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ABC is providing an overview of several new provisions included in the Patient Protection and Affordable Care Act (PPACA) that are scheduled to become effective in the new year. Additional information about PPACA, including reference guides and webinars, may be found in ABC’s health care employer toolkit.  

Annual Health Insurance Tax (HIT)
Under the HIT, a fee will be assessed on health insurance companies – almost all of which will be passed onto consumers in the fully insured marketplace, where nearly all small businesses and the self-employed purchase their coverage. The HIT will result in the collection of $8 billion in 2014, and that number will reach $101.7 billion in the first 10 years.  Learn more about the HIT and the Stop the HIT Coalition, which ABC is a member, here.

Transitional Reinsurance Program Fee
The transitional Reinsurance Program fee is effective from 2014 through 2016, and will be assessed on insured and self-funded plans.  For 2014, HHS has proposed an assessment of $63 per individual, which will be collected from health insurance providers. (Recent modification: the $63 per capita reinsurance contribution for 2014 will be collected in two installments: $52.50 in January 2015, and $10.50 late in the fourth quarter of 2015).

Patient Centered Outcomes Research Institute (PCORI) Fee
This research fee applies to insured and self-insured plans.  For plan years beginning on Oct. 1, 2013 through Sept. 2014, the fee increases from $1 to $2 per covered life. 

Risk Adjustment Program Fee
Fully insured plans that participate in the individual and small market will pay a fee of $1 per member.  

Individual Mandate 
Individuals are required to obtain minimum essential health coverage for themselves and their dependents or pay a tax. Some exemptions from paying the tax apply. Learn more about the individual mandate here

Health Insurance Marketplace enrollment began on Oct. 1, 2013 and coverage through the Marketplace can begin as soon as Jan. 1, 2014.  The Small Business Health Options Program (SHOP) Marketplace is open to employers with 50 or fewer full-time equivalent employees in 2014. On Nov. 27, HHS announced online enrollment for small businesses in the federally-facilitated SHOP Marketplace is delayed one-year until November 2014. ABC’s Insurance Trust estimates the SHOP will be appropriate for approximately 1 percent or less of ABC members.

Employees who purchase coverage through the Marketplace will be eligible for premium subsidies if:  their income is between 133 percent and 399 percent of the Federal poverty line; coverage is not available through a government program; and their employer fails to offer health coverage that is affordable and meets the minimum value standards under PPACA. 

For non-grandfathered insured health plans in the small group market (companies with fewer than 50 employees), the maximum deductible allowed is $2,000 for an individual and $4,000 for a family.  The only exception for deductibles to be above this amount is if they are required to meet the actuarial requirements for one of the Metal levels. According to ABC’s 2013 employee benefits survey, 35 percent of ABC contractors with fewer than 50 employees have deductibles that exceed $2,000 for an individual.

For non-grandfathered group health plans (including self-funded plans and those in the large group market, the annual out-of-pocket maximum cannot exceed the out-of-pocket limit applicable to high-deductible health plans ($6,250 for an individual and $12,700 for a family).  There is a limited exception for a group health plan or group health insurance issuer using more than one service provider to administer benefits that are subject to the annual limitation on out-of-pocket maximums. Read the DOL’s FAQ here.

Non-grandfathered plans may not terminate coverage because an individual participates in an approved clinical trial for the treatment of cancer or another life-threatening disease or deny coverage of routine patient costs for items and services furnished in connection with participation in the trial. 

Non-grandfathered plans offered in the individual and small group markets, including those offered in the Health Insurance Marketplace, must offer essential health benefits

Annual dollar limits on coverage of essential health benefits are prohibited. Learn more about lifetime and annual limits here.

Group health plans and health insurers are prohibited from imposing pre-existing condition exclusions on any covered individual. More information is available here.

Generally, a group health plan or health insurance issuer offering group health insurance coverage may not impose a waiting period longer than 90 days.  Read the DOL’s FAQ here.
This article is meant for educational purposes only and is not intended, and should not be relied upon, as legal advice. Members should seek advice based on their particular circumstances from an independent legal counsel.