2010 Requirements
- Dependent coverage – Plans offering dependent coverage required to extend coverage to adult children until age 26
- Emergency/OBGYN – Emergency services covered without pre-authorization and covered in-network; plans prohibited from requiring authorization/referral for OB/GYN services
- Grandfather Status – Grandfathered status is available for plans in effect on March 23, 2010
- Lifetime limits – No annual (phased out gradually through 2014) or lifetime limits for essential health benefits
- Pre-existing conditions – No pre-existing condition exclusions for enrollees under age 19
- Preventative Services – Most preventative services covered without cost-sharing
- Primary Care Physician – Designation of any network doctor as primary care physician, if PCP designation required by the plan
- Rescission – Coverage rescissions prohibited except in the case of fraud or intentional misrepresentation by the enrollee
- Small Employer Tax Credit – Small employer tax credits available for employers with less than 25 full time equivalent employees
2011 Requirements
- HSA tax – Additional tax on non-medical HSA distributions increases from 10% to 20%
- MLR reporting – First Medical Loss Ratio reporting year begins; fully insured carriers to provide rebates in 2012 if MLR is not met
- Nondiscrimination safe harbor – “Simple Cafeteria Plan” safe harbor from nondiscrimination rules available for small employers (under 100)
- OTC medicines – OTC medicines excluded from coverage by FSA/HRS/HSA unless obtained with a prescription or medicine is insulin
- Wellness Grants – Small Group Wellness Grant program created for employers with under 100 employees
2012 Requirements
- MLR rebates – Fully-insured health plans prepare for receipt and distribution of MLR rebates (if any); applies to Grandfathered plans
- PCOR fees – Plans ending after September 30, 2012 required to pay a per participant fee to fund the Patient Centered Outcomes Research (PCOR) Institute; applies to Grandfathered plans
- Reporting – Plans and insurers required to report on how health outcomes are improved through plan’s quality of care provisions
- SBCs – Plans required to provide easy to understand Summary of Benefits and Coverage (SBC) to all participants and eligible individuals; applies to Grandfathered plans
- W-2 reporting – Employers filing 250 or more Form W-2s in 2011 must report the aggregate cost of employer sponsored coverage on each employee’s Form W-2; applies to Grandfathered plans
- Women’s preventative care – Plans must comply with HHS preventative health guidelines requiring preventative care for women, for plan years beginning after August 1, 2012
2013 Requirements
- Drug subsidy – Medicare Part D retiree drug subsidy ends
- Exchange Notice – Employers to provide employees with written notice about Health Insurance Exchanges
- Exchanges open – Exchanges initial open enrollment period to begin in the fall
- FSA limits – Employee salary reduction contributions to FSAs limited to $2,500 for plan years beginning on or after January 1, 2013
- Medicare Tax – Medicare Part A tax rate will increase by 0.9% for highly compensated individuals
2014 Requirements
- Clinical trials – Coverage for routine costs of clinical trials must be provided for approved clinical trials
- Community ratings – Modified community rating standards to apply to fully insured small groups*
- Deductible limits – Small group deductibles limited to $2,000 for individuals and $4,000 for families (except grandfathered plans and large group plans)*
- Essential Health Benefits – Individual and small group non-grandfathered plans must cover Essential Health Benefits*
- Exchanges – Health Insurance Exchanges open
- Guaranteed issue/renewal – All insured plans (individual and group) must be guaranteed issue and guaranteed renewal
- Out-of-pocket cost limits – Small group and large group out-of-pocket costs limited to annual HSA contribution limits ($6,350 individuals and $12,700 for families in 2014)*
- Pre-existing condition exclusion – Pre-existing condition exclusions prohibited for all ages
- Reinsurance Fees – Fully insured carriers and TPAs, on behalf of self-insured groups, to pay reinsurance fees to stabilize rates in individual and small group markets
- Small employer tax credit – Amount of small employer tax credit increases from 35% to 50% of employer costs
- Waiting period limits – Eligibility waiting periods limited to 90 days for all group health plans
- Wellness incentives – Wellness incentives for standards-based wellness programs increases from 20% of premium to 30% of premium
2015 Requirements
- Employer reporting – Employers must report to government and plan participants whether plan offers “minimum essential coverage”
- Employer penalties – Employers with 50 or more full time equivalent employees may be subject to penalties for failure to offer coverage or, if offering coverage, failure to offer coverage that provides “minimum value” or that is affordable for employees
2016-2018 Requirements
- Small group definition – All states must define small group as less than 100 employees and large group as 100 or more employees (2016)
- Large employers in Exchange – States may permit large employers (over 100) to purchase coverage through a Health Insurance Exchange (2017)
- Cadillac Tax – Nondeductible 40% excise tax on “excess benefit” (premium value above $10,200 single/$27,500 family) provided to employees or retirees under employer sponsored group health plans (2018)
*Small group in North Carolina is defined as 50 or fewer employees. PPACA defines small group as an employer with less than 100 employees, but allows states the option of maintaining the current small group definition as 50 or less until 2016. Beginning in 2016, PPACA requires all states to define small group as less than 100 employees.
Note: This document is a high-level overview of the key employer requirements of healthcare reform. It is subject to change in the event of further legislation, guidance and regulations. This abbreviated checklist is not all-inclusive.
