Spring Spotlight: Lai-Sahn Hackett

The term “consultant” is fairly vague, the term “actuary” is fairly confusing, and the term “captive insurance” is fairly unknown among many crowds. We’re looking to clear things up and put some faces to our name, especially since we’ve been blooming with new team members lately. So we’re bringing you a behind-the-scenes look at Spring to give you a better understanding of the people behind our work with our bi-weekly Spring Spotlight, starting with Lai-Sahn.

Lai-Sahn Hackett

Title: Consultant

Joined Spring in: June of 2013

At work: Lai-Sahn is a force to be reckoned with when it comes to Spring’s absence management consulting arm, helping clients to effectively manage any and all employee leaves (such as maternal or disability). She is particularly involved in market research, heading up various benchmarking surveys so we have insights and data to intelligently advise our clients.

Outside-of-work: When not buried in research data, Lai-Sahn can be found outside running. She is an avid runner and participates in a few races a year.

Favorite season: “Fall, because it’s good for running and I like the leaves.” (See, we didn’t force Spring upon her).

Favorite flower: Daisy.

Favorite food: Ice cream – coffee oreo is her fave flavor.

Favorite part about working at Spring: “The people. I really like my team. We also have a great location – I love being in downtown Boston.”

What is your spirit animal? “Probably a panda…that’s my login icon on my computer. I just love them and they’re also clumsy like me.”

 

Spring’s Managing Partner to Speak at IGP Employee Benefits Seminar

Karin Landry, Managing Partner at Spring, will be participating in a panel at the International Group Program (IGP) International Employee Benefits Seminar, which takes place from May 9th to the 11th at the Westin Copley Place Hotel in Boston.

Risk ManagementIGP will be celebrating its 50th anniversary at this year’s event – a three day conference focused on educating HR and like professionals about global employee benefits. Topics of discussion will include:

  • Typical benefits plan design
  • Funding requirements
  • Legislative updates
  • Recent trends and new products

All of these will be looked at from an international perspective, where attendees have the option of attending up to 11 different country panel discussions, as policies and norms are certainly not the same in every country. IGP is also offering training sessions as part of the event, with plenty of networking opportunities as well.

Our very own Karin Landry will be presenting on Thursday, May 11th at 9AM, alongside fellow benefit captive experts. They will be discussing how to best incorporate employee benefits coverage in a captive insurance arrangement. Specifically, they will offer their expertise on the ideal roles of HR and risk management, regulatory changes and industry trends.

If you’re interested in captive insurance and will be at the IPG seminar in May, be sure to check out Karin’s session. If you can’t make it (or are extra-interested), you might also enjoy our white paper – Funding Employee Benefits Through a Captive.

6 Trending Topics from the IBI Annual Forum

By Karen English, PCU, ARM
Partner, Spring Consulting Group

I recently had the pleasure to attend and speak at the Integrated Benefits Institute (IBI) Annual Forum in San Francisco. I always enjoy networking with colleagues, meeting new faces, and contributing to the latest industry news and trends, and this event was no disappointment.

Integrated Benefits Institute annual forum
Throughout three days of workshops, seminars, cocktail receptions, and waking up at 5AM to dial into East Coast morning meetings, I was happy to see a number of important topics covered. In case you were not able to attend, I have summarized a few key areas below (many of which are closely related).
1. Prevention/Early Intervention

The ever-increasing importance of being proactive instead of reactive when it comes to health issues including chronic conditions like diabetes, cancer, depression (see below), and others was highlighted in several IBI sessions.

Denise Zoe Algire of Albertson’s Companies and Michael Coupland of IMCS Group stressed the importance of getting in front of these issues as many of them are predictive based on psychological factors, and early intervention will reduce claims costs (among other positive outcomes). A panel of professors and folks from Liberty Mutual focused on disability prevention in the realm of the opioid crisis and proposed strategies to reduce sick leave. Further, Andrew Yohe and Michael Parkinson of UPMC, along with Wendy Lynch of Lynch Consulting, talked about how to use big data to get ahead of mental health problems, which leads us to the next important topic…

2. Behavioral/Mental Health

It’s nice to finally see mental health being addressed at a more wide-spread level, especially since it affects 1 in 5 workers. This is something we highlighted in the panel on which I participated – alongside professionals from Cigna and DMEC, I spoke about how mental health is a growing concern when it comes to absenteeism and productivity, and advised on how employers can best address it head-on.

Employee WellbeingWe weren’t the only ones talking about it though! A group from The Standard and Regions Hospital discussed how to accommodate for behavioral health issues while still complying with short-term disability and FMLA guidelines, and Judy Gordon and Jenna Carl emphasized the impact of sleep (or lack thereof) on mental health and productivity. One workshop discussed the national standard for workplace health passed in Canada and how it’s helped to relieve and address issues before they result in excessive absence. Lastly, a panel of professionals from Intermountain Healthcare, Willis Towers Watson, and The Hartford talked about how to approach behavioral health claims – covering different models and explaining how to best leverage multiple facets like health plan design and education.

3. Technology to Increase Access & Utilization

It’s 2017, so no surprise that technology is playing a role in almost every discussion. Specifically, one IBI session highlighted how

Aging Workforce

Photo credit Matthias Zomer

technology can help keep a knowledgeable, aging workforce healthy and engaged. Tele-behavioral health was also a hot topic, with a group of folks from CarMax, AbleTo, and Aetna arguing that technology can increase access to care, mitigate some of the existing stigmas, and ultimately prevent conditions that lead to work impairment and high medical costs.

Yet another session highlighted how Chesapeake Energy uses telehealth systems to improve health and productivity, particularly for those employees in more rural areas with limited access to care.

4. Back-To-Work Strategies

Making sure employees can get back to work safely are reasonably continues to be a challenging priority for many employers. Speakers from Northrup Grumman Corporation and Anthem talked specifically about improving returning to work for those affected by cancer, while another session focused on broader tactics and introduced on-site resources to reduce disability durations, contain costs and boost employee engagement.

5. The Positive Correlation Between Business Outcomes & Workplace Wellbeing

It’s not always easy to measure the success or ROI of different health and wellness programs. However there was a lot of talk at IBI about Value on Investment, or VOI, and how a healthier, more engaged workforce can improve the likelihood of businesses meeting their goals.

Presenters from companies like Nestle, Bank of America and Comcast took the first deep-dive into this relationship. Then Sandra Morris and Bruce Sherman identified three areas where companies should be investing more: prevention and well-being, Centers of Excellence, and the reduction of out-of-pocket costs for prescription medicines. Later on, speakers from Central Michigan University and Virgin Pulse shared helpful tips for measuring wellness outcomes and demonstrating VOI to senior leadership.

6. Managing Global Leaves & Benefits

This a growing topic that came up in two different seminars. It’s hard enough to manage leave and policies for employees within a single country, given that each state and region can have different regulations. Then if you add in a global element, things get all the more complicated.Global Employee Benefits

Rich McDonald from Johnson & Johnson and Tyler Amell of Morneau Shepell gave advice on how to find a harmonious approach to leave policies across different nations and regions and their corresponding legislative factors. Another workshop outlined how the World Bank Group used evidence-based data analytics modeling tools, along with U.S. Preventive Medicine (USPM), to establish preventive health strategies that are culturally-specific. The goal was to provide a more seamless delivery of health services to international locations, and to shift from merely treating illness to actually managing and improving health.

 

It was certainly an enlightening conference and I’m glad I had the chance to participate. I hope you find it helpful to learn what the hot topics of discussion were…doesn’t it almost feel like you were there?

If the above themes are of interest to you, you might also enjoy our white paper, Managing an Absent Workforce: A Guide to the Family Medical Leave Act.

Spring Heading to Philly for the 2017 RIMS Annual Conference & Expo

While we wouldn’t hate going back to San Diego (home of the 2016 conference) during this dreary stretch of New England weather, Spring is excited to sponsor and attend the 2017 RIMS (The Risk & Insurance Management Society) annual conference in Philadelphia this April 23rd to the 26th.

Photo by Gladson Xavier via Pexels.com: https://www.pexels.com/photo/war-chess-59197/

Why Go?

Risk management is a complex business matter, and one that is evolving quickly as emerging technologies and cyber-related issues continue to arise at a rapid pace. As such, it’s important for professionals in this field to come together to share ideas and learn from each other. That’s why we’re delighted to send our own thought leaders to the RIMS annual conference for the 10th year in a row.

Spring’s Managing Partner Karin Landry, Partner Karen English, and Consultant Prabal Lakhanpal will be joining other experts in the risk management field for an action-packed four day conference. If you’ll be there too, be sure to say hello – we’ll be at booth 436!

What to Expect

Conference attendees will hear from speakers like Michael J. Fox and Tom Lawson (President & CEO of FM Global). Topics for discussion and educational sessions will include:

  • Enterprise Risk Management
  • Claims Management
  • Contractual Risk Transfer
  • Cyber Risk Management
  • Insurance and Contract Management
  • Emerging Risks
  • & more

For additional event details, visit the RIMS annual conference website.

In the meantime, you might also be interested in our white paper, Self-Funding and the Management of Risk, which you can download here.

Looking forward to seeing you at booth 436 from April 23rd-26th at the Pennsylvania Convention Center!

Spring Consulting Group Brings New & Innovative Risk Management Solution to Market: Bloom Insurance Company

Bloom Insurance to Offer Businesses & Groups Benefit of Managing Medical Stop Loss and other Risk through a Captive Without Having to Create One

bloom cell captiveWe are very excited to announce the launch of Bloom Insurance Company, a cutting-edge risk funding solution. Licensed in Delaware, Bloom Insurance Company is a series captive that offers businesses and organizations the benefits of insuring without the responsibility of creating a stand-alone captive.

Since 2004, Spring Consulting Group has been the premier provider of integrated and innovative solutions that help businesses and organizations yield health, wealth and productivity.

Bloom Insurance Company, which is bringing risk management to the sharing economy by creating a legal entity that can be divided into cells and rented out to companies and organizations interested in benefitting from a captive funding model to finance their risk; Most notably medical stop loss.

“We are so pleased to introduce Bloom Insurance Company, a turn-key solution to an often complex financial model,” said Karin Landry, Managing Partner of Spring Consulting Group. “We have found that developing an individual captive can seem complicated or even overwhelming to many businesses. Bloom will streamline this process, helping groups and businesses manage their risk through this innovative funding solution, and eliminating a headache for them.”

Businesses and organizations who rent a cell with Bloom Insurance Company will have access to an array of innovative product offerings from Spring Consulting Group, many of which provide a high-quality and plentiful marketplace for employee benefit vendors.

Members will also have access to Spring’s industry-leading human capital management system module, which refines and automates HR, Payroll and Benefits tasks – such as onboarding, time tracking, or compliance – bringing members into the digital age. Finally, Bloom members will benefit from the award-winning Spring team, whose decades of experience as captive consultants, underwriters, and employee benefit consultants will be available to them.

As a full-service offering that takes care of set-up and implementation for members, Bloom Insurance Company can save members both time and money typically spent on captive development. Additionally, Bloom offers the general benefits of insuring casualty/benefits risk using a series captive such as: continued administrative savings and day-to-day management services from an industry-leading captive expert.

To learn more about Bloom Insurance Company, click here.

Spring’s Karin Landry Receives 2017 CICA Distinguished Service Award

Landry Recognized As Industry Leader With Highest Honor from Captive Insurance Companies Association

CICA Cites Landry’s Significant Contributions to Advance Captive Insurance Industry Throughout Her Career 

karin landry cica distinguished service awardWe are pleased to announce that Karin Landry, Managing Partner of Spring Consulting Group, was today presented with the Captive Insurance Companies Association’s (CICA) highest honor: the CICA Distinguished Service Award. Established in 2006, the award was created to recognize individuals or organizations that have made significant contributions to advancing the captive insurance industry.

Karin Landry Spring Consulting Group“Captives are the LEGO of the insurance industry; there are a million different ways to piece them together and take them apart, allowing for infinite creativity. After 25 years in the industry, I am still excited to play with them and find the newest innovation to serve our clients,” said Karin Landry, Managing Partner of Spring Consulting Group.  “Captives allow companies like Spring to view insurance as more than just an expense but rather as a problem-solving opportunity for the myriad of financial challenges our clients face. I am deeply humbled by this honor from CICA, and I want to thank our dedicated team and incredible clients for supporting me and giving me the opportunity to do the work I love.”

Landry has more than 25 years of experience in the insurance, health care, risk financing, retirement and benefits industries. She is an internationally recognized leader in captive insurance strategy, benefits and financing. In addition, Landry helps a variety of governmental, corporate, insurance, financial services and health care provider clients develop and implement new strategies and programs, both domestically and internationally. Her expertise in life, health and retirement benefits, risk financing, property and casualty as well as insurance has helped clients to develop customized, innovative solutions.

Spring Consulting Group Members Named ‘Power Broker’ Once Again in 2017

power broker 2017

Image courtesy Risk & Insurance

We are pleased to announce that Risk & Insurance has honored two Spring Partners in their Power Broker award series for 2017.

Spring Managing Partner Karin Landry has been named a 2017 Power Broker and Spring Partner and Spring Partner Teri Weber, has been named a 2017 Finalist by the magazine. Landry’s award is in the Employee Benefit category and Weber was named in the Workers’ Compensation category.

The Power Broker designation recognizes individuals that display “devoted customer service, dedication to learning as much as you can about the industry you serve and driven creativity in finding solutions.” A description that fits both Landry and Weber very well.

Karin Landry, Spring Consulting Group Power BrokerKarin Landry has over 25 years of experience in the insurance, health care, risk financing, retirement and benefits industries. She is an internationally recognized leader in captive insurance strategy, benefits and financing. She is Past-Chairman of the Board of The Captive Insurance Company Association and a member of the ERISA Industry Committee and was recently appointed to the Board of Directors for Fallon Community Health Plan. She is also a Professor of Employee Benefits and member of the finance committee for the International Center of Captive Insurance Education part of the University of Vermont. Karin’s expertise around benefits allowed her to co-author a white paper for Business Insurance Magazine titled “Captives for Benefits: How to Use a Captive to Save Money and Enhance Benefits Coverage”, which is currently a top seller.

Teri Weber Spring Consulting Group Power Broker 2017Teri Weber has over 10 years of experience in health and welfare plan strategy, design, pricing and implementation. She also works with absence management programs, including disability, family medical leave and leave of absence tracking. Her areas of expertise have allowed her to work with diverse employers and vendors to streamline processes and programs to meet the needs of insurers, administrators, employers and employees. Teri is on the Board for the New England Employee Benefits Council (NEEBC) and recently served as lead editor for the Disability Management Employer Coalition’s (DMEC) Return to Work Program Manual.

Congratulations Karin and Teri for these well-deserved accolades!

More information about some of the services Karin and Teri provide to our clients can be found here.

Deconstructing ACA “Repeal and Replace”

The efforts to “repeal and replace” the Affordable Care Act (ACA) have occupied a good deal of recent media attention. This should not come as a surprise, since the ACA’s repeal was one of the centerpieces of Mr. Trump’s campaign, and it has also been a staple of Republican campaigns and legislation for the past eight years. The U.S. House of Representatives has voted to repeal or cripple the ACA on 60 separate occasions during that time. (For an excellent summary of these efforts, please see the November 2016 paper, prepare by Stephen Redhead, Health Policy Specialist, and Janet Kinzer, Senior Research Librarian, Congressional Research Service, entitled Legislative Actions to Repeal, Defund, or Delay the Affordable Care Act.)

aca repeal and replace

Image credit: Phil Roeder via flickr

While the mantra “repeal and replace” has become ubiquitous with reference to the ACA, for important political, budgetary and procedural reasons, these are really two different concepts, with radically different consequences. “Repeal” has a very different political calculus than “repeal and replace.”

What an ACA Repeal Really Means:

Despite their campaign promises, Republican lawmakers lack sufficient votes to repeal the ACA outright. This would require 60 votes in the Senate; Republicans have 52. So they must instead rely on a special budget strategy—referred to as “reconciliation”—that permits them to repeal those provisions of the ACA that directly impact federal spending. Created by the Congressional Budget Act of 1974, reconciliation allows for expedited consideration of certain tax, spending, and debt limit legislation. In the Senate, reconciliation bills aren’t subject to filibuster. Because any controversial bills in the Senate tend to attract a filibuster, the Senate Parliamentarian reviews the bill and decides whether it qualifies for reconciliation. Under the so-called Byrd rule, reconciliation bills can only make legislative changes that affect the federal budget. A previous ACA repeal bill was approved for budget reconciliation, which passed by the Senate in December of 2015. The bill was vetoed by President Obama, however.

The ACA is a massive law with 10 titles and hundreds of provisions. Of these, it is the insurance reforms, the individual and employer mandates, and the exchanges/marketplaces that are the most well-known. But the ACA also includes Medicare reforms, workforce provisions, FDA approval of biosimilars, and the many other provisions.

Repeal – The Reconciliation Process

Of all of the ACA’s many provisions, the following items are those that can be addressed by reconciliation in a stand-alone “repeal” measure (i.e., that can pass be a simple majority in the Senate):

  • Individual mandate penalty reduced to zero
  • Employer mandate reduced to zero
  • 40% excise tax on so-called Cadillac plans repealed (currently delayed until 2020). The excise tax may be replaced with a cap on the amount excluded from the employee’s income for employer-sponsored health plan coverage.
  • Increase the dollar limit on flexible health spending account contributions for Section 125 cafeteria plans (currently set at $2,600 for 2017)
  • Federal government subsidies for individuals to purchase exchange coverage reduced to zero (likely to be phased in over time)
  • Federal government “risk stabilization” payments to insurance companies reduced to zero (likely to be phased in over time)
  • Federal government payments to states adopting the optional Medicaid expansion reduced to zero, with Medicaid payments as block grants

A complete list of ACA provisions that are subject to repeal under the reconciliation process can be found in Table 3 of the Congressional Research Service paper cited above.

Replace – Requires 60 Votes

In contrast, the following items may not be repealed using reconciliation. This means that 60 votes will be required in the Senate to proceed:

  • Coverage mandates for insured and employer self-insured group health plans:
    • Coverage of adult children to age 26
    • Prohibitions on imposing:
      • Preexisting condition coverage exclusions
      • Waiting periods exceeding 90 days
      • Annual and lifetime dollar limits on essential health benefits
      • Reporting requirements (e.g., Summary of Benefits and Coverage)
      • Other ACA insurance mandates (the full list is set out below)
    • Additional ACA Requirements for Non-Grandfathered Plans:
      • Coverage of preventive services without cost-sharing (the regulatory interpretation of “preventive services” as including contraceptive coverage is likely to be changed eventually by new regulations under a Trump Administration)
      • Limits on employee cost-sharing
      • Independent external review of denied claims for plans not already subject to IRO under state insurance laws
    • Insurance Market Reforms
      • Small employer insurance plans required to offer coverage of all ten essential health benefits
    • The requirement to report the cost of employer-sponsored health plan coverage on Form W-2 cannot be repealed via budget reconciliation

Any attempt to repeal these provisions through normal legislative channels would be subject to a filibuster. Consequently, these provisions would remain in effect even if the ACA revenue provisions were repealed under a reconciliation measure. (A complete listing of the insurance market reforms is provided in the accompanying tables.)

Ignore – No Change

There is alternative to the handling of the ACA insurance market reforms, which are enforced through an excise tax penalty imposed on the employer. The Penalty is $100 per affected individual, per day, and it applies to any employer (regardless of the size of its workforce) that offers a group health plan that fails to comply with the ACA’s market reform requirements. Congress could reduce the excise taxes to zero. Or the the Trump Administration might adopt a non-enforcement policy regarding some certain market reform violations, but still enforce other popular market reforms (e.g., coverage of adult children up to age 26).

The “state of play”

There are currently at least five separate “repeal and replace” proposals. There are no stand-alone “repeal” proposals. Among other things, there is widespread concern that the repealing the ACA without providing a replacement would destabilize the insurance markets, and even lead to the collapse of the non-group market. The reasons for this collapse are explained in compelling fashion in a study by the Urban Institute, which claims that repeal of the ACA without replacement would devastate the non-group market “causing 7.3 million . . . people to become uninsured” as a result of three factors:

  • Eliminating premium tax credits and cost-sharing assistance would make coverage unaffordable for many of the people currently enrolled, causing them to drop coverage. Those with the fewest health problems would drop their coverage fastest
  • Eliminating the individual mandate penalty would reduce the incentive to enroll for healthy people who can afford coverage
  • Insurers would remain subject to the requirement to sell coverage that meets adequacy standards to all would-be purchasers, and they would remain subject to the prohibition against charging higher premiums or offering reduced benefits to those with health care needs

While we find the Urban Institute’s analysis compelling, Congressional Republicans are almost certainly aware of this risk, and they may be prepared to appropriate funds necessary to stabilize the insurance markets pending passage of comprehensive ACA replacement legislation.

The impact of repeal and replace on Government programs (Medicare and Medicaid)

Medicare

The ACA made some valuable, and correspondingly costly, changes to Medicare. Among other things, it expanded Medicare coverage to include certain preventive services, like mammograms or colonoscopies, without charging Part B coinsurance or deductible. In addition, the ACA phased out the prescription drug “donut hole.” Finally, the law took steps to ensure the Medicare program’s long-term solvency. All of this would be rolled back in the case of a full-blown ACA repeal. But at least one of the major replacement plans proposes to leave the ACA changes to Medicare intact. Presumably, this is a nod to popularity of the phase-out of the prescription drug donut hole.

One replacement plan (proposed by Rep. Paul Ryan) does not stop here. It instead proposes “transforming the [Medicare] benefit into a fully competitive market-based model using premium support.” Under the Ryan plan, beginning in 2024, Medicare beneficiaries would be given a choice of private plans competing alongside the traditional fee-for-service Medicare program on a newly created Medicare Exchange.

Medicaid

Medicaid is another matter entirely. The ACA vastly expanded the reach of the Medicaid program. The matter of Medicaid’s regulation post-ACA was further complicated by the Supreme Court’s ruling in 2012 that states were free to reject the ACA Medicaid expansion.

Before the ACA, Medicaid provided health care for children, pregnant mothers, the elderly, the blind, and the disabled.” The ACA expanded Medicaid’s reach to all low- income individuals. The Republican members of Congress roundly criticized this expansion, noting that the program’s expansion under the ACA accounts for more than 15 percent of all health care spending in the United States. This, they claim, is unsustainable.

The “Ryan” Plan’s approach to Medicaid is representative of the various “replace” proposals. Like the other plans, it makes radical changed to Medicaid that go well beyond mere repeal. This and the other plans offer two alternative approaches that states can elect: per capita allotment and block grants.

Per capita allotment

Under the per capita allotment approach a total federal Medicaid allotment would be available for each state to draw down on. The amount of the federal allotment would be the product of the state’s per capita allotment for the four major beneficiary categories—aged, blind and disabled, children, and adults—and the number of enrollees in each of those four categories. The per capita allotment for each category would be determined by each state’s average medical assistance and non-benefit expenditures per full-year-equivalent enrollee during the base year (2016), adjusted for inflation. The per capita allotment would be designed to grow at a rate slower than under current law.

Block Grants

Under the block grant option, a state that opts out of the per capita allotment could automatically receive a block grant of federal funds to finance their Medicaid program. States would then be free to manage eligibility and benefits generally as they see fit without the need to apply to the Department of Health and Human Services for waivers.

Individual and Group Market Reforms*

Provision Effective Date Section Title/Heading
(1) PPACA §1201§10103(e); PHSA §2704 Plan years beginning on or after September 23, 2010 Prohibition on preexisting condition exclusions for enrollees who are under 19 years of age.
(2) PPACA §1001§10101(a)HCERA §2301(a); PHSA §2711 Plan years beginning on or after September 23, 2010 Ban on annual and lifetime dollar limits on essential health benefits. Applies to group and individual insurance markets, and group health plans, including grandfathered group and individual plans. Annual or lifetime limits are permitted for items and services that are not part of the essential health benefits.
(3) PPACA §1001HCERA §2301(a); PHSA §2712 Plan years beginning on or after September 23, 2010 Rescissions permitted only for fraud or intentional misrepresentation of material fact and with prior notice to the enrollee. Applies to group and individual insurance markets, and group health plans, including grandfathered group and individual plans.
(4) PPACA §1001; PHSA §2713 Plan years beginning on or after September 23, 2010 Group and individual insurance contracts and group health plans (other than grandfathered plans) must cover the following preventive health services with no cost-sharing:
• Evidence-based items/services with a rating of “A” or “B” in the current recommendations of the U.S. Preventive Services Task Force (USPSTF).
• Immunizations recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (CDC).
• Evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration (HRSA) for infants, children and adolescents.
• With respect to women, additional preventive care and screenings provided for in guidelines supported by HRSA.
(5) PPACA §1001HCERA §2301(a)§2301(b); PHSA §2714 Plan years beginning on or after September 23, 2010 Group health plans that provide dependent coverage must make coverage available to age 26. Grandfathered group health plans may delay to plan years commencing on and after January 1, 2014, for adult children eligible to enroll in an employer-sponsored plan.
(6) PPACA §1001§10101; PHSA §2715 Plan years beginning on or after September 23, 2010 Group health plans must provide summaries of benefits and coverage (SBC) explanation that meets standards developed by HHS.
(7) PPACA §1001§10101(d); PHSA §2716 Plan years beginning on or after September 23, 2010, but enforcement suspended (Notice 2011-1, 2011-2 I.R.B. 259) Insured group health plans (other than grandfathered plans) must satisfy benefits-related non-discrimination rules under §105(h)(2) prohibiting discrimination in favor of highly compensated individuals in terms of eligibility and benefits.
(8) PPACA §1001; PHSA §2717 Plan years beginning on or after September 23, 2010 Group and individual market policies and group health plan (other than grandfathered plans) must establish quality programs and report quality data to HHS and to enrollees during each open enrollment period. Required elements of a quality program include:
• Improve health outcomes through activities such as quality reporting, effective case management, care coordination, case management and medication and care compliance initiatives, including through the use of the medical home model.
• Implement activities to prevent hospital readmissions through a hospital discharge program that includes patient-centered education and counseling, comprehensive discharge planning and post-discharge reinforcement by an appropriate individual.
(9) PPACA §1001; PHSA §2718 Plan years beginning on or after September 23, 2010 Bringing down the cost of health care coverage: Health insurance issuers provide an annual accounting for coverage offered (including grandfathered health plans) and rebates to enrollees if medical loss ratios are not met.
(10) PPACA §1001§10101(g); PHSA §2719 Plan years beginning on or after September 23, 2010 Internal appeals/external review:
• Issuers in the group market and group health plans must have an internal claims and appeals process based on existing DOL claims and appeals procedures, updated by standards established by HHS.
• Non-group plans must have an internal claims and appeals process based on existing law, updated by standards established by HHS.External Review: Issuers in the group market and group health plans must comply with applicable state or federal external review requirements.
(11) PPACA §10101(h); PHSA §2719A Plan years beginning on or after September 23, 2010 Group health plans must provide patient protections, including more choice of health care professionals, coverage of emergency services, and access to pediatric care and obstetrical or gynecological care.

 

Health Insurance Market Reforms*

Provision Effective Date Section Title/Heading
(1) PPACA §1201; PHSA §2704 Plan years beginning on or after January 1, 2014 Prohibition on preexisting condition exclusions or other discrimination based on health status.
(2) PPACA §1201; PHSA §2701 Plan years beginning on or after January 1, 2014 Fair health insurance premiums.
(3) PPACA §1201; PHSA §2702 Plan years beginning on or after January 1, 2014 Guaranteed availability of coverage.
(4) PPACA §1201; PHSA §2703 Plan years beginning on or after January 1, 2014 Guaranteed renewability of coverage.
(5) PPACA §1201; PHSA §2705 Plan years beginning on or after January 1, 2014 Prohibiting discrimination against individual participants and beneficiaries based on health status.
(6) PPACA §1201; PHSA §2706 Plan years beginning on or after January 1, 2014 Nondiscrimination in health care.
(7) PPACA §1201; PHSA §2707 Plan years beginning on or after January 1, 2014 Comprehensive health insurance coverage.
(8) PPACA §1201HCERA §2301(a); PHSA §2708 Plan years beginning on or after January 1, 2014 Prohibition on excessive waiting periods.
(9) PPACA §10103(c); PHSA §2709 Plan years beginning on or after January 1, 2014 Prohibition on denial of participation in approved clinical trials.

Tables used with permission. © 2017 by The Bureau of National Affairs, Inc. (800-372-1033) http://www.bna.com2017.