Insurance Solutions for Today's Nonprofits

ObamaCare: It’s the Law!
Written by: Fred Scaglione

There is a lot of detail we still don’t fully understand about the Affordable Care Act. One thing, however, is finally certain. After a lengthy struggle in Congress; a legal battle that went all the way to the Supreme Court; and a national election which revolved in large part around Republican threats to repeal the legislation on “day one” of a new administration, “ObamaCare” is now the law of the land. And, any reluctance or hesitation to begin moving towards compliance with its provisions is, or at least should be, a thing of the past.

The Affordable Care Act will have implications for almost every individual and all employers in the nation, both for-profit and not-for-profit. Up until now, these impacts have been relatively limited. But, over the coming six to nine months, New York State will begin taking important steps towards the next major set of deadlines that take effect on January 1, 2014. On that date, the law will begin to require certain employers to provide specified healthcare coverage to their employees, or face a series of penalties. And, all individuals will be required to have coverage, either through employer sponsored policies or through insurance that they purchase on their own. To guarantee that all individuals and small employers can purchase reasonably-priced health insurance, New York State will be establishing a “health insurance exchange” where coverage will be available to everyone, regardless of their medical histories. In addition, federal premium subsidies will be available to help cover the cost of health care for low- and moderate-income individuals and families. There are even “small business” tax credits that are available to help smaller employers meet the costs of complying with the law’s new mandates.

So, what will the Affordable Care Act mean for your nonprofit and its employees? That depends on a number of factors.

First and foremost is the determination as to whether you are a “small” or “large” employer – since “large” employers are subject to the employer mandate to provide health insurance coverage or face penalties.
The Affordable Care Act defines “large” employers as those who have 50 or more full-time – or full-time equivalent – employees. It is important to note that the ACA defines “full-time” employees as those working 30 hours per week or more. Consequently, it also calculates both full-time (FT) and full-time equivalents (FTEs) by taking the total number of hours worked by your employees and dividing by 30 (or 120 hours per month). As a result, your agency could have only 40 “full-time” employees who work 40 hours per week, another 20 employees who work 20 hours per week and still be considered a “large employer” because that translates into 66.7 FTEs.

As of January 1st, 2014, “large employers” are required to provide “full-time” employees with health insurance coverage that complies with the ACA guidelines. If they do not provide coverage – and have at least one full-time employee who receives a premium tax credit, through the newly formed Insurance Exchange, to help purchase coverage as an individual -- they will face penalties of $2,000 per full-time employee. (For reasons that seem unclear, an employer’s first 30 employees are excluded when calculating the penalty amount.) For those large employers who do provide coverage – but still have at least one full-time employee who receives a premium tax credit to help cover the costs of insurance purchased individually, the penalty is the lesser of $3,000 for each FT employee receiving a premium credit or $2,000 per full-time employee, again excluding the first 30 employees.

What does the ACA require in terms of employer-provided coverage? There are three key required components of care defined in the law that will affect nonprofits and other “large employers”.
First, generally speaking, these employers must offer coverage to eligible full-time employees that begins within 90 days of being hired. Those “very large” employers with 200 or more FTEs, must automatically enroll employees into health insurance plans – rather than ask employees if they wish to be enrolled – and then allow those who wish to opt-out an opportunity to do so.

Second, the employee share of health insurance premiums that an employer can require is being substantially limited. The maximum employee share of premium coverage for employer-sponsored individual coverage cannot exceed 9.5% of the employee’s gross income. In light of the historic trend towards increasing requirements for employee contributions, the relatively low salary levels which many nonprofits pay for direct care and other employees, and the rising cost of health insurance premiums in recent years, this mandate has the potential to significantly impact a broad range of nonprofit service providers. For example, under this provision, a “full-time” direct care staff member who works 35 hours per week at $10 per hour would have annual income of $18,200 per year or $1,516 per month. Based on this requirement, that staff member’s maximum contribution towards his health insurance premium would be approximately $144 per month. As a result, it is not inconceivable that an agency which had required employees to pay half the cost of their health insurance coverage would no longer be able to do so in these cases.

Third, the law mandates that all health insurance policies – including those provided by employers – meet certain coverage standards in terms of what costs of services are paid by the insurance and what the consumer’s out-of-pocket costs might be. Under the ACA, policies are required to have an actuarial value of 60%, meaning that a consumer’s out-of-pocket costs of healthcare would not exceed 40% of total medical expenses. Since New York State has traditionally required policies sold in the state to meet relatively high quality standards, it seems unlikely that this would have a significant impact on coverage currently being offered by nonprofit employers. However, recent trends towards low-cost but high-deductible policies might well run up against these limitations.

Many of New York State’s nonprofits are likely to fall below the ACA’s “large employer” threshold and, therefore, face no new mandate to provide health insurance coverage to their employees. However, the law still may offer a series of opportunities – and some interesting questions -- both for these “small employer” nonprofits and their employees.

New York State’s Health Insurance Exchange which is expected to be developed as early as October 1st, 2013 – and must by law be in place by January 1, 2014 – is designed to allow individuals without access to small group plans to purchase coverage at a cost which is considerably lower than current individual premium levels. In fact, it is estimated that individual coverage available through the exchanges may reduce premiums by between 60 and 70%.

Moreover, individuals purchasing insurance through these exchanges may be eligible for income-based premium tax credits that would limit their cost of coverage to as low as 2% of income for those with household incomes between 100% and 133% of the Federal Poverty Levels (FPL), and just 9.5% of income for those earning up to 400% of (FPL), or $92,201 for a family of four. For example, a single mother with two children who earns $25,390, or 133% of the current FPL for a family three, would receive premium credits covering health insurance costs above $42.32 per month.

Based on these lower costs and premium supports, many staff at nonprofits may feel that better insurance options are available through the exchanges. However, employees who are offered an employer sponsored plan that meets the maximum contribution criteria of 9.5% of gross income and provides the 60% coverage value outlined above are not eligible for exchanges or premium credits. As a result, it will be interesting to see whether some smaller nonprofits decide to terminate coverage benefits and urge their employees to seek insurance through the exchange/premium credit option.

New York State’s Health Insurance Exchange will also offer “small employers” with 50 or fewer full-time employees an opportunity to purchase insurance. However, due to New York’s current community-rating system, it is not anticipated that policies sold through the Exchange will be considerably less expensive than those currently available to small employers on the open market.

Another feature of the ACA, however, may help smaller employers – those with fewer than 25 full-time equivalent employees – to obtain tax credits to help offset the cost of health insurance benefits for their employers. The credits are available based on a sliding scale to nonprofits whose average salary level is less than $35,000, with the maximum benefit going to those whose average salary is $25,000 or less. While this sounds like it may be a significant benefit for many small nonprofits, it appears that relatively few organizations actually meet these average salary guidelines. Once again, this is driven in part by the calculations used to determine both your number of FTEs – in this case using 2,080 hours per year or 40 hours per week – and your total salary expenses. Based on these formulas, many organizations with staff who work a 35-hour week will see their number of FTEs fall below their actual number of full-time employees – and as a result, their calculated average salary rise above the levels which staff actually receive.

During the course of 2013, we will learn many additional details about how the Affordable Care Act will be implemented and how the State health insurance exchanges will operate. Nonprofits and the individuals who work in them need to begin thinking about what compliance with the law’s requirements will mean and how emerging details affect their plans.
Peter Andrew is President and CEO of Council Services Plus, the insurance brokerage subsidiary of the New York Council of Nonprofits