Changes

• 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