Need Help!!

[newt103]

I have a school district in PA that offers health insurance to employees. Over 300 employees in group. They are offering Blue Cross Medical plans with optional Prescription drug plan. The Medical plan is considered affordable for all employees (contribution < 9.5% of their income) but when you add the Prescription plan it is not affordable for a lot of the employees who are paraprofessionals. My question is are they eligible to get a plan at Healthcare.gov and get a tax credit "subsidy"??

Is the Drug plan an essential benefit for large group??

Thanks in advance

 

[david_adams]

That's a really good question. Because large group plans don't have the same Essential Health Benefits requirements that small group and individual plans do under ACA, I guess it's not automatic that the lack of prescription benefits would qualify those employees for tax credits in the exchange. But large group plans are required to have 60% actuarial value, so it's possible that the lack of prescription coverage would make the plan fail that test. Do you know the actuarial value of the plan?

 

[taterpeeler]

ann gave me a simple word of advice once... if the group size is over 100 just leave them alone, she said I just don't have the skill set to figure that out..... I like her advice... im dumb on groups and want no part of a legal issue of getting them a subsidy then having the feds fine them then finding out they didn't qualify for a subsidy.... sorry I cant help you but ann will come along in a bit and straighten all this out

 

[newt103]

@ david adams No...I do not...the lowest cost Medical plan offered is a very good plan and would certainly meet the 60% requirement but the Prescription plan is not apart of the Medical plan and is optional. The Prescription plan is $400.00 contribution a month if you add it.
Something tells me that they do not have to offer the Prescription plan because the the Medical plan is $200.00 contribution a month.

The school district is not stupid and I am sure they are probably offering the minimum requirement so they are not penalized under the ACA.

But I am not sure...because it makes no sense...if somebody needs injections for Lupus they need the Drug coverage but can not afford it.

@tater - I do not do group insurance and stay away from it but I am getting a lot of questions from people I know who work for the School district concerning this. Hopefully Ann will know....

 

[Ann H]

Hey guys, I've been overwhelmed lately and didn't read this thread until now. Unfortunately, I don't know the answer.

 

[leevena]

I do not have sufficient information to give you a definitive answer, but on the surface it does appear that the plan is structured legally and the employees would not have the subsidy available to them.

David Adams is correct, large groups and self-funded groups are not subject to the EHB regulations. So assuming that the rx plan is a separate from the medical plan, which it does appear, then the rx costs should not get counted towards the medical plan costs.

Also keep in mind that drug coverage may very well be covered through the medical plan. As a rule of thumb, most medical plans (large, small, fully-insured, and self-funded) cover injectables through the medical plan, not the drug portion.

 

[taterpeeler]

since ann just confused me with her answer as I look to her as the supreme leader on any and all group I now wish to change my original answer..... no one knows the answer, you are now about to embark on a trailblazing journey... god speed fellow solider

 

[Ann H]

Secretly, I was hoping that Leevena would chime in. I almost wrote in my prior post that Lee should be answering this question! Thanks, Lee for your answer.

And, no, Ann is NOT the supreme leader on any and all group issues. I'm having a hard time keeping up with the shifting landscape that this law caused.

 

[taterpeeler]

And, no, Ann is NOT the supreme leader on any and all group issues. I'm having a hard time keeping up with the shifting landscape that this law caused.

So is Obama Admin......