Healthcare Reform Timeline

Frequently Asked Questions

 

Benefits/coverage

Plans that are not grandfathered provide coverage for routine patient costs received by a member who is participating in an approved clinical trial. Coverage includes phase I clinical trials and expands the types of conditions beyond cancer. 

Plans cover routine costs associated with a phase I, phase II, phase III, or phase IV clinical trial that is being done to prevent, detect, or treat cancer or a life-threatening disease or condition (a disease or condition from which the likelihood of death is probable unless the course of the disease or condition is interrupted). Routine patient costs are considered the medically necessary services that would be otherwise covered by a health plan if the member was not a part of a clinical trial.

To qualify, a clinical trial must be at least one of the following:

  • Federally funded
  • Conducted under an investigational new drug application reviewed by the Food and Drug Administration
  • A drug trial that is exempt from having such an investigational new drug application

This information is subject to change based on new or revised laws or regulations, and additional coverage rules and limitations may apply. For more information on how these benefits may apply to your coverage, please check your subscriber agreement or call Customer Service.

Benefits/coverage

Yes. Dependents up to age 26 can be covered whether or not they: 

  • Are married
  • Are students
  • Live with their parents
  • Are financially dependent on their parents
  • Are eligible for coverage through their employers*

However: 

  • If they are married, their spouses cannot be covered.
  • If they have children of their own, the children cannot be covered under their grandparents’ plan.

Coverage remains effective until the first of the month following the dependent’s 26th birthday. For more information about dependent coverage, please read this fact sheet.

 

Benefits/coverage

You can now offer more incentives for your employees to participate in wellness programs. Under federal healthcare reform, the reward has increased to 30 percent of the cost of employer and employee contributions (and up to 50 percent for programs designed to prevent or reduce tobacco use). If an employee can’t meet the health standard established by the program because of a medical issue, the employer must provide a reasonable alternative way for the employee to meet the requirement.

Benefits/coverage

Health plans provide full coverage for many preventive services with no cost sharing (deductibles, copays,  or coinsurances) when members visit in-network doctors. Preventive care is healthcare that is aimed at screening for and preventing disease, including:

  • Flu shots and other immunizations 
  • Blood tests 
  • Other screenings such as mammograms, Pap tests, and colonoscopies
  • Other preventive services covered under federal healthcare reform

When state law is more generous than the federal mandates for preventive services, we follow state law. For more information about preventive care services, please read this sheet.

Benefits/coverage

Employer responsibilities

Under the Affordable Care Act, employers with at least 50 full-time employees or a combination of full-time and full-time equivalent employees are required to offer health coverage (as explained on the large employer page). Here are the rules for counting employees to determine if you need to offer health coverage:

  • Employers take the average number of full-time employees and full-time employee equivalents in the preceding calendar year. If that number is 50 or greater, the employer is required to offer coverage. (To help businesses transition to the new regulations, the federal government is only requiring employers with 100 or more full-time or full-time equivalent employees to offer coverage.)
  • To determine the number of full-time equivalent employees, the employer adds up all of the hours worked by part-time employees in a month and divides by 120. That number is then added to the number of full-time employees. While part-time employees are counted for purposes of determining employer size, the requirement to offer minimum essential coverage applies only to full-time employees and their dependents. 
  • An employer is not considered to exceed 50 full-time employees if the excess is due to seasonal employees working for 120 days or less during the calendar year. If the employer did not exist in the preceding year, employer size is based on the average number of employees who are reasonably expected to be employed in the current calendar year.

For more information, please see our infographic, "Will Your Business Have to Pay a Penalty?"

Employer responsibilities

The penalty for not offering coverage is more significant than the penalty for not offering coverage that meets minimum requirements as described in What Large Employers Need to KnowHere is a look at both:

If you don’t offer coverage and at least one employee receives a premium tax credit or cost-sharing reductions through HealthSource RI, you pay $2,000 per full-time employee—excluding the first 30. (Please note: To help businesses transition to the new regulations, the federal government is excluding the first 80 full-time employees from the penalty calculation for 2015 only.) HealthSource RI is our state’s health insurance marketplace (also called an exchange).

Example for an employer with 50 employees with one employee who receives a tax credit through Healthsource RI: $2,000 x 20 (50 employees – 30 employees)=$40,000

If you offer coverage that doesn’t meet minimum requirements and an employee receives a premium tax credit through HealthSource RI, you pay $3,000 for each full-time employee receiving a premium tax credit. If that amount exceeds what you would pay under the first penalty—$2,000 per full-time employee, excluding the first 30 (or 80 in 2015)—the first penalty applies.

Example for an employer with 50 employees with one employee who receives a tax credit on the exchange: $3,000 x 1=$3,000

Employer responsibilities

Employers with 100 or more full-time employees or full-time equivalent employees are required to provide affordableminimum essential coverage that provides minimum value to full-time employees starting in 2015. In 2016, the requirement to offer coverage applies to employers with 50 or more full-time employees or full-time equivalent employees. For more information, please see What Large Employers Need to Know.

Employer responsibilities

Yes, you must report the cost of employees’ health insurance if you filed more than 250 W-2 forms last year. This includes both the cost paid by you and the cost paid by the employee. This amount is not taxable. 

Employer responsibilities

You must provide a notice explaining coverage options available through HealthSource RI to all new employees within 14 days of their start date. You can use the model notices created by the Department of Labor. There is one model for employers who offer a health plan to some or all employees (also available in Spanish) and another model for employers who do not offer a health plan (also available in Spanish). 

You aren’t required to use the model notice. If you create your own notice, it must include:

  • What the Health Insurance Marketplace is
  • Contact information and description of the services provided by the Health Insurance Marketplace
  • That the employee may be eligible for a premium tax credit under section 36B of the Internal Revenue Code if the employee purchases a qualified health plan through the Health Insurance Marketplace
  • A statement informing the employee that if he or she purchases a qualified health plan through the Health Insurance Marketplace, he or she may lose the employer contribution (if any) to any health benefits plan offered by the employer, and that all or a portion of such contribution may be excluded from income for federal income tax purposes. 

For more information, please read this fact sheet.

Employer responsibilities

Other

No. The Department of Health and Human Services has clarified that retroactive cancellations of health insurance done in the normal course of business are not rescissions. Instead, groups may apply terminations retroactively within a short period of time if they are based on a delay in administrative record-keeping. For example, if your human resources department only reconciles eligibility based on monthly data feeds, then terminations done as a result of such reconciliation may be allowed. For more information on rescissions, please see this fact sheet.

Other

Taxes and fees

While regulations have yet to be issued about the “Cadillac” tax, group plans valued at over $10,200 for individual coverage and $27,500 for family coverage will be subject to an excise tax starting in 2018. (The values may be adjusted for employers in high-risk industries, and based on the age and gender of the employer’s population.) The tax will be 40 percent of the “excess benefit.” For example, if an individual plan is valued at $11,000, the $800 “excess benefit” will be taxed at 40 percent.

The tax applies to all plans in the group market, including self-funded plans, but not to plans sold in the individual market. When calculating the value of your plan, you should include health coverage, prescription drug coverage, and contributions to flexible spending accountshealth reimbursement arrangements, and health savings accounts. Values do not include dental or vision coverage. 

Taxes and fees

PCORI fee – We are filing and paying the fee for our fully insured accounts. These fees are included in monthly premiums. 

Reinsurance fee – We are filing and paying the fee for our fully insured accounts. These fees are included in your fully insured monthly premiums.

Taxes and fees

Waiting period

The Affordable Care Act requires that employees eligible for health coverage must be able to enroll in health coverage that is effective within 90 calendar days. 

Blue Cross has made changes to our systems to ensure that an employer's waiting period does not exceed 90 calendar days. Employers will be able to establish waiting periods as long as they do not exceed 90 calendar days. Our standard waiting period will continue to be the first of the month following the date of hire. For more information on waiting periods, please see our fact sheet.

Waiting period

If you have an employee who doesn’t have a regular schedule, you can use a 12-month measurement period (beginning on any date between the employee’s start date and the first day of the first calendar month following the employee’s start date) to calculate whether the employee meets the plan’s eligibility requirements. When using this measurement period, the employee’s coverage must be made effective no later than 13 months from the employee’s start date. However, if the employee’s start date is the first day of a calendar month, coverage may be effective the first day of the next calendar month. For more information on the 90-day waiting period, please read this fact sheet.

Waiting period
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