With the passage of federal health care reform legislation, we are working hard to ensure all necessary changes to our policies and procedures are implemented accurately and on time. We are currently assessing and evaluating the law, and its many provisions, to determine how and when our products and customers are affected. Rest assured, WPS will comply with all federal and state requirements by the required implementation dates.
If you are a current WPS customer, we will also be sending notifications via renewal letters and other communications, fully explaining your options and any plan changes mandated under the new legislation. Our priority is to ensure that you understand how you may be affected by each new provision.
Many aspects of the legislation are still being finalized by federal and state regulatory bodies. The following chart lists the provisions of the law and the regulatory information that has been released. As new information becomes available, we will continue to post updates to this chart.
| Provision Topic |
Brief Description |
Federal Regulations |
Related Resources |
| 2010 |
| Annual Limits |
May only impose annual limits on "Essential" benefits, as determined by the Secretary, until they are completely eliminated in 2014. Applies to individual and group (including ASO). Applies to Group Grandfathered plans. Special rules apply in the case of collectively bargained plans. |
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| Appeals Process |
A new health plan appeals process must be followed. New rules require external review in some situations. Does not apply to grandfathered plans. |
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| Dependent Coverage of Children Who Have Not Attained Age 26 |
Provide dependent coverage for children up to age 26 for all individual and group (including ASO) policies. Applies to Grandfathered plans. The coverage must be extended to married children, but not their dependents (spouse and children) if they are not eligible for other employer-sponsored coverage. But for plan years starting in 2014, you can no longer impose the ER-sponsored requirement. The plan will have to satisfy the federal requirements and any state law requirements that require the extension of adult dependent coverage. Plans will need to provide the better of the two requirements in each state. {Except, self-funded will follow federal requirement only.} Internal Revenue Code Section 105(b) is amended to permit an employee to exclude from gross income the value of employer-provided health coverage to any child of a taxpayer who has not reached age 27 as of the end of the tax year. |
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| Early Retiree Reinsurance Program |
A temporary reinsurance program for employers providing health insurance coverage, whether the benefits provided are self-funded or delivered through the purchase of insurance, to retirees over age 55 who are not eligible for Medicare (and the eligible spouses, surviving spouses, and dependents of such retirees). Program will reimburse employers or insurers for 80% of retiree claims between $15K-$90K. Payments from the reinsurance program will be used to lower the costs for enrollees in the employer plan and can't be used for any other purposes. $5 billion will be appropriated to the Secretary to carry out this program.On April 5, 2011 (HHS) announced that the ERRP will stop accepting new applications effective May 6, 2011. |
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| Lifetime Limits |
Prohibits individual and group (Including ASO) health plans from placing aggregate dollar lifetime limits on "Essential" coverage. Includes Applies to Grandfathered plans. Special rules apply in the case of collectively bargained plans. |
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| Medical Loss Ratio Reporting |
Requires health plans to report the proportion of premium dollars spent on clinical services, quality, and other costs for the amount of premium spent on clinical services and quality that is less than 85% for plans in the large group market and 80% for plans in the individual and small group markets. |
Regulations |
Guidance
Forms
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| Medicare Expansion |
Medicare coverage will be expanded to include individuals who have been exposed to environmental health hazards from living in a subject area to an emergency declaration made as of 6/17/09 and have developed certain health conditions as a result. |
Not Yet Available |
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| Nondiscrimination Rules for Insured Plans |
Insured group plans may not discriminate in favor of highly compensated employees. Self-funded plans are already subject to this rule under the Internal Revenue Code. Does not apply to Grandfathered plans. |
Not Yet Available |
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| Part D $250 Rebate |
A $250 rebate will be provided to Medicare beneficiaries who reach the Part D coverage gap in 2010. |
No Guidance Expected |
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| Phase I Tax Credits for Small Employers (25 or less EE's and average annual wages of less than $50K that purchase health insurance for employees with a tax credit) |
Phase I: For tax years 2010 through 2013, a tax credit of up to 35% of the employer's contribution toward the employee's health insurance premium if the employer contributes at least 50% of the total premium cost or 50% of a benchmark premium. The full credit is available to employers with 10 or fewer employees and average annual wages are less than $25K. The credit phases-out as firm size and average wage increases. Tax-exempt small businesses meeting these requirements are eligible for tax credits up to 25% of the employer's contribution toward the employee's health insurance premium. |
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| Pre-existing conditions for children |
Prohibits individual and group (including ASO) health plans from placing pre-existing condition exclusions on children under age 19. Applies to Group Grandfathered plans. |
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Additional Information
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| Prescription Drugs - Biologic Drugs |
Authorizes the Food and Drug Administration to approve generic versions of biologic drugs and grant biologic manufacturers 12 years of exclusive use before generics can be developed. |
Not Yet Available |
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| Preventive Care |
Requires qualified health plans to provide at a minimum coverage without cost-sharing for preventive services rated A or B by the US Preventive Services Task Force, recommended immunizations, preventive care for infants, children, and adolescents, and additional preventive care and screenings for women. Does not apply to Grandfathered plans. |
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| Rate Review |
The Secretary of DHHS, in conjunction with the states, will have new authority to monitor health insurance premium rates to prevent unreasonable increases. Carriers that have a pattern of unreasonable increases may be barred from participating in the Exchange. |
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| Rescissions |
Prohibits individual and group (including ASO) insurers from rescinding coverage, except in cases of fraud or when enrollees make an intentional misrepresentation of material fact as prohibited by the terms of the plan or coverage. Applies to Grandfathered plans. |
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Patient Rights
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| Taxation of RDS impact on company's financial statements |
With the elimination of the tax benefits for RDS in 2013, employers receiving the subsidy, will need to reflect the financial impact of the Patient Protection Act. |
Not Yet Available |
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| Temporary High-Risk Pool |
A temporary national high-risk pool will be established to provide health coverage to individuals with pre-existing medical conditions and who have been uninsured for at least six months. Premiums for the pool will be established for a standard population and may vary by no more than 4:1 due to age. Maximum cost-sharing will be limited to current law HSA limit ($5,950/individual and $11,900 family in 2010.) |
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| Therapeutic Discovery Tax Credit |
Creates a federal tax credit for businesses with 250 or less employees that make a qualified investment in acute and chronic disease research during 2009 or 2010. |
Not Yet Available |
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| HHS Web Portal |
Requires the establishment of a website through which individuals and small businesses can obtain information about the insurance coverage options that may be available to them in their State. Interim final rule adopts the categories of information that will be collected and displayed via the website, and the data required from issuers, states, associations, and high risk pools in order to create this content. |
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Additional Resources
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| Health Insurance Exchanges |
Beginning in 2014, individuals may enroll in a plan through the Exchange of the state where they reside. Only lawful residents may obtain coverage in an Exchange. Unauthorized aliens will be prohibited from obtaining coverage through an Exchange. Beginning in 2014, small employers can offer coverage to their employees through an Exchange. A “small employer” is an employer that employed an average of at least one but not more than 100 employees on business days during the preceding calendar year, and employs at least one employee on the first day of the plan year. |
Regulations
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| Patient Protection Rules |
Patient Protection rules allow individual’s to designate a primary care provider or designate a pediatrician as a primary care provider, improves patient access to obstetrical and gynecological care without a referral and allows individuals to designate an OB/GYN as a primary care provider, and requires coverage of emergency services. |
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Related Resources |
| 2011 |
| 10% bonus payments |
Provides a 10% Medicare bonus payment to primary care physicians and to general surgeons practicing in health professional shortage areas. |
Not Yet Available |
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| Adoption of operating rules for health insurance administration |
Simplify health insurance administration by adopting a single set of operating rules for eligibility verification and claims status. Health plans must document compliance with these standards or face a penalty of no more than $1 per covered life. |
Not Yet Available |
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| AEP/OEP for drug and health plan changes |
The AEP will run from 10/15 through 12/7/2011 with coverage effective 1/1/2012. OEP will run from 1/1/2011 through 2/15/2011 for disenrollment from MA plans - can only go back to Original FFS. |
Not Yet Available |
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| CLASS Program: Community Living Assistance Services and Support |
Establishes a national, voluntary insurance for purchasing CLASS services. Employers are expected, but not required, to allow for payroll deductions and automatically enroll employees. Employees have the option to opt-out. |
Not Yet Available |
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| Coverage of Emergency Services |
Mandates coverage of emergency services at in-network level, regardless of provider. Applies to individual and group (including ASO) plans. Does not apply to grandfathered plans |
Not Yet Available |
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| Eliminate Cost-Sharing for Preventive Services in Medicare and Medicaid. |
Improve prevention by covering only proven preventive services and eliminating cost-sharing for preventive services in Medicare and Medicaid. Increase Medicare payments for certain preventive services to 100% of actual charges or fee schedule rates. |
Not Yet Available |
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| Expanded federal income tax requirements |
All business owners will be subject to new expanded federal income tax requirements on payments of fixed or determinable income or compensation. |
Not Yet Available |
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| Form 5500 studies |
The Department of Labor will begin annual studies on self-funded plans using data collected from Form 5500. |
Not Yet Available |
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| Health Risk Assessment for Medicare Beneficiaries |
Provide Medicare beneficiaries access to a comprehensive health risk assessment (HRA) and creation of a personalized prevention plan. Provide incentives to Medicare and Medicaid beneficiaries to complete behavior modification programs. |
Not Yet Available |
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| Income Threshold Freeze-Medicare Part B Premiums |
Freeze the income threshold for income-related Medicare Part B premiums for 2011 through 2019 at 2010 levels, and reduce the Medicare Part D premium subsidy for those with incomes above $85K/individual and $170K/Couple. |
Not Yet Available |
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| Medical Loss Ratio premium rebates |
Provide rebates to consumers for the amount of premium spent on clinical services and quality that is less than 85% for plan in the large group market and 80% for plans in the individual and small group markets. |
Not Yet Available |
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| Medicare Advantage Cost-Sharing |
Prohibits Medicare Advantage plans from imposing higher cost-sharing requirements for some Medicare covered benefits than is required under the traditional fee-for-service program. |
Not Yet Available |
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| Medicare Advantage Payments |
Restructure payments to Medicare Advantage (MA) plans by setting payments to different percentages of Medicare fee-for-service (FFS) rates with higher payments for areas with low FFS rates and lower payments (95% of FFS) for areas with high FFS rates. |
Not Yet Available |
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| Medicare Cost Contract Extension |
Extends Medicare Cost contract to December 2012 |
Not Yet Available |
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| Non-Qualified distributions/Tax impact |
Increases the tax on distributions from a health savings account or an Archer MSA that are NOT used for qualified medical expenses to 20% of the disbursed amount. |
Not Yet Available |
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| Nutritional Information |
Requires chain restaurants and food sold from vending machines to disclose the nutritional content of each item. |
Not Yet Available |
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| Over-the-counter drugs |
Prohibits reimbursement of over-the-counter drugs from FSAs, HRAs, and HSAs, except for insulin. |
Not Yet Available |
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| Phase down of Part D Coverage Gap |
Phase down gradually the beneficiary coinsurance rate in the Medicare Part D gap from 100% to 25% by 2020. For brand-name drugs, require pharmaceutical manufacturers to provide a 50% discount on prescriptions filled in the Medicare Part D coverage gap beginning in 2011, in addition to federal subsidies of 25% of the brand-name drug cost by 2020 phased in beginning in 2013. For generic drugs, provide federal subsidies of 75% of the generic drug cost by 2020 for prescriptions filled in the Medicare Part D coverage gap phased in beginning in 2011. Between 2014 and 2019, reduce the out-of-pocket amount that qualifies an enrollee for catastrophic coverage. |
Not Yet Available |
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| Reporting on W2's |
Requires all employers to include the aggregate cost of employer-sponsored health, vision and dental coverage, and contributions made to health savings accounts on each employee's W-2 tax form. |
Not Yet Available |
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| "Simple Cafeteria" plans |
Small employers (less than 100 lives) will be allowed to adopt new "simple cafeteria plans." In exchange for satisfying minimum participation requirements, these plans would be treated as meeting the nondiscrimination requirements that would otherwise apply to the cafeteria plan. |
Not Yet Available |
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| Special rule for employers that are health insurance issuers |
Limits the deductibility of executive and employee compensation to $500K per applicable individual for health insurance providers. |
Not Yet Available |
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| Standard Uniform Explanation of Coverage |
New standards will be developed for insurers (includes Grandfathered plans) to use in providing information on benefits and coverage. Changes some of ERISA's SPD requirements. Requires 4-page summary with 12 pt. type and is culturally/linguistically appropriate. [Insurer must comply with standards within 24 months following enactment.] |
Not Yet Available |
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| Tax on indoor tanning services |
A 10% tax will be imposed on the amount paid for indoor tanning services. |
Not Yet Available |
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| Tobacco Cessation |
Requires Medicaid coverage for tobacco cessation services for pregnant women. |
Not Yet Available |
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| Wellness grants |
Grants will be provided, for up to five years, to small employers (i.e., less than 100 employees and not currently providing wellness programs) that establish wellness programs which meet the Secretary's criteria. Each small employer must apply to the Secretary with its wellness program proposal. |
Not Yet Available |
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| 2012 |
| Adoption of operating rules for health insurance administration |
Electronic funds transfers and health care payment and remittance . Health plans must document compliance with these standards or face a penalty of no more than $1 per covered life. |
Not Yet Available |
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| New annual fees on Drug Manufacturers |
New annual fees will be imposed on the pharmaceutical manufacturing sector, according to this schedule:
- $2.8 billion in 2012-2013
- $3.0 billion in 2014-16
- $4.0 billion in 2017
- $4.1 billion in 2018
- $2.8 billion in 2019 and later.
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Not Yet Available |
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| Part B rebates |
Prohibition on Part B rebates (MA plans) |
Not Yet Available |
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| Preventable Hospital Admissions |
Reduces Medicare payments that would otherwise be made to hospitals by specified percentages to account for excess (preventable) hospital readmissions. |
Not Yet Available |
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| 2013 |
| Consumer Operated and Oriented Plan [CO-OP] |
$6 billion will be appropriated to finance the program and to award loans and grants to establish CO-Ops. To be eligible to receive funds, an organization must not be an existing health insurer or sponsored by a state or local government, and substantially all of its activities must consist of the issuance of qualified health benefit plans in each state in which its licensed. Governance of the organization must be subject to a majority vote of its members, must operate with a strong member focus, and any profits must be used to lower premiums, improve benefits, or improve the quality of health care delivered to its members. |
Not Yet Available |
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| Employer notice requirement |
All employers must provide notice to their employees informing them of the existence of the state-based exchanges. |
Not Yet Available |
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| Employer subsidy for Medicare Part D ends |
The tax deduction for employers who receive Medicare Part D retiree drug subsidy payments ends. |
Not Yet Available |
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| Health Care Choice Compacts and national plans |
Permits states to form health care choice compacts and allow insurers to sell individual policies in any state participating in the compact no earlier than 1/1/2016. |
Not Yet Available |
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| Medicare Part A payroll tax increase |
The hospital insurance tax on wages will increase 0.9% (from 1.45% to 2.35%) for those earning more than $200K ($250K couple filing jointly) and it includes net investment income. It also imposes a 3.8% assessment on unearned income for higher-income taxpayers ($120K individual or $250K couple filing jointly). The tax would be applied to investment income including interest, dividends, rents, royalties, annuities and capital gains. (Thresholds not indexed.) |
Not Yet Available |
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| New Federal premium tax ("Comparative Effectiveness Fee") |
New federal premium tax on fully-insured and self-insured group health plans to fund comparative effectiveness research program. It imposes an annual fee on private plans equal to $1for each individual covered for first plan year ending after 9/30/2012; $2 per participant following year; adjusted thereafter. |
Not Yet Available |
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| Salary reductions for FSAs |
The amount of contributions to a flexible medical spending account will be limited to $2500 per year and will increase annually, based on the cost of living adjustment starting on 1/1/2014. |
Not Yet Available |
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| Tax change for unreimbursed medical deductions. |
The threshold for the itemized deduction for unreimbursed medical expenses will increase from 7.5% of AGI to 10% AGI for regular tax purposes. Those 65 and older can claim the 7.5% deductible through 2016. |
Not Yet Available |
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| Taxable medical devices |
A 2.3% excise tax will be imposed on the sale of any taxable medical device. |
Not Yet Available |
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| 2014 |
| Abortion coverage (Requires separation of tax dollars from premiums.) |
Permits states to prohibit plans participating in the Exchange from providing coverage for abortions. If a plan chooses to offer coverage for abortions beyond those for which federal funds are required, allocation accounts for segregating premium payments must be implemented. Plans must also estimate the actuarial value of covering abortions by taking into account the cost of the abortion benefit [valued at no less than $1 per enrollee, per month] and cannot take into account any savings that might be reaped as a result of the abortions. |
Not Yet Available |
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| Adoption of operating rules for health insurance administration |
Health claims or equivalent encounter information, enrollment and disenrollment in a health plan, health plan premium payments, and referral certification and authorization. Health plans must document compliance with these standards or face a penalty of no more than $1 per covered life. |
Not Yet Available |
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| Annual limits are eliminated |
Prohibits individual and group (including ASO) health plans from placing annual limits on the dollar value of coverage. Applies to Grandfathered plans. |
Not Yet Available |
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| Auto enrollment requirement for Employers 200+ |
Requires employers with more than 200 employees to automatically enroll employees into health insurance plans offered by the employer. Employees may opt out of coverage. |
Not Yet Available |
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| Basic Health Plan (For uninsured individuals with incomes between 133-200% FPL) |
Permits states the option to create a Basic Health Plan for uninsured indivduals with incomes between 133-200% FPL who would otherwise e eligible to receive premium subsidies in the Exchange. States opting to provide this coverage will contract with one or more standard plans to provide at least the essential health benefits and must ensure that eligible indivdiuals do not pay more in premiums than they would have paid in the Exchange and that the cost-sharing requirements do not exceed those of the platinum plan for enrollees with income less than 150% FPL or the gold plan for all other enrollees. States will receive 95% of the funds they would have been paid as federal premium and cost-sharing subsidieis for eligible individuals to establish the Basic Health Plan. Individuals with incomes between 133-200% FPL in states creating Basic Health Plans will not be eligible for subsidies in the Exchanges. |
Not Yet Available |
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| Cost-Sharing Reductions |
Cost-sharing credits will be provided to eligible individuals and families to reduce the cost-sharing amounts and limits on plans. It has the effect of increasing the actuarial value of the basic benefit plan to the following percentages of the full value of the plan for the specified income level:
- 100-150% FPL: 94%
- 150-200% FPL: 87%
- 200-250% FPL: 73%
- 250-400%FPL: 70%
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Not Yet Available |
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| Creation of state-based exchange for small businesses and individuals. |
Health insurance exchanges will open in each state to individuals and small employers to comparison shop for standardized health plans. Require the Office of Personnel Management to contract with insurers to offer at least two multi-state plans in each Exchange. At least one plan must be offered by a non-profit entity and at least one plan must not provide coverage for abortions beyond those permitted by federal law. Each multi-state plan must be licensed in each state and must meet the qualifications of a qualified plan. If a state has a lower age rating requirement than 3:1, the state may require multi-state plans to meet the more protective age rating rules. These multi-state plans will be offered separately from the FEHBP and will have a separate risk pool. |
Not Yet Available |
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| Eligibility for premium tax credits and cost-sharing reductions through the Exchange |
Limited to US citizens and legal immigrants who meet income requirements. Employees who are offered coverage by an employer are not eligible for premium credits unless the employer plan does not have an actuarial value of at least 60% or if the employee share of the premium exceeds 9.5% of income. Legal immigrants who are barred from enrolling in Medicaid during their first five years in the US will be eligible for premium credits. |
Not Yet Available |
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| Employer Penalty for those who offer coverage |
An employer with more than 50 employees that offers coverage but has at least one FTE receiving the premium assistance tax credit will pay a penalty of $3,000 for each employee receiving subsidized Exchange coverage with an aggregate limit of $2,000 times the total number of employees. FTE is defined as 30 or more hours/week. |
Not Yet Available |
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| Employer Penalty if they don't offer coverage |
Employers with 50 or more workers who do not offer coverage, face a fine of $2,000, (Indexed) for each employee, if any worker receives subsidized insurance on the exchange. FTE is defined as 30 or more hours/week. The first 30 employees are excluded from the assessment. |
Not Yet Available |
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| Essential Benefits Package |
Create an Essential health benefits package that provides at least 60% of the actuarial value of the covered benefits, limits annual cost-sharing to the current law HSA limits $5950/Ind. And $11,900/Family in 2010 and is equal to the scope of benefits provided under a typical employer plan. Require the Secretary to define and periodically update the benefit package through a transparent and public process. |
Not Yet Available |
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| Essential Plan/Abortion coverage |
Prohibit abortion coverage from being required as part of the Essential health benefits. |
Not Yet Available |
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| Exchange plans |
Four separate benefit categories of plans will be created plus a separate catastrophic plan.
- Bronze Plan: Represents minimum creditable coverage and provides the essential health benefits, covers 60% of the benefit costs of the plan, with an OOP limit equal to the HSA law limit [$5950 for individuals and $11,900 for families in 2010]
- Silver Plan: Provides the essential health benefits, covers 70% of the benefit cost of the plan, with the HSA OOP limits.
- Gold Plan: Provides the essential health benefits, covers 80% of the benefits costs of the plan, with the HSA OOP limits.
- Platinum: Provides the essential health benefits, covers 90% of the benefits costs of the plan, with the HSA OOP limits.
- Catastrophic Plan: Restricted to Individual market only. Available to those up to age 30 or are exempt from the mandate to purchase coverage and provides catastrophic coverage with the coverage level set at the HSA current law levels, except that preventive benefits and coverage for three primary care visits would be exempt from the deductible.
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Initial Guidance to States on Exchanges |
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| Exchange Reinsurance Program |
$25B tax on insurers and TPAs from 2014 through 2016 for Exchange reinsurance program. |
Not Yet Available |
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| "Free Choice" Vouchers to Qualified Employees |
Employers who offer minimum essential coverage to its employees through an eligible employer-sponsored plan and who pay a portion of the costs of such plan will be required to provide a free choice voucher to employees with incomes less than 400% FPL whose share of premium exceeds 8%, but is less than 9.8%, of their income and who choose to enroll in a plan in the Exchange. The voucher amount is equal to what the employer would have paid to provide coverage to the employee under the Employer's plan and will be used to offset the premium costs for the plan in which the employee is enrolled. Employers providing free choice vouchers will not be subject to penalties for employees that receive premium credits in the Exchange. |
Not Yet Available |
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| Health Insurance Industry Tax |
An annual fee will be imposed on the health insurance sector, according to the following schedule:
- $8 billion in 2014
- $11.3 billion in each of 2015-16
- $13.9 billion in 2017
- $14.3 billion in 2018
For subsequent years, the fee shall be the amount from the previous year increased by the rate of premium growth.
For non-profit insurers, only 50% of net premiums are taken into account in calculating the fee. Exemptions are granted for non-profit plans that receive more than 80% of their income from government programs targeting low-income or elderly populations, or people with disabilities and VEBAs not established by an employer. |
Not Yet Available |
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| Individual insurance mandate |
Requires U.S. citizens and legal residents to have qualifying health coverage. Those without coverage pay a tax penalty of the greater of $695 per year, up to a maximum of three times that amount [$2,085] per family or 2.5% of household income. The penalty will be phased-in according to the following schedule: $95 in 2014, $325 in 2015, and $695 in 2016 for the flat fee or 1.0% of taxable income in 2014, 2.0% of taxable income in 2015, and 2.5% of taxable income in 2016. Beginning after 2016, the penalty will be increased annually by the cost-of-living adjustment. Exemptions will be granted for financial hardship, religious objections, American Indians, those without coverage for less than three months, undocumented immigrants, incarcerated individuals, those for whom the lowest cost plan option exceeds 8% of an individual's income, and those with incomes below the tax filing threshold [in 2009 the threshold for taxpayers under age 65 was $9,350 for singles and $18,700 for couples]. |
Not Yet Available |
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| Insurance Market and Rating Rules (For all fully insured individual and small groups up to 100 ees.) |
Requires guarantee issue and renewability and allow rating variation based only on age [limited to 3:1], premium rating area, family composition, and tobacco use [limited to 1.5:1] in the individual and small group market and in the Exchange. Requires risk adjustment in the individual and small group markets and in the Exchange. Applies to non-grandfathered fully-insured small group and individual plans. Also will apply to fully insured large group plans in states that allow them to purchase through the Exchange. |
Not Yet Available |
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| Merging Individual/Small Group Markets |
Each state can have a separate exchange for employers and individuals or merge their exchanges to include both markets. State can also apply for a waiver on their exchange design from DHHS, and currently operational state exchanges are exempt. |
Not Yet Available |
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| Operating In/Out of Exchange |
Requires all new policies (except stand-alone dental, vision, and long-term care insurance plans), including those offered through the Exchanges and those offered outside of the Exchanges, to comply with one of the four benefit categories. Existing individual and employer-sponsored plans do not have to meet the new benefit standards. |
Not Yet Available |
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| Out of Pocket Limits with Exchange plans |
Reduce the OOP limit for those with incomes up to 400% FPL to the following levels:
- 100-200% FPL: 1/3 of the HSA limit
- 200-300% FPL: 1/2 of the HSA limit
- 300-400% FPL: 2/3 of the HSA limit
These OOP reductions are applied within the actuarial limits of the plan and will not increase the actuarial value of the plan. |
Not Yet Available |
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| Part D OOP reduction |
The law will reduce the out-of-pocket amount that qualifies an enrollee for catastrophic coverage between 2014 and 2019. In 2020, the level would revert to that which it would have been absent the reductions in the intervening years. |
Not Yet Available |
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| Phase II: Tax Credits for small employers (25 or less full time equivalent employees with average annual wages of less than $50K that purchase health insurance for employees with a tax credit) |
Phase II: For tax years, 2014 and later, a tax credit of up to 50% of the employer's contribution toward the employee's health insurance premium if the employer contributes at least 50% of the total premium cost through the state exchange. The credit is available for two years. The full credit will be available of employers with 10 or less employees and its average annual wages are less than $25K. The credit phases out as firm size and wages increase. Tax-exempt small businesses meeting these requirements are eligible for tax credits of up to 35% of the employer's contribution toward the employee's health insurance premium. |
Not Yet Available |
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| Pre-existing condition exclusion eliminated |
Pre-existing exclusions prohibited for all enrollees. Applies to Group Grandfathered plans. |
Not Yet Available |
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| Premium Credits |
Eligible individuals and families with incomes between 133-400% FPL will receive refundable and advanceable premium tax credits to purchase insurance through the Exchange. The premium tax credits are tied to the second lowest cost Silver plan in the area and will be set on a sliding scale:
- Up to 133% FPL: 2% of income
- 133-150% FPL: 3-4% of income
- 150-200% FPL: 4-6.3% of income
- 200-250% FPL: 6.3-8.05% of income
- 250-300% FPL: 8.05-9.5% of income
- 300-400% FPL: 9.5% of income
Increase the premium contributions for those receiving subsidies annually to reflect the excess of the premium growth over the rate of income growth for 2014-2018. Beginning in 2019, further adjust the premium contributions to reflect the excess of premium growth over CPI if aggregate premiums and cost sharing subsidies exceed .504% of GDP. |
Not Yet Available |
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| Prevention/Wellness |
Permits employers to offer employees rewards up to 30%, increasing to 50% if appropriate, of the cost of coverage for participating in a wellness program and meeting certain health-related standards. Establish 10- state pilot programs to permit participating states to apply similar rewards for participating in wellness programs in the individual market. |
Not Yet Available |
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| Qualification of participating health plans |
Required qualified health plans participating in the Exchange to meet marketing requirements, have adequate provider networks, contract with essential community providers, contract with navigators to conduct outreach and enrollment assistance, be accredited with respect to performance on quality measures, use a uniform enrollment form and standard format to present plan information.
Requires participating health plans to report information on claims payment policies, enrollment, disenrollment, number of claims denied, cost-sharing requirements, out-of-network policies, and enrollee rights in plain language. |
Not Yet Available |
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| Qualified Benefit Plans/"Essential" plan |
All qualified health benefit plans, including those offered through the Exchange and those offered outside the exchange, except grandfathered individual and employer-sponsored plans, are required to offer at least the "Essential" health benefits package. |
Not Yet Available |
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| Reinsurance program ends for Retirees Age 55 to 64. |
Reinsurance program ends for Retirees Age 55 to 64. |
Not Yet Available |
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| Small Group deductible limit of $2K |
Limit deductibles for health plans in the small group market to $2K for individuals and $4K for families, subject to annual indexing increases, unless contributions are offered that offset deductible amounts above these limits. This deductible limit will not affect the actuarial value of any plans. |
Not Yet Available |
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| Temporary high-risk pool ends |
Temporary high-risk pool ends. |
Not Yet Available |
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| Waiting Periods |
Waiting periods in excess of 90 days are prohibited for all group (including ASO) plans. Applies to Group Grandfathered plans. |
Not Yet Available |
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| 2015 |
| Hospital penalty for hospital-acquired conditions |
Reduces Medicare payments to certain hospitals for hospital-acquired conditions by 1%. |
Not Yet Available |
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| 2016 |
| Health Care Choice compacts and national plans |
Permits states to form health care choice compacts and allow insurers to sell policies in any state participating in the compact. Compacts may only be approved if it is determined that the compact will provide coverage that is at least as comprehensive and affordable as coverage provided through the state Exchanges. |
Not Yet Available |
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| 2017 |
| Expanding Exchange |
States have the option of expanding the exchange to larger employers. "Large employer" generally means more than 100 employees, but for plan years beginning before 1-1-16, a state may define it as more than 50 employees. |
Not Yet Available |
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| Waiver for State Innovation |
Permit states to obtain a five-year waiver of certain new health insurance requirements if the state can demonstrate that it provides health coverage to all residents that is at least as comprehensive as the coverage required under an Exchange plan and that the state plan does not increase the federal budget deficit. |
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| 2018 |
| "Cadillac" plan tax |
A 40% excise tax will be imposed on high-cost, employer-provided health plans beyond $27,500 for family coverage and $10,200 for individuals. These threshold values will be indexed to CPI for urban consumers for years beginning in 2020. The threshold amounts will be increased for retired individuals age 55 and older who are not eligible for Medicare and for employees engaged in high-risk professions by $1,650 for individual coverage and $3,450 for family coverage. The threshold amounts may be adjusted upwards if health care costs rise more than expected prior to implementation of the tax in 2018. The threshold amounts will be increased for firms that may have higher health costs because of the age or gender of their workers.
The tax is equal to 40% of the value of the plan that exceeds the threshold amounts and is imposed on the issuer of the health insurance policy, which in the case of a self-funded plan is the plan administrator or, in some cases, the employer. The aggregate value of the health insurance plan includes reimbursements under a flexible spending account for medical expenses [health FSA] or health reimbursement arrangement [HRA], employer contributions to a health savings account [HSA], and coverage for supplementary health insurance coverage, excluding dental and vision coverage. |
Not Yet Available |
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