We’ve had a lot of employers request a simple, at-a-glance way to see all the PPACA requirements that apply to their business. This is no easy task given group size, SHOP exchanges and self-funding variables! Let’s just look at a few provisions that are effective for the plan year beginning on or after 1/1/2014:
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 are 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
If you need any additional clarification, do not hesitate calling us at 916-932-2864 as we’re here to help!
