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Broker Health Care Reform Guide

Minimum Essential Coverage Reporting

Health plan companies, like Health Net, are required to report Minimum Essential Coverage (MEC) data to the IRS for individuals, including covered dependents, beginning in 2016. This requirement is Section 6055 of the Affordable Care Act.

There are two forms to file:

Both forms are filed for these plan types:

Reporting is not required for government programs including state health plans, Medicare and Medicaid (Medi-Cal in California).

Reporting details

The IRS forms require the name and Social Security number (SSN) or a tax identification number (TIN) for each covered individual. The months for which that individual was enrolled for at least one day of coverage and entitled to receive benefits also will be reported.

Health plans are required to make three attempts to collect SSNs/TINs for covered members in order to provide complete reporting to the IRS.

Health Net specifics
Health Net will solicit SSN/TIN numbers at time of enrollment, followed by two annual solicitations for any member for whom we do not have a number. We will begin these attempts in 2015.

Please encourage your clients – employer groups and individuals alike – to provide Health Net with SSNs/TINs for themselves and any covered dependents.

Reassure them that it is completely safe to give Health Net this information. It’s also to their benefit. Without the SSN/TIN, the IRS will not be able to match coverage reported on your client’s IRS Form 1040 with the coverage information Health Net will report on the Form 1095-B. The inability to match could result in a tax penalty related to the ACA individual responsibility mandate.

Annual statements to consumers
Health plans must send Form 1095-B statements to responsible individuals by January 31 of each year, starting in 2016 for the 2015 calendar year. Consumers can use the statement as supporting documentation for tax purposes.

Filing requirements at-a-glance
In addition to the forms that health plans are required to file, the Marketplaces and certain employer groups also have form-filing requirements. The chart below outlines who sends what form.

Plan Type Minimum Essential Coverage Reporting (Section 6055) Employer Shared Responsibility Reporting (Section 6056)
Individual (marketplace plan) Form 1095-A Sent by the marketplace N/A
Individual (non‑marketplace) Forms 1094-B and 1095-B Filed and sent by the health plan N/A
Small Group fully insured plan (SHOP and non‑marketplace) Forms 1094-B and 1095-B Filed and sent by the health plan N/A
Small Group self-insured plan (non-ALE) Forms 1094-B and 1095-B Employer's responsibility to file and send statements to employees/former employees N/A
ALE  fully insured plan Forms 1094-B and 1095-B Filed and sent by the health plan Forms 1094-C and 1095-C (sections I and II only) Employer's responsibility to file and send statements to employees
ALE  self-insured plan Forms 1094-C and 1095-C (all sections)
  • Employer's responsibility to file and send statements to employees
  • Self-insured large group plans meet reporting requirements of both section 6055 and 6056 by filing Forms 1094-C and 1095-C

Additional forms and information

More details about the ACA employer shared responsibility.

This information is for general purposes only and is not legal or tax advice. For more detailed information about IRS filings, tax or legal implications, please contact your professional tax advisor or legal counselor.

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Important Notice

General Purpose
Health Net's National Medical Policies (the "Policies") are developed to assist Health Net in administering plan benefits and determining whether a particular procedure, drug, service, or supply is medically necessary. The Policies are based upon a review of the available clinical information including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the drug or device, evidence-based guidelines of governmental bodies, and evidence-based guidelines and positions of select national health professional organizations. Coverage determinations are made on a case-by-case basis and are subject to all of the terms, conditions, limitations, and exclusions of the Member's contract, including medical necessity requirements. Health Net may use the Policies to determine whether, under the facts and circumstances of a particular case, the proposed procedure, drug, service, or supply is medically necessary. The conclusion that a procedure, drug, service, or supply is medically necessary does not constitute coverage. The Member's contract defines which procedure, drug, service, or supply is covered, excluded, limited, or subject to dollar caps. The policy provides for clearly written, reasonable and current criteria that have been approved by Health Net's National Medical Advisory Council (MAC). The clinical criteria and medical policies provide guidelines for determining the medical necessity criteria for specific procedures, equipment and services. In order to be eligible, all services must be medically necessary and otherwise defined in the Member's benefits contract as described in this "Important Notice" disclaimer. In all cases, final benefit determinations are based on the applicable contract language. To the extent there are any conflicts between medical policy guidelines and applicable contract language, the contract language prevails. Medical policy is not intended to override the policy that defines the Member's benefits, nor is it intended to dictate to providers how to practice medicine.

Policy Effective Date and Defined Terms.
The date of posting is not the effective date of the Policy. The Policy is effective as of the date determined by Health Net. All policies are subject to applicable legal and regulatory mandates and requirements for prior notification. If there is a discrepancy between the policy effective date and legal mandates and regulatory requirements, the requirements of law and regulation shall govern. In some states, prior notice or posting on the website is required before a policy is deemed effective. For information regarding the effective dates of Policies, contact your provider representative. The Policies do not include definitions. All terms are defined by Health Net. For information regarding the definitions of terms used in the Policies, contact your provider representative.

Policy Amendment without Notice.
Health Net reserves the right to amend the Policies without notice to providers or Members. In some states, prior notice or website posting is required before an amendment is deemed effective.

No Medical Advice.
The Policies do not constitute medical advice. Health Net does not provide or recommend treatment to Members. Members should consult with their treating physician in connection with diagnosis and treatment decisions.

No Authorization or Guarantee of Coverage.
The Policies do not constitute authorization or guarantee of coverage of any particular procedure, drug, service, or supply. Members and providers should refer to the Member contract to determine if exclusions, limitations and dollar caps apply to a particular procedure, drug, service, or supply.

Policy Limitation: Member's Contract Controls Coverage Determinations.
Statutory Notice to Members: The materials provided to you are guidelines used by this plan to authorize, modify or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract. The determination of coverage for a particular procedure, drug, service, or supply is not based upon the Policies, but rather is subject to the facts of the individual clinical case, terms and conditions of the Member's contract, and requirements of applicable laws and regulations. The contract language contains specific terms and conditions, including pre-existing conditions, limitations, exclusions, benefit maximums, eligibility, and other relevant terms and conditions of coverage. In the event the Member's contract (also known as the benefit contract, coverage document, or evidence of coverage) conflicts with the Policies, the Member's contract shall govern. The Policies do not replace or amend the Member contract.

Policy Limitation: Legal and Regulatory Mandates and Requirements
The determinations of coverage for a particular procedure, drug, service, or supply is subject to applicable legal and regulatory mandates and requirements. If there is a discrepancy between the Policies and legal mandates and regulatory requirements, the requirements of law and regulation shall govern.

Reconstructive Surgery
California Health and Safety Code 1367.63 requires health care service plans to cover reconstructive surgery. "Reconstructive surgery" means surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following:

1. To improve function; or
2. To create a normal appearance, to the extent possible.

Reconstructive surgery does not mean "cosmetic surgery," which is surgery performed to alter or reshape normal structures of the body in order to improve appearance.

Requests for reconstructive surgery may be denied, if the proposed procedure offers only a minimal improvement in the appearance of the enrollee, in accordance with the standard of care as practiced by physicians specializing in reconstructive surgery.

Reconstructive Surgery after Mastectomy
California Health and Safety Code 1367.6 requires treatment for breast cancer to cover prosthetic devices or reconstructive surgery to restore and achieve symmetry for the patient incident to a mastectomy. Coverage for prosthetic devices and reconstructive surgery shall be subject to the copayment, or deductible and coinsurance conditions, that are applicable to the mastectomy and all other terms and conditions applicable to other benefits. "Mastectomy" means the removal of all or part of the breast for medically necessary reasons, as determined by a licensed physician and surgeon.

Policy Limitations: Medicare and Medicaid
Policies specifically developed to assist Health Net in administering Medicare or Medicaid plan benefits and determining coverage for a particular procedure, drug, service, or supply for Medicare or Medicaid Members shall not be construed to apply to any other Health Net plans and Members. The Policies shall not be interpreted to limit the benefits afforded Medicare and Medicaid Members by law and regulation.


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