or more participants.  E-mail support@solutionslawyer.net.


Agencies Invite Public To Share Input About Insurer Obligation To Report About Health Premium Use Under Health Care Reform Law

April 14, 2010

April 15, 2010

By Cynthia Marcotte Stamer

The Departments of Treasury (IRS), Labor (DOL) and Health & Human Services (HHS) are inviting public comments in advance of future rulemaking on impending new federal requirements that will obligate health insurance issuers offering individual or group medical coverage to send annual reports to HHS on the percentages of premiums that the coverage spends on  reimbursement for clinical services and activities that improve health  care quality, and to provide rebates to enrollees if this spending does  not meet minimum standards for a given plan year added as Section 2718  of the Public Health Service Act (PHS Act) by the Patient Protection and Affordable Care Act  (PPACA), Public Law 111-148, enacted on March 23, 2010. 

Among other things, the new requirements in Section 2718 of  the PHS Act, Section 715 of the Employee Retirement Income Security Act  of 1974 (ERISA) and Section 9815 of the Internal Revenue Code of 1986  (the Code) will require  health  insurance issuers offering group or individual  coverage to report to HHS annually:

  • The ratio of the incurred loss (or incurred claims) plus the  loss adjustment expense (or change in contract reserves) to earned  premiums (also known as the medical loss ratio (MLR)); and
  • The percentage of total premium revenue–after accounting for collections or receipts for risk  adjustment and risk corridors and payments of reinsurance–that the  coverage spends: (1) on reimbursement for clinical services provided to enrollees; (2) for activities that improve health care quality;  and (3) on all other non-claims costs, including an explanation of the nature of these costs, and excluding Federal and State taxes and  licensing or regulatory fees.

PPACA also requires that HHS make these reports available to the public on the Internet Web site of HHS.  To review the request for comments and its instructions for commenting on the new requirements, see here.

For Added Information or Assistance

If your organization need advice or help with these or other health benefit, labor and employment, employee benefits, compensation or related matters, consider contacting Cynthia Marcotte Stamer at (469) 767-8872 or via e-mail here

Board Certified in Labor and Employment Law by the Texas Board of Legal Specialization, Chair of the American Bar Association (ABA) Real Property, Probate & Trust Section Employee Benefits & Other Compensation Arrangements Group, a Council Member of the ABA Joint Committee On Employee Benefits Council, Past Chair of the ABA Health Law Section Managed Care & Insurance Section, Vice President of the North Texas Health Care Compliance Professionals Association, and Exempt Organization Vice-Coordinator of the Southern States IRS TEGE Council,  , Ms. Stamer has extensive experience advising and representing management about labor and employment, employee benefits, compensation and other related management matters.  A nationally recognized author and lecturer, Ms. Stamer also speaks and writes extensively on these and other related matters. For additional information about Ms. Stamer and her experience or to access other publications by Ms. Stamer see here or contact Ms. Stamer directly.

Other Information & Resources

We hope that this information is useful to you. If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information – including your preferred e-mail – by creating or updating your profile here or e-mailing this information here or registering to receive future editions of our Solutions Law Press HR & Benefits Update distributions here.  Examples of other recent updates that may be of interest include:

For important information about this communication click here.   If you do not wish to receive these updates in the future, send an e-mail with the word “Remove” in the Subject here.

 ©2010 Cynthia Marcotte Stamer. All rights reserved.