2018 Cadillac Tax: 40% excise tax on the amount by which the total cost of employersponsored health plan exceeds specified thresholds 2010 thresholds are: $10,200 for self-only coverage; $27,500 for other coverage (these figures will be adjusted for 2018) 2015 Employer mandate (aka "pay-or-play") - Potential penalties on ERs who don't offer minimum essential coverage to at least 95% of EEs who work at least 30 hrs/wk (& to dependents), or who do offer coverage but it does not meet Affordability test & minimum value requirement. Affordability test: If EE cost for self-only coverage exceeds 9.5% of: EE s W-2 income from the ER, or EE s hourly rate x 130 hrs/month, or FPL for single individual, potential penalty on employer Employer reporting requirements: must report to gov t & employees, certain plan information/terms & if employer offered minimum essential coverage 2014 Employer mandate (aka "pay-or-play") - Potential penalties on ERs who don't offer specified coverage. Provision delayed, see entries under 2015 and 2016. Affordability test: If EE cost for self-only coverage exceeds 9.5% of income; See entry under 2015, since this provision is delayed until 2015 Employer reporting requirements: must report specified plan & coverage information to gov t & employees. Delayed to 2015. See entry under 2015. 1/1/2018 Applies in 2015 to ERs with at least 100 FTEEs and FTEs. Delayed to 2016 for ERs with 50-99 EEs. Also, for 2015 only, offer of coverage may be to only 70% of FTEEs, rather than 95%. In 2015, applies only to ERs with 100 or more FTEEs or FTEs. Applies for 2015, report due in 2016. Originally effective for 2014, report due in 2015. Delayed to 2015 or 2016 depending on ER size. Originally effective in 2014. Delayed to 2015 or 2016 depending on ER size. Originally effective 1 st Plan Year on or after One-yr delay of reporting requirements. Originally effective for 2014, reporting due in 2015. Employer mandate only applies to ERs with 50 or more FT EEs (and FT equivalents) Penalties only apply if at least one FT EE gets a gov't subsidy for buying insurance in an Individual Employer mandate only applies to ERs with 50 or more FT EEs (and FT equivalents) Penalties only apply if at least one FT EE gets a gov't subsidy for buying insurance in an Individual Applies to employers at with at least 50 employees, even though in 2015 ERs with 50-99 EEs are not subject to ER mandate penalties penalty and no Affordability test on ERs with 99 or fewer FT EEs (and FT equivalents) penalty and no Affordability test on ERs with fewer than 50 FT EEs (and FT equivalents) Copyright 2014 LGAA, Inc. This document is not intended or provided as legal advice. 1
2014 continued Minimum Value (MV): Employer health plans and health insurance policies must pay at least 60% of actuarial value of allowed benefits under the plan. Different standard populations for large and self-insured plans, small plans and individual policies. Health Insurance Industry Fee Fee on health insurance carriers based on market share, to fund subsidies in Individual Requirement that plans & policies provide "essential health benefits" and meet specified actuarial values annual dollar limits on essential health benefits. (Prior to 2014, restricted annual dollar limits applied) Modified Community Rating ( Fair Health Insurance Premiums ). (California does not allow tobacco use as a rating factor, for small insured plans.) Limits on cost-sharing:: Maximum deductible in 2014 will be $2,000/ $4,000 (but exceptions) and for 2015 $2,050 / $4,100 Limits on cost-sharing: Out-of-pocket maximums same as for HSA-compatible HDHPs, which for 2014 is $6,350/$12,700 and for 2015 $6,600/$13,200 pre-existing condition exclusions for anyone Waiting period for coverage cannot exceed 90 days (1 st of month after 60 days of eligibility) In California it is 60 days (1st of month after 30 days) Mandatory coverage for clinical trials (N/A to grandfathered plans.), but Obama administration on 11-14-13 allowed carriers to renew non-aca Compliant plans, and on 3-5-2014 allowed, but Obama admin, but Obama admin, but Obama admin (unless grandfathered) (Only on insured plans, not on self-funded Also N/A to any-size self-funded plan (t required to cover EHBs, but if plan does it cannot impose annual limits on them, even if grandfathered) (Only on insured plans, not on selffunded small group & individual policies small group & individual policies small insured plans Copyright 2014 LGAA, Inc. This document is not intended or provided as legal advice. 2
2014 continued Extension of dependent coverage up to age 26, even if dependent has other group coverage available. Before 2014, GF plan is not required to offer if over-age dependent has other group coverage available. Transitional Reinsurance Fee Imposed on group health plans & policies, based on number of enrollees. For 2014, fee is $63/year /participant (employee & dependents) For 2015, fee is $44 For employees who meet certain resultsbased wellness program standards, ERs can offer financial incentives of up to 30% of the total premium or cost of coverage in the GHP, + additional 20% for tobacco cessation or reduction programs (total 50% for tobacco) For employees who meet certain resultsbased wellness program standards, ERs can offer financial incentives of up to 30% of the total premium or cost of coverage in the GHP, + additional 20% for tobacco cessation or reduction programs (total 50% for tobacco) Automatic enrollment in employer group health plan (but employee can opt out) Waiting period for coverage cannot exceed 90 days (1 st of month after 60 days of eligibility). Can start after bona fide orientation period of not more than 1 month. In California it is 60 days (1 st of month after 30 days) 2013 W-2 Reporting of Health Care Coverage $2500 limit on annual Employee pre-tax contribution to Health FSA Comparative Clinical Effectiveness Research Fee (aka CER fee or PCORI Fee). $1 per member per year, 2nd year increases to $2 per member. Employers to provide tice of Health Insurance s to employees - 12/31/2016 1 st Plan Year or Wellness Program on or after 1 st Plan Year or Wellness Program on or after Delayed until after 2014 (until regulations issued) by 1/31/2013, for the 2012 tax year 1/1/2013 due by 7/31/13, for the 2012 plan year (Only applies if more than 200 full-time employees) (Employers that filed at least 250 W-2s in prior year) N/A until future guidance applies requirement to small employers by October 1, 2013 Copyright 2014 LGAA, Inc. This document is not intended or provided as legal advice. 3
2013 Continued Coverage of all FDA-approved contraceptive methods, as part of preventive services for women. N/A to certain religious employers & 1-year delay for religious-affiliated employers. 2012 Start capturing necessary information for W-2 Reporting of value of employer-sponsored health coverage MLR Rebates (will apply annually) MLR rebate is from the carrier, so only applies to insured plans, N/A to self-funded Benefit appeals procedures & external review procedures (GF plans are subject to existing ERISA claims & appeals rules but not to new HCR rules) Coverage of all FDA-approved contraceptive methods, as part of preventive services for women. N/A to certain religious employers & 1-year delay for religious-affiliated employers. Uniform Summary of Benefits & Coverage (SBC). SBC required for H.S.A.s or for excepted benefits such as separate dental or vision plans or most HFSAs 2011 Medical Loss Ratio (MLR): 80% for small groups, 85% for large groups; only applies to insured plans Over-the-counter (OTC) drugs no longer reimbursable by Health FSA plan, HSAs, MSAs or HRAs, unless prescribed by doctor HSAs - non-qualified distributions - penalty increases from 10% to 20%, plus income tax 8/1/12 (1/1/13 for calendar year 1st 2012 payroll period, for 2012 W-2s (which must be sent by 1/31/13) (Employers that filed at least 250 W-2s in prior year) N/A until future guidance applies requirement to small employers 8/1/2012 Delayed until 2012 PY for calendar year plans 8/1/12 (1/1/13 for calendar year 1 st Open Enrollment period on or after 9/23/2012 Applies for 2011 calendar year, rebates in 2012 1/1/2011 1/1/11 2010 - First Plan Year on or after September 23, 2010 Extension of dependent coverage up to age 26. Before 2014, GF plan is not required to offer if over-age dependent has other group coverage available. pre-existing condition exclusions for enrollees under age 19 t applicable to grandfathered individual coverage Copyright 2014 LGAA, Inc. This document is not intended or provided as legal advice. 4
2010 continued First Plan Year on or after September 23, 2010 lifetime dollar limits on "essential health benefits" (EHB) Restricted annual dollar limits on "essential health benefits" (EHB): $750,000 if PYB is -9/22/11 $1.25 mil if PYB is 9/23/11-9/22/12 $2 mil if PYB is 9/23/12-12/31/13 annual dollar limits on "essential health benefits" Preventive services Patient protections: Can select pediatrician as PCP Patient protections: Cannot require referral or pre-authorization for OB/GYN Patient protections: Cannot require preauthorization or referral for emergency care Patient protections: Cannot impose additional costs or limits on out-of-network emergency care n-discrimination testing for insured plans; self-insured already subject to 105(h) nondiscrimination testing. Grandfathered Plan tice: GF plan must notify participants it is GF. Must provide with all/most notices about benefits rescissions -- except if fraud or misrepresentation t required to offer coverage, but if plan does, it cannot impose lifetime dollar limits on them, even if grandfathered. Applies to all plans that offer EHB, even if grandfathered Enforcement delayed until IRS issues final regulations not issued as 3/5/14 t applicable to grandfathered individual coverage; NO annual dollar limits in 2014, restricted annual limits before 2014 This publication is intended for general information purposes only and does not and is not intended to constitute legal advice. The reader must consult with legal counsel to determine how laws or decisions discussed herein apply to the reader s specific circumstances and obligations under the PPACA. Copyright 2014 LGAA, Inc. This document is not intended or provided as legal advice. 5