March 11, 2013
By David M. Glanstein, Esq.
Starting January 1, 2014, most of the key provisions of the Affordable Care Act – the individual mandate to purchase health insurance or pay a penalty, the expansion of Medicaid eligibility for persons under age 65 with low incomes, and the various state and federal government run health insurance exchanges, are scheduled to be implemented.
For single and multi-employer health plans to comply with the Affordable Care Act when these features will be fully implemented, plan administrators, consultants, and their union and employer trustees need to examine in 2013 how these and other provisions of the law will effect their plans' terms of coverage and cost sharing features.
For example, any multi-employer plans which were "grandfathered" since 2010 will by January 1, 2014 need to eliminate any remaining annual limits on coverage, adopt new claim appeals procedures, and add preventive services which other non-grandfathered plans have already implemented. All health plans must also change their waiting periods for enrollment to no longer than 90 days for eligible employees.
Some other steps which should be taken in 2013 are:
· Reviewing schedules of benefits to ensure that all categories of "essential health benefits" as defined in the law will be covered. For many plans this includes adding preventive care services, mental health and substance abuse benefits (which previously only had to be in parity with other medical benefits if they were offered at all), additional prescription drug coverage without cost sharing, and revised wellness program incentives.
· Reviewing funding mechanisms including cost sharing and deductibles to comply with the new limitations in 2014 on participants' out of pocket expenses. As of now multi-employer plans' lower income participants are not eligible for the premium subsidies that are a central feature of the law.
· Review eligibility rules. Besides full-time and regular part-time employees dependent children will still have to be covered up to age 26, but spouses do not have to be covered.
· Reviewing and updating plan documents to illustrate any new benefits and cost sharing and to enhance claims appeals procedures. Such changes then need to be include in a health plan's 2014 Summary of Benefits Coverage notice before January 1.
· Make sure all fees required under the Affordable Care Act are being collected, such as new covered lives fee to fund the new Patient Centered Outcomes Research Trust Fund. The 2012 payments for calendar year health plans are due by July 1, 2013.
· Maintain adequate records demonstrating that the plan is complying with these and other requirements in case of an audit.
This list could go on, and will get much longer as new agency regulations and guidance continue to be issued about the requirements of the Affordable Care Act later this year and afterwards. With a step by step implementation of these and other requirements of the law, every health plan's representatives can ease their members' anxiety about any changes to their coverage, and insure that their health plans are in full compliance with this historic legislation.
David M. Glanstein is a partner in Glanstein LLP, where he has represented unions and their multi-employer welfare and pension plans more than ten (10) years.