less than 50 employees
Choose coverage that fits.
The information in
this toolkit is a general
overview of the rules,
regulations and
consequences of the
ACA. It may not address
every aspect of the ACA
that affects employers
and their insurance and
is not intended to be
legal or tax advice.
Blue Cross of Idaho prepared this toolkit to
help you define where your business fits in the
affordable Care act (aCa) and understand
how the law will impact the coverage you offer
your employees.
What does it mean for you?
The aCa is the final version of healthcare reform legislation passed by Congress and signed into law in 2010. Some of these regulations took effect immediately, while others were rolled out over the last few years. The individual mandate took effect on January 1, 2014, and we expect regulations that impact employers to take effect over the next few years.
Blue Cross of Idaho will continue to implement aCa changes and provide you with information about the new regulations and their impact on your health insurance.
Impacts of the aCa
At its core, the federal government is trying to do three primary things through the ACA:
IMPACTS OF THE
Affordable
Care Act
Ensure more people have access to and get health insurance
coverage
Set coverage standards for health insurance
benefits
Lower premium and out-of-pocket
costs through subsidies
The affordaBle
Care aCT
employers face the difficult task of
determining whether or not it makes better
financial sense to offer group health insurance
to employees or leave it to employees to
purchase individual coverage.
With your specific employee and business information, we can create a strategic impact report that can help you see how the aCa affects your employees and your bottom line – now and in the future. This report gives you:
• premium and cost sharing estimates for employer-based plans vs. individual plans,
• anticipated tax credits if you have less than 25 employees,
• estimated impact on premium rates if you have less than 50 employees,
• estimates of aCa eligibility and affordability for employees,
• estimates on employee compensation needed to replace the value of the health plan,
• pre- and post-tax implications of terminating current coverage,
• Your projected cadillac tax risk.
To complete a study, you simply provide Blue Cross of Idaho with information about your employees and business and we do the rest. We can provide you a preformatted excel file for you to easily enter the information we need. We can also help your broker enter the information if you would like.
To get started, we need
to know the following
information:
Your Business:
• local income tax rate
• Workforce category (white or blue collar)
For all of your employees:
• Salary/hourly wage
• average weekly hours
• premium contribution (employee and employer)
• hra/hSa employer funding levels
underSTandInG The
aCa’S ImpaCT on Your
BuSIneSS
If you determine that
you have the equivalent
of 50 or more full-time
employees, please refer
to our large-group toolkit
for more information.
For employees not currently covered by Blue Cross of Idaho we also need:
• date of birth
• Zip code of residence
• Gender
• marital status
• number of children
Grandfathered status
If your plan was effective prior to march 23, 2010, it may be grandfathered under the aCa. If you have a grandfathered plan, you can continue offering your current coverage and avoiding some of the impacts of the aCa. however, changes you make to your existing health plan can affect its grandfathered status. In general, if you decrease coverage and/ or increase your employees’ cost-sharing responsibilities, your plan may lose its grandfathered status.
for questions about grandfathered coverage, call your account manager, one of our statewide offices at
800-365-2345 or your health insurance agent.
IF You Are noT grAndFAThered Small businesses with health insurance effective after march 23, 2010, but before January 1, 2014, are non-grandfathered under the aCa. non-grandfathered plans were scheduled to end in 2014, but the federal government has decided to extend these plans through 2016. Blue Cross of Idaho will keep our small groups updated on the latest changes to this part of the aCa.
underSTandInG The
aCa’S ImpaCT on Your
BuSIneSS
If you’re interested in
receiving a Blue Cross of
Idaho analysis to assess
the ACA’s impact on your
employees, contact your
insurance broker or local
Blue Cross of Idaho district
office at 800-365-2345.
Get a Break on Costs
employer tax credit
If you are a small or medium sized employer with up to 25 full-time equivalent employees (See Determining Your Group Size on page 4 to calculate your full-time equivalent employees.) you may be eligible for a tax credit to partially
offset the cost of providing health insurance coverage for employees. If the average annual pay of your employees
is less than $50,000 and you pay 50 percent or more of the cost of health insurance, your tax credit can be as
much as 50 percent of what your company pays for health benefits today.
exchange notice
employers should provide employees with information about their health insurance, the health Insurance exchange, and possible financial assistance with the cost of insurance. employees should receive notice within 14 days of beginning work. Blue Cross of Idaho provided group administrators with a template of this notice. please contact us if you want a copy.
employee waiting period
probationary periods for new employees cannot exceed 90 calendar days. This means if you hire a new employee on June 1, his/her health insurance must begin no later than august 30. however, you can include an orientation period of 30 days to meet your enrollment timeline.
pediatric dental coverage
The aCa requires certain small groups that offer health insurance to their employees to include qualified pediatric dental coverage for members under 19. The dental plans we currently offer do not include pediatric dental, an essential health Benefit under the aCa.
WhAT does ThIs meAn For You? If you currently provide a Blue Cross of Idaho dental plan and your medical coverage is grandfathered, you can keep your plan without needing to make any changes.
If you currently provide a Blue Cross of Idaho dental plan and your medical coverage is not grandfathered, your options include the following:
• You may keep your existing dental coverage for anyone age 19 and older and add a qualified dental plan for pediatric members, or
• You may replace your current group dental coverage with a new qualified group plan that covers all of your participating employees and dependents, or
• You may keep your current group dental coverage with the knowledge that the dental plans we currently offer do not include pediatric dental, an essential health Benefit under the aCa. You do not need to have Blue Cross of Idaho group medical coverage to purchase a separate dental plan for your employees and their dependents.
reGulaTIonS ThaT
maY ImpaCT You
Blue Cross of Idaho
products and services
bcidaho.com
The Idaho Health
Insurance Exchange
yourhealthidaho.org
The following is a summary of Blue Cross of
Idaho’s coverage and plan changes resulting
from the aCa. The information below is
general and intended to provide an overall
view of the aCa regulations and how
Blue Cross of Idaho is responding.
new and non-grandfathered groups grandfathered groups G NG G NG
G NG G NG
dependenT Age
We extended coverage for dependent adult children up to age 26, regardless of marital status, income, financial status, educational status or place of residence.
G NG G NG
pre-exIsTIng WAITIng perIods
In 2010, we stopped requiring waiting periods for pre-existing conditions for members under age 19. effective at your group renewal in 2014, we will remove waiting periods for pre-existing conditions for all members regardless of age.
G NG
prevenTIve heAlTh servICes
We cover preventive care services at 100 percent, not subject to deductible or coinsurance, when provided by an in-network provider. We also expanded covered preventive services to include additional women’s health services.
G NG
prevenTIve heAlTh servICes
We cover preventive care services at 100 percent, not subject to deductible or coinsurance, when provided by an in-network provider.
G NG G NG
AnnuAl mAxImum lImIT on essenTIAl heAlTh BeneFITs We removed annual dollar maximums from essential health benefits, including prescription drug services.
The effeCTS on Your
CompanY’S CoveraGe
and ServICeS
G NG G lIFeTIme BeneFIT lImITs NG
We removed all lifetime dollar maximum limits.
G NG G NG
summArY oF BeneFITs & CoverAge (sBCs)
Blue Cross of Idaho provides individual members, employer groups and potential members access to a uniform overview of their health insurance coverage. These materials contain a short, easy-to-understand summary of benefits and coverage (SBC) and a list of definitions (called the uniform glossary) that explains terms commonly used in health insurance coverage such as “deductible” and “copayment.”
G NG G NG
Wellness progrAm InCenTIves – eFFeCTIve JAnuArY 1, 2014 or AT reneWAl
The aCa allows employers who offer wellness programs to increase the incentive for participation to up to 30 percent of the premium contribution.
G NG G NG
ouT-oF-poCkeT mAxImums – eFFeCTIve JAnuArY 1, 2014 or AT reneWAl
The aCa sets a maximum amount you have to pay out of your own pocket for services. effective January 1, 2014, or when your plan renews, this limit is $6,350 for individuals and $12,700 for families. for 2015, the limits for grandfathered and non-grandfathered groups increase to $6,600 for individuals and $13,200 for families. This maximum amount includes all deductibles, coinsurance and copayments for medical services. This limit will vary each year based on federal guidelines.
G NG G NG
essenTIAl heAlTh BeneFITs – eFFeCTIve JAnuArY 1, 2014 For neW plAns, or AT plAn reneWAl
To ensure our status as a qualified health plan, all Blue Cross of Idaho plans include coverage for essential health benefits in the following 10 categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care. We removed annual dollar maximums for all essential health benefits.
that you receive timely information about your health insurance and understand your rights as a Blue Cross of Idaho member. Blue Cross of Idaho will:
• respond to urgent care requests for prior authorization within 72 hours of receipt.
• provide members with a description of the diagnosis and treatment codes and their corresponding meanings on request.
• provide unique, identifiable denial codes/reasons on all adverse benefit determinations and add a general definition of investigational and medical necessity to the explanation of benefits.
• provide an external review process.
• provide translation of some forms into Spanish, Tagalog, Chinese and navajo Indian (dine) on request.
WhAT Is heAlThCAre reForm? The affordable Care act (aCa) was passed by Congress and signed into law in 2010. Some regulations and laws are already in place and may have impacted your insurance coverage. The primary regulations were effective January 1, 2014. does The ACA requIre ThAT I oFFer InsurAnCe To mY emploYees?
The aCa does not require businesses with the equivalent of less than 50 full-time employees to offer insurance to employees.
I heArd ThAT The governmenT delAYed some pArTs oF The ACA For A YeAr. WhAT WAs delAYed And WhAT does ThAT meAn For mY BusIness? The aCa requires employers with 50 or more full-time employees to offer qualified health insurance that provides adequate coverage at an affordable price or pay an IrS tax penalty. This rule was supposed to take effect in 2014. however, the federal government delayed the IrS reporting mandate for employers until 2015, giving large businesses extra time to meet the requirements of the new healthcare law.
The delay in the employer reporting mandate did not delay the individual mandate, which required all legal uS residents to have health insurance by January 1, 2014.
CAn I ConTInue oFFerIng mY CurrenT InsurAnCe plAn To mY emploYees?
If your current health plan was effective prior to march 23, 2010, your plan may be grandfathered, allowing you to continue offering your current coverage. See the grandfathered section on page 5 of this toolkit for more information. hoW WIll mY CoverAge ChAnge?
depending on the plan you currently have, it may change quite a bit, or very little. all aCa-qualified plans must cover essential health benefits without dollar limits.
WIll IT CosT me more To oFFer InsurAnCe To mY emploYees? The impact of the aCa on your rates will depend largely on the changes you have to make to your existing insurance coverage. depending on your benefit plan, the aCa may not have much effect on your rates; if you make significant changes to your current plan to comply with the aCa, it may increase your costs.
does The ACA puT A lImIT on enrollmenT WAITIng perIods? as of 2014, the waiting period for health insurance enrollment can’t be longer than 90 days. You may include a bona fide orientation period no greater than 30 days in order to meet enrollment timeline needs. WIll I Be ABle To BuY heAlTh InsurAnCe From Blue Cross oF IdAho?
Blue Cross of Idaho will continue to offer insurance to our small group clients.
IF I oFFer quAlIFYIng
InsurAnCe To mY emploYees, CAn TheY Choose noT To TAke IT And quAlIFY For suBsIdIzed InsurAnCe Through The neW mArkeTplACe?
no. employees and their dependents with access to an employee-
sponsored, qualified health plan are not eligible for subsidies through the marketplace.
QueSTIonS and
anSWerS
p.o. Box 7408 · Boise, Id · 83707 1 888 go Cross (1 888-462-7677)
bcidaho.com
STreeT addreSS 1010 17th Street lewiston, Id 83501
maIlInG addreSS p.o. Box 1468 lewiston, Id 83501 208-746-0531 lewiston
STreeT addreSS 275 South 5th avenue Suite 150 pocatello, Id 83201
maIlInG addreSS p.o. Box 2578 pocatello, Id 83206 208-232-6206 pocatello
STreeT addreSS 1431 north fillmore Street
Suite 200 Twin falls, Id 83301
maIlInG addreSS p.o. Box 5025
Twin falls, Id 83303-5025 208-733-7258
Twin falls
STreeT addreSS 3000 east pine avenue meridian, Id 83642-5995
maIlInG addreSS p.o. Box 7408 Boise, Id 83707 208-387-6683 800-365-2345 meridian
ClaImS InQuIrIeS
(208) 331-7347 | (800) 627-1188
STreeT addreSS 1910 Channing Way
maIlInG addreSS p.o. Box 2287 Idaho falls
Coeur d’alene
1450 northwest Boulevard, Suite 106 Coeur d’alene, Id 83814
208-666-1495
