United Benefit Advisors Insight and Analysis Blog

Boiling Down PPACA

By Bill Olson, VP, Marketing & Communications at United Benefit Advisors
  Oct 21, 2013 1:26:00 PM

health care reformWe’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

For an at-a glance chart of over 40 PPACA requirements, whether they apply to large groups and their respective effective dates, request Large Group Insured Plans (More Than 50 Employees) and PPACA.

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

For an at-a glance chart of over 40 PPACA requirements, whether they apply to small insured plans outside and/or inside the SHOP exchange and their respective effective dates, request Small Group Insured Plans (50 or Fewer Employees)  and PPACA

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

For more information on over 40 PPACA requirements, whether they apply to small and/or large insured group self-funded plans and their respective effective dates, request Self-funded Plans and PPACA.

Topics: compliance, ACA, employee benefits, hr consulting, health care reform, PPACA, HR compliance