What Is Minimum Essential Coverage Under Obamacare?


Minimum essential coverage

To avoid the fee in 2014 you need insurance that qualifies as minimum essential coverage. If you’re covered by any of the following in 2014, you’re considered covered and don’t have to pay a penalty:

* Any Marketplace plan, or any individual insurance plan you already have

* Any employer plan (including COBRA), with or without “grandfathered”status. This includes retiree plans

* Medicaid

* The Children’s Health Insurance Program (CHIP)

* TRICARE (for veterans and veteran families)

* Veterans health care programs

* Peace Corps Volunteer plans

             Other plans may also qualify.



Do You Qualify for Lower Out-of-Pocket Costs in the Marketplace?


When you get coverage through the Marketplace, you may be able to get lower costs on deductibles, copayments, and coinsurance. This will depend on your income.

The Marketplace cost-sharing reduction lowers the amount you have to pay for out-of-pocket costs like deductibles, coinsurance, and copayments. These are costs you have to pay when you get care.

This savings is based on your income and family size.   Savings depend on your income

Health insurance companies offering coverage through the Marketplace must lower the amount you pay out of pocket for essential health benefits if your household income is below the following amounts. (Incomes below are based on 2013 numbers. They are likely to be slightly higher in 2014. Amounts are different for each family size, up to 8.)

Up to $28,725 for individuals         /         Up to $38,775 for a family of 2    

Up to $48,825 for a family of 3      /          Up to $58,875 for a family of 4

Up to $68,925 for a family of 5      /          Up to $78,975 for a family of 6

Up to $89,025 for a family of 7      /          Up to $99,075 for a family of 8

When you apply for coverage in the Marketplace, you’ll learn if you’re eligible for these savings on out-of-pocket costs.

Out-of-pocket savings apply only to Silver plans

Plans in the Marketplace are separated into 4 different categories: Bronze, Silver, Gold, and Platinum. These categories are based on how much of your medical costs you pay and how much the plan pays when you get medical care. They are not based on plan quality. Learn more about plan categories and what they mean.

If you qualify for out-of-pocket savings, you must choose a Silver plan to get the savings. If you qualify for these savings, you’ll get the out-of-pocket savings benefits of a Gold or Platinum plan for a Silver plan price. You can choose any category of plan, but you’ll get the out-of-pocket savings only if you enroll in a Silver plan.

You’ll be able to choose your plan category when you fill out your Marketplace application.

Until October 1, you can get a rough estimate of costs and savings by using the Kaiser Family Foundation calculator.



Non-Profit Religious Organizations Exemption to Cover Contraceptive Services


Introducing the Eligible Organization Designation

The final rules replace the TESH with a new exception for Eligible Organizations. An Eligible Organization is a non-profit religious organization with religious objections to covering contraceptive services. Those organizations that self-certify as an Eligible Organization may exclude coverage for some or all contraceptive services. The new Eligible Organization designation is effective for plan years starting on or after Jan. 1, 2014.

A new self-certification form from the Department of Labor must be completed by employers claiming the Eligible Organization exception for plan years beginning on or after Jan. 1, 2014: EBSA Form 700 – Certification for Plan Years beginning on or after 1/1/14.

ACA Final Rules On Contraceptive Coverage for Religious Organizations


The Affordable Care Act (ACA) requires non-grandfathered health plans to cover contraceptive services for women without cost-share. However, group health plans sponsored by certain religious employers, and group health insurance coverage provided in connection with such plans, are exempt from the requirement to cover contraceptive services for women.

On June 28, 2013, the Departments of Health and Human Services (HHS), Labor, and the Treasury issued final rules on contraceptive coverage and announced four key changes:

  1. Modification of the Religious Employer Exemption (REE) definition.
  2. Extension of the current Temporary Enforcement Safe Harbor (TESH) through Dec. 31, 2013.
  3. Replacement of the TESH with an Eligible Organization designation for plan years starting on or after Jan. 1, 2014, including a new self-certification form for Eligible Organizations.
  4. Requires that a health insurance issuer providing fully insured coverage or a third-party administrator that receives certification from an Eligible Organization provide direct payment for contraceptives services at no cost to the plan or its members.

For more information, review the Religious Exemptions to Contraceptive Coverage.





The Administrative Simplification provision under Section 1104 of the Patient Protection and Affordable Care Act issued a final rule Aug. 24, 2012 that adopts a 10-digit healthplan identifier (HPID) for health plan entities to use with other entities.  Effective date to comply for small health plans is November 5, 2015.   Currently, the use of HPID is only requred for electronic transactions. 

Certain individual health care providers are to obtain and disclose a national provider identifier (NPI). Effective date is November 5, 2014. 

This is intended to improve the standards for electronic transactions under HIPAA.

Employer Shared Responsibility & Reporting Delayed


Federal Government Delays Enforcing Employer Shared Responsibility and Insurer Reporting Requirements Until 2015

The federal government announced in a blog on July 2, 2013, that it will delay enforcing certain provisions of the Affordable Care Act (ACA). Instead of being effective on the first day of the first plan year on or after January 1, 2014, the following provisions will not be enforced until 2015:

  • Employer Shared Responsibility: Employers with 50+ eligible employees will have until their first plan year on or after January 1, 2015, to comply with the ’Employer Shared Responsibility’ requirement to provide their workers with healthcare coverage that meets minimum value and affordability rules.
  • Reporting Requirements: Insurers and employers that self-insure will also have until their first plan year on or after January 1, 2015, to comply with the requirement to provide certain information about their healthcare coverage to the Internal Revenue Service and to each covered employee.

MMO Update email 07/08/2013

Health Reform Week of July 15, 2013

Most of the health care reform news in the past week focused on the implications of a recent decision by the U.S. Treasury Department delaying enforcement of the Affordable Care Act’s (ACA) employer mandate until 2015.  Both politicians and media had widely diverging assessments of whether the decision is a helpful sign of flexibility or a harbinger of growing chaos surrounding implementation of the law. Less widely covered, but far more definitive, was a decision last week from the Fourth Circuit Federal Court of Appeals affirming the constitutionality of the employer mandate in a case brought by Liberty University. On the issue of the Commerce Clause, the court held that the employer mandate “is simply another example of Congress’s longstanding authority to regulate employee compensation offered and paid for by employers in interstate commerce.” The court also held that the ACA did not violate the plaintiffs’ religious freedom rights under the First Amendment because it was a “valid and neutral law of general applicability.”  In June 0f 2012, the U.S. Supreme Court upheld the ACA’s individual mandate.Liberty University now says it intends to pursue its case to the U.S. Supreme Court as well.


The Senate Finance Committee held a hearing last week titled, “Repealing the SGR and the Path Forward: A View from CMS.” The hearing was held to focus on approaches that can be used to repeal the Sustainable Growth Rate (SGR) formula in Medicare, and replace it with other reimbursement methods for physician services provided to Medicare beneficiaries. Jon Blum, Acting Principal Deputy Administrator and Director of the Centers for Medicare and Medicaid Services (CMS), said that Medicare physician payment re-design approaches must consider: 1) how to set a realistic baseline for physician payments; and 2) how best to shift the payment system towards value-based payments rather than volume-based incentives. Blum suggested that Medicare physician payment reform should provide a multi-year period of stable updates to payment rates, while also continuing development of new payment models that hold providers accountable for the cost and quality of care, such as accountable care.

The House Energy and Commerce Subcommittee on Health held a hearing last week titled “Making Medicaid Work for the Most Vulnerable.” Speakers discussed Medicaid expansion under the ACA and potential Medicaid reforms. The hearing built on the Energy and Commerce Committee’s ongoing efforts to review Medicaid’s current weaknesses and identify reasonable reforms, as included in the policy blueprint issued by Chairman Upton (R-MI) and Senate Finance Committee Ranking Member Orrin Hatch (R-UT) in May 2013. Subcommittee Chairman Joe Pitts (R-PA) suggested that health outcomes for Medicaid beneficiaries are typically worse than the outcomes of those who have no insurance, and stressed the need for waiver reform, noting that CMS fails to encourage states to pursue new and innovative models of care. Pitts added that many states attempt to modernize and tailor their programs to the individual populations they serve. However, they often spend years waiting for CMS to approve their waivers, if they approve them at all.

The House Ways and Means Subcommittee on Health held a hearing on the administration’s decision to delay the ACA’s employer mandate and employer information reporting requirements. Subcommittee Chairman Kevin Brady (R-TX) said that he believed the delay in the employer mandate indicates that the President’s health care plan is not ready. Ranking Member Jim McDermott (D-WA) said that the exchanges are on track to open on schedule, and noted that it is impossible to know what the landscape will look like on January 1, 2014. But it is entirely possible that the delay will actually help consumers in the long run, he added. McDermott said that it is more important to delay the employer mandate, and get it right, than to rush and get it wrong.


Aetna Health Reform Weekly

Exchange Navigator Requirements Defined


On April 3, 2013, the Centers for Medicare & Medicaid Services (CMS) issued proposed regulations outlining standards for Navigators and non-Navigators (also known as “in-person assisters”) for training and certification, cultural and linguistic services, disability access and conflict of interest disclosures.

Navigators are organizations and individuals that will help individuals and small employers shopping for coverage on public Exchanges through the eligibility and enrollment process.

“In-person assisters,” “non-Navigator assistance programs” and “non-Navigator assistance personnel” may supplement the Navigators in some states. These roles were added to ensure that states would have enough resources to support all those who need assistance. Their responsibilities are similar to Navigators and the standards and training requirements in these proposed regulations apply to them as well.

Who Can and Cannot Be a Navigator

To ensure that Navigators are objective, CMS has proposed the following rules:

Can be a Navigator

  • Agents and brokers may be Navigators as long as they are not receiving any compensation from health insurance or Stop Loss insurance carriers for enrolling people in health coverage, either on or off the Exchange.

Note: Agents and brokers who sell products other than health insurance or Stop Loss insurance can continue to receive commissions on the sale of other types of insurance, provided they comply with the proposed disclosure requirements.

Cannot be a Navigator

  • Companies that issue health insurance and Stop Loss insurance, and their subsidiaries, cannot be Navigators.
  • Associations that include members of, or lobby on behalf of, the insurance industry cannot be Navigators.

What Navigators and In-Person Assisters Will Need to Disclose

Navigators and in-person assisters will need to disclose the following types of information to both the Exchange and to the consumers they are assisting:

  • Any current or former employment relationships over the last five years with companies that issue health insurance or Stop Loss coverage, or their subsidiaries.
  • Any other business, financial or contractual relationships with companies that issue health insurance or Stop Loss coverage, or their subsidiaries.
  • Any employment or business relationship their spouse or domestic partner has with companies that issue health insurance or Stop Loss coverage, or their subsidiaries.

Navigator and In-Person Assister Training and Certification Requirements

Navigators and in-person assisters will be required to:

  • Meet any licensing, certification or other standards prescribed by the state or Exchange.
  • Complete a training program approved by the Department of Health and Human Services (HHS) that may include up to 30 hours of training.
  • Pass an examination to be certified.
  • Obtain continuing education and be recertified at least annually.
  • Be prepared to serve both the individual and small group Exchanges.
  • Be trained to work with individuals with limited English proficiency and individuals with disabilities.

Cigna MAY 13 2013

“Employee Choice” in Federal SHOP Exchanges Delayed

 “Employee Choice” in Federal SHOP Exchanges Delayed

On March 11, HHS announced it is delaying the “employee choice” option in the Small Business Health Options Program (SHOP) Exchanges from 2014 to 2015. This delay will impact states where the Federal government will run the Exchanges and states that are developing their Exchanges in partnership with the Federal government.

The employee choice option will allow employers to determine how much they will contribute toward the cost of employee coverage and offer their employees a choice of Exchange plans from different carriers at a certain metal level (Bronze, Silver, etc.).

In 2014, small employers in states impacted by this delay will choose an Exchange plan and their employees will decide whether or not to enroll in that plan. Employers will not be able to offer their employees a choice of plans until 2015.

Exchanges being developed by states may choose to offer employee choice in 2014, or they may choose to delay implementation of that feature until 2015. The employee choice option will be available in all SHOP Exchanges for plan years beginning on or after January 1, 2015.

Cigna May 13, 2013

Healthcare Reform Bill Cost

Healthcare Bill — Gross Cost of Medicaid & CHIP Outlays

Cost:   $434,000,000,000

The healthcare bill significantly expanded eligibility for Medicaid and the Children’s Health Insurance Program (CHIP). In March 2010, the Congressional Budget Office (CBO) estimated that under the bill there would be roughly 16 million more enrollees in Medicaid and CHIP than the number projected under the laws in place before the bill was enacted. According to the CBO, the gross cost of Medicaid and CHIP outlays under the bill will be an estimated $434 billion over ten years.

Fox News:  05/07/2013