Personal Lines inSights Newsletter

Washing Your Hands Can Stop Infections
The holiday season is often spent with family and friends, so people don’t want to end up bedridden with an illness. And, according to the CDC, 80 percent of common infections are spread through hand contact. That’s why it’s so important to regularly and effectively wash your hands.
When you wash your hands, always use warm, clean water and soap. Water alone simply rinses dirt and germs away, but soap is what prevents them from sticking to your skin. Make sure to lather and scrub all surfaces of your hands for 20 seconds. Then, rinse your hands well, and dry them using a paper towel or air dryer.
When soap and water aren’t available, hand sanitizer can be used to protect yourself from infection. Sanitizing products don’t remove any dirt or residue from your hands, but they do kill 99.9 percent of germs within 15 seconds.
You should always wash your hands at the following times:
• Before eating food
• After using the restroom
• When you’ve been near children
• Before and after you’ve been near someone who is sick
• After coughing, sneezing or blowing your nose

Women’s Preventive Care

From Omni Project, LLC

Health Care Reform: Women’s Preventive Care
The Affordable Care Act (ACA) requires health plans to cover certain preventive care services for participants without any cost-sharing such as deductibles, copayments or coinsurance. This requirement includes additional preventive care for women.
Under the ACA, more types of preventive care must be provided to women than men at no extra cost. This is because women have unique health needs and higher rates of chronic diseases, such as diabetes, heart disease and stroke.
What Is Covered?
Health plans must cover certain additional preventive services with no copay, coinsurance or deductible required from the patient, even if the yearly deductible hasn’t been met. The following items are included in this coverage:
• Well-woman visits (annual preventive care visits in which women under 65 obtain recommended preventive services)
• Gestational diabetes screenings for women 24 to 28 weeks pregnant, and women who are considered high risk
• Human papillomavirus (HPV) testing for women aged 30 and older, once every three years
• Annual counseling for HIV and sexually transmitted infections, plus annual HIV testing for all sexually active women
• Contraceptives and contraceptive counseling. (Certain religious employers, such as churches, are not required to cover contraceptives)
• Breast-feeding support, supplies and counseling
• Domestic violence screening and counseling
A full list of preventive health services for women is available here.
Be sure to check your plan’s specific rules before receiving care. The preventive care rules do not apply to health plans that have “grandfathered” status under the ACA.
Though plans are required to provide these services free of charge, they do have the option of using cost-control measures, such as requiring that a patient pays for a brand name drug even if a comparable generic drug is available, or charging a copayment for preventive services received at out-of-network facilities.

Eating Out Can Be Healthy

EATING OUT CAN BE HEALTHY
Though it may seem like an impossible feat, you can still maintain your diet while enjoying a meal out with friends and family.
Furthermore, it can still be an enjoyable experience.
Since restaurants (especially fast food chains) tend to serve meals with more fat, salt and sugar than a meal prepared at home, it is important to understand what foods to avoid and which ones to select from the menu.
Foods to Avoid
There are many foods full of excess fat and calories that can destroy your healthy diet. Steer clear of these foods while dining out:
• Condiments such as salad dressings, cheese sauces, tartar sauce, gravy and guacamole
• Butter and cheese
• Fried foods such as chicken or French fries
• Beverages such as regular soda, whole milk and various alcoholic drinks
Foods to Try
To make healthier decisions while out enjoying a meal, try some of these foods to keep your diet on track and your waistline thin:
• Soups made with juices and broth versus cream
• Raw vegetables without a marinade
• Fresh fruit
• Steamed seafood
• Poached or boiled eggs
• Salads with low-calorie or fat-free dressing on the side
• Whole-grain breads and crackers
• Baked, boiled and steamed potatoes without sour cream, butter or cheese on top
• Roasted, baked, broiled and grilled meats and poultry
• Diet soda, low-fat or non-fat milk, or water
• Yogurt
• Whole wheat tortillas
General Suggestions
In addition to opting for healthier foods, there are many other things you can do as a restaurant patron to make your dining experience less fattening. First, order your food to go. Research suggests that Americans eat less at home on their own plates than they do in a restaurant. Plus, you can prepare a healthy side dish to accompany the meal you purchased from the restaurant.
Also, avoid buffets whenever possible. They promote over-eating with so many choices and the option to return for seconds and thirds.
In addition, remember that you have the option to special order your meal. Ask the wait staff if the chef can prepare your vegetables with olive oil as opposed to butter, or bake your chicken breast instead of frying it.
Finally, one of the most important proactive approaches to healthy eating you can do is to watch your portion sizes. Restaurant portions are typically double what you would normally eat at home. Either request a smaller portion of the desired meal or ask the wait staff to wrap up half the meal right away and take it home to eat the next day.

Children’s Health: Prescription Drug Safety

CHILDREN’S HEALTH: PRESCRIPTION DRUG SAFETY
While drug abuse is common among teens, a growing trend is the abuse of prescription medications, which can be just as dangerous as illicit drugs, but more readily available. Parents should take precautions to keep their children safe.
Commonly Abused Drugs
A large variety of prescription drugs are abused, including painkillers, depressants (such as sleeping pills), stimulants (such as medications for ADHD or asthma), steroids and more. In addition, over-the-counter (OTC) drugs such as cold medicine and diet pills are often abused by teens.
Risks
Prescription and OTC drugs can be just as dangerous as illicit ones, even though they are either prescribed by doctors or available in stores. These legal drugs can be extremely dangerous when taken in excess, and may cause addiction, serious illness or even death.
It’s unclear if teens choose to abuse prescription and OTC drugs because they think they are safer than other drugs, or simply because they are more available. Many children and teens may try drugs out of peer pressure, curiosity or misinformation. Unfortunately, all parents today need to consider taking steps to keep their medications safe to prevent abuse and misuse.
Precautions
Consider taking the following steps to safeguard against medication abuse in your household:
• Monitor all prescription medications. Pay attention to how many pills are left and how often you expect to refill.
• Explain to kids that all medications should only be taken as instructed by a doctor and/or the label, and that prescription drugs should never be shared.
• Dispose of old medications. If you throw them in the trash, conceal them to discourage individuals from removing them later.
• Talk to your children about the dangers of abusing drugs, and explain that prescriptions and OTCs can be just as dangerous as illegal drugs.
• If you are concerned that someone in your house is abusing prescription or OTC drugs, consider hiding medications or securing them in a locked space.

Bites and Stings

BITES AND STINGS
As you plan for summer picnics, hiking, camping and other outdoor activities, be prepared for encountering bugs. Here are some tips on how to recognize, treat and avoid common bug bites and stings.
Identifying Bites and Stings
Knowing what certain bugs’ bites and stings look like can help you treat them more effectively.
• Bees and wasps—The site of a bee or wasp sting will be red, swollen, and possibly painful or itchy. Wasps sting multiple times, while bees sting only once, leaving their stingers behind. If you are stung by a bee, remove the stinger carefully with a scraping motion to avoid injecting further venom, then disinfect the area. To reduce swelling, apply ice. Acetaminophen can be used to reduce the pain.
• Ants—Ant stings produce itchy lumps, followed by blisters within a few hours. Disinfect the area, and to avoid a bacterial infection, do not break the blister. Oral antihistamines or cortisone creams will reduce itching.
• Mosquitoes—Mosquito bites cause red, itchy bumps. To relieve the itching, apply calamine lotion. For severe swelling, take an oral antihistamine.
• Ticks—Ticks are often embedded in the skin. If a tick is no longer present, the area around the bite may be red. After spending time in wooded areas, thoroughly check yourself for ticks. To remove a tick, place tweezers at its head where it is attached to the skin and gently pull. Disinfect the area. In some regions, ticks may transmit Lyme disease. It is also important to check your pets for ticks after they have been outside. Save the tick in a jar for several weeks so that you can bring it to the doctor or vet if you or your pet become ill.
Seeking Medical Attention
If you exhibit any of the following symptoms, call your doctor immediately:
• Swelling larger than two inches in diameter around the bite site
• Swelling of the face, tongue or throat
• Difficulty breathing
• Chest pain or heart palpitations
• Joint pain
• Muscle stiffness or spasms
• Rash or hives
• Fever, nausea or vomiting
• Severe headaches
Preventing Bites and Stings
The following tactics can be used to avoid bites and stings:

• Limit exposure to high-risk environments such as marshes, stagnant water and heavily wooded areas.
• Avoid outdoor activity during peak mosquito times (dawn, dusk or after a heavy rain).
• Wear light-colored protective clothing such as long pants, long-sleeve shirts, socks and shoes.
• Use caution when drinking from open beverage containers, and keep food covered to avoid ant, bee and wasp stings.
• Keep window screens in good repair.
• Use insect repellent. Be sure to follow directions carefully, especially for use on children.

Preventive Care Coverage Guidelines

Preventive Care Coverage Guidelines
The Affordable Care Act (ACA) requires non-grandfathered health plans to cover certain preventive health services without imposing cost-sharing requirements for the services. This requirement, which generally became effective for plan years beginning on or after Sept. 23, 2010, does not apply to grandfathered health plans. On July 19, 2010, the Departments of Labor (DOL), Health and Human Services (HHS) and the Treasury (the Departments) issued interim final rules relating to coverage of preventive care services.
In August 2011, HHS issued additional preventive care guidelines for women. These additional guidelines, which generally became effective for plan years beginning on or after Aug. 1, 2012, require non-grandfathered health plans to cover women’s preventive health services (such as well-woman visits, breastfeeding support, domestic violence screening and contraceptives) without charging a copayment, a deductible or coinsurance. Special rules regarding contraceptive coverage apply to religious employers, including churches and other religious-based institutions, such as schools, hospitals, charities and universities.
COVERAGE OF PREVENTIVE CARE SERVICES
For plan years beginning on or after Sept. 23, 2010, non-grandfathered group health plans must cover certain preventive care services and may not charge copayments, coinsurance or deductibles for these services when delivered by a network provider. The recommended preventive care services covered by these requirements are:
• Evidence-based items or services that have in effect a rating of A or B in the current recommendations of the United States Preventive Services Task Force;
• Immunizations for routine use in children, adolescents and adults that are currently recommended by the Centers for Disease Control and Prevention (CDC) and included on the CDC’s immunization schedules;
• For infants, children and adolescents, evidence-informed preventive care and screenings provided for in the Health Resources and Services Administration (HRSA) guidelines; and
• For women, evidence-informed preventive care and screening provided in guidelines supported by HRSA (for plan years beginning on or after Aug. 1, 2012).
A list of recommended preventive services is available at: www.healthcare.gov/what-are-my-preventive-care-benefits.
Office Visits
The interim final rules clarify the cost-sharing requirements when a recommended preventive care service is provided during an office visit. Whether cost-sharing requirements may be imposed will depend on:
• Whether the preventive care service is billed or tracked separately; and
• Whether the preventive care service is the primary purpose of the office visit.
Cost-sharing is permitted only if:
• The recommended preventive care service is billed separately (or is tracked as individual encounter data separately) from an office visit; or
• The recommended preventive care service is not billed separately from the office visit and the primary purpose of the office visit is not to obtain the recommended preventive care service.
Cost-sharing requirements are not allowed in cases where the recommended preventive care service is not billed separately, but it is the primary purpose of the office visit.
EXAMPLES
Example 1—An individual covered by a group health plan visits an in-network health care provider. While visiting the provider, the individual is given a cholesterol screening (a recommended preventive care service). The provider bills the plan for an office visit and for the laboratory work of the cholesterol screening test. The plan may not impose any cost-sharing requirements with respect to the laboratory work. Because the office visit is billed separately from the cholesterol test, the plan may impose cost-sharing requirements for the office visit.
Example 2—An individual covered by a group health plan visits an in-network health care provider to discuss recurring abdominal pain. During the visit, the individual has a blood pressure screening (a recommended preventive care service). The provider bills the plan for an office visit. The blood pressure screening was not the primary purpose of the visit. Therefore, the plan may impose a cost-sharing requirement for the office visit charge.
Example 3—A child covered by a group health plan visits an in-network pediatrician to receive an annual physical exam (a recommended preventive care service). During the office visit, the child receives additional items and services that are not recommended preventive services. The provider bills the plan for an office visit. The recommended preventive care service was not billed as a separate charge and was the primary purpose of the visit. Therefore, the plan may not impose a cost-sharing requirement for the office visit.

Additional Clarifications
The interim final rules make clear that plans may continue to impose cost-sharing requirements on preventive care services that employees receive from out-of-network providers. Also, plans may use reasonable medical management techniques to determine the frequency, method, treatment or setting for preventive care services, as long as they are not specified in the recommendation or guideline.
The USPSTF recommends that clinicians ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products. An FAQ issued on May 2, 2014, clarifies what are plans and issuers expected to provide as preventive coverage for tobacco cessation interventions. According to the Departments, evidence-based clinical practice guidelines can provide useful guidance for plans and issuers. The Departments will consider a group health plan or health insurance issuer to be in compliance with the requirement to cover tobacco use counseling and interventions, if, for example, the plan or issuer covers, without cost-sharing:
• Screening for tobacco use; and
• For those who use tobacco products, at least two tobacco cessation attempts per year. For this purpose, covering a cessation attempt includes coverage for:
o Four tobacco cessation counseling sessions of at least 10 minutes each (including telephone counseling, group counseling and individual counseling) without prior authorization; and
o All Food and Drug Administration (FDA)-approved tobacco cessation medications (including both prescription and over-the-counter medications) for a 90-day treatment regimen, when prescribed by a health care provider, without prior authorization.
This guidance is based on the Public Health Service-sponsored Clinical Practice Guideline, Treating Tobacco Use and Dependence: 2008 Update.
WOMEN’S PREVENTIVE CARE SERVICES
On Aug. 1, 2011, HHS issued the HRSA-supported preventive care guidelines for women to fill the gaps in the current preventive health services guidelines for women. According to HHS, these guidelines help ensure that women receive a comprehensive set of preventive health services without having to pay a copayment, a deductible or coinsurance.
Non-grandfathered health plans were required to cover these services without cost-sharing for plan years beginning on or after Aug. 1, 2012 (Jan. 1, 2013, for calendar year plans), subject to the special provisions described below for religious employers. The list of recommended preventive services for women is available through HHS at: www.healthcare.gov/what-are-my-preventive-care-benefits.
According to HHS, health plans may use reasonable medical management techniques for women’s preventive care to help define the nature of the covered service, consistent with guidance provided in the interim final rules. For example, health plans may control costs and promote efficient delivery of care by continuing to charge cost-sharing for brand-name drugs if a safe and effective generic version is available. In addition, the interim final rules confirmed that plans may continue to impose cost-sharing requirements on preventive services that employees receive from out-of-network providers.
CONTRACEPTIVE COVERAGE AND RELIGIOUS EMPLOYERS

Exemption for Churches
In 2011, the Departments provided an exemption from the ACA’s contraceptive coverage requirement for group health plans of certain nonprofit religious employers (such as churches and other houses of worship). Under this exemption, eligible employers offering health coverage may decide whether or not to cover contraceptive services, consistent with their beliefs. A “religious employer” was defined as an employer that:
• Has the inculcation of religious values as its purpose;
• Primarily employs persons who share its religious beliefs; and
• Primarily serves persons who share its religious beliefs.
On July 2, 2013, the Departments published a final rule that simplifies the definition of a “religious employer” as it relates to the contraceptive coverage exemption, effective for plan years beginning on or after Jan. 1, 2013. Under the simplified definition, a religious employer will qualify for the exemption to the contraceptive coverage mandate if it is a nonprofit entity that is referred to in section 6033(a)(3)(A)(i) or (iii) of the Internal Revenue Code. This definition primarily includes churches, other houses of worship and their affiliated organizations.
The simplified definition is intended to clarify that a house of worship is not excluded from the exemption because, for example, it provides charitable social services to, or employs, persons of different religious faiths.
Temporary Safe Harbor
HHS established a temporary enforcement safe harbor for nonprofit organizations that do not provide some or all of the required contraceptive coverage based on their religious beliefs. The enforcement safe harbor is effective for plan years beginning before Jan. 1, 2014. For plan years beginning on or after Jan. 1, 2014, the accommodations approach described below is effective.
Under the terms of the safe harbor, the Departments will not take any enforcement action against employers, group health plans or group health issuers that meet the eligibility criteria for the safe harbor and that fail to cover some or all of the recommended contraceptive services without cost sharing. This safe harbor covers church-affiliated organizations that do not qualify for the exception for non-profit religious employers, such schools, hospitals, charities and universities.
Accommodations Approach
The June 2013 final rule provides accommodations for nonprofit religious organizations that object to contraceptive coverage on religious grounds and do not qualify for the church exemption. The accommodations are effective for plan years beginning on or after Jan. 1, 2014. The temporary safe harbor applies until then.
An eligible organization is one that:
• Opposes providing coverage for some or all of any contraceptive services which are required to be covered on account of religious objections;
• Is organized and operates as a nonprofit entity;
• Holds itself out as a religious organization; and
• Self-certifies that it meets these criteria.
Under the accommodations, eligible organizations do not have to contract, arrange, pay or refer for any contraceptive coverage to which they object on religious grounds. However, separate payments for contraceptive services will be provided to females in the health plan by an independent third party, such as an insurance company or third-party administrator (TPA), directly and free of charge.
The Departments also proposed rules for religious non-profit organizations that are institutions of higher education. If this type of organization arranges for student health insurance coverage, it is eligible for an accommodation comparable to the type available for a religious organization with an insured group health plan.
On June 30, 2014, in Burwell v. Hobby Lobby Stores, Inc. et al., the U.S. Supreme Court created a narrow exception to the contraceptive mandate for closely held for-profit businesses that object to providing coverage for certain types of contraceptives based on their sincere religious beliefs. In light of the Supreme Court’s decision, the Departments issued a proposed rule on Aug. 27, 2014, that would amend the definition of an “eligible organization” for purposes of the accommodations approach under the July 2013 final rule. The amended definition would include a closely held for-profit entity that has a religious objection to providing coverage for some or all of the contraceptive services otherwise required to be covered. This proposed change would extend the accommodations approach available for non-profit entities to group health plans established or maintained by certain closely held for-profit entities with similar religious objections to contraceptive coverage.
Thus, under the proposed rules, a qualifying closely held for-profit entity would not be required to contract, arrange, pay or refer for contraceptive coverage. Instead, payments for contraceptive services provided to participants and beneficiaries in the eligible organization’s plan would be provided or arranged separately by an issuer or a TPA.

Life Insurance

From Omni Project, LLC

Life Insurance
Life insurance isn’t a fun thing to think about, and it may seem like an unnecessary expense. But if you have people who depend on you for financial support, then life insurance is really about protecting them in case something happens to you – your designated beneficiary would collect a financial benefit upon your death. Life insurance can be confusing, so here’s a rundown of the basics.
Types of Life Insurance
Term: This is the simplest and generally the cheapest form. You buy coverage for a specific period of time. It can usually be renewed, but premiums will increase based on age and health factors. There is no cash value.
All other types of life insurance are permanent, but there are several varieties. They all include a savings element that builds cash value, in addition to the death benefit. Once that cash value accumulates, it is accessible to the policyholder tax-free. The following are some of the common types of permanent life insurance.
Whole Life: You purchase this policy to cover your entire life, as long as you keep paying premiums. Premiums remain constant throughout the policy, and the company invests a portion of your premium that becomes the cash value. These are more expensive than term policies in the early years, but they even out because the premium does not increase.
Universal Life: This policy is similar to whole life, but has the potential for higher earnings on the savings component. It is more flexible in terms of changing premiums and face value throughout the policy. There is usually a guaranteed return on the cash value. Disadvantages include higher fees and the possibility of increasing premiums.
Variable Life: A variable life policy generally has fixed premiums, and you have control over the investment decisions for the cash value portion. However, this is riskier because there is not guarantee for the cash value.
How Much to Buy?
Omni Project, LLC offers life insurance as part of our benefit package, but it’s hard to know how much to buy. Many people decide based on an income replacement calculation, between 5 and 10 times the amount of your current income.
Think about your personal circumstances: Is yours the sole income in your household? Are there other expenses, such as college tuition, that may arise in the future? Don’t forget to include potential medical and funeral costs. Above everything, you want to be sure your family does not get stuck with bills, debts or expenses that they cannot afford. Depending on your needs, you may want to consider buying supplementary coverage beyond what Omni Project, LLC offers.
Why Purchase Now?
Buying life insurance may seem unmanageable right now, but it could be a smart decision. Unlike many other benefits, life insurance is actually more affordable right now than in the recent past. Plus, during this tough economic period, ensuring that your family will be financially secure in the future is more important than ever.
If you have more questions about our life insurance benefit, please make an appointment with HR.

How to Choose Quality Health Care

©2007-2009, 2011, 2013, 2014 Zywave, Inc. All rights reserved.
From Omni Project, LLC
Quick Tips:
How to Choose
Quality Health
Care
Quality among health plans, doctors and
hospitals varies a lot in this country. In order
to make informed decisions, you need to
know which ones do a better job than others
at helping you stay healthy and treating you
when you are ill. The tips below will help you
find out how to choose a quality health plan,
doctor and hospital.
Choosing a Health Plan
Your health plan affects many things:
• How much choice you have in your
health care providers
• What kind of care you receive
• Where you will receive your care
• How much you will pay for your care
For this reason, if you have a choice of
health plans, it is vital that you evaluate them
carefully and choose the one that best fits
your needs.
If you’re trying to dig deeper into the quality of your health plan choices, ask the
following questions.
What do current members think of the health plan?
One of the best ways to learn about a plan is to find out what existing members think
about it. This information is called “consumer ratings” or “consumer satisfaction
information.” Consumer satisfaction data is readily available to consumers in the form
of a series of surveys called the Consumer Assessment of Health Plans (CAHPS).
The results of CAHPS surveys are typically summarized into reports to help you
compare health plans and make the best decision.
Ask your employer or the health plan in question if CAHPS surveys are available. If
not, see if there is other consumer information available from your State Department
of Health or insurance commissioner’s office.
Does the plan do a good job of preventing as well as treating illness?
Certain performance and quality measures (how well a health plan actually performs
at helping people) are reported in the Health Plan Employer Data and Information Set
(HEDIS). States, employers, health plans and other groups use the HEDIS data to
prepare and publish reports for consumers. These reports, typically known as report
cards or performance reports, provide a comparison of how well health plans prevent
and treat illness, and may even provide member satisfaction and consumer ratings.
Contact your employer or health plan, or your State Department of Health or
insurance commissioner’s office for HEDIS information on a particular health plan.
Is the plan accredited?
Many plans choose to be reviewed and accredited (given a “seal of approval”) from
various organizations that review and rate health plan quality. Contact the
organizations listed below to see if a plan you are interested in has been accredited.
In order to make informed medical decisions, you need
to know which doctors, hospitals and plans do a better
job than others at helping you stay healthy and treating
you when you are ill.Quick Tips: How to Choose Quality Health Care
• The National Committee for Quality
Assurance (NCQA) evaluates and rates
managed care plans using more than 50
standards. Visit www.ncqa.org to find
out more.
• The Joint Commission evaluates and
accredits all types of health care
organizations. Visit
www.jointcommission.org to learn more.
• The American Accreditation HealthCare
Commission/URAC develops
accreditation standards and programs
for managed care. Visit www.urac.org to
find out more.
Other questions you should ask include:
• Does the plan have the doctors and
hospitals I want or need?
• Does the plan provide the benefits I
need?
• Do the doctors, pharmacies and other
services in the plan have convenient
times and locations?
• Does the plan meet my budget?
Choosing a Doctor
Choosing a quality physician requires a great
deal of care and consideration. If you are
already enrolled in a health plan, your
choices may be limited to doctors in your
plan. However, if you have a choice of plans,
you may want to select your doctor first and
then choose a plan that includes your doctor.
Decide what you want and need in a
doctor.
For example:
• Has he or she been rated highly by a
consumer group?
• Does the doctor have experience with my condition(s)?
• Does he or she have privileges at a certain hospital?
• Is this physician part of my health plan?
Make a list of potential choices.
Check out quality.
• Find out if a consumer or other group has rated the doctors in your area.
• The American Board of Medical Specialties can tell you if a doctor is boardcertified. This means that the doctor has completed a training program in a
specialty and has passed an exam to assess his or her training, knowledge, skills
and experience to provide quality care in that specialty.
• The American Medical Association (AMA) can provide information on training,
specialties and board certification about many licensed doctors in the United
States. Use the DoctorFinder feature on the AMA’s website at www.amaassn.org/.
Contact the doctors’ offices. Be sure the doctor is covered by your plan and is taking
new patients. Ask other relevant questions to determine if the doctor will fit your
needs, such as average wait times for appointments, if the doctor has experience or
specialty in a particular disease, etc. If necessary, ask to speak directly to the doctor
over the phone or in person.
Choosing a Hospital
Research shows that some hospitals simply do a better job than others. Keep the
following questions in mind, even if you don’t have a choice because of health plan or
physician constraints.
Does the hospital meet national quality standards?
Hospitals can choose to be surveyed by the Joint Commission to be sure they make
certain quality standards. These standards address the quality of staff, equipment,
and their success in treating and curing patients. Order free performance reports by
visiting their website at www.jointcommission.org.
How does the hospital compare with others in my area?
Look at hospital reports compiled by your state or by local consumer groups. To find
out what information is available, call your State Department of Health, a local health
care council or local hospital association. Also, don’t hesitate to ask your doctor his or
her opinion about a particular hospital.Quick Tips: How to Choose Quality Health Care
Has the hospital had success with my
condition?
Ask your doctor how often the procedure is
done there, how often the doctor does the
procedure and the success rate. Some
health departments may publish “outcomes
studies” about certain procedures.
How well does the hospital check and
improve on its own quality of care?
Ask the hospital quality management
department how it monitors and improves
the hospital’s quality of care. Also, ask for
any patient satisfaction surveys the hospital
has done.
Consider these additional questions
regarding the hospital:
• Does my doctor have privileges
(permitted to admit and treat patients) at
the hospital?
• Does my health plan cover care at the
hospital?
• Does the hospital have experience with
my condition?
Thoroughly doing your homework when it
comes to the medical care you choose can
pay off in the long run, in terms of cost, and
especially in terms of quality of care.

Kaiser Permanente B2B BCR Resource Guide

Use this navigation bar to explore this resource guide

Health care reform
Helping you navigate changes for your business

Although we have attempted to present accurate information, Kaiser Permanente disclaims any express or implied warranty as to the accuracy of any material contained herein, any liability with respect to it, and any responsibility to update this material for subsequent developments.
As required by the IRS, we inform you that any tax advice contained in this document was not intended or written to be used or referred to, and cannot be used or referred to, (i) for the
purpose of avoiding penalties under the Internal Revenue Code, or (ii) in promoting, marketing, or recommending to another party any transaction or matter addressed herein. Users should consult with their own attorney or tax professional before making tax-related decisions.

Introduction
INTRODUCTION > Q&A > TIMELINE > SMALL BUSINESS CHECKLIST > LARGE BUSINESS CHECKLIST > PROVISIONS >

Health care reform is in full swing now, with many of the major provisions in place. More than 8 million individuals have enrolled in coverage through the health insurance marketplaces. And it’s easier to compare plans now with defined levels of coverage. But there’s still more to come.
We’re here to help as you continue to navigate this constantly changing landscape. In this guide, you’ll find a high-level overview of the primary provisions, things to consider, and steps you may need to take as a result. Use it as a resource to decide about your health care strategy.

Legend
Look for these symbols to see which provisions are most relevant to your business.

Small business (1 to 50 employees; increases to up to 100 employees in 2016)

Large business (51 or more employees, includes labor & trust funds)

Health care industry (implemented by health plans and providers)

Questions & Answers

5 common questions about the Affordable Care Act (ACA)
The ACA affects every business differently. Some regulations are still being defined, and many of the effective dates keep changing. Here are answers to some of the top questions we’re hearing from you.

The ACA doesn’t explicitly require employers to offer coverage to their employees, but employers with 50 or more full-time-equivalent (FTE) employees face potential tax penalties if they don’t offer minimum essential coverage to their full-time employees and child dependents. If you fall into this category and want to avoid penalties, you’ll need to provide minimum essential health coverage starting in 2015 or 2016 (depending on group size and compliance with certain requirements for transitional relief).
Learn more.

1. Do I have to offer coverage to my employees under the ACA?
2. Is my business considered large or small under the ACA?
3. What are “grandfathered” health plans?
4. What’s the excise or “Cadillac” tax?
5. Does the ACA affect the way rates are calculated?

Percentage of employers
who say the ACA is the primary driver behind their health care strategy.*

* Towers Watson/National
Business Group on Health, 2014.

Major milestones

January 1, 2011 — Over-the-counter reimbursements and FSA/HRA/HSA change: Over-the-counter drugs no longer qualify as eligible medical expenses for health payment accounts. More

October 1, 2013 — Health insurance marketplaces: Marketplaces opened in each state, giving small businesses and individuals new options to compare, purchase, and enroll in health plans. More
FSA limit: Employee contributions to health flexible spending accounts (FSAs) were limited to $2,500 annually. More

January 1, 2015 — Employer shared responsibility: Employers with 100 or more FTE employees must offer minimum essential coverage to 70% of full-time employees and certain child dependents up to age 26. More
FSA limit change: Employee contributions to health FSAs increased to $2,550 annually. More

January 1, 2018 — Excise (“Cadillac”) tax: There will be a 40% tax on the “excess benefit” of any employer-sponsored group health plan with premiums that exceed a predetermined level. More

January 1, 2010 — Small business health care tax credit: Businesses with 24 or fewer FTE employees may qualify for a tax credit. More
March 23, 2010 — Grandfathered status: Grandfathered health plans that have had at least one enrollee at all times since March 23, 2010, are exempt from many ACA requirements. More
September 23, 2010 — Dependent child coverage: Young adults can remain on their parents’ group health plan until they turn 26.
Lifetime and annual dollar limits:
The ACA banned lifetime dollar limits on essential health benefits, and annual dollar limits are prohibited for 2014 plans and after. More
No rescissions: Group health plans and insurers can’t retroactively terminate a member’s coverage, except in case of fraud or intentional misrepresentation. More
Preventive care: Commercial nongrand- fathered plans (with some exceptions) must cover certain preventive services with no cost sharing. More

January 2, 2012 — W-2 reporting of benefits: The ACA requires some employers to report the cost of employer-sponsored health benefits on their employees’ W-2 forms. More

January 1, 2014 — Guaranteed availability: For businesses, guaranteed availability provides for continuous open enrollment throughout the year, during which group coverage can’t
be denied on the basis of employee health. More
Rating reforms for individuals and small business: The ACA has defined new standards for individual and small group rates. More
Wellness program rewards: The federal government has established rules that provide incentives for participating in workplace wellness programs. More

January 1, 2016 — Employer shared responsibility: Employers with 50 or more FTE employees must offer minimum essential coverage to 95% of full-time employees and certain child dependents
up to age 26. More
Small business expansion: In states that haven’t already done so, the definition of a small group will be expanded to include employers with up to 100 employees.

Small business checklist

What to consider
As a small business with 1 to 50 full-time- equivalent employees, you realize the importance of investing in the health of your employees.
Choose from the three options below:
1. Continue purchasing group coverage directly from an insurer.
2. Make coverage available to your employees through the Small Business Health Options Program (SHOP).
3. Offer neither group coverage nor access to the SHOP — sending your employees
to the individual marketplace in your state.*

What to do
The actions you need to take depend on your business size and how you plan to prioritize health care as a business strategy in the coming years.
• Decide what you plan to do well in advance of your next renewal:
— If you have a metal plan, decide whether you’ll keep that plan or select a different metal plan.
— If you have a nonmetal plan and have the option to keep that plan, decide whether you’ll keep that plan or choose a metal plan.
— If you have a nonmetal plan and can’t keep that plan, you may be offered a metal plan that most closely resembles your current plan. Decide whether you’ll offer that metal plan or choose a different metal plan.
• If you have 24 or fewer full-time-equivalent employees, evaluate whether you’re eligible for a tax credit. You can carry any eligible health care tax credit back one year.

• If you’re a larger small business with part- time workers — or a subsidiary of a larger organization — you’ll need to determine whether you’re subject to the ACA’s employer shared responsibility regulations.
• Starting in 2015, make sure you’re limiting annual employee paycheck contributions to flexible spending accounts (FSAs) to $2,550.
• Review your current wellness program to make sure you’re maximizing employee rewards. Starting in 2014, the maximum reward for health-contingent wellness programs is 30% of the cost of coverage (with an additional 20% available for pro- grams that reduce tobacco use).
• Get ready for a possible requirement to report the cost of employees’ health benefit coverage on 2014 W-2 forms distributed in January 2015 (employers who filed fewer than 250 W-2 forms for the preceding calendar year are exempt from this requirement until the IRS issues further guidance).

* If you have 50 full-time-equivalent employees, you may be subject to the employer shared responsibility provision.

Large business checklist

What to consider
When planning your renewal strategy, you may want to consider the many provisions that affect large businesses. While the ACA doesn’t officially define a large business, you may be subject to employer shared responsibility if you have 50 or more FTE employees. Use this checklist to help you prepare for upcoming changes:
• For plans beginning in 2015, employers with 100 or more FTE employees must offer minimum essential coverage to 70% of
full-time employees and certain child dependents up to age 26. An exception to this requirement is that if employers don’t currently offer dependent coverage, they won’t be required to provide it in 2015 as long as they’re taking steps to offer it in 2016.
• For plans beginning in 2016, employers with 50 or more FTE employees must offer minimum essential coverage to 95% of
full-time employees and certain child dependents up to age 26.
• If you offer coverage to your full-time employees, it must meet the following

requirements to qualify as minimum essential coverage:
— cover a minimum value of at least 60% of expected costs for a standard population
— limit an employee’s share of the premium contribution for employee-only coverage to 9.5% of the employee’s income*

What to do
• Make sure you’re limiting annual employee paycheck contributions to FSAs to $2,550.
• If your company is subject to the Fair Labor Standards Act, has more than 200 full-time employees, and offers employees at least one health plan, prepare at some point
in the future to automatically enroll new
full-time hires in a coverage option, following any permissable waiting period (no longer than 90 days under the ACA) and/or orientation period. You’ll also have to automatically continue existing selections for current full-time employees from year to year. Employers aren’t required to comply with this provision until regulations are issued and take effect.

• If you filed at least 250 W-2 forms for the previous calendar year, report the cost of employees’ health benefit coverage on W-2 forms distributed in January. If you filed fewer than 250 W-2 forms for the previous calendar year, get ready for a possible requirement to report the cost of employees’ health benefit coverage on W-2 forms distributed in January (employers who filed fewer than 250 W-2 forms for the preceding calendar year are exempt from this requirement until the IRS issues further guidance).
• Review your current wellness program to make sure you’re maximizing employee rewards. Starting in 2014, the maximum reward for health-contingent wellness programs is 30% of the cost of coverage (with an additional 20% available for programs that reduce tobacco use).

* Due to the difficulty in determining household income by an employer, the final regulations indicate that the percentage of household income calculation will be based on whether self-only coverage exceeds 9.5 percent of an employee’s
W-2 wages from the employer for the calendar year. It can also be measured by whether self-only coverage exceeds
9.5 percent of an amount equal to 130 hours multiplied by an employee’s hourly rate of pay, or exceeds 9.5 percent of the Federal Poverty Level divided by 12.

Provision directory

Below is a list of some of the key provisions shaping health care reform for group customers. Select one to view the associated fact sheet. You can return to this page from any fact sheet by clicking on “Provisions” in the navigation toolbar.

Employer shared responsibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

Grandfathered status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Health insurance marketplaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Keeping nongrandfathered plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Lifetime and annual dollar limits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 New fees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Nondiscrimination in eligibility and benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Out-of-pocket (OOP) maximums and accumulation . . . . . . . . . . . . . . . . . . 17 Over-the-counter reimbursements and
FSA/HRA/HSA changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Pre-existing conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Preventive care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20

Rating reforms for individuals and small business . . . . . . . . . . . . . . . . . . . . . . 21 Rescissions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23 Small business health care tax credit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Wellness program rewards 25

Provision fact sheet

Employer shared responsibility

Provision timeline: Groups affected:
2015 2016

At a glance
Employers with 50 or more FTE employees who don’t offer minimum essential coverage to full-time employees and their child dependents will face potential tax penalties. This provision is known as employer shared responsibility.
Originally set to be implemented on January 1, 2014, the IRS extended some transition relief for certain groups in its final regulations on this requirement to give employers additional time to comply:1
• For plans beginning in 2015, employers with 100 or more FTE employees must offer minimum essential coverage to 70% of
full-time employees and certain child dependents up to age 26. An exception to this requirement is that if employers don’t currently offer dependent coverage, they won’t be required to provide it in 2015 as long as they’re taking steps to offer it in 2016.

• For plans beginning in 2016, employers with 50 or more FTE employees must offer minimum essential coverage to 95% of
full-time employees and certain child dependents up to age 26.
• Under the final rules for the provision of employer coverage, foster children and stepchildren aren’t considered dependents who must be offered coverage.
Full-time employees are those who work a monthly average of at least 30 hours a week or 130 hours a month. Part-time employees also count toward the 50-employee threshold, so you’ll need to calculate the number of full-time equivalents (FTEs) that they represent (see sidebar). However, your part-time employees aren’t included in calculations of tax penalties. And part-time employees or child dependents receiving premium subsidies through health insurance marketplaces don’t trigger any tax penalties for you.

Calculating full-time equivalents
You’ll need to calculate how many FTE workers you have to determine if you meet the threshold for the employer shared responsibility provision for any calendar year.* For example, one method is to average your number of employees across the months in the year:
1. Write down the number of full-time employees who average at least 30 work hours a week or 130 work hours in a calendar month.
2. Calculate the number of full-time equivalents by adding total monthly hours of your part-time employees divided by 120.
3. Add these two numbers together to get your total number of FTE employees for the month.
4. Repeat this calculation for every calendar month in the 12-month period.
5. Add all your calendar month totals together. Divide this number by 12 to determine your average monthly FTE employee count.

* Part-time employees also count toward the 50-employee threshold, so you’ll need to calculate the number of full-time equivalents (FTEs) that they represent. However, your part-time employees aren’t included in calculations of tax penalties. And part-time employees or child dependents receiving premium subsidies through individual health insurance marketplaces don’t trigger any tax penalties for you. Also, seasonal employees who work less than 120 days during the year don’t count toward this calculation.

Employer shared responsibility

Provision timeline: Groups affected:
2015 2016

What you need to know
SMALL BUSINESSES
• Small businesses with fewer than 50 FTE employees aren’t subject to employer shared responsibility obligations.
• If you’re a larger small business with part- time workers — or a subsidiary of a larger organization — you may be subject to employer shared responsibility obligations.

LARGE BUSINESSES
Under employer shared responsibility, large group employers can avoid potential penalties by offering minimum essential coverage to FTE employees and their child dependents up to age 26 that:
• covers a minimum value of at least 60% of expected costs for a standard population
• limits an employee’s share of the premium contribution for employee-only coverage to 9.5% of the employee’s income2

If employers don’t offer coverage that complies with these requirements, and any full-time employees (excluding dependents) are certified as eligible to receive financial assistance through the individual marketplace, the employer penalty will be $2,000 multiplied by the number of full-time employees employed for the year minus the first 30 employees.
If employers offer coverage but it doesn’t meet the minimum value or affordability guidelines and employees are then certified as eligible
to receive financial assistance through the individual health insurance marketplace, the employer penalty will be $3,000 per full-time employee certified as eligible to receive a premium tax credit or cost-sharing assistance
— up to a maximum of $2,000 per year for each full-time employee, minus the first 30 employees. This penalty will be calculated calendar month to calendar month.
To determine what your responsibilities are, contact your own legal counsel and tax and financial experts.

Learn more
• IRS Questions and Answers on Employer Shared Responsibility Provisions Under the Affordable Care Act

1 Consult an independent tax advisor or legal counsel to confirm if you qualify for the transitional relief. You can also visit irs.gov for further information.
2 Due to the difficulty in determining household income by an employer, the final regulations indicate that the percentage of household income calculation will be
based on whether self-only coverage exceeds 9.5 percent of an employee’s W-2 wages from the employer for the calendar year. It can also be measured by whether self- only coverage exceeds 9.5 percent of an amount equal
to 130 hours multiplied by an employee’s hourly rate of pay, or exceeds 9.5 percent of the Federal Poverty Level divided by 12.

Grandfathered status

Provision timeline: Groups affected:
2010

At a glance
If you have a commercial plan that has had at least one enrollee at all times since March 23, 2010, and that meets all grandfathering requirements, that plan is grandfathered and is exempt from some ACA requirements.
Grandfathered plans are subject to some ACA mandates, such as those on:
• lifetime and annual dollar limits

• rescissions

• coverage of dependent children until they turn 26
• 90-day waiting period

What you need to know
LARGE AND SMALL BUSINESSES
Keep in mind that if you stop offering a grandfathered plan, you can’t go back to it once you switch to an ACA-compliant plan. If you offer one or more grandfathered plans:
• Include the required statement of grandfathered status in any plan materials provided to a participant or beneficiary that describe the benefits provided under the plan, stating that you believe the plan is a grandfathered health plan as defined by the ACA and providing contact information for questions and complaints.
• Retain, and make available upon request, records documenting the plan terms that were in effect on March 23, 2010, and any other documents that confirm your plan’s grandfathered status. Keep these records as long as you claim a plan to be grandfathered.

• You can add or remove employees and family members to your grandfathered plan without affecting your plan’s status.
• You have the flexibility to change your insurer without losing your grandfathered status.
• Make sure you’re familiar with all the requirements you need to follow to maintain grandfathered status, and what changes could jeopardize that status.
• Plans that are currently grandfathered because they are maintained as part of a collective bargaining agreement ratified before March 23, 2010, are generally able to maintain their grandfathered status through the end of the
bargaining agreement that was in place in 2010.

Learn more
• HealthCare.gov
• Keeping your grandfathered status

Health insurance marketplaces

Provision timeline: Groups affected:
2014 2016 2017

At a glance
On October 1, 2013, health insurance marketplaces opened in each state, giving small businesses and individuals the ability to easily compare, purchase, and enroll in health plans. Each marketplace is operated by either that state’s government, the federal government, or some type of state and federal partnership. The ACA allows for four main levels of coverage within the marketplace — bronze, silver, gold, and platinum — also known as “metal plans.” Each metal level has a different actuarial value
— the percent that the health plan will pay for covered essential health benefits based on the claims of a standard population:1
• Platinum — 90% actuarial value
• Gold — 80% actuarial value
• Silver — 70% actuarial value
• Bronze — 60% actuarial value
For example, a silver plan pays for 70 percent of covered essential health benefit expenses.

The average member pays for the remaining 30 percent through some combination of deductibles, copayments, and coinsurance.
Because the plans within each metal level offer similar coverage of health care expenses, it’s easier for employees to shop for and compare plans. Not all states offer all four levels of coverage.

What you need to know
SMALL BUSINESSES
The marketplace for small businesses is called the Small Business Health Options Program (SHOP).2 Some of the benefits of the SHOP include:
• More choice — The SHOP consolidates the buying power of small businesses to offer more options for affordable health care coverage.
• One-stop shopping experience — Employees can research, compare, purchase, and enroll in primary and ancillary coverage, such as dental and vision, all through the SHOP.

• Easy comparisons — Since all insurers within each metal level are required to offer approximately the same actuarial level of coverage, it will be easy to compare pricing, benefits, and features to make a more informed decision.3
• Less administration — The SHOP will handle enrollment, plan administration, and billing, which will help employers save time and resources.4
• One monthly payment — Employers make only one monthly payment directly to the SHOP (if premium aggregation is available in your state).
• Tax credit — The small business tax credit is only available through participation in the SHOP.

continue >

Health insurance marketplaces

Provision timeline: Groups affected:
2014 2016 2017

LARGE BUSINESSES
• For 2015, the SHOP is only open to groups with up to 50 or 100 employees, depending on the state.
• In 2016, all states will make the SHOP available to groups with up to 100 employees.
• In 2017, states can open their SHOP to even larger employers.

Learn more
• HealthCare.gov

< back 1 The ACA allows a difference of +/- two points for actuarial value percentage. 2 For federally facilitated marketplaces, HHS has delayed implementation of the provision intended to give small business employees the choice of multiple health plan options within each metal level until 2015. The delay is optional for state-operated marketplaces. States may also choose to delay other aspects of the SHOP, including open enrollment. 3 See note 2. 4 Federally facilitated marketplaces will not be handling premium billing until 2015. Keeping nongrandfathered plans Provision timeline: Groups affected: 2014 2015 2016 At a glance In 2013, the federal government announced that individual and small group plans that don’t meet the requirements of the ACA could be extended by carriers for one year. That transitional policy has since been extended to plans issued on or before October 1, 2016. The extension is subject to regulatory approval in each state — and some states have chosen not to provide this transition relief. What you need to know SMALL BUSINESSES Check with your broker or attorney to see if you have the option of renewing your current plan. In states that allow you to keep your nongrandfathered plan, decide if you’ll: • keep your current plan following your group’s renewal date — taking into consideration that it may not meet the current minimum coverage requirements and financial protections under the ACA • select a new ACA-compliant plan LARGE BUSINESSES This transition relief doesn’t apply to large businesses. Learn more • Extension of transitional policy Lifetime and annual dollar limits Provision timeline: Groups affected: 2010 2014 At a glance For grandfathered and nongrandfathered commercial plans (with some exceptions, such as retiree and dental-only plans), the ACA banned lifetime dollar limits on essential health benefits starting with plan years beginning on or after September 23, 2010. Plans can still apply annual and/or lifetime dollar limits on any benefits that aren’t defined as essential health benefits. Annual dollar limits for essential health benefits are also prohibited for plan years beginning on or after January 1, 2014. Lifetime and annual day, visit, and frequency limits are still allowed. What you need to know LARGE AND SMALL BUSINESSES • Nongrandfathered small group plans that were moved to metal level plans starting January 1, 2014, won’t have lifetime or annual dollar limits on essential health benefits. • As of January 1, 2014, nongrandfathered and grandfathered large group plans don’t have lifetime or annual dollar limits on essential health benefits. Learn more • HealthCare.gov New fees Provision timeline: Groups affected: 2012 2014 2018 At a glance New fees on insurers included in the ACA may translate into rate changes. The new fees include: • Health insurer fee — Starting in 2014, this annual fee on insurers will be collected as a percentage of premium. The size of this fee will vary depending on the insurer’s net written premiums. • Patient-Centered Outcomes Research Institute (PCORI) fee — The ACA established a research institute to commission studies on drugs, medical devices, tests, surgeries, and care delivery — with a broad goal of improving the overall quality and efficiency of our nation’s health care system. To help fund this research, health insurers and sponsors of self-funded group health plans will be assessed an annual fee between 2012 and 2019. • Transitional Reinsurance Program Contribution — The ACA created this program to help stabilize the individual market during the first years of the marketplaces. It provides additional payments to insurers that enroll the highest-cost individuals, both on and off the marketplaces. To fund these payments, a fee will be collected from group health plans — including all insurers, self-funded plans, and third-party administrators — from 2014 through 2016. • Excise (“Cadillac”) tax — Starting in 2018, there will be a 40% excise tax on the “excess benefit” of any employer-sponsored group health plan with premiums that exceed a predetermined level. What you need to know LARGE AND SMALL BUSINESSES • PCORI fee — This fee has been included in all rate proposals. — The fee is set to expire in 2019. • Health insurer fee and Transitional Reinsurance Program Contribution — These two new fees were included in your latest rate proposals. — The reinsurance contribution is set to expire by January 2017. • Excise tax on high-cost health plans — Although the excise tax on high-cost health plans doesn’t take effect until 2018, many employers are starting to analyze their benefit programs to find ways to minimize the impact of this new tax. — Customers with collectively bargained plans have a special interest in starting the process to work through any necessary negotiations before the tax takes effect. Learn more • Internal Revenue Service Nondiscrimination in eligibility and benefits Provision timeline: Groups affected: 2010 At a glance The nondiscrimination in eligibility and benefits provision seeks to ensure that benefits offered don’t discriminate among employees. Group plans aren’t allowed to have: • different waiting periods for different classes of employees • different contribution amounts for different classes of employees • carve-out and benefit options that are available to management but not other employees However, employers can continue to charge lower-earning employees lower premiums. As an example, an employee who earns $30,000 can be charged a $30 premium while a similarly situated employee earning $50,000 can be charged a $50 premium without the plan being considered discriminatory. What you need to know LARGE AND SMALL BUSINESSES • You’re responsible for making sure your group complies with nondiscrimination rules. However, there’s currently no established date by which plans must comply with this regulation. The provision was scheduled to be effective the first plan year after September 23, 2010, but has since been delayed pending the release of regulations or other administrative guidance. Learn more • Internal Revenue Service notice Out-of-pocket (OOP) maximums and accumulation Provision timeline: Groups affected: 2014 At a glance Beginning with the 2014 plan year, the ACA requires plan services that are categorized as essential health benefits to accumulate cost sharing to a single OOP maximum. This applies to nongrandfathered large group plans and small group ACA-compliant plans. What you need to know SMALL BUSINESSES Check with your broker or account manager to see how this provision might impact your plan. For example, in California: • prescriptions provided by Kaiser Permanente pharmacy services will accumulate to the OOP maximum for small group ACA-compliant HMO plans • prescriptions provided by MedImpact will accumulate to the OOP maximum for small group ACA-compliant PPO plans LARGE BUSINESSES Starting in 2015, outpatient drugs provided by Kaiser Permanente pharmacy services will accumulate to the Kaiser Permanente medical OOP maximum for nongrandfathered large group plans as contracts renew. If we don’t manage your pharmacy services: • Cost shares for services provided by outside vendors or carriers won’t accumulate to the Kaiser Permanente medical plan OOP maximum. • Services provided by outside vendors or carriers will have separate OOP maximums if the combined amount doesn’t exceed the 2015 annual limitation of $6,600 per individual or $13,200 per family. Learn more • HealthCare.gov • Department of Labor Over-the-counter reimbursements and FSA/HRA/HSA changes Provision timeline: Groups affected: 2011 2013 At a glance As of January 1, 2011, over-the-counter (OTC) drugs or medicines — except prescribed OTC drugs and insulin — no longer qualify as eligible medical expenses for: • flexible spending accounts (FSAs) • health reimbursement arrangements (HRAs) • health savings accounts (HSAs) • Archer medical savings accounts (MSAs) Although Kaiser Permanente doesn’t currently offer MSAs, our members may have accounts through their employers. Also, employee contributions to health FSAs were limited to $2,500 annually for plan years beginning on or after January 1, 2013. On January 1, 2015, the limit was increased to $2,550. In subsequent years, this limit will be indexed to the consumer price index and increase accordingly to account for changes in the cost of living. What you need to know LARGE AND SMALL BUSINESSES • If you offer FSAs, make sure your employees get information from you or your vendor about the stricter reimbursement rules. All members with spending accounts should keep any relevant prescription or other documentation in case the card vendor or IRS requests substantiation. • Members using HSA and Archer MSA debit cards should be extra careful as OTC purchases may go through at the point of sale even if the purchases don’t qualify for reimbursement. Members will be responsible for substantiating their expenses with physician prescriptions, receipts, bills, and any other documentation needed for tax purposes. As of January 1, 2011, nonqualified purchases using HSA or MSA funds are now subject to a 20% tax penalty. • If you offer an FSA, make sure you’ve established a $2,550 limit on your employees’ annual pretax salary contributions. Learn more • Internal Revenue Service • HealthCare.gov • Society for Human Resource Management Pre-existing conditions Provision timeline: Groups affected: 2010 2014 At a glance Effective for plan years beginning on or after September 23, 2010, health plans can’t limit or deny coverage to children under 19 based on pre-existing conditions. A pre-existing condition is a physical or mental condition, disability, or illness diagnosed prior to enrollment. As of 2014, the same protection is now provided to adults. This is also known as guaranteed availability. In addition, guaranteed availability provides businesses with continuous open enrollment throughout the year, during which group coverage can’t be denied on the basis of the health status of employees. What you need to know SMALL BUSINESSES • Under guaranteed availability, insurers can establish minimum contribution and participation requirements for small businesses applying for group coverage. However, insurers must allow for an annual open enrollment period from November 15 through December 15, during which small groups that don’t meet these requirements must be offered coverage upon application. LARGE BUSINESSES • You don’t have any action to take. Learn more • Kaiser Family Foundation* * The Kaiser Family Foundation is a nonprofit, private organization not affiliated with Kaiser Permanente. Preventive care Provision timeline: Groups affected: 2010 2012 At a glance Commercial nongrandfathered plans (with some exceptions, such as retiree and dental-only plans) must cover certain preventive services with no cost sharing for plan years beginning on or after September 23, 2010. The requirement to cover certain women’s preventive services, including contraceptive services, became effective for plan years beginning on or after August 1, 2012. Not all plans are subject to the requirement to cover contraceptive services. What you need to know SMALL BUSINESSES • All new small groups will automatically have our Health Care Reform Preventive Services Package included in their group’s plan. • We added women’s preventive services to your grandfathered and nongrandfathered coverage at your first renewal on or after August 1, 2012. • Adding these services doesn’t affect a plan’s grandfathered status. LARGE BUSINESSES All new large groups will automatically have our Health Care Reform Preventive Services Package included in their group’s plan. For existing groups with nongrandfathered plans, women’s preventive services were added to those plans at their first renewal on or after August 1, 2012. Existing groups with grandfathered plans can purchase the Health Care Reform Preventive Services package without affecting their grandfathered status. If they currently cover health care reform preventive services with no cost sharing, women’s preventive services were added to their coverage at their first renewal on or after August 1, 2012, which doesn’t cause these plans to lose their grandfathered status. Learn more • List of preventive services • HealthCare.gov • U.S. Department of Health & Human Services Rating reforms for individuals and small businesses Provision timeline: Groups affected: 2014 2016 At a glance Beginning for plan years on or after January 1, 2014, the ACA defined new standards for individual and small group rates. Under these standards, health plans must maintain a single risk pool for nongrandfathered coverage in the individual market and another single risk pool for nongrandfathered coverage in the small group market. Health plans will also be required to base rates for nongrandfathered plans in the individual and small group insur- ance markets at the member level using community rating by class. Under these new guidelines, there will be no medical underwrit- ing and health plans will be allowed to vary rates based only on the following factors: • Individual vs. family enrollment — Different rates can be charged based on whether the plan covers only an individual or a family (an individual plus spouse or dependents). • Geographic area — Rates can be higher for people who live in areas with high medical costs. • Age limited to a ratio of 3 to 1 for adults — Older adults can’t be charged more than three times the rate of a younger person. Under this guideline, the HHS has proposed three uniform age bands: — Band 1: child age bands — a single age band from age 0 to 20 — Band 2: adult age bands — one-year age bands from age 21 to 63 — Band 3: older adults — a single age band for age 64 and older • Tobacco use — People who use tobacco products can be charged higher rates, but they can’t exceed more than 1.5 times the rate of a non-tobacco user. A person could achieve nonsmoker status by either being a nonsmoker or, in the small group market, by participating in a smoking cessation program consistent with wellness program require- ments. States can decide not to permit rate restrictions for tobacco use. • Depending on state law, a small employer may request composite rates based on the individual rates for each group member. continue >

Rating reforms for individuals and small businesses

Provision timeline: Groups affected:
2014 2016

What you need to know
SMALL BUSINESSES
• Rates for your Kaiser Permanente small group plans will be quoted based on these regulations.
• These regulations ensure that all employees who apply for coverage in an individual or small group plan can’t be denied coverage based on their medical history or medical condition.
LARGE BUSINESSES
At the moment, most large fully insured and self-funded employers are exempt from this requirement. These requirements will apply to groups of 51 to 100 employees starting in 2016. Beginning in 2017, if a state chooses to
include large groups in its SHOP marketplace, these rating restrictions will then apply to nongrandfathered large commercial groups in the state. Self-funded group health plans would be exempt.

Learn more
• Kaiser Family Foundation — Health Insurance Market Reforms: Rate Restrictions*
• HHS final rule on rate review

< back * The Kaiser Family Foundation is a nonprofit, private organization not affiliated with Kaiser Permanente. Rescissions Provision timeline: Groups affected: 2010 At a glance Group health plans and insurers can’t retroactively terminate a member’s coverage, except in case of fraud or intentional misrepresentation, such as if a person leaves a material fact off the application. In cases of termination that results from fraud or misrepresentation, we’re required to provide the member with 30-day advance notice of the retroactive termination and the right to appeal the rescission decision. During the appeal, coverage remains in effect. In general, when an employer notifies Kaiser Permanente of a member’s retroactive termination within the employer’s contractual limits, it’s not considered rescission. These transactions are usually administrative and reflect routine changes in enrollment. Terminations outside contractual limits are less routine and require additional review to ensure compliance. What you need to know LARGE AND SMALL BUSINESSES • Make sure your employees understand how important it is to be accurate and honest when filling out their applications. Learn more • HealthCare.gov Small business health care tax credit Provision timeline: Groups affected: 2010 2014 At a glance Under the ACA, businesses with 24 or fewer FTE employees may qualify for a small business tax credit of up to 50 percent (35 percent for tax-exempt groups). This tax credit is available to qualified small businesses that participate in the Small Business Health Options Program (SHOP). Small employers can claim the credit for two years beginning in 2014. The maximum credit will be available to employers with 10 or fewer FTE employees and average annual wages below $25,000. Businesses that receive state health care tax credits may also qualify for the federal tax credit. Dental and vision care also qualify for the credit. What you need to know SMALL BUSINESSES The ACA doesn’t require small businesses to offer health insurance. Businesses may qualify for the small business tax credit if they: • have 24 or fewer FTE employees for the taxable year (for example, two half-time employees equal one full-time employee for purposes of the credit) • pay average annual wages below $50,000 • contribute 50% or more toward employee health insurance premiums LARGE BUSINESSES Large businesses aren’t eligible for this tax credit. Learn more • HealthCare.gov • Internal Revenue Service Calculating your tax credit To determine how many full-time-equivalent workers you have: 1. Take the number of full-time employees who work at least 40 hours a week. 2. Calculate the number of full-time-equivalent employees by dividing the total annual hours of your part-time employees by 2,080. 3. Add these two numbers together to get your total number of full-time-equivalent employees. You can also calculate your eligibility using the IRS Small Business Health Care Credit Estimator. Wellness program rewards Provision timeline: Groups affected: 2014 At a glance The U.S. Departments of Health and Human Services, Labor, and the Treasury have established rules that provide incentives for participating in workplace wellness programs. Employees can receive a reward (premium discounts or rebates, lower cost-sharing requirements, extra benefits) that equals up to 30 percent of the total cost of health coverage. This increases to a maximum of 50 percent if they participate in programs to prevent or reduce tobacco use. There are also protections in place to prevent discrimination against employees. What you need to know LARGE AND SMALL BUSINESSES • These rules are effective for plan years beginning on or after January 1, 2014. • Review your current wellness program to make sure you’re maximizing employee rewards. Learn more • Department of Labor final rules

Group Health Insurance Plans

©2014 Zywave, Inc. All rights reserved.
From Omni Project, LLC
Group Health
Insurance
Plans
Making decisions about health insurance
probably isn’t at the top of your list of favorite
things to do. However, health insurance is an
important part of your finances and medical
care, so you want to make an educated
choice about which plan to enroll in. If you
are offered group health insurance through
your employer, you can take advantage of
several benefits.
What Are Group Health Plans?
Group health insurance plans are employerbased plans that offer coverage to a pool of
employees. In contrast, an individual plan is
purchased to cover only one person or
family. The difference between how group
and individual plans are designed affects
your costs.
Why Choose a Group Health Plan?
Group health insurance plans hold several
advantages over individually purchased
health insurance, including lower costs and
convenience.
• Shared risk. Because a group plan
covers multiple people, the risk is spread
out over what is likely a fairly healthy
group of participants. This helps keep
your premium rates lower than individual
plans whose rates are based on individual risk.
• Shared costs. With group coverage, your monthly premium is even lower
because the cost is shared between you and your employer. Employers will pay
varying percentages of coverage, but whatever amount they choose, it reduces
the amount you owe. Depending on your employer’s benefits, you may be
responsible for the full cost of the premium for your enrolled family members, or
your company may choose to contribute to those premiums as well.
• Tax advantages. If you pay health insurance premiums for an employersponsored group health plan, you can pay your premium with pre-tax dollars,
which means you are not taxed on the money that is spent on your premium. This
lowers your taxable income, giving you another financial benefit from group health
coverage. If you are enrolled in an individual health plan, your premium will
typically be paid with taxed dollars.
• Easy enrollment. A huge advantage of group health coverage through your
employer is the ease of enrolling and paying. Your employer will handle the
administrative burden of facilitating coverage, and typically your premiums will be
automatically deducted from your paychecks.
• COBRA. Under certain circumstances, such as voluntary or involuntary job loss,
you have the option to keep your group insurance plan for a certain length of time
under the Consolidated Omnibus Budget Reconciliation Act (COBRA). You will
have to pay more for the premium because your employer is no longer paying a
share of the cost, but it is an option available to you while you work on acquiring
new medical coverage after a job loss or other qualifying circumstance. For more
information on COBRA, visit www.dol.gov/dol/topic/health-plans/cobra.htm.
Group health insurance plans are employer-sponsored
plans that offer you multiple advantages.

Why Are Health Care Costs Rising?

©2013-2014 Zywave, Inc. All rights reserved.
From Omni Project, LLC
Why Are Health
Care Costs
Rising?
Health care costs, and consequently
employee health benefit costs, have been
growing at an alarming rate for nearly a
decade. Employers have seen their health
insurance premiums increase 119 percent
since 1999. Total health insurance costs for
employers could reach nearly $850 billion by
2019. Why are costs rising so high, so fast?
National Health Care Costs
As health care costs climb, the amount your
employer must pay for your health benefits
also increases. Unfortunately, the trend of
health benefit costs rising faster than the rate
of inflation is expected to continue.
Do you know how much your employer pays
for your health benefits? According to the
Hewitt Health Value Initiative, the average
cost of health care benefits for active
employees is expected to climb from
$10,471 in 2013 to $11,176 in 2014. For a
family of four, the cost is about $16,000 a
year.
Unpredictable and uncontrollable health
insurance rate increases are having a very
serious financial impact on many employers
and employees. Employers are also passing
more of these costs onto employees, as the
percentage that employees are asked to pay
is also increasing. In 2013, employees paid an annual average of $2,303; this figure
is projected to grow to $2,499 in 2014 (22.4 percent of the total cost).
Why Are Costs Rising?
Several market conditions working together have led to steep increases.
Understanding these factors will help you be aware of the reasons behind any benefit
or employee contribution (the amount you are required to pay out of your paycheck)
changes your employer decides to make.
Several factors that have contributed to climbing health care costs over the past
decade include:
• Demographics
• Expansion of health care providers
• Consolidation of managed care companies
• Government regulation
• Increased utilization and consumer demand
• New medical technology
• Weakening of managed care system
• Health care spending and medical cost inflation
• Increased prescription drug costs
In addition, Hewitt has identified specific factors that are contributing to the current
health care costs and projected figures that continue to rise:
Unpredictable and uncontrollable health insurance rate
increases are having a very serious financial impact on
many employers and employees.Why Are Health Care Costs Rising?
The Aging of America
According to the U.S. Census Bureau, the
number of Americans age 65 and older is
expected to nearly double by 2025, and the
elderly population (80 and older) will
increase 80 percent. As this population ages,
there is a subsequent rise in the occurrence
of chronic diseases such as asthma, heart
disease and cancer, and the need for more
resources to fight these diseases. This leads
to the increased use of prescription drugs
and other medical services, and an overall
increase in health care spending.
The Dramatic Rise of Prescription Drug
Costs
Prescription drug costs continue to represent
an increasingly large portion of health care
expenditures. According to the Centers for
Medicare & Medicaid Services (CMS),
spending in the U.S. for prescription drugs
was $234.1 billion in 2008, more than six
times what was spent in 1990. In 2012, the
cost growth slowed slightly, reaching $263.3
billion. The U.S. Department of Health and
Human Services projects U.S. prescription
drug spending to reach $457.8 billion in
2019—almost double what it was in 2008.
While prescription drug spending has been a
fairly small proportion of national health care
spending compared to spending for hospital
and physician services, it has been one of
the fastest-growing components, compared
to hospital and physician services.
A number of factors contribute to changes in
prescription drug costs, including the
following:
• Increased use – More people are using more prescription drugs, thereby driving
up spending. In the decade between 1999 and 2009, the number of prescriptions
purchased increased 39 percent, compared to a U.S. population growth of 9
percent.
• Increased prices – Prescription drug prices increased at 3.4 percent in 2009,
although the increase slowed in 2012, only growing 0.4 percent, down from the
2011 growth of 2.5 percent.
• Changes in the types of drugs used – Prescription drug spending is affected when
new drugs enter the market and when existing medications lose patent protection.
New drugs can either increase or decrease overall drug spending, depending on
price and how the new drug relates to existing drugs on the market—e.g.,
replaces a drug, is a new treatment, adds competition, etc. Drug spending is also
typically reduced when brand name drugs lose patent protection and face
competition from new, cheaper generic substitutes.
• Advertising – Prescription use in general and brand-name, higher-priced drugs
can be influenced by advertisements. Critics of direct-to-consumer advertising feel
that promotion of drugs to consumers instead of doctors creates inappropriate
consumer demand and utilization of certain medications.
• Profits – Prescription drug sales were $300.3 billion in 2009, an increase of 5.1
percent over 2008. This increase was more than double the increase from 2007 to
2008. In 2013, a study indicates that prescription sales reached approximately
$326 billion, with increases of 3 to 5 percent projected for the next year.
• Insurance coverage – Individuals with insurance are more likely to use
prescription drugs than those without, and the growing prevalence of managed
care plans—which tend to offer drug benefits—has fueled increased prescription
drug use.
The Consolidation of Insurance Companies
During the economic boom of the 1990s, competition among insurance carriers and
managed care companies was fierce. In order to gain market share, many large
insurance companies acquired smaller, weaker firms and kept their rates low in order
to stay competitive. This practice has taken its toll, leading to dips in profitability and
stock prices for a number of large insurance carriers. Now, those companies that
have survived are faced with much less competition and are committed to returning to
profitability, which has ultimately resulted in increased rates for employers and
contributed to greater cost-sharing for employees.Why Are Health Care Costs Rising?
The Weakening of the Managed Care
System
Also in the 1990s, employers began offering
plans that allowed patients to see out-ofnetwork doctors or those that had less strict
referral processes through benefits, such as
point-of-service (POS) plans. In addition,
many employers making health plan
purchase decisions focused on keeping
employees happy by ensuring that most
doctors in an area were in a chosen network,
rather than choosing narrower networks with
deeper discounts. All of this has led to a
general weakening of the managed care
system. With the level of premium increases
over the last few years, many employers
have backed away from offering such rich
benefits, and instead have implemented a
number of tactics to reduce costs.
Political Environment and Government
Regulation
Health insurance, and more specifically
managed care, is one of the most regulated
insurance sectors on both the state and
federal levels, and has become one of the
most highly debated topics in the political
arena. With the passage of the health care
reform legislation on March 23, 2010, comes
more regulation. Many provisions have taken
effect and more regulations will continue
through the decade.
Increased Utilization and Consumer
Demand
Utilization of many health care services has
risen over the last decade. A number of
factors such as improvements in medical
technology, the influence of managed care,
elevated consumer awareness and demand,
and a boost in the number of practicing physicians caused health services like the
number of surgical procedures and the number of prescription drugs dispensed to rise
significantly. Other services such as breast cancer screenings, immunizations for
children, and diagnostic procedures like CT and MRI have also experienced sharp
utilization increases.
Health Care Spending and Medical Cost Inflation
Overall health care spending and medical cost inflation are also ascending, due to
many of the factors discussed previously.
What Does It All Mean?
Your employer, like others, is undoubtedly trying to determine how to keep
accelerating health plan rates from having a serious financial impact on both
employees and the company. Many firms absorbed the increasing costs for years to
avoid further burdening their employees. Now, most are realizing that they will have to
pass portions of the costs on to employees in the form of greater contributions from
their paychecks, or benefit designs that require them to pay more out-of-pocket for
the medical services they use through increased coinsurance, copayments or
deductibles.
Sources: National Coalition on Health Care, U.S. Census Bureau, Centers for
Medicare & Medicaid Services, IMS Health, U.S. Department of Health and Human
Services.

Compare Your Health Care Options

Compare Your
Health Care
Options
Improve Your Quality of Care With These
Resources
The Affordable Care Act (ACA) makes many
changes to the health care system in an
effort to control costs, but that is not its only
objective. ACA was also designed to
improve quality of care for patients.
The Department of Health and Human
Services (HHS) maintains a website,
www.healthcare.gov, with information
regarding the health care reform law. The
site includes links to resources that help you
compare health care facilities near you
based on a number of quality-of-care
measures. These tools allow you to find
facilities compatible with your medical needs
and expectations.
Compare Hospitals
Find hospitals near you and compare them
based on a number of factors, including
processes, outcome of care, surveys of
patients’ experiences and more. You can
also filter your search by particular
conditions or procedures in order to find the
hospital that is best for your specific needs.
Compare Nursing Homes
This tool provides information for every
Medicare- and Medicaid-certified nursing
home in the country. Find and compare
nursing homes based on quality ratings,
health inspection results, nursing home staff
data and fire safety inspection results. Plus, this site offers other resources to help
you choose the right nursing home or learn more about alternatives to nursing homes.
Compare Home Health Agencies
This link allows you to compare home health services such as skilled nursing care,
physical therapy, medical social services, home health aide services and more. Find
agencies that provide the specific services you need, and then compare them based
on various quality measures such as pain management, treatment and preventive
practices.
Compare Dialysis Facilities
Here you can access resources regarding chronic kidney disease, dialysis and
choosing a dialysis facility. You can also find dialysis facilities near you and compare
them based on services provided and quality measures.
Compare Physicians
This tool allows you to compare physicians based on different qualities, including
specialty, clinical training, languages spoken and more.
Get Started Today
To get started choosing the best facility for your health care needs, visit the health
care provider information section of healthcare.gov and click on the appropriate link.
These resources allow you to compare facilities and
find one that is compatible with your medical needs
and expectations of care.

Find out if you qualify for Financial Assistance to help pay for your health insurance

TM Financial Assistance
Find out if you qualify for
to help pay for your health insurance
Got questions? We can help.
Avoid a tax penalty and ensure your coverage for 2016 by enrolling prior to January 31, 2016.
* All numbers are estimates. For more information, please visit the Shop&Compare Tool on CoveredCA.com
For coverage effective on… Complete enrollment by… First payment must be received by…
December 15, 2015
January 31, 2016
January 15, 2016
December 28, 2015
February 24, 2016
January 26, 2016
January 1, 2016
March 1, 2016
February 1, 2016
See if you may be eligible for financial assistance:
Enrollment deadlines
Number of people
in your household
1 2 3 4 5
If your 2016 household
income is less than…
If your 2016 household
income is between…
$16,243
$27,725
$39,206
$16,243 – $47,080
$27,725 – $80,360
$39,206 – $113,640
$21,984
$33,466
You may be eligible
for Medi-Cal
$21,984 – $63,720
$33,466 – $97,000
You may be eligible for fnancial
help to purchase insurance
through Covered California
Covered California™ is the state’s
destination for quality, affordable
health care.
As part of the national health care
law (also called the Affordable
Care Act), Covered California
is a program from the state
of California where most legal
residents of California and their
families can compare quality
health plans and choose the one
that works best for their health
needs and budget. Covered
California is the only place where
you can get fnancial help to pay
for your health insurance.
Your notes:ayuda económica
Entérate si puedes calificar para
en la compra de tu seguro de salud
¿Tienes preguntas? Te podemos ayudar.
Para que la cobertura
empiece el…
Completa tu inscripción en
o antes del…
El primer pago se debe recibir
en o antes del…
15 de diciembre de 2015
31 de enero de 2016
15 de enero de 2016
28 de diciembre de 2015
24 de febrero de 2016
26 de enero de 2016
1o de enero de 2016
1o de marzo de 2016
1o de febrero de 2016
Entérate si puedes calificar para ayuda económica:
Fechas límite para inscribirte
Número de personas
en tu hogar
1 2 3 4 5
Si tu ingreso familiar
en 2016 es menor de…
Si tu ingreso familiar
en 2016 es entre…
Podrías califcar para
obtener Medi-Cal
Podrías califcar para ayuda
económica en la compra de un
seguro de salud a través de
Covered California
Covered California™ es el
sitio del estado para
obtener cobertura de salud
de calidad a bajo costo.
Como parte de la ley de cuidado
de salud nacional (también
conocida como Ley de Cuidado
de Salud a Bajo Precio), Covered
California es un programa del
estado de California donde la
mayoría de los residentes legales
de California y sus familiares
que califquen pueden comparar
planes de salud de calidad y
elegir el que mejor se adapte
a sus necesidades de salud y
presupuesto. Covered California
es el único lugar donde puedes
obtener ayuda económica
para ayudar a pagar por tu
seguro de salud.
Tus apuntes:
TM
$16,243
$27,725
$39,206
$21,984
$33,466
$16,243 – $47,080
$27,725 – $80,360
$39,206 – $113,640
$21,984 – $63,720
$33,466 – $97,000
*Las cantidades son sólo estimaciones. Para más información, visita la herramienta
de buscar y comparar en CoveredCA.com/espanol
Evita una multa y asegura tu cobertura para el 2016 inscribiéndote antes del 31 de enero de 2016.

Pay is the Right Play for Many Employers

White Paper Continues >
Pay is the Right Play for Many Employers
Think back to 2010. Remember all that effort you spent planning out pay or play scenarios for ACA
mandates? How many conference talks focused on it? That conversation was very important as employers
who had always provided major medical benefits began to wrestle with the law. The most proactive employers
made their decisions and began solving for ACA way back then. The least proactive got hit by the mandate in
the last year. Now, the final group of employers (those with 50-99 employees) will be forced to act this fall if
they have not done so already.
Looking For A Solution
In most cases, the employers who are struggling are those who have never offered coverage and are trying
like mad to figure a way out. We have variable hour tracking, affordability calculations and eventually selffunded plans that exclude hospitalization (let’s call it the calculator mistake). We also have MEC plans, which
have been widely used by employers who used to offer nothing.
Then, there are the penalties. These things worked. We have seen many an employer and broker break their
necks to avoid a penalty. This was the wrong approach. Fortunately, more CFOs are getting involved, and
companies are looking at bottom-line numbers. When looking to provide the best coverage at the right price
for a group of employees who had never been offered coverage, the key may lie in what an employer doesn’t
offer.
What Do Employees Really Want?
Numerous surveys have shown employee health benefits satisfaction dropping steadily. Mercer reported that
only 30% of employees thought their health package was “definitely worth it” in 2014 (from 45% in 2011).i
Towers Watson’s “2013/2014 Global Benefit Attitudes Survey” indicated that from 2007 to 2013, satisfaction
among all age groups declined by 10% to a new low of 59% in 2013.ii Many commentators have attributed
this deepening frustration to “cost shifting” (increasing employee premiums, copays and deductibles), narrow
networks and restricted drug formularies, all of which make obtaining care more difficult.
Major Medical Isn’t Always The Right Answer
What is new, and possibly revolutionary, is that employers who add major medical coverage may actually be
contributing to the dissatisfaction of their employees. Employers who pay more to comply with the Affordable
Care Act (ACA) and actually offer health coverage may, in fact, be leaving their low wage employees with a
reduced benefit that costs more each month than what they could in an exchange marketplace. Industries
with low or middle wage employees, specifically temporary staffing, restaurant and retailers have not
historically offered major medical insurance. These uninsured hourly employees, sometimes nicknamed the
“unbenefited,” were directly target by the Affordable Care Act (ACA) with the purported goal of offering
medical insurance comparable to that offered at a middle or high wage firm like Google, Boeing or federal or
state employers.White Paper – Pay is the Right Play for Many Employers
The American Worker
Copyright © 2015. The American Worker provided by Fringe Benefit Group
www.theamericanworker.com / 800.551.3424
Read The Fine Print
The following key facts are helpful in understanding how to navigate these issues:
1. The state exchanges and federally facilitated marketplace (FFM) were designed to provide a place to
obtain coverage to individuals who were not offered insurance by their employer.
2. Employees who have coverage from their employer that is both “affordable” (e.g. less than 9.5% of
box 1 income) and “minimum value” (60% actuarial value) are not eligible for any subsidies for
themselves or their dependents.
3. Over 86% of individuals who obtained coverage from an exchange have received an Advance
Premium Tax Credit (APTC) or health plan “subsidy.”
4. Individuals who receive a subsidy in excess of what they qualify for must repay the excess advance
payments on their next tax return.iii
5. According to the U.S. Bureau of Labor Statistics, fast food cooks earn a mean annual wage (MAW) of
$18,870, dishwashers earn $19,490 and waiters and waitresses earn $21,390.iv The list goes on, but
employees who earn up to 400% of the poverty level are eligible for a subsidy.
6. ACA has two primary employer penalties: “A” and “B” under section 4980H.v Put simply, the “A”
penalty is for large employers (over 100 full time equivalent (FTE) in 2016 and 50 FTE employees in
2016) for not offering minimum essential coverage. This “A” penalty costs $167 per employee per
month who was not offered Minimum Essential Coverage (“MEC”). The “B” penalty is $250 per
employee per month who received subsidized coverage.
7. MEC has been defined as preventive care benefits that were mandated U.S. Preventive Services
Task Force (USPSTF).vi Currently, there are 63 items for both adults and children that must be
covered in order for a plan to be considered to meet MEC. These items include, immunizations,
mammograms and screening all adults for HIV, Colorectal Cancer, blood pressure, depression and
alcohol misuse.
Take the following scenario as an example. An employer has not offered coverage historically so an
employee goes out to the Federally Facilitated Marketplace (FFM) and obtains individual coverage that is
subsidized. Most individuals have enrolled in “Silver” level plans (70% of the actuarial value with respect to
essential benefits) since they typically offer the best value. A plan costs $711.25, but the employee receives
an Advance Premium Tax Credit (APTC) of $665 per month, resulting in direct pay costs of $46.25 per month.
By contrast, according to the Kaiser Family Foundation, an average employer sponsored high deductible plan
(60% actuarial value), will cost employers $366 and the employee $75 per month, respectively, on average.
Weighing Deductibles And Subsidies
For less than $11 per week, the employee has a plan that has a deductible that is approximately 2/3 the cost
of their employer’s high deductible plan, which also costs 57% more. It is not surprising that many employees
will opt for the better coverage that costs less. Exacerbating this is the fact that many employers have not
been clear about the fact that the employee loses their subsidy once given an opportunity to enroll in the
employer’s compliant plan. If the employee does not correctly dis-enroll from the exchange-based individual
plan, any subsidy that was incorrectly provided will be clawed back by the IRS at tax time the following year.
In the example above, $665 over six months would equal a tax bill of nearly $4,000!White Paper – Pay is the Right Play for Many Employers
The American Worker
Copyright © 2015. The American Worker provided by Fringe Benefit Group
www.theamericanworker.com / 800.551.3424
Exchange Based Plan Employer Plan
Actuarial Value (AV) Silver Level (70%) “Bronze comparable” (60%)
Out-of-pocket Maximum (annual) $3,200 – $4,200 (income based) $6,250 HDHP
Employer Cost (annual) $3,000 (4980H(b) penalty) $4,394
Employee Cost (annual) $555 $905
Total Employer & Employee Cost $3,555 $5,299
What then is an employer to do? Is there a way to remove the “sledgehammer” $2,000 penalty on all
employees and instead pay the “B” penalty, which costs less than offering coverage? There is.
The Best Value for Employers and Employees
Employers can offer a self-funded MEC preventive-only plan that provides the mandated preventive
coverage. While there is no coverage for any accidents or illnesses, the cost is typically under $600 per
year total. If a young, healthy, low wage employee enrolls in the MEC, both the employer and the employee
have met all of their ACA requirements. While there is no accident or other coverage, Limited Supplemental
Indemnity plans can be offered that provide the first dollar coverage this population understands and likes. In
the unlikely event that a catastrophic issue occurs, the employee can always fall back on Medicaid (as they
do not have assets to protect). By contrast, if the employee has health issues or wants to be enrolled in major
medical coverage, the exchange-based plans remain available for them and, more importantly, their family.
Employers who offer a MEC are still subject to the “B” penalty, which impacts large employers if the coverage
provided does not preclude the employee from receiving a subsidy in the state exchange.vii The “B” penalty is
“an amount equal to 1/12 of $3,000.”3 In other words, an employer pays $250 per month for each employee
who receives a government subsidized plan.
Everyone wins:
1. Low wage employees, if they perceive a need for coverage, receive a plan that is subsidized based
on their family’s income.
2. Employees have subsidized major medical coverage that is portable (not employer-based) if they
leave their jobs.
3. Employers / employees pay a low cost to enroll in a MEC if the employee is looking to avoid the
penalty and/or wants a preventive plan.
4. Employers pay less than market rates for those actually enrolled in subsidized coverage.
While all of the above items were delineated in the law (or associated laws), it is not clear if ACA authors
foresaw the above as a way to drive additional participation in the exchanges or if this was an unintended
consequence. In any event, the law will be anything but “revenue neutral” for the government as employers
adopt the above plan and billions are spent on unfunded subsidies. With annual deficits of $483 billion in
2014viii what will this one aspect of ACA alone contribute to the national debt?
Political arguments aside, clients and brokers need practical solutions. The majority of employers who will
face this issue will have to deal with it this fall. You might want to take a closer look at that MEC.White Paper – Pay is the Right Play for Many Employers
The American Worker
Copyright © 2015. The American Worker provided by Fringe Benefit Group
www.theamericanworker.com / 800.551.3424
About The American Worker
For more than 20 years, The American Worker has specialized in providing insurance for hourly and part-time
employee groups. From our headquarters in Austin, Texas, we provide a turnkey solution for employers
across the country, serving more than 250,000 members. As a privately held, independent third party
administrator (TPA), we have created a unique solution for our clients who have needs that are distinct and
different from most employers.
Please visit our newly redesigned website at www.theamericanworker.com.
Footnotes
i
http://www.benefitspro.com/2014/01/30/employee-satisfaction-with-health-benefits-cooling
ii
http://www.towerswatson.com/en-US/Insights/Newsletters/Americas/insider/2014/retirement-security-tops-list-ofemployee-concerns
iii
https://www.healthcare.gov/glossary/advanced-premium-tax-credit/
iv
http://www.bls.gov/oes/current/naics3_713000.htm
v https://www.law.cornell.edu/uscode/text/26/4980H
vi
https://www.healthcare.gov/preventive-care-benefits/
vii
The “B” penalty would become unenforceable in more than 30 states, which rely on HealthCare.gov – the federal
insurance marketplace, if the plaintiffs succeed in King v. Burwell currently before the Supreme Court.
viii
http://www.treasury.gov/press-center/press-releases/Pages/jl2664.aspx

P&C Pro-File – Health Care

HEALTH CARE
DID YOU KNOW?
Health care workers face an increased risk
of exposure to influenza during flu season.
Follow these tips to help your employees
stay healthy:
 Encourage vaccinations.
 Establish proper hygiene and
cough etiquette.
 Encourage employees to stay
home if they are ill rather than risk
infecting co-workers or patients.
 Provide gloves, gowns, surgical
masks and other protective
equipment when appropriate.
When these patients then attempt to
secure opioids through friends or
relatives, or turn to heroin as a
cheaper replacement, they risk
overdose or even death. And, when
a patient’s initial opioid prescription
was to treat an on-the-job injury,
employers may be liable in the
event of an overdose.
Health care employees who work long
hours or graveyard shifts are more
likely to have difficulty managing their
work-life balance, and they are more
likely to suffer musculoskeletal neck
pain, according to a study from the
George Washington University School
of Public Health and Health Services
(SPHHS).
The study posits that the problems are
related: The stress of long hours and
exhausting work contributes to neck
pain, which, in turn, makes it difficult
for health care workers to devote their
full attention to home and family
obligations. The study suggests that
offering more accommodating shifts
could reap a host of benefits, including
more productive, pain-free employees.
Work-life Imbalance
Pains Workers
DEA Names Prescription Meds a
Top Drug Threat
Prescription medications—
particularly opioid painkillers—are
the number one drug threat in the
United States, according to the Drug
Enforcement Administration (DEA).
That’s the finding coming out of the
2015 National Drug Threat
Assessment, and it has some
serious consequences for
employers.
The threat can be tied, in large part,
to the skyrocketing increase in the
number of opioid painkiller
prescriptions written in the past
several decades. Well-intentioned
health care providers have been
prescribing the painkillers to patients
who have been injured on the job,
only to find that many of those
patients develop a subsequent
dependence or addiction.

Selecting an HSA Provider

This HSA Benefits Insights is not intended to be exhaustive nor should any discussion or opinions be construed as professional advice.
© 2009-2011 Zywave, Inc. All rights reserved.
Selecting an HSA Provider
If you are offering a Health Savings
Account (HSA) to your employees, you
have the option of establishing a
relationship with an HSA provider for your
employees, requiring individuals on your
health plan to select their own provider or
giving your employees a list of providers
from which to choose their own. If you
choose to partner with a provider to ease
the process for employees, consider the
following variables.
Fees
HSA administrators charge employees to
manage their accounts, keep records and
send out appropriate forms and
statements.
 How are fees established?
 Are employee fees based on the
amount in accounts or on how
much is contributed monthly?
 Is there a fixed fee that does not
correlate with how much is
contributed to the account?
 Which fees can be assessed (stop
payment charges, fees to close
account, charges to replace lost or
stolen checks, etc.)?
 Does the employer or employee
pay the fees?
 Can employees pay fees directly or
must they pay out of the HSA?
Account Earnings
One benefit of owning an HSA is that
employees can accrue investment
earnings over time.
 What is the rate of return on the
account?
 What is the minimum amount of
money that the HSA must hold to
make investments?
 Is there a charge to make
investments?
 Are investment earnings
forfeitable?
 Does the HSA carry an investment
risk?
 Is the HSA insured?
Investment Issues
 Can creditors seize the balance of
an HSA if an employee declares
personal bankruptcy?
 Does the account
trustee/custodian impose limits on
the number of distributions that
employees can take for a specific
period of time?
 Does the account
trustee/custodian accept rollovers
or trustee-to-trustee transfers from
other eligible accounts?
Value-Added HSA Services
 Does the account
trustee/custodian provide
employees with a bill review and
negotiation help?
 Do employees have access to
price transparency information and
health care quality comparison
tools?
 Does the account
trustee/custodian provide phone or
Web counseling to help employees
review and minimize their
spending?
 Does the provider prepare annual
IRS reports for the employer?
 Does the provider provide
assistance with following
comparability rules for employer
contributions?
 Does the provider offer checks or a
debit card for HSA payments or
withdrawals?

Before selecting an HSA provider, consider the following
variables to provide the best HSA experience for you and your
employees.

The Top 25 Ways to Reduce Your Healthcare Costs

The Top 25 Ways to Reduce Your Healthcare Costs
According to Aetna, a leading health insurance company, healthcare spending in the United States is
expected to reach $4.8 trillion by the year 2021 – this is a leap from the $2.6 trillion spent in 2010 and
the mere $75 billion spent in 1970. Each and every year, Americans spend more on healthcare than they
did the previous year. With the passing of the Affordable Care Act, more Americans than ever are
covered by a health insurance plan. Still, many people struggle to pay their health insurance premiums
and an unexpected medical bill can send them into bankruptcy.
If you are struggling to cover your health insurance costs, you are not alone. You should also take solace
in the fact that there are plenty of simple things you can do to reduce your costs. Below you will find a
list of the top twenty-five ways to save money on healthcare:
1. Pay with cash. Speak to your provider or the billing office about a cash discount – you may be
able to save as much as 10% on your bill.
2. Check your bill for mistakes. Do not just pay your bill without going over it – mistakes are very
common and even a simple mistake could cost you hundreds. Go over the itemized version of
your bill and ask questions if you find errors.
3. Research costs in your area. Use an online tool to check for the price of certain procedures by
other providers in your area before you get the service. You may be surprised to find that some
providers charge a much lower fee.
4. Negotiate a price with your provider. After you do your research to see how much a procedure
should cost, talk to your provider about negotiating a lower rate. Providers offer deep discounts
to insurance companies, so why shouldn’t they do the same for you?
5. Try your local health clinic. If you have a minor problem or just need to ask a question, save
money by visiting the local clinic instead of paying a copay or co-insurance for your regular
doctor. You can also try calling a nurse hotline.
6. Follow instructions carefully. When you are taking prescriptions or administering treatments
yourself, follow instructions carefully so they work the way they should. This will save you from
possibly having to make another visit to the doctor.
7. Stay within your network. One of the most common (and most costly) mistakes people make is
not checking to see if their provider is in-network before they go. If your provider isn’t in the
network, find one that is rather than paying hefty out-of-network fees.
8. Always ask questions. If your doctor refers you to an out-of-network provider or specialist, ask
whether there is an in-network option. You can also try calling the plan to see if they will accept
in-network rates, especially if the only provider available is out of network.
9. Know your plan. Go over your plan in detail so you know exactly what is and is not covered. If
there are services covered that you don’t use, ask about removing those services for a lower
rate.
10. Keep your insurance. As costly as health insurance can be, lapsing on your coverage can be even
more expensive. If you lose employer coverage, ask about COBRA or other short-term plans.
11. Appeal claim denials. If the plan denies a claim and you think it should be coverage, do not
assume that the plan knows best – fight for your rights. Each company has its own appeals
process, so call the plan to find out what you have to do and then stick to your guns.
12. Choose a plan wisely. Before you settle on a health insurance plan, do your research to find the
plan that truly meets your needs and that stays within your budget. Think about what kind ofmedical expenses you are likely to incur throughout the year and make sure the plan you choose
covers those services.
13. Think about opening an HSA. A Health Savings Account (HSA) is typically combined with a highdeductible insurance plan and it enables you to set aside funds to use in the future for noncovered medical expenses. A high-deductible plan primarily provides protection against
catastrophic illness or hospitalization while the HSA allows you to save some money to put
toward routine services and smaller expenses along the way. The limit for 2015 on HSA
contributions is $3,350 for an individual and $6,650 for families. For individuals 55 and older you
can contribute an extra $1,000.
14. Take advantage of employee FSAs. An FSA is a Flexible Spending Account and it is an employee
benefit program which allows you to put money aside for healthcare expenses. The 2014 limit
for FSA contributions is $2,500 and it is on a pre-tax basis.
15. Keep up with preventive care. Many studies have shown that people who maintain regular
preventive care are less likely to visit the emergency room. By taking simple steps to prevent
illness you will end up using your health plan less which will save you money.
16. Take advantage of free services. Ask your doctor about free clinics in your area where you can
find free or reduced-cost care including vaccinations. There are also plenty of prescription
savings plans (most of which are free), some of which you can use on top of your prescription
coverage to save money on drugs.
17. Ask for a second opinion. If your doctor wants you to have some kind of expensive test or
treatment, get a second opinion to make sure you really need it before you spend hundreds or
thousands of dollars.
18. Think twice before going to the ER. Never go to the ER if a visit to your regular doctor will do
the trick. ER visits can cost hundreds, even thousands of dollars even if all you receive is a couple
of aspirin from a physician’s assistant.
19. Get treatment at a dental school. You can save a lot of money on dental work if you visit a
dental school rather than a regular dentist’s office. You can receive a discount of 20% to 60% off
services and even though the services will be conducted by students, they are closely supervised
by instructors.
20. Save money on contact lenses. There are plenty of websites and stores which offer discounts on
contact lenses. As long as you have a current prescription you can save up to 70% on your
contacts by ordering them online.
21. Always brush and floss. Maintaining good dental hygiene not only reduces the amount of dental
work you need, but it can also have an impact on your overall health. The cost of treatment for
dental diseases are very high so take a minute to brush and floss each day to save yourself some
money.
22. Stop smoking. According to the ACA, health insurance plans are allowed to charge people who
smoke up to 50% higher premiums than those who do not. Not only will you save on your
premiums by quitting but you will be saving $2,000 or more per year by not buying cigarettes.
23. Take a chill pill. According to an online survey, about 90% of visits to the doctor are for stressrelated conditions. Things like meditation and yoga can go a long way in reducing your stress
which, in turn, will boost your immune system.24. Follow a healthy lifestyle. In addition to keeping up with preventive care, following a healthy
diet and getting some regular exercise will go a long way in maintaining good health. The
healthier you are, the less you will use your plan and the more money you will save.
25. Always wash your hands. According to the CDC, washing your hands is the most effective way
to prevent the spread of germs. It is estimated that 80% of common infections are spread by
hand-to-hand contact.
As simple as many of these tips are, they can do a lot in terms of saving you money on healthcare. The
more you learn about your plan, the more you will be able to use it to your advantage and the healthier
you are, the less you will need to use it.

Getting Your Financial House in Order

Getting Your Financial House in Order

Name Date

Your Financial Concerns

What Would Make This a Great Meeting?

Your Financial Ranking
To help us get a better understanding of how you feel, please give us a score that ranks your overall financial situation.

Client Client
#1 #2

Please rank with a single number from 1 to 10.
1 = Things couldn’t be worse to 10 = Everything is perfect

Please Help Us Understand Your Concerns Further:
1. What is your #1 financial concern to discuss together?
2. How long have you had this concern for?
3. What steps have you taken to address this concern?
4. How have those steps worked out so far?
5. Would you be OK leaving things as they are?

Check if YES Check if YES
1. My finances cause me occasional worry, stress or anxiety
2. I’m concerned about maintaining my current lifestyle in the future
3. I spend less time doing the activities I enjoy because I worry about money
4. I am concerned about accomplishing future goals, plans and objectives
5. My finances impact my time spent with family and friends

Please Help Us Understand More About Your Financial Management/Decisions:
1. Who advises you or manages your investments now?
2. How long has that been for?
3. What did they recommend to address your concerns?
4. Does anyone else help you with your financial decisions?

Concern #1

Concern #5 Concern #2

Concern #4 Concern #3
What’s in
Your Financial House?

• A Lifetime of Work
• All of Your Savings
• CDs, Treasuries
• Stocks, Bonds

• Mutual Funds
• Annuities
• Life Insurance
• IRAs and 401(k)s

• Pensions
• Residence
• Real Estate
• Businesses

A Lifetime of Work and Savings

Our Role: To give you clear and balanced information
We will always give you the pros and the cons of every strategy, product, concept, or idea we talk about.

Your Role: To decide what direction you want to go
Your job is to give us your feedback and a clear “Yes” or “No” decision with each step we take.

Remember that every product has pros & cons and a proper use in your planning!
This is an illustration risk continuum. Actual results may vary.
For specific expenses in 6 to 15 years: To never touch or to leave for heirs:

Notes:

*Financial Professionals must be properly licensed before entering into any discussion regarding the repositioning of assets from one asset class to another.

Notes:

*Financial Professionals must be properly licensed before entering into any discussion regarding the repositioning of assets from one asset class to another.

ASSET CHECKLIST

Checking Savings Money Market

CDs Treasuries

Fixed Annuities
Fixed Index Annuities

C ash Value in Life Insurance

Variable Annuities

REITs
Bonds

Stocks Mutual Funds Options

Primary Residence Other Real Estate Other

Asset Name / Type / Product Client #1
Amount ($) Client #2
Amount ($) Q/NQ Monthly
Contributions Average
Return % Notes
■ ■
■ ■
■ ■
■ ■
■ ■
■ ■
■ ■
■ ■
■ ■
■ ■
■ ■
■ ■
■ ■
■ ■
■ ■

Total Value Money Assets

Total Value Residence & Real Estate

Total Mortgages, Credit Cards & Other Liabilities
$

Total Net Worth:

$ $ $

Notes:

Red Money Desired %
What’s your growth goal? What’s your 10 year average? How much are you willing to risk?

Green Money Desired %
What’s your growth goal? How much are you willing to risk? My Reasons For Taking Investment Risk:

What’s your worst loss ever? How long to make that back? Loss during last downturn?

Need higher return Enjoy the excitement Advice from others

Make up recent losses
Enjoy the research/planning Time or energy invested

Actual dollar amount lost? Other

Notes:

Income Needs
How much income do you need today to meet your expenses? $
How much income will you need in the future (inflation, etc)? $
Have you ever calculated your income potential? ■ Yes ■ No Amount $
If you could, would you like to have more income now? ■ Yes ■ No Amount $

Now 5 years 10 years 15 years
$35,000 $41,168 $48,424 $56,960
$50,000 $58,812 $69,179 $81,372
$75,000 $88,219 $103,768 $122,058

Notes:

INCOME ASSESSMENT WORKSHEET

IRA Distributions

Trusts
Salary

Post-Retirement Net Cash Flow

Notes:

The Four Roads of Tax Planning

Taxed on Growth or Taxed on Withdrawal Estate-Taxable

Tax-Deferred Growth Taxed on Withdrawal Estate-Taxable

Tax-Deferred Growth Tax-Free Withdrawal Estate-Taxable

Deferred Growth
Tax-Free Withdrawal
Estate Tax-Free Potential

Savings, Checking, CDs, Stocks, Bonds,
Mutual Funds, Dividends Non-Qualified Annuities, 401k Plans, Qualified Annuities,
SEPs, IRAs, 403b Roth IRA, Roth 401k, Municipals† Specially Designed Life Insurance††
$ $ $ $

Notes:

*Always consult with a tax professional before making decisions regarding taxes.
This booklet is designed to gather general information on the subjects covered. It is not, however, intended to provide specific legal or tax advice and cannot be used to avoid tax penalties or to promote, market, or recommend any tax plan or arrangement.

Essential Documents

Do You Have Client #1 Client #2 Notes
A Healthcare Power of Attorney Y N Y N

A Financial Power of Attorney Y N Y N
A Will Y N Y N
A Living Will Y N Y N
A Living Trust Y N Y N
If you have a trust, is it a Joint Trust Y N Y N

Do You Have/ Have You Client #1 Client #2 Notes
Ever been divorced Y N Y N

Any dependents with special needs Y N Y N
A desire to disinherit any of your children Y N Y N
A parent who requires special care Y N Y N
Any expectations of an inheritance Y N Y N
A desire to help a charity Y N Y N
Are you a Veteran Y N Y N
Calculated your potential estate tax Y N Y N

Would you like to receive our free Getting Your Estate In Order guide? Client #1 Client #2
Y N Y N

Notes:

*Always consult with an attorney before making decisions regarding legal documents.
This booklet is designed to gather general information on the subjects covered. It is not, however, intended to provide specific legal or tax advice and cannot be used to avoid tax penalties or to promote, market, or recommend any tax plan or arrangement.

Notes:

Life Insurance CLIENT #1 CLIENT #2
Do you have any policies now? Type of policy (term, whole)? Purpose of policy? Has it been reviewed recently? What are you paying? Level or increasing premiums?

Your Health

Notes:

Client #1 Name

Client #2 Name Children’s Names

Grandchildren’s Names Birthdate Birthdate Birthdate Birthdate Birthdate Birthdate Birthdate Birthdate Birthdate Birthdate Birthdate Birthdate Birthdate Birthdate
Birthdate

Notes:

What Would You Like To Accomplish In Our Next Meeting?
What would improve most in your life if we could help build a protective shield around your financial house?

Please check ou Cornerstone areas to focus on: Additional Planning
Workbook Completion Acknowledgement
This workbook was completed based on information I provided to the agent taking me through the process. This information may be incomplete because I either would not provide the information or did not have the information readily available.

Employee Benefit Compliance Chart: Notice and Disclosure Rules

1
Employee Benefit Compliance Chart: Notice and Disclosure Rules
The following chart is a summary of basic federal notice and disclosure compliance requirements that apply to group
health plans and/or employers under various employee benefits and employment laws. It includes the additional
reporting and disclosure obligations created by the Affordable Care Act (ACA). Note that not all notice and disclosure
requirements are reflected in this chart. State laws may impose additional obligations. Users of this chart should refer
to the specific federal law at issue for complete information.
LAW GOVERNS NOTICE REQUIREMENT SUMMARY
Affordable Care
Act
Group health
plans and
health
insurance
issuers
Statement of grandfathered
status—Plan administrator or
issuer must provide on a
periodic basis with any
participant materials describing
plan benefits
Grandfathered plans are group health plans or health
insurance coverage in which an individual was enrolled on
March 23, 2010, (the ACA’s enactment date) that satisfy
certain requirements. Grandfathered plans can avoid
certain ACA reforms, such as the requirement to cover
preventive care services without cost-sharing. To maintain
grandfathered plan status, a plan administrator or health
issuer must include a statement of grandfathered status in
plan materials provided to participants describing the
plan’s benefits (such as the summary plan description
(SPD) and open enrollment materials).
A model notice is available from the Department of Labor
(DOL).
Notice of rescission—Plan
administrator or issuer must
provide notice of rescission to
affected participants at least 30
days before the rescission
occurs
Group health plans and health insurance issuers may not
rescind coverage once the enrollee is covered, except in
cases of fraud or intentional misrepresentation. Plan
coverage may not be rescinded without prior notice to the
enrollee.
Notice of patient protections
and selections of providers—
Plan administrator or issuer
must provide notice of patient
protections whenever the SPD or
similar description of benefits is
provided to participants
This requirement does not apply
to grandfathered plans.
Group health plans and health insurance issuers that
require designation of a participating primary care provider
must permit each participant, beneficiary and enrollee to
designate any available participating primary care provider
(including a pediatrician for children). Group health plans
and issuers that provide obstetrical/gynecological care and
require a designation of a participating primary care
provider may not require preauthorization or referral for
obstetrical/gynecological care. These reforms do not apply
to grandfathered plans.
A model notice is available from the DOL.
Uniform summary of benefits
and coverage—Plan
administrator and issuer must
provide to participants and
Group health plans are required to provide a uniform
summary of the plan’s benefits and coverage to applicants
and enrollees. The Departments of Labor, Health and
Human Services and the Treasury (Departments) haveEmployee Benefit Compliance Chart: Notice and Disclosure Rules
This Legislative Brief is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers
should contact legal counsel for legal advice.
© 2007-2015 Zywave, Inc. All rights reserved. 4/13; EM 4/15
2
LAW GOVERNS NOTICE REQUIREMENT SUMMARY
beneficiaries at the following
times:
 With any written application
materials distributed for
enrollment;
 If written application
materials for enrollment are
not provided, no later than
when the participant is first
eligible to enroll in
coverage;
 By the first day of coverage,
if there was any change to
the information that was
provided upon application
and before the first day of
coverage;
 To special enrollees, no later
than the deadline for
providing the SPD;
 Upon renewal, if participants
and beneficiaries must
renew to maintain
coverage; and
 Upon request.
The SBC requirement became
effective starting with the first
open enrollment periods and
plan years beginning on or after
Sept. 23, 2012.
provided a template for the summary of benefits and
coverage (SBC) that plans and issuers must use, as well as
additional instructional guidance and sample language for
completing the template. The Departments have also
provided a uniform glossary of health-coverage-related
terms and medical terms for plans and issuers to make
available to plan participants and beneficiaries.
The template, glossary and other related guidance are
available on the Center for Consumer Information &
Insurance Oversight (CCIIO) website.
60-Day Advance Notice of
Plan Changes—Plans and
issuers must provide at least 60
days’ advance notice of midyear material modifications in
plan terms or coverage that
would affect the content of the
SBC and are not reflected in the
most recent SBC.
This notice requirement became
effective when the SBC
requirement went into effect.
A health plan or issuer must provide 60 days’ advance
notice of any material modifications to the plan that are not
reflected in the most recent SBC. This notice requirement
is limited to material modifications that do not occur in
connection with a renewal or reissuance of coverage.
A “material modification” is any change to a plan’s
coverage that independently, or in connection with other
changes taking place at the same time, would be
considered by the average plan participant to be an
important change in covered benefits or other terms of
coverage.
A material modification may include:
 An enhancement in covered benefits or services or
other more generous plan or policy terms (for
example, reduced cost-sharing or coverage of
previously excluded benefits); or
 A material reduction in covered services or benefits orEmployee Benefit Compliance Chart: Notice and Disclosure Rules
This Legislative Brief is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers
should contact legal counsel for legal advice.
© 2007-2015 Zywave, Inc. All rights reserved. 4/13; EM 4/15
3
LAW GOVERNS NOTICE REQUIREMENT SUMMARY
more strict requirements for receiving benefits (for
example, a new referral requirement or increased
premiums or cost-sharing).
Affordable Care
Act
Employers
sponsoring
group health
plans
IRS Form W-2—Aggregate cost
of applicable employersponsored coverage must be
included on employees’ Forms
W-2.
This requirement was originally
effective for tax years beginning
after Dec. 31, 2010. However,
the IRS made reporting optional
for all employers for the 2011
tax year.
Small employers (those filing
fewer than 250 W-2-Forms) and
employers contributing only to
certain plans, such as
multiemployer plans or HSAs,
are exempt at least until further
guidance is issued.
Large employers must comply
with the W-2 requirement
beginning in 2012.
Employers must disclose the aggregate cost of
applicable employer-sponsored coverage provided to
employees on the employees’ W-2 forms. This
requirement does not mean that the cost of the
coverage will be taxable to employees.
The Form W-2 and Instructions, including a category for
reporting the cost of employer-sponsored coverage, are
available on the IRS website.
Affordable Care
Act
All employers
subject to the
FLSA
Exchange Notice—The ACA
requires employers to provide all
new hires with a written notice
about the health insurance
Exchanges. This requirement
became effective on Oct. 1,
2013.
Employers were also required to
provide all current employees
with an Exchange Notice no later
than Oct. 1, 2013.
Employers must provide all new hires with an Exchange
notice that:
 Includes information regarding the existence of the
Exchange, as well as contact information and a
description of the services provided by the
Exchange;
 Explains how an employee may be eligible for a
premium tax credit if the employee purchases a
qualified health plan through the Exchange; and
 Contains a statement informing the employee that,
if the employee purchases a qualified health plan
through an Exchange, the employee may lose the
employer contribution (if any) to any health
benefits plan offered by the employer and that all
or a portion of this employer contribution may be
excludable for federal income tax purposes.
The DOL has provided model Exchange notices for
employers to use, which will require some
customization. The model Exchange notices are
available on the DOL’s website.
Affordable Care
Act
Applicable
large
employers
with full-time
Code §6056 Reporting—
Effective for 2015, applicable
large employers (those with at
least 50 full-time employees,
Code section 6056 requires applicable large employers
to report to the IRS information about the health care
coverage, if any, they offered to full-time employees.
Section 6056 also requires those employers to furnishEmployee Benefit Compliance Chart: Notice and Disclosure Rules
This Legislative Brief is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers
should contact legal counsel for legal advice.
© 2007-2015 Zywave, Inc. All rights reserved. 4/13; EM 4/15
4
LAW GOVERNS NOTICE REQUIREMENT SUMMARY
employees including full-time equivalents)
with full-time employees must
file an annual return with the
IRS regarding the health
coverage, if any, provided to
full-time employees. These
employers must also provide a
related annual statement to fulltime employees.
Reporting is required for
2015, with the first returns
due in 2016.
The deadlines for these returns
and employee statements are as
follows:
 Section 6056 returns must
be filed with the IRS
annually, no later than Feb.
28 (March 31, if filed
electronically) of the year
after the calendar year to
which the return relates.
 The employee statements
for each calendar year must
be furnished to full-time
employees by Jan. 31 of the
next calendar year.
Extensions may be available
in certain circumstances.
related statements to employees. Reporting is required
for 2015, with the first returns due in 2016.
According to the IRS, this information reporting is
necessary in order to administer the employer shared
responsibility “pay or play” rules. The IRS information
return will give the IRS information about the
employer’s compliance with the pay or play rules. These
rules impose penalties on applicable large employers
that do not offer required coverage to full-time
employees and dependents.
The employee statements provide information to
employees about coverage that was provided in the
prior year. The information will be used to determine
whether employees can claim a premium tax credit on
their tax returns for coverage purchased through an
Exchange.
Affordable Care
Act
Employers
with selfinsured health
plans that
provide
minimum
essential
coverage
(MEC)
Code §6055 Reporting—
Effective for 2015, sponsors of
self-insured health plans that
provide MEC must file an annual
return with the IRS regarding
the health coverage. These
employers must also provide a
related annual statement to
covered individuals.
Reporting is required for
2015, with the first returns
due in 2016.
The deadlines for these returns
and statements are as follows:
 Section 6055 returns must
be filed with the IRS
annually, no later than Feb.
28 (March 31, if filed
electronically) of the year
after the calendar year in
The ACA requires health insurance issuers, self-insured
health plan sponsors, government agencies that
administer government-sponsored health insurance
programs and any other entity that provides MEC to
report information on that coverage to the IRS and
covered individuals. This requirement is found in Code
section 6055. Reporting is required for 2015, with the
first returns due in 2016.
These reporting requirements are intended to provide
the IRS with information necessary to administer other
ACA mandates, such as the large employer shared
responsibility penalty and the individual mandate.
To simplify the reporting process, the IRS will allow
applicable large employers with self-insured plans to
use a single combined form for reporting the
information required under both section 6055 and
section 6056.Employee Benefit Compliance Chart: Notice and Disclosure Rules
This Legislative Brief is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers
should contact legal counsel for legal advice.
© 2007-2015 Zywave, Inc. All rights reserved. 4/13; EM 4/15
5
LAW GOVERNS NOTICE REQUIREMENT SUMMARY
which MEC is provided.
 The statements for covered
individuals must be provided
by Jan. 31 of the year after
the calendar year in which
MEC is provided. Employers
showing good cause may be
allowed the flexibility to
apply for an extension of
time, not exceeding 30
days, to furnish statements.
COBRA Employers that
had 20 or
more
employees on
more than 50
percent of the
typical
business days
during the
previous
calendar year
Government
and church
plans are
exempt
Initial/General COBRA
notice—Plan administrator must
provide generally within 90 days
of when group health plan
coverage begins.
Notice to covered employees and covered spouses of the
right to purchase temporary extension of group health
coverage when coverage is lost due to a qualifying event.
A model General COBRA Notice is available on the DOL
website under COBRA guidance.
Notice to plan
administrator—Employer must
notify plan administrator within
30 days of a) qualifying event or
b) the date coverage would be
lost as a result of the qualifying
event, whichever is later.
Notice of certain qualifying events must be sent to plan
administrator when employer is not plan administrator (for
example, employer has contracted with a third party to
administer COBRA).
The following qualifying events trigger the employer’s
notice requirement: (a) employee’s termination or
reduction in hours; (b) employee’s death; (c) employee’s
Medicare entitlement; and (d) employer’s bankruptcy.
COBRA election notice—Plan
administrator must generally
provide within 14 days after
being notified by the employer
or qualified beneficiary of the
qualifying event (or 44 days
after qualifying event if
employer is also plan
administrator).
Notice to qualified beneficiaries of their right to elect
COBRA coverage upon occurrence of qualifying event.
Qualified beneficiaries may be covered employees, covered
spouses and dependent children.
A model COBRA Election Notice is available on the DOL
website under COBRA guidance.
Notice of unavailability of
COBRA—Plan administrator
must provide this notice
generally within 14 days after
being notified by the individual
of the qualifying event (or 44
days after qualifying event if
employer is also plan
administrator).
Plan administrator must send a notice that an individual is
not entitled to COBRA coverage to those individuals who
provide notice to the plan administrator of a qualifying
event whom the plan administrator determines are not
eligible for COBRA coverage.Employee Benefit Compliance Chart: Notice and Disclosure Rules
This Legislative Brief is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers
should contact legal counsel for legal advice.
© 2007-2015 Zywave, Inc. All rights reserved. 4/13; EM 4/15
6
LAW GOVERNS NOTICE REQUIREMENT SUMMARY
Notice of early termination of
COBRA coverage—Plan
administrator must provide as
soon as practicable following the
plan administrator’s
determination that coverage will
terminate.
Notice to qualified beneficiaries that COBRA coverage will
terminate earlier than the maximum period of coverage.
The notice must include the reason for early termination,
date of termination and any rights that qualified beneficiary
may have to elect alternative group or individual coverage,
such as a conversion right.
Notice of insufficient
payment—Plan administrator
must provide reasonable period
of time to cure deficiency before
terminating COBRA (for
example, 30-day grace period).
Plan administrator must notify qualified beneficiary that
payment for COBRA was not significantly less than the
correct amount before coverage is terminated for
nonpayment. A payment is not significantly less than the
amount required if the deficiency is no greater than the
lesser of $50.00 or 10 percent of the amount the plan
requires to be paid.
Premium change notice—Plan
administrator should provide at
least one month prior to
effective date.
COBRA does not explicitly require advance notice of a
premium increase. However, COBRA regulations provide
that if a COBRA premium payment is short by an amount
that is insignificant, the qualified beneficiary must be
provided notice of such underpayment and a reasonable
amount of time to make the payment difference.
Also, COBRA requires equal coverage and, to some extent,
equal treatment between COBRA qualified beneficiaries and
similarly situated non-COBRA beneficiaries.
The DOL has stated that continuation coverage should not
be terminated for insufficient payment if COBRA qualified
beneficiaries are not provided a reasonable advance notice
of increased premiums and a reasonable opportunity to pay
the increased premium.
ERISA ERISA
employee
welfare benefit
plans, unless
exempted
Summary plan descriptions –
Plan administrator must provide
automatically to participants
within 90 days of becoming
covered by the plan (though a
new plan has 120 days after
becoming subject to ERISA to
distribute SPD). Updated SPD
must be furnished every 5 years
if changes made to SPD
information or plan is amended.
Otherwise, must furnish every
10 years.
The SPD is the primary vehicle for informing participants
and beneficiaries about their plan and how it operates.
Must be written for average participant and be sufficiently
comprehensive to apprise covered persons of their
benefits, rights and obligations under the plan.
Summary of material
modification—Plan
administrators must provide
automatically to participants
within 210 days after the end of
the plan year in which the
change is adopted.
If benefits or services are
Describes material modifications to a plan and changes in
the information required to be in the SPD. Distribution of
updated SPD satisfies this requirement.Employee Benefit Compliance Chart: Notice and Disclosure Rules
This Legislative Brief is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers
should contact legal counsel for legal advice.
© 2007-2015 Zywave, Inc. All rights reserved. 4/13; EM 4/15
7
LAW GOVERNS NOTICE REQUIREMENT SUMMARY
materially reduced, participants
must be provided notice within
60 days from adoption; or,
where participants receive such
information from the plan
administrator at regular
intervals of not more than 90
days, notice of materially
reduced benefits or services
must be provided within the
regular interval.
Plan documents—Plan
administrator must provide
copies no later than 30 days
after a written request and
make copies available at
specified locations.
The plan administrator must furnish copies of certain
documents upon written request by a participant and/or
beneficiary and must have copies available for
examination. The documents include the latest updated
SPD, latest Form 5500, trust agreement, and other
instruments under which the plan is established or
operated.
Form 5500—Plan administrator
generally must file by the last
day of the seventh month
following the end of the plan
year, unless an extension has
been granted. For calendar year
plans, the deadline is normally
July 31 of the following year.
Small health plans (less than
100 participants) that are fully
insured, unfunded or a
combination insured/unfunded,
are generally exempt from the
Form 5500 filing requirement.
Form 5500 filing requirements vary according to type of
filer (that is, small plans, large plans and direct filing
entities). Certain employee benefit plans are exempt from
the annual reporting requirements or are eligible for limited
reporting options.
The DOL website and the latest Form 5500 instructions
provide information on who is required to file and detailed
information on filing.
Form M-1—Plan administrator
must file with the DOL by March
1st of each year for the previous
calendar year. A 60-day
automatic extension is available
upon request.
Form M-1 is the annual report that must be filed by
multiple employer welfare arrangements (MEWAs) and
entities claiming exception from MEWA status. In general,
a MEWA offers health benefits to the employees of two or
more employers. More information about the M-1 filing
requirement, and the online filing system, is available on
the DOL website.
Summary annual report –Plan
administrators must provide
automatically to participants
within 9 months after end of
plan year, or 2 months after due
date for filing Form 5500 (with
approved extension).
Plans that are exempt from the
annual 5500 filing requirement
are not required to provide an
SAR. Large, completely
The summary annual report is a narrative summary of the
Form 5500 and includes a statement of the right to receive
the annual report. Model notices are found in 29 CFR
2520.104b-10(d).Employee Benefit Compliance Chart: Notice and Disclosure Rules
This Legislative Brief is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers
should contact legal counsel for legal advice.
© 2007-2015 Zywave, Inc. All rights reserved. 4/13; EM 4/15
8
LAW GOVERNS NOTICE REQUIREMENT SUMMARY
unfunded health plans are also
generally exempt from the SAR
requirement.
Internal
Revenue Code
Group health
plans
IRS Form 8928—Report and
Pay Excise Taxes—Generally
must be filed (with the
applicable excise tax) by the due
date for filing the plan sponsor’s
or administrator’s federal
income tax return for the year in
which the failure occurred.
An automatic extension for filing
is available, although the
extension does not affect the
time to pay the excise tax.
There is also limited relief for
certain inadvertent failures and
“reasonable cause” mistakes
that are corrected within 30
days.
The Form 8928 excise tax reporting requirement applies to
failures to comply with certain group health plan mandates
included in the IRC, such as:
 Required levels of coverage for pediatric vaccines;
 COBRA continuation coverage requirements;
 HIPAA’s portability, access and renewability and
nondiscrimination rules;
 Genetic information nondiscrimination requirements;
 Mental health parity requirements; and
 Health care reform mandates.
Family and
Medical Leave
Act (federal
FMLA)
Private sector
employers
with 50 or
more
employees in
20 or more
workweeks in
current or
preceding
calendar year,
as well as all
public
agencies and
all public and
private
elementary
and secondary
schools
General Notice—Must be
posted in a location available to
both employees and applicants
and included in written
guidance, if it exists.
All covered employers are required to post a notice
explaining the FMLA, including the family military leave
amendments, regardless of whether they have eligible
employees. If written guidance regarding employee
benefits or leave rights exists, such as in an employee
handbook, then FMLA information regarding entitlements
and obligations must be included in it as well.
The DOL has issued a model poster.
Notice of Eligibility and
Rights & Responsibilities—
Employer must provide written
guidance, upon employee notice
of need for FMLA leave.
Written guidance must be provided to an employee upon
the employee’s notice to the employer of the need for
FMLA leave. The employer must detail the specific
expectations and obligations of the employee, and explain
the consequences of the failure to meet these obligations.
The DOL has issued an optional notice which may be used
to satisfy this requirement.
Designation Notice—Employer
must notify employer of whether
leave has been designated as
FMLA leave.
Within five days of receiving sufficient information to grant
or deny FMLA leave, it must provide a designation notice
informing the employee whether the leave is designated as
FMLA leave. The DOL has issued an optional notice which
may be used to satisfy this requirement.
Genetic
Information
Nondiscrimination
Act (GINA)
Group health
plans and
health
insurance
issuers
Notice of Research
Exception—To satisfy the
research exception, plans or
issuers must provide
participants with a written
request and must file a Notice of
Research Exception with the
designated federal agency.
Title I of GINA prohibits health plans and health insurance
issuers from requiring or requesting that an individual
undergo a genetic test, subject to some narrow exceptions.
The research exception allows a health plan or issuer to
request (but not require) that an individual undergo a
genetic test if the information is not used for underwriting
and some additional requirements are met. The plan or
issuer must:Employee Benefit Compliance Chart: Notice and Disclosure Rules
This Legislative Brief is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers
should contact legal counsel for legal advice.
© 2007-2015 Zywave, Inc. All rights reserved. 4/13; EM 4/15
9
LAW GOVERNS NOTICE REQUIREMENT SUMMARY
 Make the request in writing to the participant;
 Clearly indicate that the test is voluntary and will not
impact plan eligibility or contributions; and
 Complete a Notice of Research Exception.
Genetic
Information
Nondiscrimination
Act (GINA)
Employers in
the private
sector and
state and local
governments
that employ
15 or more
employees
General Notice—Must be
posted in a conspicuous place.
Covered entities must post notices describing GINA’s
provisions in conspicuous places where notices to
employees, applicants and members are customarily
posted. A model poster is available.
Request for Medical
Information—Notice is not
generally required; however,
model language can be used by
an employer lawfully requesting
medical information so that any
genetic information included
with the response will be
deemed inadvertent.
Any receipt of genetic information in response to the
request for medical information will be deemed inadvertent
if the employer’s request includes the model (or similar)
language. The model language can be found at EEOC Reg.
§ 1635.8(b)(1)(i)(B)
Request for Genetic
Information for Toxic
Substance Monitoring—
Written notice required if genetic
information is acquired for toxic
substance monitoring.
Employers that want to obtain genetic information of
employees in order to monitor the biological effects of
exposure to toxic substances in the workplace must
provide each affected employee with:
 Written notice of the genetic monitoring; and
 The individual monitoring results.
The employee must authorize the monitoring, unless it is
required by law.
Notice of Disclosure—Notice is
required for certain permitted
disclosures of genetic
information.
Employers generally may not disclose an employee’s
genetic information. Certain exceptions apply to this rule,
including disclosure of genetic information in response to a
court order or to public health agencies regarding
contagious, life-threatening illness. Notice to the employee
is required if the employer discloses genetic information for
these purposes.
HIPAA and the
ACA—Wellness
Programs
Group health
plans and
issuers that
offer healthcontingent
wellness
programs
Notice of Alternative
Standard—Plans and issuers
must disclose the availability of
an alternative standard in all
materials describing the
wellness program.
Health-contingent wellness programs, or wellness
programs that require individuals to satisfy a standard
related to a health factor in order to receive a reward,
violate federal nondiscrimination rules unless the program
satisfies a number of conditions:
 Limit reward to 30 percent of cost of coverage (or 50
percent for health-contingent wellness programs
designed to prevent or reduce tobacco use). For plan
years beginning before Jan. 1, 2014, the maximum
permissible reward was 20 percent of the cost of
health coverage;
 Designed to reasonably promote health and prevent
disease;Employee Benefit Compliance Chart: Notice and Disclosure Rules
This Legislative Brief is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers
should contact legal counsel for legal advice.
© 2007-2015 Zywave, Inc. All rights reserved. 4/13; EM 4/15
10
LAW GOVERNS NOTICE REQUIREMENT SUMMARY
 Provide annual opportunity to qualify;
 Provide reasonable alternative standard for obtaining
the reward for certain individuals; and
 Disclose availability of an alternative standard.
The disclosure must include contact information for
obtaining the alternative and a statement that
recommendations of an individual’s personal physician will
be accommodated. If plan materials merely mention that a
wellness program is available, without describing its terms,
this disclosure is not required. Final regulations provide
sample language that can be used to satisfy this
requirement.
HIPAA—
Privacy and
Security
Covered
Entities: Group
health plans,
health care
clearinghouses, health
care providers
that transmit
any health
information
electronically,
and enrolled
sponsors of
Medicare
prescription
drug discount
card, unless
exception
applies
Business
Associates:
entities that
create,
receive,
maintain or
transmit
protected
health
information
(PHI) on
behalf of a
Covered Entity
Notice of Privacy Practices—
The plan administrator or
insurer must provide the Notice
of Privacy Practices when a
participant enrolls, upon request
and within 60 days of a material
revision to the notice.
At least once every three years,
participants must be notified
about the availability of the
Notice of Privacy Practices.
HHS regulations require that participants be provided with
a detailed explanation of their privacy rights, the plan’s
legal duties with respect to protected health information,
the plan’s uses and disclosures of protected health
information, and how to obtain a copy of the Notice of
Privacy Practices.
HHS has developed three model privacy notices for health
plans—a booklet version, a full page version and a layered
version. These model notices, as well as instructions on
how to use them, are available on HHS’ website.
Notice of Breach of
Unsecured PHI—Covered
entities and their business
associates must provide
notification following a breach of
unsecured PHI without
unreasonable delay and in no
case later than 60 days following
the discovery of a breach.
Following a breach of unsecured PHI, covered entities must
provide notification of the breach to affected individuals,
HHS and, in certain circumstances, to the media. If the
unsecured PHI is held by a business associate, the business
associate must notify the covered entity that a breach has
occurred.
HIPAA—
Transaction
Standards and
Operating
Rules
Controlling
health plans
HIPAA Certification—
Controlling health plans must file
a statement with HHS certifying
their compliance with HIPAA’s
electronic transaction standards
and operating rules.
Health plans must file a statement with HHS certifying their
compliance with HIPAA’s electronic transaction standards
and operating rules. The ACA specified an initial
certification deadline of Dec. 31, 2013, for the following
transactions:Employee Benefit Compliance Chart: Notice and Disclosure Rules
This Legislative Brief is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers
should contact legal counsel for legal advice.
© 2007-2015 Zywave, Inc. All rights reserved. 4/13; EM 4/15
11
LAW GOVERNS NOTICE REQUIREMENT SUMMARY
The first certification deadline is
Dec. 31, 2015, although small
health plans may have
additional time to comply.
 Eligibility for a health plan;
 Health care claim status; and
 Health care electronic funds transfers (EFT) and
remittance advice.
HHS extended the first certification deadline to Dec. 31,
2015, although small health plans may have additional
time to comply. Controlling health plans (CHPs) are
responsible for providing the initial HIPAA certification on
behalf of themselves and their subhealth plans, if any.
Based on HHS’ definition of CHPs, an employer’s selfinsured plan will likely qualify as a CHP, even if it does not
directly conduct HIPAA-covered transactions. For
employers with insured health plans, the health insurance
issuer will likely be the CHP responsible for providing the
certification. However, more definitive guidance from HHS
on this point would be helpful.
HIPAAPortability
Group health
plans and
issuers of
group health
plan insurance
coverage,
unless
exception
applies
Certificate of Creditable
Coverage—Plan administrators
and issuers must provide
automatically when covered
individuals lose group health
plan coverage, become eligible
for COBRA coverage and when
COBRA coverage ceases. A
certificate may be requested
free of charge any time prior to
losing coverage and within 24
months of losing coverage.
Notice from group health plan to individuals who lose
coverage, documenting prior group health plan creditable
coverage and length of time covered.
Effective for plan years beginning on or after Jan. 1, 2014,
the Affordable Care Act prohibits plans from imposing
preexisting condition exclusions. In connection with this
reform, the requirement to provide HIPAA certificates was
eliminated, beginning Dec. 31, 2014. Thus, beginning in
2015, health plans and issuers are no longer required to
provide HIPAA certificates.
General notice of preexisting
condition exclusion—Plan
administrators and issuers must
provide as part of any written
application materials distributed
for enrollment. If the plan or
issuer does not distribute such
materials, by the earliest date
following a request for
enrollment that a plan or issuer,
acting in a reasonable and
prompt fashion, can provide the
notice.
Notice to participants describing a group health plan’s
preexisting condition exclusion and how prior creditable
coverage can reduce the preexisting condition exclusion
period.
Effective for plan years beginning on or after Jan. 1, 2014,
the Affordable Care Act prohibits plans from imposing
preexisting condition exclusions.
Individual notice of period of
preexisting condition
exclusion—Plan administrators
and issuers must provide as
soon as possible following the
determination of creditable
coverage.
Notice to an individual that a specific preexisting condition
exclusion period applies after consideration of creditable
coverage evidence, as well as an explanation of appeal
procedures if the individual disputes the plan’s
determination. Effective for plan years beginning on or
after Jan. 1, 2014, the Affordable Care Act prohibits plans
from imposing preexisting condition exclusions.Employee Benefit Compliance Chart: Notice and Disclosure Rules
This Legislative Brief is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers
should contact legal counsel for legal advice.
© 2007-2015 Zywave, Inc. All rights reserved. 4/13; EM 4/15
12
LAW GOVERNS NOTICE REQUIREMENT SUMMARY
Notice of special enrollment
rights—Plan administrators
must provide at or before the
time an employee is initially
offered the opportunity to enroll
in the group health plan.
Notice to employees eligible to enroll in a group health plan
describing the group health plan’s special enrollment rules
including the right to enroll within 30 days of the loss of
other coverage or of marriage, birth of a child, adoption, or
placement for adoption, or within 60 days of the loss of
coverage under a Medicaid plan or CHIP, or within 60 days
of a determination of eligibility for a premium assistance
subsidy under Medicaid or CHIP.
CHIPRA Employers that
maintain group
health plans
covering
employees in
states that
provide
premium
assistance
subsidies
under a
Medicaid plan
or CHIP
Annual Employer CHIP
Notice—If an employer’s group
health plan covers residents in a
state that provides a premium
subsidy, the employer must
send an annual notice about the
available assistance to all
employees residing in that state.
States may offer eligible low-income children and their
families a premium assistance subsidy to help pay for
employer-sponsored coverage. If an employer’s group
health plan covers residents in a state that provides a
premium subsidy, the employer must send an annual
notice about the available assistance to all employees
residing in that state. Employers may use the model notice
provided by the DOL as a national notice to meet their
obligations under CHIPRA. The notice may be provided in
writing by first-class mail or electronically if DOL electronic
disclosure requirements are satisfied.
Medicare Part
D
Group health
plan sponsors
that provide
prescription
drug coverage,
except entities
that contract
with or
become a Part
D plan
Disclosure Notices for
Creditable or Noncreditable Coverage—At a
minimum, must be provided
by the plan sponsor at the
following times:
1) Prior to the Medicare Part
D Annual Coordinated
Election Period—Oct. 15
through Dec. 7 of each
year;
2) Prior to an individual’s
Initial Enrollment Period
for Part D;
3) Prior to the effective date
of coverage for any
Medicare eligible
individual that joins the
plan;
4) Whenever prescription
drug coverage ends or
changes so that it is no
longer creditable or
becomes creditable; and
5) Upon request by a
Medicare Part D eligible
individual.
*If the plan sponsor provides
Group health plan sponsors — or entities that offer
prescription drug coverage on a group basis to active and
retired employees and to Medicare Part D eligible
individuals — must provide, or arrange to provide, a notice
of creditable or non-creditable prescription drug coverage
to Medicare Part D eligible individuals who are covered by,
or who apply for, prescription drug coverage under the
entity’s plan. This creditable coverage notice alerts the
individuals as to whether or not their prescription drug
coverage is at least as good as the Medicare Part D
coverage.
Model forms are available from CMS.Employee Benefit Compliance Chart: Notice and Disclosure Rules
This Legislative Brief is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers
should contact legal counsel for legal advice.
© 2007-2015 Zywave, Inc. All rights reserved. 4/13; EM 4/15
13
LAW GOVERNS NOTICE REQUIREMENT SUMMARY
notice to all participants
annually, CMS will consider 1
& 2 above to be met. “Prior
to” means in the prior 12
months.
Disclosure to CMS—Plan
sponsor must make on an
annual basis (60 days after
the beginning of the plan
year) and upon any change
that affects creditable
coverage status (within 30
days of the change)
Employers must disclose to CMS whether the coverage is
creditable. An entity is required to provide the Disclosure
Notice through completion of the Disclosure Notice form,
unless specifically exempt as outlined in related CMS
guidance. This is the sole method for compliance with the
disclosure requirement.
Medicare Part
D-Retiree Drug
Subsidy
Employers
with group
health plans
that cover
retirees who
are entitled to
enroll in Part D
but who elect
not to do so
Retiree drug subsidy
application—At least 90 days
before the beginning of each
plan year, plan sponsors must
apply for retiree drug subsidy,
unless CMS approves request for
extension.
An employer who wishes to sponsor a prescription drug
plan with retiree prescription drug coverage that is at least
as good as Part D coverage may apply for the retiree drug
subsidy, which is exempt from federal income tax. The
subsidy is available to employers with group health plans
that cover retirees who are entitled to enroll in Part D but
who elect not to do so.
*The Affordable Care Act provides that, beginning in 2013,
employers receiving the Medicare Part D retiree drug
subsidy cannot deduct the amount of the subsidy.
Mental Health
Parity and
Addiction
Equity Act
(MHPAEA)
Group health
plans (of
employers
with over 50
employees)
offering
mental health
and substance
use disorder
benefits
Exemption
available for
group health
plans that can
demonstrate a
certain cost
increase
Notice of cost exemption—
Group health plans claiming the
increased cost exemption must
promptly notify the appropriate
federal and state agencies, plan
participants and beneficiaries.
Notice must also be provided
upon request.
The cost exemption will apply to a group health plan if its
cost increase exceeds 2 percent in the first plan year and 1
percent in a subsequent year. If the 2-percent or 1-percent
increased cost is incurred, the plan is exempt for the plan
year following the year the cost was incurred. Thus, the
exemption lasts one year and then the plan is required to
comply again.
A group health plan or health insurance issuer must
promptly notify the Secretaries of the DOL, HHS and the
Treasury, the appropriate state agencies, and participants
and beneficiaries in the plan of such election. A notification
to the Secretaries must include:
 A description of the number of covered lives under the
plan (or coverage) involved at the time of the
notification, and as applicable, at the time of any prior
election of the cost-exemption by such plan (or
coverage);
 For both the plan year upon which a cost exemption is
sought and the year prior, a description of the actual
total costs of coverage with respect to medical and
surgical benefits and mental health and substance use
disorder benefits under the plan; andEmployee Benefit Compliance Chart: Notice and Disclosure Rules
This Legislative Brief is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers
should contact legal counsel for legal advice.
© 2007-2015 Zywave, Inc. All rights reserved. 4/13; EM 4/15
14
LAW GOVERNS NOTICE REQUIREMENT SUMMARY
 For both the plan year upon which a cost exemption is
sought and the year prior, the actual total costs of
coverage with respect to mental health and substance
use disorder benefits under the plan.
Upon request—The plan administrator or health insurance
issuer must provide the criteria for medical necessity
determinations made under a group health plan with
respect to mental health or substance use disorder
benefits, upon request by a current or potential participant,
beneficiary or contracting provider. The plan administrator
or health insurance issuer must also make available upon
request, or as otherwise required, the reason for any denial
of reimbursement or payment for services with respect to
mental health or substance use disorder benefits in the
case of any participant or beneficiary.
Michelle’s Law Employersponsored
group health
plans
Michelle’s Law Notice—Plan
administrators and group health
plan insurers must include with
any notice regarding a
requirement for certification of
student status.*
If a group health plan (or insurance issuer providing
coverage for the plan) requires a certification of student
status for coverage under the plan, it must send a
Michelle’s Law Notice along with any notice regarding the
certification requirement. The Michelle’s Law Notice must
be written in language understandable to a typical plan
participant and must describe the terms of the continuation
coverage available under Michelle’s Law during medically
necessary leaves of absence.
*Under the Affordable Care Act (ACA), group health plans
are required to cover dependent children up to age 26,
regardless of student status. The ACA’s coverage mandate
for adult children limits the impact of Michelle’s Law.
However, group health plans that extend coverage past the
age of 26 for adult children who are students will still be
subject to the requirements of Michelle’s Law.
Newborns’ and
Mothers’
Health
Protection Act
(NMHPA)
Group health
plans that
provide
maternity or
newborn infant
coverage
NMHPA Notice—Plan
administrators must include a
statement within the SPD (or
SMM) timeframe.
The plan’s SPD must include a statement describing any
requirements under federal or state law applicable to the
plan, and any health insurance coverage offered under the
plan, relating to any hospital length of stay in connection
with childbirth for a mother or newborn child. If the
federal law applies in some areas in which the plan
operates and state law applies in other areas, the SPD
should describe the different areas and the federal or state
requirements applicable in each.
Qualified
Medical Child
Support Orders
Plan
administrators
of group
health plans
and state child
support
enforcement
agencies
Medical child support order
notice—Upon receipt of medical
child support order, plan
administrator must promptly
issue notice, including plan’s
procedures for determining its
qualified status. Within a
reasonable time after its receipt,
plan administrator must also
issue separate notice as to
whether the medical child
This is a notification from the plan administrator regarding
receipt and qualification determination on a medical child
support order directing the plan to provide health insurance
coverage to a participant’s noncustodial children.Employee Benefit Compliance Chart: Notice and Disclosure Rules
This Legislative Brief is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers
should contact legal counsel for legal advice.
© 2007-2015 Zywave, Inc. All rights reserved. 4/13; EM 4/15
15
LAW GOVERNS NOTICE REQUIREMENT SUMMARY
support order is qualified.
National Medical Support
notice—Within 20 days after
the date of notice or sooner, if
reasonable, employer must
either send Part A to State
agency, or Part B to plan
administrator. Plan
administrator must promptly
notify affected persons of receipt
of notice and procedures for
determining its qualified status.
Plan administrator must within
40-business days after its date
or sooner, if reasonable,
complete and return Part B to
State agency and must also
provide required information to
affected persons. Under certain
circumstances, employer may be
required to send Part A to State
agency after plan administrator
has processed Part B.
Notice used by State agency responsible for enforcing
health care coverage provisions in a medical child support
order. Depending upon certain conditions, employer must
complete and return Part A of the National Medical Support
notice to the State agency or transfer Part B of the notice
to the plan administrator for a determination on whether
the notice is a qualified medical child support order.
Uniformed
Services
Employment
and
Reemployment
Rights Act
(USERRA)
All public and
private
employers,
regardless of
size
USERRA Notice—Employers
must provide notice by posting
where other employee notices
are customarily posted, or
provide to employees by
alternate means.
Employers must provide notice of rights, benefits and
obligations of persons entitled to USERRA and of
employers.
Medicare
Secondary
Payer (MSP)—
Reporting
Requirements
(Medicare,
Medicaid and
SCHIP
Extension Act
of 2007)
Responsible
Reporting
Entities
(RREs)—For
group health
plans, RREs
are insurers
and
administrators
of group
health plans
MSP Reporting
Requirements—Plan
administrators and issuers must
file quarterly reports with CMS
containing information on
certain participants and
beneficiaries for MSP purposes.
The Medicare, Medicaid and SCHIP Extension Act of 2007
amended the MSP rules to require plan administrators and
health insurance issuers to report certain participant
information to CMS for purposes of coordinating benefits
with Medicare. More information about this reporting
requirement, including a health plan user guide, is
available on the CMS website.
Women’s
Health and
Cancer Rights
Act (WHCRA)
Group health
plans that
provide
coverage for
mastectomy
benefits
WHCRA Notice—Plan
administrators and issuers must
provide notice upon enrollment
in the plan and annually
thereafter.
The DOL has published sample language for both the
enrollment notice and the annual notice.
Enrollment notice should include a statement that for
participants and beneficiaries who are receiving
mastectomy-related benefits, coverage will be provided in
a manner determined in consultation with the attending
physician and the patient, for all stages of reconstruction of
the breast on which the mastectomy was performed,
surgery and reconstruction of the other breast to produce aEmployee Benefit Compliance Chart: Notice and Disclosure Rules
This Legislative Brief is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers
should contact legal counsel for legal advice.
© 2007-2015 Zywave, Inc. All rights reserved. 4/13; EM 4/15
16
LAW GOVERNS NOTICE REQUIREMENT SUMMARY
symmetrical appearance, prostheses, and treatment of
physical complications of the mastectomy, including
lymphedema. Notice should also include a description of
any deductibles and coinsurance limitations applicable to
such coverage.
Annual notice should include a copy of the WHCRA
enrollment notice, or a simplified disclosure providing
notice of the availability of benefits for the four required
coverages and information on how to obtain a detailed
description.

Qualifying Event Checklist

© 2014-2015 Zywave, Inc. All rights reserved.
Employee Name
Job Title
Change in Legal Marital Status Date of Change Required Documents
Marriage Marriage certificate
Divorce/Annulment Divorce decree/Court ruling for
annulment
Legal separation Court order verifying legal
separation
Death of spouse Death certificate
Change in Number of Dependents Date of Change Required Documents
Birth Birth certificate
Death Death certificate
Adoption/Placement for adoption Court order for adoption/placement
for adoption
Gain or Loss Eligibility for Other Group
Coverage (HIPAA special enrollment)
Date of Change Required Documents
Group health plan
Documentation from plan or issuer
regarding change in eligibility (with
effective date)
Change in Employment Status of
Employee or Spouse
Date of Change Required Documents
Loss of employment Termination documents or
unemployment application
Start of employment Employer documentation of
employment start date
Change in worksite Employer documentation showing
change and impact on eligibility
Leave of absence
Employer documentation stating
employee has commenced or
returned from leave
Change in Place of Residence Date of Change Required Documents
Change in place of residence of the
employee, spouse or dependent that
Documents indicating how change
in residence affects employee
Qualifying Event Checklist
Omni Project, LLC© 2014-2015 Zywave, Inc. All rights reserved.
affects HMO eligibility eligibility
Entitlement to Medicare or Medicaid Date of Change Required Documents
Employee, spouse or dependent becomes
covered under Medicare or Medicaid or
loses eligibility for his or her Medicare or
Medicaid coverage (including coverage
under a state Children’s Health Insurance
Program, or CHIP)
Government verification that
coverage was gained or lost
Changes in Coverage Date of Change Required Documents
Significant cost increases N/A
Significant curtailment of coverage N/A
Addition or significant improvement of
benefits package option
N/A
Change in coverage under other employer
plan
Documentation from employer
showing change in coverage
Loss of health coverage sponsored by
governmental or educational institution
Government verification of loss of
eligibility
Other Date of Change Required Documents
Change of custody, judgment, court order
or decree requiring health coverage
Court documentation, including
qualified medical child support order
(QMCSO)
COBRA qualifying event N/A
FMLA leave N/A
Eligibility for premium assistance subsidy
through a Medicaid plan or CHIP
Government verification of eligibility
for subsidy (with effective date)
Exchange enrollment
Employee representation regarding
enrollment in a plan under an
Exchange
Reduction in hours of service to less than
30 hours without loss of eligibility N/A
Employee Signature Date