Health & Welfare Plans Newsletter

July 27, 2015

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[Official Guidance]

ACA Information Returns Submission Composition and Reference Guide (PDF)
Version 2.0, dated July 2015; 89 pages. "The purpose of this document is to provide guidance to all types of external transmitters about composing and successfully transmitting compliant submissions to IRS. The audience of this document is ... [1] A business filing their own ACA Information Returns regardless of whether they are required to file electronically (transmit 250 or more of the same type of information return) or volunteer to file electronically.... [2] A third-party sending the electronic information return data directly to the IRS on behalf of any business required to file.... [3] An organization writing either origination or transmission software according to IRS specifications." (Internal Revenue Service [IRS])  


[Advert.]

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[Official Guidance]

IRS Publication 5164, Test Package for Electronic Filers of ACA Information Returns (PDF)
July 2015, 19 pages. "[This publication] contains general and program specific testing information for use with ACA Assurance Testing System (AATS). AATS refers to both the process and the system used to test software and electronic transmissions prior to accepting Software Developers, Transmitters and Issuers into the AIR System. Software Developers are required annually to pass pre-defined AATS submissions and test scenarios for the forms that they will support. Transmitters and Issuers are required to pass communication tests for the forms they will file." (Internal Revenue Service [IRS])  

[Official Guidance]

IRS Draft Publication 5165: Guide for Electronically Filing ACA Information Returns for Software Developers and Transmitters (Processing Year 2015) (PDF)
Version 2.0, July 2015; 46 pages. "[This publication] outlines the communication procedures, transmission formats, business rules and validation procedures for returns transmitted electronically through the AIR system. To develop software for use with the AIR system, Software Developers, Transmitters, and Issuers should use the guidelines provided in this publication along with the Extensible Markup Language (XML) Schemas published on IRS.gov. The procedures in this publication should be used when the following information returns are transmitted electronically: Form 1094-B, Transmittal of Health Coverage Information Returns; Form 1095-B, Health Coverage; Form 1094-C, Transmittal of Employer-Provided Health Insurance Offer and Coverage Information Returns; Form 1095-C, Employer-Provided Health Insurance Offer and Coverage Note: This publication does not contain information or procedures for filing Forms 1095-A." (Internal Revenue Service [IRS])  

[Guidance Overview]

ACA Reporting Requirements for Carriers and Employers (Part 2 of 24): The Cost of Failing to Comply Just Doubled
"The Trade Preferences Extension Act of 2015 ... includes a provision that increases penalties for incorrect information returns, including those required by the ACA, to $250 per day (from $100 per day) with an annual cap of $3,000,000 (up from $1,500,000). Thus, for example, if an applicable large employer fails to file an information return and fails to furnish timely the statement to a single employee, the penalty is $500.... [T]he IRS has announced that it will not impose penalties under Code sections 6721 and 6722 on issuers of minimum essential coverage (Forms 1094-B and 1095-B) or applicable large employers (Forms 1094-C and 1095-C) that can show that 'they have made good faith efforts to comply with the information reporting requirements.' The relief is available, however, only where compliance is timely." (Mintz Levin)  

Tax Year 2014 Schemas and Business Rules for ACA Information Returns
"The links [on this IRS web page] provide information and technical guidance for software developers and transmitters who are interested in developing software for [ACA Information Returns (AIR)] for Tax Year 2014. Included are the XML Schemas, Business Rules, Release Memorandums and specific instructions." (Internal Revenue Service [IRS])  

AIR Working Group Meeting: Employer Information Reporting Scenario Review Forms 1094-C, 1095-C (PDF)
65 presentation slides, dated July 28, 2015. "This ... AIR working group webinar ... is intended to demonstrate how to complete Forms 1094-C and 1095-C using a set of typical fact patterns as submission narratives. The submission narratives have been modified for use in the AATS environment which evaluates the accuracy of the submission using a systemic character-by-character comparison tool. In the Production environment there may be multiple ways of correctly filling out the form." (Internal Revenue Service [IRS])  

Reducing Employee Hours to Avoid ACA Obligations to Offer Coverage Violates ERISA Section 510, Class Action Alleges
"[T]he plaintiff is claiming that the employer reduced her hours of work to below that which the ACA would cause her to be a 'full-time employee.' In doing so, the defendant avoided the requirement under the ACA to offer her coverage, as well as any the corresponding penalty under Internal Revenue Code Section 4980H if she were a full-time employee. In other words, the essence of the plaintiff's claim is that by reducing her hours of employment, the employer interfered with her attainment of a right under the plan to be eligible to be offered coverage under the medical plan." [Marin v. Dave & Buster's, Inc., No. 1:15-cv-03608 (S.D.N.Y. filed May 8, 2015] (Jackson Lewis P.C.)  

Internet-Based Document Sharing and PHI on Personal Laptop Lead to HIPAA Settlement
"Adopting new technologies may be appropriate, but only after careful scrutiny of the privacy and security risks they present. Allowing workforce members to store ePHI on personal devices is fraught with danger -- especially if those devices are unencrypted or continue to store ePHI after the workforce member's relationship terminates. A thorough risk assessment evaluating threats and vulnerabilities, followed by adoption of an appropriate risk-management strategy, is fundamental to HIPAA security compliance." (Thomson Reuters / EBIA)  

Anthem-Cigna Merger Could Offer Opportunities for Employers
" 'Large employers will have concerns about the merger between Anthem and Cigna because employers will be left with only three major insurers who can support large multi-state employers on a nationwide basis,' adds Brian Marcotte, president and CEO of the National Business Group on Health.... 'The merger may rebalance provider negotiation leverage in Anthem's favor after years of provider consolidation that has gone pretty much under the radar screen,' Marcotte says. 'And employers will want to see the additional negotiating leverage, coupled with efficiencies of scale, translate into better pricing for them and employee plan participants.' " (Employee Benefit News)  

Medicare's Financial Condition: Beyond Actuarial Balance (PDF)
"In the long-range the condition has improved for all parts of Medicare due to lower long-range health care cost growth assumptions in this year's report. Nevertheless, the program faces three fundamental long-range financing challenges: [1] Income to the HI trust fund is not adequate to fund the HI portion of Medicare benefits; [2] Increases in SMI costs increase pressure on beneficiary household budgets and the federal budget; [3] Increases in total Medicare spending threaten the program's sustainability." (American Academy of Actuaries)  

ACA Medicare Experiment Fails to Show Savings
"The test to coordinate treatment for high-risk Medicare patients in hundreds of communities was one of many demonstrations run by the [HHS] innovation center. The [ACA provided for establishment of] the lab and gave it $10 billion over a decade to test new ways to improve care and save money. As the trial wound down last fall, 69 percent of the clinics that hadn't dropped out had obtained full accreditation as 'medical homes' -- primary care practices that coordinate care across the maze of specialists, hospitals and emergency rooms. HHS had hoped for 90 percent." (Kaiser Health News)  

[Opinion]

ERIC Comment Letter to CMS on HPID for Group Health Plans (PDF)
"First, the concepts of a controlling health plan (CHP) and a subhealth plan (SHP) ... do not reflect terms or terminology used by employers, TPAs, or the other federal agencies regulating group health plans. Second, there was little or no recognition that HIPAA standard transactions are almost never conducted by self-insured group health plans, and that these plans generally do not have trading partner agreements relating to the exchange of information in electronic transactions. Third, the enumeration process was clearly not designed for self-insured group health plans -- employers sponsoring group health plans had no familiarity with the CMS Enterprise Portal or with HIOS (a system designed exclusively for insurance carriers, and almost every employer encountered procedural and information obstacles to obtaining an HPID, a process involving more than 20 steps" (The ERISA Industry Committee [ERIC])  

[Opinion]

Relief for Cities' Budget-Busting Healthcare Costs
"The new rules further provide an incentive for local governments to establish a dedicated trust with assets invested today to help pay health-care benefits in the future. But here the GASB takes one step backward, by allowing local governments to make overly optimistic assumptions, including excessive returns for the trust." (The Brookings Institution)  

[Opinion]

ACA Moves Insurance Market from Oligopoly to Duopoly
"Only massive bureaucracies with huge compliance and legal departments are equipped to deal with the approximately 40,000 pages of the [ACA's] laws and regulations. It is crushing competition. Ultimately ... we will end up with two nationwide carriers and at that point the market will be so broken we will need the government to intervene and set the market free or turn it into a fully socialized program." (Benefit Revolution)  

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