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
Linda Rowings is director of compliance at United Benefit Advisors. Any questions should be referred to UBA marketing officer Bill Olson at
This Legal Alert is intended for educational purposes and should not be taken as specific legal advice.
