Boiling Down the ACA

By Linda Rowings

October 25, 2013

 

A lot of employers and advisers might want a simple, at-a-glance way to see all the Affordable Care Act requirements that apply to their business(es). This is no easy task given group size, SHOP exchanges and self-funding variables. Let’s take a look at a few provisions that are effective for the plan year beginning on or after January 1.

 

Here’s what (non-grandfathered) large group insured plans (more than 50 employees) should be focused on:

• Eligibility waiting period maximum of 90 days
• Pre-ex not permitted on anyone
• Annual dollar limits prohibited on essential health benefits
• Protections for those in clinical trials
• Out of pocket may not exceed $6,350/$12,700
• Guarantee issue and renewal apply
• Revised wellness program rules

If you have a (non-grandfathered) small group (50 or fewer employees) insured plan, keep a watch on the following requirements that apply BOTH inside and outside the SHOP exchange:

• Modified community rating applies
• Essential health benefits (EHBs) must be offered
• Deductible generally may not exceed $2,000/$4,000
• Out of pocket may not exceed $6,350/$12,700
• Must meet metal levels (60%, 70%, 80%, 90%)
• Guarantee issue and renewal apply (subject to participation)
• Single risk pool
• Revised wellness program rules
• Eligibility waiting period maximum of 90 days
• Pre-ex not permitted on anyone
• Annual dollar limits prohibited on essential health benefits
• Protections for those in clinical trials

If you are a small OR large self-funded plan, the following requirements should be on your radar:

• Eligibility waiting period maximum of 90 days
• Pre-ex not permitted on anyone
• Annual dollar limits prohibited on essential health benefits
• Protections for those in clinical trials
• Out of pocket may not exceed $6,350/$12,700
• Revised wellness program rules
• Transitional reinsurance fee, including reporting

See the full article here