Tag: Affordable Care Act

Benefits Insights: Preventive Care

Once an underused component of the health care world that benefits both employees’ health and employers’ health care spending, preventive care is now a mandatory part of any health benefits package. Preventive care consists of measures taken to prevent diseases, rather than curing them or treating their symptoms. There is significant research demonstrating that increased use of effective preventive services will result in less suffering from ailments that could have been prevented had they been detected and treated early on. Preventive care is often more cost-effective than treating diseases once symptoms appear. Some preventive care services even save more money than it costs to implement them. Download the PDF version This Benefits Insights is not intended to be exhaustive nor should any discussion or opinions be construed as professional advice. © 2009, 2011, 2013, 2018 @www.MyTPG.com. All rights reserved. Under the Affordable Care Act (ACA), private insurers—except for plans that have been grandfathered—are required to cover certain preventive services without any cost to the patient. Medical services such as immunizations, screening tests, medications and any other services that would prevent disease, injury and premature death fall under the umbrella of preventive care. Preventive care should be incorporated into employer-sponsored health plans to lessen the cost and number of future medical claims by helping employees and their families stay healthy, while also complying with the provisions of the ACA. Preventive Care for Adults The following types of preventive care are available to all adults within specified age ranges or risk groups. Abdominal aortic aneurysm screening: A one‐time screening for abdominal aortic aneurysm by ultrasonography in men ages 65 to 75 who have ever smoked. Alcohol misuse screening and counseling: A risk assessment available for all adults and voluntary counseling for those who are found to have a substance abuse problem. Many do not realize that their alcohol use is excessive and contributes to other health and lifestyle problems. Aspirin use: Counseling on the use of aspirin for men ages 45 to 79 and women ages 55 to 79, when the potential benefit due to a reduction in myocardial infarctions outweighs the potential harm due to an increase in gastrointestinal hemorrhage. Blood pressure screening: Routine measurements of adult blood pressure and treatment with anti-hypertension medication to prevent cardiovascular disease. Hypertension and related complications account for $100 billion in medical costs every year, yet only 1 in 3 people with hypertension actually controls it. Cholesterol screening: Screenings for lipid disorders in men over 35 and women over 45, and treatment with lipid-lowering medications to prevent cardiovascular disease. One out of 4 adults with high cholesterol will suffer a heart attack, and 1 in 3 adults will die from coronary heart disease. Screening to detect high cholesterol is effective in identifying those who need medication to control cholesterol levels. Colorectal cancer screening: Screenings for colorectal cancer using fecal occult blood testing, sigmoidoscopy or colonoscopy, beginning at age 50 and continuing until age 75. The risks and benefits of these screening methods vary. About 19,000 diagnoses could be prevented annually if people get screened, yet only one-third of adults complete regular screenings. Depression screenings: Screenings for depression when staff-assisted depression care supports are in place to ensure accurate diagnosis and effective treatment and follow-up. Diabetes screening: Screenings for adults 40 to 70 years who are overweight or obese. Diet counseling: Intensive behavioral dietary counseling for adult patients with hyperlipidemia and other known risk factors for cardiovascular and diet‐related chronic disease. Intensive counseling can be delivered by primary care clinicians or by referral to other specialists, such as nutritionists or dietitians. HIV screenings: Screenings for everyone ages 15 to 65 and other ages at increased risk Obesity screening and counseling: Screening for all adults; clinicians should offer or refer patients with a body mass index (BMI) of 30 or higher to intensive, multi-component behavioral interventions. Sexually transmitted infection (STI) prevention counseling: Counseling for adults at higher risk Syphilis screening: Screenings for adults at greater risk Tobacco use screening: Screenings for adults at higher risk; tobacco users may receive intervention and cessation support. A comprehensive, effective smoking cessation program usually costs less than 50 cents per member per month, or less than $6 per member per year. You can save an average of $210 on yearly health care costs for each smoker who quits. Vaccinations: Shots for hepatitis A, hepatitis B, herpes zoster, human papillomavirus (HPV), influenza, measles, mumps, rubella, meningitis, pneumococcal disease, tetanus, diphtheria, pertussis and varicella; doses, recommended ages and populations vary Preventive Care for Women In addition to the services listed above, the ACA also mandates coverage for the following preventive services for adult women as part of all non-grandfathered health plans. Anemia screening: Screenings for iron deficiency in pregnant women Breast cancer genetic test counseling (BRCA): Screenings designed to identify women with increased risk of developing breast cancer due to family history. Women with positive screening results should receive genetic counseling and, if indicated after counseling, BRCA testing. Breast cancer mammography screening: Mammograms for women age 40 or over every one to two years, with or without clinical breast examination Breast cancer chemoprevention: Discussions with clinicians about benefits, risks and adverse effects of chemoprevention for women at high risk of developing breast cancer Breastfeeding support and counseling: Guidance from trained providers and access to breastfeeding supplies for pregnant and nursing women Cervical cancer screening: Screenings for cervical cancer in women ages 21 to 65 with a Pap smear every three years; for women who want to lengthen the screening interval, screenings with a combination of Pap smear and HPV testing every five years, for women ages 30 to 65 Chlamydia infection screening: Screenings for chlamydial infection in all sexually active nonpregnant young women age 24 years and younger and for older nonpregnant women who are at increased risk Contraception: U.S. Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity. It does not include abortifacient drugs. This […]

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California Employment Law: Individual Mandate

Beginning in 2020, California imposes a state individual mandate that requires individuals in California to maintain acceptable health coverage or pay a penalty. The California law largely mirrors the federal individual mandate requirement under the Affordable Care Act (ACA) that was effectively eliminated, beginning in 2019. California was among the first states to enact its own health insurance individual mandate. Individuals in California should become familiar with the state individual mandate requirement before it takes effect in 2020 and monitor any future developments. Download the PDF version This guide is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. It is provided for general informational purposes only. Readers should contact legal counsel for legal advice. © 2019 MyTPG.com. All rights reserved. BR 12/19 Individual Mandate Overview California’s individual mandate requires most individuals in the state (and their family members) to be covered under minimum essential coverage for each month of the year, beginning in 2020. Individuals that don’t obtain acceptable health insurance coverage will be penalized Minimum Essential Coverage For purposes of the California individual mandate, minimum essential coverage (MEC) generally has the same definition as under the ACA. MEC includes coverage under: A government-sponsored program, such as coverage under the Medicare or Medicaid programs, the Children’s Health Insurance Program (CHIP), TRICARE and certain types of veterans’ health coverage; An eligible employer-sponsored plan (including a self-funded plan, COBRA and retiree coverage), defined as any plan offered by an employer to an employee which is a governmental plan or a plan or coverage offered in the small or large group market within a state; A health plan purchased in the individual market; or A grandfathered health plan. The University of California Student Health Insurance Plan and the University of California Voluntary Dependent Plan also constitute MEC for this purpose. The Penalty Amount California’s individual mandate penalty is calculated in the same manner as the ACA’s individual mandate. The penalty is the greater of two amounts—the flat dollar amount ($695) or the percentage of income amount (2.5% of income). For purposes of calculating the penalty, income is the taxpayer’s household income for the taxable year over the state income tax filing threshold for the taxable year. Families will pay half the penalty amount for children, up to a family cap of three times the annual flat dollar amount. Also, the penalty is capped at the California state average of the annual bronze plan premium. Individual Mandate: Affected Individuals The requirement to maintain MEC applies to individuals of all ages (including children), unless that individual falls within a specific exception or is exempt. An individual is treated as having coverage for a month if he or she has coverage for any one day of that month. The following categories of individuals are exempt from the California individual mandate: Individuals who cannot afford coverage; Religious conscience objectors; Members of a health care sharing ministry; Incarcerated individuals; Individuals not lawfully present in the United States; Members of an Indian tribe; Nonresident taxpayers; Individuals enrolled in limited or restricted scope coverage under the Medi-Cal program (or of a substantially similar program). An individual who is eligible for an exemption for any one day of a month is treated as exempt for the entire month. Individual Mandate: Reporting Requirement To help administer the individual mandate, California law imposes a reporting requirement on every entity that provides MEC to an individual during a calendar year, similar to the ACA’s reporting requirement under Internal Revenue Code Section 6055. This reporting requirement applies to: Employers or other sponsors of employment-based health plans, for employment-based MEC; The State Department of Health Care Services and county welfare departments, for MEC under a state program; Carriers licensed or otherwise authorized to offer health coverage, for MEC they provide that is not described above (including catastrophic plan coverage); The Exchange, for individual health plans (except catastrophic plans) on the Exchange; and Any other provider of MEC (including the University of California, for coverage under a student health insurance program). Under this reporting requirement, entities that provide MEC will be required to provide the following information to covered individuals and the California Franchise Tax Board by March 31 of each year: The name, address and Social Security number (SSN) or taxpayer identification number (TIN) of the primary insured, and the name and SSN or TIN of each other individual covered under the policy; The dates during which those individuals were covered under MEC during the calendar year; and Any other information the Franchise Tax Board may require. The new law specifically provides that the California reporting requirement may be satisfied by providing the same information that is currently reported under the federal Section 6055 reporting requirement. Health Insurance Subsidies Until Jan. 1, 2023, the new law also creates Individual Market Assistance, which provides health insurance premium assistance subsidies to California residents with household incomes at or below 600% of the federal poverty level. Advance payments of these subsidies will be available at the time an individual purchases coverage through the Exchange. These advance payments will then be reconciled at the end of each year, based on the individual’s actual household income, family size and other factors. Future regulations are expected to provide more detail on these subsidies. STATE RESOURCES California Franchise Tax Board https://www.ftb.ca.gov/ 2019-2020 State Budget Legislation http://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201920200SB78 Download the PDF version […]

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