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Health Care Reform

  A Timeline & Perspective 
For Big “I” Members’ Clients
Legislative Timeline
November 7, 2009 – House of Representatives passes House version of Health 
Care Reform by a vote of 220‐215.
December 24, 2009‐ Senate passes their version of Health Care Reform 60‐39.
March 21, 2010 – House of Representatives passes Senate version of Health 
Care Reform by a vote of 219‐212 and the “Reconciliation bill” that made a 
number of changes to the legislation.
March 23, 2010 – President Obama signs the Patient Protection & Affordable 
Care Act, H.R. 3590, into law (the Senate version).  H.R. 3590 becomes the law 
of the land.
March 25, 2010 – Senate passes “Reconciliation bill” by a vote of 56‐43, with two 
minor changes, and sends the bill back to the House for their consideration.
March 25, 2010 – House passes revised “Reconciliation bill” and sends the 
legislation to the President for his signature.
A Timeline of the Health Care 
Provisions that could affect you.

  2010               2018


           2014
2010 
Insurance plans prohibited 
                                 Insurance plans required to    Insurance plans required to 
  from imposing lifetime 
                                 carry dependents up to the      cover preventive services 
benefit limits and restricted 
                                         age of 26.                without cost sharing.
       annual limits.




 Insurance plans prohibited      Temporary high risk pool 
                                                                Insurance plans required to 
  from denying coverage to       established for individuals 
                                                                    report proportion of 
individuals under the age of       (older than 19) who are 
                                                                 premium dollars spent on 
   19 based on pre‐existing      denied coverage based on 
                                                                     non‐medical care.
         conditions.              pre‐existing conditions.




                                 Insurance plans prohibited 
                                  from rescinding coverage 
                                   except in cases of fraud.
2010 Cont’d
                                                                               First Phase of Small Business Tax Credit: 
                                                                                   Small businesses with less than 25 
                                        States begin reviewing premium          employees and average annual wages of 
 Temporary reinsurance program             trends and companies must              less than $50,000 are eligible for tax 
                                                                                 credits of up to 35% of the employer’s 
 created for employers providing         justify increases. Plans may be      contribution toward the employee’s health 
coverage to retirees over 55 who are         potentially blocked from            insurance premium. Employers must 
     not eligible for Medicare.             Exchange for unwarranted           subsidize at least 50% of their employees’ 
                                                    increases.                  premiums in order to be eligible for the 
                                                                                tax credit. Credit only available through 
                                                                                                   2013.



                     Create the Consumer Operated 
                       and Oriented Plan (Co‐Op)             Establish state  websites to help 
                    program to foster the creation of       residents identify health coverage 
                     non‐profit, member‐run health              options (effective July 1) and 
                      insurance companies in all 50            develop a standard format for 
                    states. $6 billion is appropriated           presenting information on 
                   to finance the program and award           coverage options (60 days after 
                    loans and grants to establish Co‐                   enactment).
                            Ops by July 1, 2013.
2011
“CLASS Act”: A national long term care       Insurance plans must comply with the 
 assistance/disability insurance plan is     new medical loss ratios (MLR): 80% for 
  established. The benefit amount is          individual and small group plans and 
varied based on the “scale of functional      85% for large group plans. Companies 
ability” with a $50‐75/day cash benefit.          required to provide rebates to 
        All working adults will be            consumers if they fail to comply with 
 automatically enrolled in the program                      the MLRs.
     unless they choose to opt‐out.




 Funding available for states to begin        Provides grants for up to five years to 
establishing Exchanges until January 1,      small employers that establish wellness 
                 2015.                                     programs.
2011 Cont’d
                              Over‐the ‐counter drugs 
States have the option to 
                             not prescribed by a doctor 
expand Medicaid to 133% 
                               may not be reimbursed 
 of federal poverty level 
                              through an FSA nor on a 
 (must be completed by 
                              tax free basis through an 
          2014). 
                                Archer MSA or HSA.
2013
     Increase Medicare tax rate on          Impose a new 3.8% tax on 
employee wages by 0.9% (from 1.45%         unearned income for higher‐
 to 2.35%) on earnings over $200,000            income taxpayers 
   ($250,000 family) for individual      ($200,000/$250,000 threshold) –
taxpayers – not indexed for inflation.      not indexed for inflation.




                      Contributions to FSAs limited to 
                              $2,500 per year.
2014 
  State‐based American Health Benefit 
  Exchanges and Small Business Health       Premium credits available via exchanges 
Options Program (SHOP) Exchanges are        for individuals/families with incomes up 
  implemented and open to individuals        to 400% of federal poverty level who do 
and small businesses (2‐100 employees).      not receive employer based coverage or 
   Exchanges will include four tiers of     whose employer‐based premiums exceed 
private plans, OPM multi‐state plans and              9.5% of their income. 
               co‐op plans. 




  Insurance plans required to abide by          Employers with more than 200 
   guarantee issue, minimum benefit             employees would be required to 
    standards, revised rate bands for         automatically enroll employees into 
individual and small group market (2‐100       health insurance plans offered by 
              employees).                     employer (employees may opt‐out).
2014 Cont’d
Phase II of Small Business Tax Credit: Small 
 businesses with less than 25 employees and 
                                                       Employers with more than 50 employees 
  average annual wages of less than $50,000 
                                                       who do not offer their employees health 
are eligible for tax credits of up to 50% of the 
                                                       insurance will be subject to a $2,000 tax 
     employer’s contribution toward the 
                                                     penalty/per full‐time employee (per year) if 
   employee’s health insurance premium. 
                                                      one of their employees is eligible for a tax 
  Employers must subsidize at least 50% of 
                                                     credit subsidy (first 30 employees exempted 
  their employees’ premiums in order to be 
                                                                  from calculation).
    eligible for the tax credit. Credit only 
            available for two years.




                             Individuals required to purchase health 
                              insurance or face a tax penalty of up to 
                              $695/year (capped at 2.5% of income). 
2014 Cont’d
  States must expand Medicaid to 
133% of federal poverty level. States 
will receive 100% federal financing       Allow states the option of merging 
 from 2014‐2106, 95% financing in           the individual and small group 
 2017, 94% financing in 2018, 93%                      markets.
     financing in 2019, and 90% 
   financing in 2020 and beyond.




                     Waiting periods for coverage cannot 
                              exceed 90 days.
2016
Permits states to form health care choice compacts and 
allows insurers to sell policies in any state participating 
in compact. Insurers selling policies through a compact 
would only be subject to laws of the state where policy is 
 written (except consumer protection laws).  Compacts 
 will only be approved if it is determined the coverage 
   will be at least as comprehensive and affordable as 
               coverage through Exchanges.  
2017

States are permitted to allow businesses with 
more than 100 employees to purchase coverage 
             in SHOP Exchanges.
2018
     “Cadillac Tax” takes effect.  A 40% excise tax is 
administered to insurers of employer‐sponsored health 
  plans with aggregate values that exceed $10,200 for 
individuals and $27,500 for families.  The tax is applied  
to the amounts that exceed the threshold and it will be 
                 indexed for inflation.
How is it paid for?
Executive and employee compensation deductibility limited to $500,000 for health insurance 
providers.
10% tax on indoor tanning services.
$2.3 billion annual tax on pharmaceutical industry (increasing to $4.0 billion in 2017 and back 
to $2.8 billion in 2019 and after).
$2 billion annual tax on medical device industry. Annual tax is increased to $3 billion in 2017.
$2 billion annual tax on health insurance companies. The tax will increase each year until 
reaching $14.3 billion in 2018. For subsequent years the fee shall increase based on the previous 
year’s premium growth.
Tax increase on distributions for non‐qualified medical expenses from an HSA (from 10% to 
20%) or an Archer MSA (15% to 20%). 
Imposes an excise tax of 2.3% on the sale of any taxable medical device.
$2.6 billion tax on insured and self insured plans to fund comparative effectiveness research.
Increases Medicare tax rate on wages by 0.9% (from 1.45% to 2.35%) on employee earnings over 
$200,000 ($250,000 family) for individual taxpayers.
Imposes a new 3.8% tax on unearned income for higher‐income taxpayers ($200,000/$250,000 
threshold)
40% excise tax on “Cadillac” plans. 
Impact on Individuals and 
         Businesses


  A new health care world.

A new way of doing business.
Current Status– Private Health 
            Insurance Marketplace

           Individual                                  Employer‐Based 
            Policies                                      Policies
    8% of market share                               92% of market share
• 14 million enrollees                          • 164 million enrollees




                         *Source - Congressional Budget Office
Projected 2019 Private Health 
           Insurance Marketplace
           Individual                                     Employer‐Based 
            Policies                                         Policies
    17% of market share                                 83% of market share
• 33 million enrollees                             • 161 million enrollees
• 73% exchange policies (24 million)               • 5 million exchange policies (only 
• 57% of exchange policies will qualify              available to employers with 2‐100 
  for subsidies                                      employees)
                                                   • 12% exchange policies will qualify for 
                                                     small business tax credits (available 
                                                     for two years)




                            *Source - Congressional Budget Office
2019 – Movement within Employer 
          Marketplace
Between 6 million and 7 million people would be covered by an 
employment‐based plan under the proposal who would not be 
covered by one under current law (largely because the mandate for 
individuals to be insured would increase workers’ demand for 
coverage through their employers).


Between 8 million and 9 million other people who would be 
covered by an employment‐based plan under current law would 
not have an offer of such coverage under the proposal. Firms that 
would choose not to offer coverage as a result of the proposal 
would tend to be smaller employers and employers that 
predominantly employ lower wage workers—people who would be 
eligible for subsidies through the exchanges.


              *Source - Congressional Budget Office
Impact on Employers 
Employers with 50‐plus full‐time (30 hours per week or more) employees are subject to the following:
  If an employer does not offer health insurance and has at least one employee who qualifies for a tax credit, 
  the employer is subject to an annual fine of $2000 for each full‐time employee  (first 30 employees are 
  excluded).
  If an employer does offer health insurance coverage but has an employee who goes to an exchange 
  (because the employee’s share of the premium exceeds 9.8% of their annual income) or if the employer 
  fails to offer the minimum health insurance coverage, the employer is subject to an annual fine of $3,000 
  per employee going to an exchange (maximum penalty is $2,000 for each full‐time employee in your total 
  workforce).
  If an employer does offer health insurance coverage, the employer is required to offer a voucher to 
  employees with incomes less than 400% FPL and whose share of the premium exceeds 8% but is less than 
  9.8 of their annual income who decide to enroll on a plan in an exchange. The voucher is equal to what the 
  employer would have paid for the employee’s health insurance coverage. (CBO: 1‐2 million employees 
  would jump from employer coverage to the exchange.)
If an employer imposes a waiting period before their employees can enroll in coverage, the employer is subject 
to a one‐time fine of $400 for a full time employee for a 30‐60 day waiting period and $600 for a 60‐90 day 
waiting period.
Employers with 200‐plus full‐time employees must automatically enroll their employees into health insurance 
plans.
A New and Confusing Marketplace
for Individual and Small Group (2‐100)

                      New 
                      Plans

                       New 
                     Subsidies

                       New 
                    Regulations

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