Adult Dependents: Dependents must be covered to Age 26 (All plans)
Annual Limits: – Restrictions on dollar value of certain benefits (Regs to further define) (All plans & insurers)
Early Retirees Temporary Reinsurance: Employers apply for reimbursement for 80% of early retiree claims (ages 55 – 64) between $15k & $90k (All plans)
Lifetime Limits: No Lifetime Limits on the dollar value of benefits (All plans & insurers)
Medical Loss Ratios: Insurer minimum medical loss ratios limited to 85% (All plans & insurers)
Pre-existing Condition Limits: No Pre-existing condition limits for children under 19 (All plans & insurers)
Rescinding coverage: Allowed only for fraud or intentional misrepresentation of material fact with advance notice of rescission (All plans & insurers)
Emergency Services: No prior authorizations and same cost sharing in & out-of-network (Non Grandfathered plans & insurers)
External appeals process : Required for denied claims (Non Grandfathered plans)
Non-discrimination Requirements: Fully insured plans may not discriminate in favor of HCEs in eligibility or benefits; insured plans subject to Section 105(h) testing (Non Grandfathered plans)
PCP Designations: Participants may choose any primary care provider, may designate a Pediatrician as PCP for children and no referral needed for OB/GYN (Non Grandfathered plans & insurers)
Preventive Care: Covered at 100% (Preventive care to be defined by U.S. Preventive Task Force, HHS & CDC) (Non Grandfathered plans & insurers)
Medicare: Seniors receive a $250 rebate to help close the Medicare “donut hole” (Retirees)
Small Businesses: Small Business Tax Credits available. Small Business defined as <25 FTEs, annual wages < $50k and subsidize 50% employee only coverage. National risk pools also established. (Small Businesses (less than 25 FTE))
Employer Checklist
Small Businesses (< 25 FTEs) apply for Small Business tax credit
If early retirees covered, apply for Early Retiree Reinsurance
Assess Grandfathered Plan (GF) implications and determine whether to keep grandfathered status
Make plan design changes:
Dependent coverage to age 26
No Lifetime dollar limits
No Pre-existing conditions for children under 19
Restricted annual limits on dollar value of certain benefits
Preventive care covered at 100%
Emergency services – no prior authorization; cost sharing same in & out-of-network
Allow OB/GYNs and Pediatricians as PCPs
Implement external review for denied claims
Prevent rescission of coverage except for fraud or intentional misrepresentation of material fact with advance notice of rescission
If do not intend to retain GF status, identify any discrimination in favor of highly compensated and make changes to conform to non-discrimination requirement
Update all employee communications and communicate changes to employees
Amend SPD Wraps and Cafeteria Plan Documents and distribute to employees
If insured plan, obtain updated EOCs from carrier(s) and distribute to employees
