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

Health insurance issuers like Blue Cross are obligated to pay claims for covered services rendered during the first month of the grace period. During the second and third months of the grace period, health insurance carriers may pend claims until the member has either paid the premiums owed or the grace period has ended. At the end of the grace period, if the member has not paid their premiums, claims may be denied.

During the grace period, Blue Cross will notify providers that their claims are pended because the member is in the grace period. In addition, we are working to ensure that when providers contact Blue Cross to confirm eligibility, they are informed that the member’s eligibility is pended as a result of the grace period. 

Members who may be eligible for this grace period will have a ZBN prefix on their ID card. It is important to note that not every member who purchases coverage through HealthSource RI in the individual market will be eligible for premium subsidies or for the grace period. 

For all other members enrolled through HealthSource RI or directly through Blue Cross, there will be a one-month grace period for members who are delinquent in paying their bills. Blue Cross will continue to pay claims during this one-month period.

Benefits/coverage

Blue Cross offers a variety of commercial plans through HealthSource RI to individuals and families as well as small businesses and their employees. These plans include VantageBlue, VantageBlue SelectRI, BlueSolutions for HSA, BasicBlue, and Blue Cross Dental. These plans operate in the same way whether they are purchased directly from Blue Cross or through HealthSource RI. Providers should continue to follow current practices for eligibility, benefits, care management, and claims processing. Please note that Medicare plans are not available through HealthSource RI.  

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

Individuals are responsible for ensuring that they, and any dependents, have minimum essential coverage. Coverage from any of the following would be considered minimum essential coverage:

  • Government-sponsored programs including: Medicare, Medicaid, Children’s Health Insurance Program coverage, TRICARE, coverage through Veterans Affairs, and Health Care for Peace Corps volunteers
  • Employer-sponsored plans, including continued coverage under COBRA or similar state laws, retiree plans, grandfathered plans and other plans offered in the small or large group market
  • Individual market plans
  • Student health insurance plans 
  • Other coverage designated as minimum essential coverage by the Department of Health & Human Services and/or the Treasury
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

Buying coverage

You can purchase coverage during open enrollment. In 2015, open enrollment is from November 15, 2014 to Feburary 15, 2014.

The start date of your coverage is based on the date you submit your application. If we receive your application by the 15th of the month, your coverage will be effective the first of the next month. Applications received after the 15th will be effective the following month. For example:

  • For applications received from December 1 to December 15, coverage is effective January 1.
  • For applications received from December 16 to December 31, coverage is effective February 1.

If open enrollment has ended and you lose your coverage or your situation changes, you may be eligible to enroll in a plan. Please contact us for details.

 

Buying coverage

Yes. People in the following groups don’t have to pay a penalty for not having health coverage:

  • Individuals with a religious conscience exemption (applies only to certain faiths)
  • Incarcerated individuals
  • Undocumented aliens
  • Individuals who cannot afford coverage (e.g., required contribution exceeds 8 percent of household income)
  • Individuals with a coverage gap of less than three months
  • Individuals in a hardship situation (as defined by the Secretary of Department of Health & Human Services)
  • Individuals with income below the tax filing threshold
  • Members of Indian tribes
Buying coverage

In addition to offering tax credits to make coverage more affordable, the government is providing a cost-sharing reduction program.  The government helps by paying part of your copays, coinsurance, and deductible. This helps limit the amount that you have to pay out of pocket for services.

If your household income is between 100 percent and 250 percent of the federal poverty level (up to 300 percent for Native Americans), you may be eligible to enroll for a plan with cost-sharing reductions.  In general, people at the income levels below will qualify to save in 2015.*

  • Up to $29,175 for individuals
  • Up to $39,325 for a family of 2
  • Up to $59,625 for a family of 4

*These amounts are based on 2014 numbers and are likely to be slightly higher in 2015. Amounts are different for each family size, up to eight.

Buying 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 fewer than 50 full-time employees or full-time equivalent employees are not required to provide health insurance to their employees. (Please note: To help businesses transition to the new regulations, the federal government has made several exceptions for 2015 only. In 2015, only employers with 100 or more full-time employees and full-time equivalent employees are required to offer coverage.).

Small employers may be eligible for tax credits for offering health coverage. For more information, please see What Small Employers Need to Know.

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

Provider responsibilities

HealthSource RI is a health insurance marketplace (also called an exchange) where Rhode Island individuals, families and small employers can compare and buy health plans. Blue Cross will be offering some of our commercial plans through HealthSource RI, and providers will participate if their contract includes our commercial plans.

Provider responsibilities

Tax credit

Small businesses may be eligible for a tax credit to offset the cost of providing health insurance to employees. To qualify, small businesses must:

  • Have 25 or fewer full-time equivalent employees.
  • Pay at least 50 percent of employees’ health insurance premiums.
  • Pay annual average wages that are below $50,000 per full-time employee.

To determine if you might qualify for the small employer tax credit, determine if you employed fewer than 25 full-time equivalent employees during the previous tax year. To do this, add up the total hours worked that year by all of your employees and divide by 2080 hours.  If the result is less than 25, you may be eligible for this credit. When you are adding up the hours your employees worked, do not include any hours worked by the owner, family members or seasonal employees. Also, if your employee works more than 40 hours a week, don’t include those additional hours.

To find out more information about the tax credit and to determine if you qualify, please visit the IRS’s Small Business Healthcare Tax Credit Center.

Tax credit

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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