Today’s Meeting Agenda 2 General Session: ACA Latest Developments & Key Provisions Luther Stueland, Director Health Reform Analysis (BCBSND) Break Out Session: Employer Impact, Analysis & Transition Strategies Mike Potts, Director of Consulting & Wellness (BCBSND) Accounting and Tax Implications Ross Manson, Partner(Eide Bailly) Employee Accounts and Defined Contribution Jason Christianson, Sales Director, (Discovery Benefits)

General Session: ACA Latest Developments & Key Provisions Luther Stueland – Director, Health Reform Analysis 3

Key ACA Provisions Understanding the impact of reform is the first step to developing a benefits strategy that aligns with the emerging market landscape Guaranteed Issue: All individuals will be able to purchase coverage regardless of health status. Benefit Standards: Qualified health plans sold on the exchange are required to cover the essential benefits and have at least a 60% actuarial value. Non-grandfathered plans will need to be a “metal tier” plan. Consumer Subsidies: Individuals with household incomes at or below 400% of federal poverty level (FPL) 1 will be eligible for income-indexed premium subsidies, and those below 250% of the FPL will be eligible for cost-sharing reduction. Public Exchange: Individuals will be able to purchase subsidized individual coverage on public exchanges. Employer Penalties: All employers with 50 or more full-time equivalents must provide adequate health benefits to employees or pay a penalty per full-time employee per year. An employee’s contribution to the group single premium should not exceed 9.5% of his or her income. 2 1) In 2012, $44,680 for an individual and $92,200 for a family of four (source: 2) If standards are not met, the employee is eligible for subsidies and the employer pays a $3K penalty per employee receiving exchange subsidies Beginning in 2014

Health Insurance Exchange: Health Insurance Exchange is an online marketplace where individuals and small groups purchase health insurance within their state –Federal government will establish Individual and Small Group (SHOP) exchange Options limited to Standard Benefit (Metallic) Plans: –Bronze 60%, Silver 70%, Gold 80%, Platinum 90% –Actuarial value = % of total average costs for covered benefits that a plan will cover –Catastrophic plan offering available to those under 30 years of age 5 North Dakota declined to run its own exchange, the federal government will manage

Overview of Premium Subsidies Estimated Individual Market Subsidies (2014) Source: BCBSA analysis (1)Premium estimate for 2014 based on an individual between the ages of 46 and 55 (2)Premium cap as described in ACA bill, based on silver level plan Consumers with household incomes at or below 400% of the FPL will be eligible for individual product premium subsidies on exchanges Subsidies will only be available through public exchanges Subsidies are based on premiums for the second lowest cost Silver plan (actuarial value of 70%) Individuals receiving affordable coverage from an employer are not eligible for subsidies Additional cost-sharing subsidies are available for individuals under 250% FPL Subsidies will only be available through public exchanges Subsidies are based on premiums for the second lowest cost Silver plan (actuarial value of 70%) Individuals receiving affordable coverage from an employer are not eligible for subsidies Additional cost-sharing subsidies are available for individuals under 250% FPL 9.5 % of Income 2.0 % of Income 9.5 % of Income 6.3 % of Income 8.1 % of Income Estimated Premium Household FPL Level Government Subsidies Estimated Individual Premium: $4,942 1 Premium Cap (sliding scale) 2

Exploring Subsidy Eligibility Government subsidies will be based on the household income and not exclusively on the employee’s salary Employee A: Single IndividualEmployee B: Family of 2 Employee Age:5030 Employee Salary:$30,000 Spousal Salary:None$50,000 Household FPL: Estimated Premium:$4,940$9,010 Government Subsidy: $2,525None Scenarios: Employee Subsidy Eligibility in the Individual Market (2014) Estimated Cost of Coverage: $2,415 (premium cap 1 ) $9,010 (full premium) Source: BCBSA analysis (1)Premium cap as described in ACA bill, based on Silver level plan Subsidy Eligible Non-Subsidy Eligible

Potential Employer Penalties There are two ways in which employers may be penalized in the post-reform market 1)Penalties go into effect in )Although the IRS has issued guidance providing a safe harbor for employers, the ACA law itself specifies that affordability be calculated based on the employee’s total household income rather than the employee’s wage Employer has at least 50 full-time equivalent employees One or more eligible employees purchase subsidized coverage through exchange General Penalty Criteria: 1 Employer is penalized if employees’ premium contributions exceed 9.5% of wages 2 and/or the plan covers less than 60% of health care expenses Employer Does Not Offer Coverage: Employer is penalized on all employees excluding the first 30 full time employees (30+ hours/week) Employer Offers Unaffordable Coverage: $2,000 (per full-time employee) No Coverage Penalty: Unaffordable Coverage Penalty: $3,000 (per full-time employee obtaining subsidies)

Calculate Group Size: Full-Time Equivalents Applicable Large Group : 50+ Full-Time Employees (Average 30 Hours Per Week) 1.Calculate your Full-Time Employees 2.Calculate your (part-time and seasonal) FTEs 3.Add the two numbers in steps 1 and 2 4.Add up the 12 monthly numbers in 3 and divide by 12 5.If less than 50, not applicable large employer 6.If more than 50, was it for greater than 120 days due to seasonal employees? 9

Full-Time Employee Coverage ACA mandates that employers offer affordable coverage to full-time employees working an average of at least 30 hours/week or 130 hours/month or pay a penalty Employer may utilize safe harbor “look-back” measurement option of up to 12 months to determine whether new variable hour and seasonal employees are full-time employees. (See IRS Notice and related) Provides the option to use specified measurement and administrative periods for on-going employees and certain newly hired employees to determine future coverage periods known as the stability period. Educational institution employees are based on hours worked during expected operating months (school year) REG , comments due by 3/18/2013, public hearing 4/23/

Key Small Group Provisions Existing small groups with non-grandfathered coverage will be placed on a metallic plan that is part of a single, new rating pool The new rating pool allows for geographic, age and tobacco rating factors Specific group claim experience cannot be a rating factor Rating rules expand to groups up to 100 in 2016 & potentially large groups in 2017 Grandfathered plans are exempt 11 Small employers with <50 full-time equivalent employees and non-grandfathered benefits will be affected by new requirements

Regulations on Grandfathering Grandfathering allows employers to maintain their health plans without being required to implement certain aspects of ACA Applicable to Grandfathered PlansNot Applicable to Grandfathered Plans No lifetime limits on coverage amounts A maximum waiting period of 90 days for new employee coverage Coverage of dependent children up to the age of 26 Required package of essential health benefits and full coverage of preventive services Limit on rate variation by age Limited cost sharing For small groups, deductible cap of $2K for an individual and $4K for a family Non-Discrimination Issues Criteria for Grandfathered Status Employers can maintain grandfathered status past 2014 but are restricted from making the following changes:  Reducing or eliminating benefits for a specific condition (e.g., diabetes or cystic fibrosis)  Raising co-insurance charges or significantly raising co-payments and deductibles  Significantly lowering employer premium contributions  Materially modifying existing benefits by purchasing coverage from a different insurer

Health Care Reform Break Out Session 13

Break Out Session Agenda: Accounting and Tax Implications Ross Manson, Partner(Eide Bailly) Employee Accounts and Defined Contribution Jason Christianson, Sales Director, Discovery Benefits Employer Impact, Analysis & Transition Strategies Mike Potts, Director of Consulting & Wellness (BCBSND) 14

Ross Manson Partner HealthCare Reform 15

Employers Key Number Is 50 > 50 = Large Employer and subject to penalties < 50 = Small Employer and NOT subject to penalties Full-time equivalent employees

Large Employer ( > 50) NOT Offering Insurance Employers NOT offering health insurance: A penalty of $2,000 per year/per FT employee (and seasonal employees the month they work full-time) Exempts the first 30 employees from computation Example: 100 employees and one goes to an Exchange and receives a subsidy Penalty = (100-30) x $ = $11,667/month $140,000 annually Triggered on all full-time employees if one full-time employee goes to the exchange and receives a subsidy Penalty is NOT tax deductible 17

Large Employer ( > 50) Offering Insurance Potential $3,000 penalty if employer OFFERS health insurance – must pass 2 tests! Subsidy eligibility based on unaffordable or inadequate insurance Unaffordable = Employee insurance premiums exceeding 9.5% of HHI (Safe Harbor created for employers – single plan premiums paid by employee cannot exceed 9.5% of wages) Inadequate = Insurance policy less than 60% of actuarial value (determined by health plan) A penalty of $3,000 per year/per FT employee who goes to the exchange and receives an exchange subsidy Capped by the amount of penalty for not offering insurance coverage 18

Controlled Group Provisions Internal Revenue Codes 1563 and 414: Parent – Subsidiary – 80% rule; Brother/Sister corporations – 50% stock; Combined Group Section 801 Companies 19

Non-discrimination in Insured Health Plans Non-grandfathered insured group health plans that impermissibly discriminate in favor of highly compensated employees face significant liability under new rules. Relates to the 1986 Tax Law – Internal Revenue Code (IRC) Section 105(h)(2). Prohibition on discrimination in favor of highly compensated individuals. Effective date for plan years beginning after ___________? (waiting for final guidance). The penalty for plans will have an excise tax of $100 per day for the plan per person discriminated against, with a maximum penalty of $500,000! 20

Key Definitions Government Entity Government of United States Any State or Political subdivision thereof Indian Tribal Government or agency Hours of service Paid for work, vacation, holiday, illness, incapacity, layoff, jury duty, military duty or leave of absence

Determining Full Time Employees Hourly Non Hourly Actual hours Days worked equivalency Weeks worked equivalency You cannot intentionally use a method to lower their actual hours (3 ten hour days using days worked would be an example)

Permissible employee categories Collectively Bargained employees and non- collectively bargained employees Each group of collectively bargained employee under separate agreements Salaried and hourly employees Employees in different states

Section 1411 Certification Department of Health and Human services will establish a process to notify employers of those employees receiving Premium tax credit or cost sharing reductions

Discovery Benefits Jason Christianson

History Growth and Stability 96% client retention rate Market Presence 7,500 clients 450,000 benefit participants 1 million covered lives (COBRA)

Our Clients

Reimbursement Accounts

Updates Flexible Spending Accounts 2013 Medical FSA max - $2500 “Use it or lose it” being reconsidered Health Reimbursement Arrangements 1/1/2014 – All HRA plans must be tied to a medical plan Employee must be enrolled in Health plan to access HRA Health Savings Accounts Seeing increase in employers offering HDHP with an HSA Employer and Employee contributions to the HSA available

Defined Contribution Plans

What are they? Why are employers considering Defined Contribution Plans? Predictable Budgets Flexibility for Employees Employees can continue to pay their portion of premiums on a pre-tax basis Administration is simplified for employer using BCBS ND’s enrollment platform

Individual Exchange Individual Exchange- If employer is dropping group coverage and directing employees to the state exchange Things to consider: Employer contribution to FSA/HSA to attract and retain employees with rich benefit offerings HRA not applicable as it’s no longer tied to a health plan

Thank You

Impact, Analysis & Transition Strategies Mike Potts, Director Employer Consulting & Wellness 35

Refining Benefit Strategy As employers develop their post-reform benefits strategies, it is important to consider key factors for sponsoring coverage Financial incentives to sponsor group healthcare coverage Talent acquisition, retention, and employee engagement Company culture and the nature of the social contract with employees Industry trends and competitor positioning Employee health and wellness There are many important considerations to choosing the right benefit strategy: Employer Impact

Group Analysis Steps Next Steps: 1.Assess Group Goals & Current Status 2.Review Financial Impact Analysis Report From BCBSND 3.Review 2014 Baseline Renewal 4.Explore Alternative Options 5.Decide on 2014 Plan 37 Analysis & Transition Strategies BCBSND will be proactive in engaging with employers to help consult and provide solutions for the group market

Understanding Employer Impact The economic impact of reform to employers will vary depending on existing benefit solutions and characteristics of the workforce Factors that Impact Decisions around Healthcare Reform Employer Specific: Employer size Employer premiums Premium cost sharing levels Employee participation rate Grandfather Status Employer Impact Employee Specific: Average employee incomes Workforce demographics (e.g., family structure and age) Market Based: Individual premiums Penalties and subsidies

Employer Incentives 39 Employer incentives are determined by the net savings or cost to each employee if coverage is dropped Est Premium Contribution Post-reform Environment Per Employee Expense or Savings $ Methodology

Net Employer Incentive 40 Calculate Incentives Per Employee An employer’s net financial incentive to drop or keep coverage is assessed through the evaluation of the financial impact to each of its employees Sum Employee Incentives to Calculate Net Employer Impact Employee 1: Cost of $500 Employee 2: Savings of $200 Employee 3: Savings of $150 Employees Incented to Maintain Coverage Employees Incented to Drop Coverage Employer ABC Aggregate Savings: $100K Total Savings: $500KTotal Cost: -$400K Methodology

Group A Report 41

Grand Fathered Group Non-Grand Fathered Group Public Exchanges Individual How Does ACA Affect 2014 premium? What is Potential Financial Impact of Public Exchanges? Stay Grandfathered? 42 Range of Scenarios BCBSND will help employers evaluate their current position and determine the best options for Maintain or Modify Current Coverage? Defined Contribution? SHOP or Private Exchange? Self-Funding (>25)? Out of Pocket Impact to Employees on Exchanges? Key Questions:Options:

Questions 43