We have just passed the first anniversary of passage of the Patient Protection and Affordable Care Act. Our Clients across the country, continue to grapple with many provisions of this law. As a result, we have fielded many questions about this topic and this is the second in a series of articles/newsletters providing a sampling of some of the questions we’ve been receiving.
Q. We have some questions dealing with the administration of leaves and benefits continuation. Does healthcare reform affect when are we allowed to cancel coverage for non-payment when an employee is on FMLA leave?
A. Healthcare reform does not affect the FMLA’s benefits continuation rules. Please see our article on FLMA click here.
Q. If a person with a pre-existing condition is uninsured, and comes onto an employer-sponsored group health plan, do pre-existing waiting periods apply?
A. Preexisting condition exclusions are prohibited effective for plan years beginning on or after January 1, 2014, for all plans including grandfathered plans. Preexisting condition restrictions on children under 19 may not be applied by both existing (grandfathered) and new plans effective for the first plan year beginning on or after September 23, 2010.
Thus, in many cases, plans may still include preexisting condition coverage waiting periods.
Under current law plans may exclude preexisting conditions from coverage for no more than 12 months (18 months for late enrollees) from the plan’s enrollment date, including any waiting period before enrollment. A late enrollee is an individual who does not enroll when first eligible to do so. The exclusion applies only to conditions for which medical advice, diagnosis, care, or treatment was recommended or received during the 6-month period ending on the enrollment date. If a doctor recommended treatment before this 6-month look-back period, an individual can be subject to a preexisting condition exclusion only if he or she receives the recommended treatment within the 6-month look-back period.
Group health plans and issuers must reduce any preexisting condition exclusion period by the length of the aggregate period of prior creditable coverage. For example, if an employee was covered under one employer’s plan for 8 months and moves to a second employer, the 12-month preexisting condition exclusion under the second plan could apply for 4 months. Creditable coverage includes most types of public and private healthcare coverage, even short-term limited coverage. Prior coverage does not qualify if there is a significant break in coverage, which is defined as a break in healthcare coverage that is longer than 63 days.
The determination of whether an individual has had a 63-day break in coverage does not include the days of waiting periods and affiliation periods. In addition, proposed HIPAA Portability regulations provide that the 63-day period is tolled for an individual if a certificate of creditable coverage is not provided on or before the day coverage ceases. In those cases, the significant-break-in-coverage period is tolled until a certificate is provided or, if earlier, until 44 days after the coverage ceases.
Q. Are there any restrictions on an employer’s ability to offer only certain management-level employees health insurance benefits?
A. Detailed information on health insurance benefits is available on HR.BLR.com® under the topic Healthcare Insurance. Portions of the topic analysis are provided below for your convenience.
The Affordable Care Act provides that the provision of Internal Revenue Code Sec. 105(h) that has barred discrimination in favor of the highly compensated by self-insured plans also applies to nongrandfathered, insured group health plans.
Nondiscrimination rules. Under IRC Sec. 105(h), a plan may not discriminate in favor of highly compensated individuals as to eligibility to participate and the benefits provided under a plan.
Eligibility test. A plan satisfies the eligibility to participate test if it benefits:
70 percent or more of all employees, or 80 percent or more of all the employees who are eligible to benefit under the plan if 70 percent or more of all employees are eligible to benefit under the plan; or
Employees that qualify under a classification set up by the employer and found by IRS not to be discriminatory in favor of highly compensated individuals. Certain employees do not have to be counted when applying this test, including:
Employees who have not completed 3 years of service;
Employees who have not attained age 25; and
Part-time or seasonal employees.
Internal Revenue Service Regulations (26 CFR Sec. 1.105-11) provide that an employer may treat employees whose customary employment is less than 25 hours a week or 7 months a year as part-time or seasonal employees.
Benefits test. A plan must provide the same benefits that it provides to participants who are highly compensated individuals to all other participants.
Highly compensated individual. For the purpose of these tests, the term “highly compensated individual” means an individual who is:
One of the five highest paid officers,
A shareholder who owns more than 10 percent in value of the stock of the employer, or
Among the highest paid 25 percent of all employees.
Enforcement delayed. Enforcement of this provision has been delayed until sometime after regulatory guidance is issued (IRS Notice 2011-1). The IRS, with the agreement of DOL and HHS, has determined that because regulatory guidance is essential to the operation of this statutory provision, compliance with PHSA Sec. 2716 will not be required until after regulations or other administrative guidance has been issued. To provide insured group health plan sponsors time to implement any changes required by the regulations or other guidance, the IRS, DOL, and HHS anticipate that the guidance will not apply until plan years beginning a specified period after issuance. Before the beginning of those plan years, an insured group health plan sponsor will not be required to file IRS Form 8928 with respect to excise taxes resulting from discrimination in favor of the highly compensated by insured group health plans.
If the management-level employees in your question meet the definition of highly compensated employees, it is likely that offering health insurance benefits exclusively to those employees would violate the nondiscrimination rules.