54 posts categorized "Healthcare Reform"

February 26, 2014

How Employees can File Whistleblower Complaints under ACA

Employees are protected from retaliation for reporting alleged violations of the Affordable Care Act’s health coverage reforms (Title I of the Act) and for receiving a premium tax credit or a cost sharing reduction for enrolling in a qualified health plan. OSHA's Fact Sheet on Filing Whistleblower Complaints under the Affordable Care Act has been updated and is available in both English and Spanish. The revised fact sheet includes a summary of the Affordable Care Act, types of retaliation, coverage, and the process of filing a complaint.

To access the Fact Sheet in English:


To access the Fact Sheet in Spanish:


February 25, 2014

Affordable Care Act 90-day Waiting Period for Coverage

Beginning 1/1/2015, the Affordable Care Act prohibits group health plans and group health insurance issuers from applying waiting periods exceeding 90 days. Under newly issued final regulations), (1) the phrase "waiting period" means the period that must pass before coverage can begin for an individual who is otherwise eligible to enroll under the terms of a group; (2) eligibility conditions based solely on the lapse of time are permissible for no more than 90 days, while other conditions for eligibility (not based solely on the lapse of time) are generally permissible unless designed to avoid compliance with the 90-day rule; (3) a plan's waiting period can begin on the first day after the employee satisfies a cumulative hours-of-service requirement, if the requirement does not exceed 1,200 hours; and (4) a requirement to successfully complete a reasonable and bona fide employment-based orientation period may be imposed as a condition for eligibility for coverage under a plan. According to the preamble, nothing in the regulations "requires a plan or issuer to have any waiting period, or prevents a plan or issuer from having a waiting period that is shorter than 90 days."

February 17, 2014

What does its cost to start up an ACO

Startup costs for the 2012 Medicare Shared Saving Plan (MSSP) Accountable Care Organizations (ACOs) are higher than estimated by CMS but considerably lower than many other estimates, according to a November 2013 survey conducted by the National Association of ACOs (NAACOS). According to the NAACOS, the average first 12 months start-up cost per ACO of $2,000,000 is a strong statement about the high level of risk ACOs are willing to take to transform care in their community.

NAACOS conducted its first short web-based survey in November 2013 covering (1) first year start-up costs, (2) financial prospects for the first year of operation, (3) operational problems launching the ACO, (4) who processes CMS claims data (CCLF), (5) total Cost of internal and external IT services, and (6) satisfaction with information technology (IT) services. The survey was designed to capture new information related to the actual first year start-up costs and IT spending experienced from the April 1, 2012, and July 1, 2012, by MSSP ACOs after they finished their first full year of operation. The survey consisted of 11 questions that required multiple choice or text answers. Spending on feasibility studies, CMS application, legal fees or other pre-contract costs were NOT included in the first year costs. Thirty-five ACOs responded and were representative of the size and geographic distribution of the ACO population. Size ranged from 5,100 to 78,000 assigned Medicare beneficiaries.

The survey found that the average actual start-up costs of the respondents in the first 12 months of operation were $2.0 million with a range from $300,000 to $6,700,000. Since savings are slow to flow as result of data and complex reconciliation process, ACOs will have almost a second full year of operations until their cash flow can be replenished with shared savings from CMS (if any) the NAACOS explained. NAACOS concluded that the average ACO will risk $3.5 million plus any feasibility and pre-application costs and estimated that ACOs on average will need $4 million of startup capital until there is a chance for any recoupment from savings.

Although at the time of the survey the ACOs had not received any interim reconciliation numbers from CMS, the NAACOS asked the ACOs to estimate their financial results after the first year of operations. The survey found that the range of predicted estimated gains was as high as $9,000,000 and losses as much as $10,000,000. About one third of the ACOs estimated a break-even level for the first year. NAACO said that including the breakeven ACOs, total estimated gains would be about equal to the estimated losses so the program as a whole would breakeven.

An high number of respondents identified CMS data and learning to access it and process it as the most challenging problem in first year operation. Respondents specifically pinpointed problems dealing with finding suitable software, meeting implementation schedules, delays in getting claims data, new skill sets to analyze data, addresses of assignees, slow stand-up of IT system, data inconsistency from CMS, and translating the data into actionable information for care managers and providers, according to NAACOS. The survey also found that about one quarter of the respondents use internal resources for the claims data processing, about one quarter use exclusively external sources and about half use a combination. In regard to IT services almost all ACOs had both internal and external costs for IT functions with an overall average of $413,000 for internal costs and $443,000 for external vendor costs. Respondents rated their satisfaction with IT services as 6.4 on a scale of 10.

January 24, 2014

January 2014 - Health Care Reform Developments

Individuals Covered under the Temporary High-risk Pool Program

The Affordable Care Act created a high-risk pool program to provide health insurance coverage for certain individuals with a pre-existing condition. The program was scheduled to end December 31, 2013. The Obama administration has announced that the program is extended through March 2014 to allow covered individuals additional time to enroll in health insurance coverage through a state insurance marketplace. 

Small Employer Health Insurance Credit

The IRS has issued the 2013 Form 8941 (Credit for Small Employer Health Insurance Premiums) and its instructions. Included in the instructions are the state average premiums for coverage in the small group market.



September 26, 2013

Health Care Reform Developments - 2014 Premium Rates

HHS released an issue brief disclosing the 2014 premium rates that will be available in the 36 states in which HHS will support or fully run the state insurance marketplace. The analysis also includes some premium information from 11 states and the District of Columbia that are implementing their own insurance marketplace. The information in the brief is current as of September 18, 2013, and is subject to change since plan data is still under review and may be revised by HHS before being displayed for consumers. The brief is available at:



September 17, 2013

No Penalty for Employers Not Telling Employees About Health Insurance Marketplaces

The Department of Labor issued a notice stating that employers will not face a penalty if they fail to inform their workers by Oct 1 about the new health insurance marketplaces created by the Accountable Care Act. These healthare "exchanges" are set to start enrolling millions of Americans beginning Oct 1.

September 11, 2013

More Health Care Reform Developments

Proposed Section 6055 Regulations

The IRS has issued proposed regulations providing guidance to providers of minimum essential health coverage that are subject to the information reporting requirements of IRC Sec. 6055. Beginning in 2015, IRC Sec. 6055 requires health insurance issuers, certain employers, governments, and others that provide minimum essential coverage to individuals to report to the IRS information about the type and period of coverage and furnish related statements to covered individuals. Generally, the required information will be reported on new Form 1095-B. However, some combined reporting may be allowed using Form W-2 and the new Form 1095-C that applicable large employers must use for the Section 6056 reporting requirements.

Proposed Section 6056 Regulations

The IRS has issued proposed regulations providing guidance to employers that are subject to the information reporting requirements under IRC Sec. 6056, which begin in 2015 and require applicable large employers to report to the IRS information about their compliance with the employer shared responsibility provisions of IRC Sec. 4980H and about the health care coverage they have offered full-time employees. IRC Sec. 6056 also requires those employers to furnish related statements to employees so that employees may use the statements to help determine whether, for each month of the calendar year, they can claim on their tax returns a premium assistance credit under IRC Sec. 36B. Generally, the required information will be reported on new Form 1095-C. However, the proposed regulations provide for simplified reporting, using Form W-2, in certain situations.

September 10, 2013

September 2013 - Health Care Reform Developments

Final Regulations on the Individual Mandate

The IRS issued final regulations on the requirement that, starting in 2014, individuals must have minimum essential health insurance coverage or be subject to a shared responsibility penalty. The regulations, which generally finalize proposed regulations issued earlier this year, define minimum essential coverage, explain who is exempt from the individual mandate, and describe how the penalty is calculated and paid.

Proposed Regulations on the Small Employer Health Insurance Credit

The IRS issued proposed regulations on the small employer health insurance credit. The proposed regulations generally incorporate the provisions of IRS Notices 2010-44 and 2010-82 as modified to reflect the differences between the statutory provisions applicable to years before 2014 and those applicable to years after 2013. 

Final Regulations on the State Insurance Marketplaces

HHS released final regulations on a number of provisions related to the Affordable Care Act. The overarching goal of the regulations, which generally finalize proposed regulations issued earlier this year, is to safeguard federal funds and to protect consumers by ensuring that issuers, the insurance marketplaces, and other entities comply with federal standards meant to ensure consumers have access to quality, affordable health insurance. The rules finalize, among other things, standards for the handling of consumer complaints by issuers in the insurance marketplaces, and other provisions meant to ensure smooth operation of the insurance marketplaces, protect consumers, and give flexibility to states. The rules explain the process for employers to contest a determination that they do not provide minimum essential coverage that is affordable and provides minimum value, individuals to appeal eligibility determinations for marketplace participation and insurance affordability programs, and employers and employees to appeal denials of eligibility to purchase coverage through the small business health options program (SHOP). 

August 12, 2013

Draft IRS Form 8960 Released

The IRS released a draft of Form 8960, which will be used by individuals, estates, and trusts to compute the new 3.8% net investment income tax (NIIT). Beginning in 2013, individuals must pay the 3.8% NIIT on the lesser of (1) net investment income or (2) modified adjusted gross income (MAGI) over a certain threshold amount. Trusts and estates will owe it on the lesser of (1) undistributed net investment income or (2) the excess of AGI over the amount at which the highest estate and trust income tax bracket begins.

August 09, 2013

Income Verification by Health Insurance Marketplaces

According to an FAQ on the CCIIO website, HHS has clarified that, for the federally-facilitated marketplaces, CMS intends to verify the income on 100% of the applications for advance payment of the premium assistance credit and cost-sharing reductions. The marketplaces will first try and verify the information electronically using available data from IRS, SSA, and Equifax. If the data on the application cannot be verified, the marketplace will request an explanation or additional documentation from the applicant to substantiate the income. For 2014, a state-based marketplace may choose to verify the income of a statistically significant sample size that is less than 100%, for applicants that meet certain requirements.