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The Tax Cuts and Jobs Act: How It Still Affects You

The Tax Cuts and Jobs Act: How It Still Affects You

Editor’s Note: This article is a follow-up to The Tax Cuts and Jobs Act – How Will It Affect YOU? published in the Winter 2018 issue.

On Aug. 8, the IRS issued proposed regulations for the newly created Section 199A 20 Percent Qualified Business Income (QBI) deduction. 199A has been one of the most talked about aspects of the Tax Cuts and Jobs Act since its passage last December. This provision of the act was included in the tax reform bill in an attempt to give pass-through entities (such as partnerships, LLCs and S corporations) and sole proprietorships similar tax savings that were provided to C Corporations (C Corp tax rates were reduced from a high of 35 percent to a flat 21 percent). The new 20 percent QBI deduction is effective for the 2018 tax year through 2025.

Although the new tax deduction is generous, the structure of the deduction is complicated with many limits, phase-ins, and phase-outs. Whether or not you will be able to take the deduction depends upon many factors, the key being your personal taxable income. Other factors include wages paid by the practice, the value of business property, nature of income, etc.

Physicians are especially impacted by limits on the deduction since the income is earned from what the law labels as a “Specified Service Trade or Business” (SSTB).

What is a Specified Service Trade or Business (SSTB)?

Most unincorporated business owners, partners and S Corporation shareholders benefit from the 199A deduction. However, Congress precludes some higher-income business owners from taking the deduction if the income is earned from an SSTB.

An SSTB is a trade or business involving the performance of services in the fields of health, law, accounting, actuarial science, performing arts, consulting, athletics, financial services, investing and investment management, trading, dealing in certain assets or any trade or business where the principal asset is the reputation or skill of one or more of its employees. Per IRS regulations:

The term “performance of services in the field of health” means the provision of medical services by physicians, pharmacists, nurses, dentists, veterinarians, physical therapists, psychologists and other similar health care professionals who provide medical services directly to a patient. The performance of services in the field of health does not include the provision of services not directly related to a medical field, even though the services may purportedly relate to the health of the service recipient. For example, the performance of services in the field of health does not include the operation of health clubs or health spas that provide physical exercise or conditioning to their customers, payment processing, or research, testing and manufacture and/or sales of pharmaceuticals or medical devices.

Based on this definition, physician practices are considered SSTBs, and therefore, limits apply on the available deduction.

How does the deduction work?

The QBI deduction is based off “pass-through income,” income reported on a Schedule K-1 earned from partnerships, LLCs and S Corporations or if a sole proprietor, what is reported on Schedule C of Form 1040 individual income tax return. Wages reported on a W2 or guaranteed payments paid to partners do not qualify as QBI. It excludes any investment-related items, such as interest, dividends or capital gains or losses from the sale of property. The maximum deduction available is 20 percent of QBI.

Although the deduction is calculated based on income earned from a trade or business (i.e. – the physician practice), the actual amount of the deduction is dependent on the taxable income of the individual. Most physicians with taxable income over $415,000 filing a joint return will be hard-pressed to qualify for the deduction. As such, it is possible for a large group practice to have some physicians qualify for a QBI deduction and some not qualify when there is a large variation in income among the owners.

The deduction itself is claimed on Form 1040 individual income tax return. Form 1040 will include a new line for the deduction in arriving at taxable income.

How do I know if I qualify to take the deduction?

The deduction is fairly simple and straightforward for individuals with married filing joint taxable income of $315,000 or less ($157,500 or less if filing single). Those taxpayers receive the full 20 percent QBI deduction. Above those taxable income amounts, the 20 percent QBI deduction becomes subject to a tangled web of limitations, phase-ins, and phase-outs. Individuals with income from SSTBs (i.e. physician practices) are subject to even more limitations that, depending on the individual’s taxable income, quickly eliminate the 20 percent deduction altogether.

Let’s first examine the limits applicable to both service and non-service businesses alike once taxable income exceeds the limits noted above. The 20 percent qualified business income deduction is limited by the greater of:

  • 50 percent of W2 wages paid by the qualifying business or
  • 25 percent of W2 wages paid plus 2.5 percent of unadjusted basis of all qualified property.

These limits are phased in for joint filers with taxable income greater than $315,000 but less than $415,000 ($157,500 / $207,500 for non-joint filers) and result in a reduced 1991A QBI deduction.

In addition to the above limits, the ability to take the 199A QBI deduction for individuals with pass-through income from a SSTB is completely lost once individual taxable income exceeds $207,500 if filing single or $415,000 if filing joint. Phase out begins at $157,500 filing single and $315,000 filing joint.

The chart at the bottom of this section summarizes the various limitations, phase-ins and phase-outs for both SSTBs and non-SSTBs.

To illustrate, assume Dr. A is a sole practitioner who files a joint return. Her practice is organized as a single-member LLC. The qualified business income as reported on Schedule C of Dr. A’s 1040 is $240,000 after wages paid to staff of $195,000. Dr. A and her husband’s taxable income for the year is $295,000.

In this example, Dr. A’s tentative 20 percent deduction is $48,000 ($240,000 QBI* 20 percent). Since Dr. A’s overall taxable income is less than $315,000, she is able to take the full deduction of $48,000 since neither the W2 phase-in limit nor the SSTB phase-out limit applies.

But what if Dr. A’s taxable income is over the $415,000 limit noted above? Since the medical practice is considered a SSTB and income is over the allowed threshold, Dr. A is not allowed to take any amount as a QBI deduction.

It is important to note 199A generally requires taxpayers to identify QBI on a business-by-business basis. Physicians who own interests in other non-SSTB pass-through entities may still qualify for a 199A deduction for that trade or business.

IRS Anti-Abuse Regulations

Various planning strategies have been considered by physicians and their advisors on how to avoid the SSTB limitation. Some of these strategies became known as “crack and pack,” which involved splitting a practice into separate legal entities to isolate non-medical activities to qualify for some amount of deduction. One of the entities would provide the medical services and the other entity would lease office space, provide billing services, or various other administrative functions.

However, the regulations issued by the IRS contain various anti-abuse provisions – one of which significantly limits the ability to segregate activities among various entities when there is common ownership among the entities solely to qualify for the 199A QBI deduction. The proposed regulations state if any trade or business provides 80 percent or more of its property or services to an SSTB, and if that other trade or business and the SSTB share 50 percent or more common ownership, then that other business is considered an SSTB too. For purposes of this anti-abuse rule, ownership is both direct and indirect ownership by related parties.

It is a common practice for various components of a physician practice to be held in separate entities, often for legal protection and tax planning. One such example is real-estate held in a separate entity and rented to the practice. This is still acceptable; the anti-abuse regulations just prohibit taking a 199A QBI deduction in such circumstances.

The regs contain various other anti-abuse provisions, such as treating non-SSTB’s as an SSTB if they share expenses/overhead with a 50 percent commonly owned SSTB. In addition, there will be increased scrutiny over changes in classification between employee versus independent contractor or partner/shareholder status due to the impact on qualifying for the 199A QBI deductions. Physicians should consult with their attorney/tax advisor prior to making any such changes in an attempt to take a 199A QBI deduction.

Planning Opportunities

Although not every physician will be able to take advantage of the new 20 percent QBI deduction, the Tax Reform and Jobs Act still provides numerous other tax breaks, such as an overall reduction in individual income tax rates, elimination of some itemized deduction limitations, increased depreciation deductions, etc. For those physicians under the SSTB thresholds noted above, now is the time to time to consult with your tax advisor to ensure optimization of the 199A QBI deduction.

  • Physicians under the SSTB threshold should review and evaluate the following items and discuss with their tax advisor and attorney:
  • Whether he or she is operating the practice in the most appropriate entity form to qualify/maximize the 20 percent QBI deduction.
  • Partners in a partnership currently receiving guaranteed payments should consider revising their partnership agreements and taking draws instead to increase QBI and the corresponding 20 percent deduction.
  • For S Corporations, review compensation agreements and ensure a reasonable compensation is paid for services provided (not QBI), and pay the remainder of income as a distribution (does qualify for QBI).

In Summary

This summary merely scratches the surface of the 199A 20 percent QBI deduction and was written in the context of physician practices. Although the regulations are still in proposed form and not expected to be finalized until later this year, the Department of the Treasury has provided sufficient insight and interpretation of the law to plan for its implementation.

Executive Summary

  • The new 20 percent QBI deduction is based on pass-through income earned from partnerships, S-Corps, LLC’s or sole proprietorships.
  • W2 wages/guaranteed payments do not qualify as QBI.
  • Deduction will be claimed on Form 1040 individual tax return.
  • Claiming the deduction will be difficult, if not impossible to claim for physicians with taxable income over $207,500 if filing single or $415,000 if married filing joint unless there are sources of income from other non-SSTB pass-through entities.
  • Newly issued IRS anti-abuse regulations limit the ability to split apart practice into various entities to isolate non-medical activities in order to take the deduction.
  • Physicians earning under the above thresholds should meet with their tax advisor and attorney now to maximize potential deductions for 2018.

Mark Baker is a Principal with Jackson Thornton CPA’s and Consultants in Montgomery, Ala. He may be reached by calling (334) 834-7660 or email Mark.Baker@JacksonThornton.com. Jackson Thornton is an official partner with the Medical Association.

Posted in: Management

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HIPAA Guidance for Mass Shootings and Other Tragic and Emergency Situations

HIPAA Guidance for Mass Shootings and Other Tragic and Emergency Situations

In the aftermath of one of the deadliest school shootings in U.S. history, many health care organizations are revisiting their HIPAA policies and procedures to determine exactly what information they are allowed to share and to whom they may share information. 

FAMILY AND FRIENDS

A health care entity may share a patient’s location, general condition or death with a patient’s family, guardian, or friend who is involved in the patient’s care or who may be responsible for payment of the patient’s treatment. This may occur in a variety of circumstances including, but not limited to, the following:

  • If the patient is present and able to consent to the disclosure, the health care provider must obtain the patient’s consent, provide the patient with the opportunity to object to the disclosure, or based on the professional judgment of the health care professional, they may reasonably conclude that the individual would not object to the disclosure being made.
  • If the patient is not present or unable to consent due to incapacity or emergency, the health care professional may in the exercise of professional judgment determine whether the disclosure to the family, friend or guardian is in the best interest of the patient.
  • If the patient is deceased, the health care provider may disclose information about the patient to the family member, friend or guardian unless the health care professional is specifically aware that the patient expressed that the disclosure not be made prior to their death.
  • Health care providers may also share information about a patient with police, media outlets or the general public when attempting to identify, locate or notify family members, guardians or personal representatives of a patient. Information that may be shared include the patient’s location, general health status or death.
  • PHI may be shared with disaster relief organizations that are legally responsible for assisting with disasters if doing so will assist in the notification of family members or other individuals responsible for the patient’s care. [1]

MEDIA OUTLETS

Hospitals and health care entities may share general information about a patient with media outlets in an effort to identify, locate or notify individuals responsible for the patient’s care. However, if the request is initiated by the media, you must consider the following:

  • If the patient is conscious and does not specifically object, limited facility directory information may be shared as long as the requestor identifies the patient by name. This information includes whether the patient is indeed seeking treatment at the facility, whether they are in critical or stable condition, and whether they sought treatment and are now released.
  • If the patient is unable to consent, the health care provider can determine based on their professional judgment whether notifying the media or general public of the patient’s status or death is in the best interest of the patient.

Specific information about a patient’s care, such as x-rays, tests performed and test results, or details of a patient’s diagnosis may not be disclosed without either the patient’s authorization or the authorization of their personal representative.

LAW ENFORCEMENT

Health care entities can provide information to law enforcement with a signed HIPAA authorization from the patient or the patient’s personal representative. However, there are instances in which PHI may be shared with law enforcement without patient consent. Those instances include:

  • When the health care professional reasonably believes that the report would prevent or lessen a serious and imminent threat to the health or safety of an individual or the public;
  • The entity believes in good faith that it is sharing information that may be evidence of a crime that occurred on the premises of the entity;
  • Alerting law enforcement of the death of an individual when there is a suspicion that the death resulted from criminal conduct;
  • When responding to an off-site medical emergency, as necessary to alert law enforcement to criminal activity;
  • When it is required by law to make reports to law enforcement, like in instances of treating gunshot or stab wounds;
  • In compliance with court orders, warrants, subpoenas or summons;
  • In response to a request by law enforcement to identify or locate a suspect, fugitive, material witness or missing person (the information must be limited to basic demographic and identifying information about the person); and
  • Instances of child abuse or neglect reporting when the entity receiving the report is officially authorized by law to receive the report[2].

WHAT ABOUT THE SUSPECT?

When law enforcement needs assistance with identifying and locating a suspect, fugitive or material witness to a crime, health care entities are encouraged to cooperate with these requests.  However, those disclosures must be limited to the following information:

  • Name and Address,
  • Date and Place of Birth,
  • Social Security Number,
  • ABO Blood Type and RH Factor,
  • Type of Injury,
  • Date and Time of Treatment,
  • Date and Time of Death, and
  • Description of Distinguishing Physical Characteristics[3] (Ex. Tattoos, mustache, beard).

Any additional disclosures about a suspect’s medical information, such as DNA tests or body fluid analysis, can only be disclosed upon the presentation of a signed authorization, court order, warrant or documented administrative request.

WHAT IS A HIPAA WAIVER, AND WHEN DOES IT APPLY?

There is no lack of confusion regarding what a HIPAA waiver is and when it may be utilized. Waivers of HIPAA sanctions and penalties occur when the President declares an emergency or disaster and the Secretary of the Department of Health and Human Services (HHS) waives provisions of the Privacy Rule during the emergency or disaster.

If the Secretary issues such a waiver, it only applies:

  • In the emergency area and for the emergency period identified in the public health emergency declaration;
  • To hospitals that have instituted a disaster protocol. The waiver would only apply to patients at such hospital; and
  • For up to 72 hours from the time the hospital implements its disaster protocol.[4] Once the limited waiver terminates, health care entities are required to comply with the HIPAA Privacy Rule.

It is important to know under what circumstances you can disclose information and to whom those disclosures can be offered. Failure to understand these requirements may place you at risk for HIPAA violations and sanctions. If you have specific questions about disclosures of PHI, please contact a health care compliance professional.

[1] 45 CFR 164.510(b)

[2] 45 CFR 164.512

[3] 45 CFR 164.512(f)(2)

[4] 45 CFR 164.510(b)(4)

Article contributed by Samarria Dunson, J.D., CHC, CHPCattorney/principal of The Dunson Group, LLC, a health care compliance consulting and law firm in Montgomery, Ala. The Dunson Group, LLC, is an official partner with the Medical Association.

Posted in: HIPAA

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Office of Civil Rights Issues Guidance on HIPAA in Light of Opioid Crisis

Office of Civil Rights Issues Guidance on HIPAA in Light of Opioid Crisis

With an increased focus on opioid use and addiction, the Department of Health and Human Services Office of Civil Rights has issued guidance related to the Health Insurance Portability and Accountability Act of 1996 due to misunderstandings over when a health care provider can share an individual’s protected health information in situations of overdose or need for emergency medical treatment related to opioid use. Generally speaking, HIPAA restricts a health care provider’s ability to share PHI, but there are instances when a health care provider may disclose PHI even if the patient has not authorized the disclosure.

Many health care providers mistakenly think they must have an authorization or the patient’s permission to release PHI. However, there are circumstances in which the patient’s permission is not required. HIPAA allows a health care provider to share information with a patient’s family or caregivers in certain emergency or dangerous situations. As outlined in the guidance, a provider may share information with family and close friends who are involved in the care of the patient if the provider determines that doing so in the best interest of an incapacitated or unconscious patient and the information shared is directly related to the family or friends involved in the patient’s health care or payment of care. OCR’s guidance states that a provider may use his/her professional judgment to talk to the parents of someone incapacitated by an opioid overdose about the overdose and related medical information, but the provider could not share general information not related to the overdose without the patient’s permission.

Another situation in which information may be shared without the patient’s permission is if the provider informs a person who is in a position to prevent or lessen a serious or imminent threat to the patient’s health or safety. OCR states “a doctor whose patient has overdosed on opioids is presumed to have complied with HIPAA if the doctor informs family, friends or caregivers of the opioid abuse after determining that the patient poses a serious and imminent threat to his or her health through continued abuse upon discharge.”

If a patient is not incapacitated and has decision-making capacity, a health care provider must give the patient an opportunity to agree or object to disclosure of health information with family, friends or others even if they are involved in that individual’s care or payment for care. The health care provider is not permitted to disclose health information about a patient who has the capacity to make his/her own health care decisions unless, as mentioned above, there is a serious or imminent threat of harm to the health of the individual.

The difference between capacity or incapacity can be a difficult determination for providers and may change during the course of treatment. OCR points out that decision-making incapacity may be temporary or situational and does not have to rise to the level where someone has been or must be appointed to act by law, i.e. power of attorney or guardianship. If during the course of treatment, the patient regains the ability to make decisions, the provider must give the patient the opportunity to object or agree to providing or sharing health information.

As has always been the case, HIPAA allows a health care provider to release or disclose information to a patient’s “Personal Representative.” HIPAA defines personal representative as a person who has health care decision-making authority under state law. In Alabama, a person holding general Durable Power of Attorney executed after 2012 is presumed to be the Personal Representative for purposes of HIPAA. Additionally, a parent of an unemancipated minor or someone holding a guardianship or conservatorship would also qualify.

To read OCR’s guidance, visit https://www.hhs.gov/sites/default/files/hipaa-opioid-crisis.pdf

Article contributed by Angie Cameron Smith, a partner at Burr & Forman LLP. Burr & Forman LLP is a partner with the Medical Association.

Posted in: HIPAA

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Judge Rejects Bid to Revive ACA Subsidies

Judge Rejects Bid to Revive ACA Subsidies

A federal judge has denied several states’ attempt to compel the Trump administration to continue paying cost-sharing reduction payments. Attorney generals from 18 states and the District of Columbia had filed a motion in the U.S. District Court seeking a temporary injunction that would reinstate the payments, which the administration decided to end earlier this month.

Judge Vince Chhabria was skeptical of the states’ argument during a hearing on the motion earlier this week, noting many states have already taken steps to diffuse the impact of CSR uncertainty. In his order denying the states’ request for a temporary injunction, Chhabria said although a federal judge did previously rule that CSR payments should end because they were not properly appropriated by Congress, in this instance, the Trump administration has the stronger legal argument. Chhabria also noted any emergency relief requested by the states would be counterproductive as state insurance regulators have been working for months to prepare for the possibility the subsidies would end.

Many states, he continued, have therefore “devised responses that give millions of lower-income people better health coverage options than they would otherwise have had.”

The Trump administration this month terminated the payments to the insurers, which help cover medical expenses for low-income Americans, as part of several moves to dismantle Obama’s signature healthcare law formally known as the Affordable Care Act. The subsidies were due to cost $7 billion this year and were estimated at $10 billion for 2018, according to congressional analysts.

Insurers have argued they do not profit from the subsidies under the Affordable Care Act, but pass them on directly to consumers to reduce deductibles, co-payments and other out-of-pocket medical expenses for low-income people. Because insurers would raise premiums on policies in the absence of the subsidies, the government would be compelled to spend more on financial assistance to low-income Americans. The Congressional Budget Office has found that a bipartisan Senate proposal to shore up Obamacare insurance marketplaces by reviving the subsidies would cut the U.S. deficit by $3.8 billion over the next decade.

Posted in: Advocacy

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Tentative Bipartisan Deal Reached to Restore CSR Payments

Tentative Bipartisan Deal Reached to Restore CSR Payments

Earlier this week, the U.S. Senate reached a bipartisan deal “in principle” to restore Obamacare cost-sharing reduction payments for two years in exchange for more state flexibility in the health care act. The proposed plan would also restore more than $100 million in funding for health care outreach.

The bipartisan bill gained momentum later in the week with 24 co-sponsors to the legislation. President Trump has suggested he was “open” to authorizing payments to insurers that help offset out-of-pocket health costs in the short term — but had not given up his goal of repealing the ACA.

The short-term solution would allow insurers to offer catastrophic insurance plans to consumers ages 30 and older on the exchanges, while maintaining a single-risk pool, meanwhile also making it easier for states to obtain waivers to customize health plan rules to their needs by speeding up administration approval of the waivers and allow states to copy provisions in waivers that were already approved. This could also provide a reprieve for the Affordable Care Act that would prevent 2018 premiums from increasing as much as previously predicted. However, consumers in many states will still face double-digit rate increases, and in many counties, health plans will be available from only one insurance company.

The proposed legislation would not allow states to change the essential benefits insurers are now required to offer individuals and small businesses under the ACA or let insurers discriminate against consumers with preexisting conditions for the next two years.

The Medical Association will continue to monitor the progress of this proposed legislation and is eager to work with lawmakers toward a positive solution.

Posted in: Advocacy

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