Changes


  • Whistleblower Protection: No discrimination against employees who receive tax credit or cost-sharing subsidy (All employers)
  • Essential Benefits: All annual limits on essential benefits ended; e.g. previously grandfathered must be added at this time. NO annual limits on the dollar value of benefits allowed; NO pre-existing condition limits for ANY participant or beneficiary. (All plans & insurers)
  • Essential Benefits Reporting: Plans required to cover minimum essential benefits and employer required to report the coverage of such benefits to the IRS and covered individuals (All plans & insurers)
  • Waiting Periods: Eligibility waiting periods cannot exceed 90 days (All plans)
  • Wellness Incentives: Wellness incentives increased from 20% to 30% of the cost of employee only coverage; Secretary has discretion to increase to 50% (All plans)
  • Free Choice Vouchers: Employees may receive free choice voucher from employer to purchase coverage through Exchange. Eligible employees - if contribution toward coverage exceeds 8% but not more than 9.8% of household income and their household income is 400% or less of poverty level and does not participate in ER plan (Employees below certain income levels)
  • Deductible Limits: Deductibles cannot exceed $2000 for individual and $4000 for family, plus limit in health FSA plan (indexed annually) (ER plan in Small Group Market)
  • Employer Mandate: “Play or pay” (ER with more than 50 F/T employees (working 30+ hours/week))
    • Plan must provide minimum essential benefits, cover at least 60% of the cost of benefits; premium cost < 9.5% of income
    • If employer fails to “play” by providing NO coverage AND at least 1 F/T employee receives Federal premium assistance for purchasing coverage through an exchange, ER pays $2000 per F/T ee, excluding the first 30 F/T ees
    • If employer fails to “play” by providing inadequate coverage AND at least 1 F/T ee receives Federal premium assistance for purchasing coverage through an exchange, ER pays the lesser of $3000 per F/T ee receiving assistance OR $2000 per F/T ees, excluding the first 30 F/T ees
    • An employee may qualify for Federal premium assistance if income level is < 400% of Federal poverty level (currently $88,200 for family of 4)
  • Individual Mandate: Individuals must obtain health insurance or pay a penalty; Individuals with household income up to 400% of poverty level (in 2010, $88,200 for family of four) may be eligible for federal tax credit and cost-sharing reduction (Individuals)
  • New tax: Annual health insured fee based on premium volume >$25M in prior year net premiums. Exemptions for government and self-insured plans. (Insurers)
  • Clinical Trials: Health plans must cover routine costs for clinical trial participants (Non Grandfathered plans & insurers)
  • Cost Sharing Amounts: Cost sharing amounts – co-pay, deductibles – capped at levels allowed for high deductible plans, indexed for inflation. Deductibles cannot exceed $2000 for individual and $4000 for family (Non Grandfathered plans & insurers)
  • Provider nondiscrimination: Group plans and insurers may not discriminate against any provider in regard to plan participation (Non Grandfathered plans & insurers)
  • CHIPRA: All states required to provide CHIPRA assistance for employer sponsored health coverage for employees and dependents who qualify for Medicaid or state health program regardless of age (States)
  • Insurance Exchanges: State based health insurance exchanges operational; for uninsured individuals and small employers (100 or fewer employees; states can lower the threshold to 50 employees) to purchase insurance. Bronze, silver, gold and platinum levels of coverage. (States)

Employer Checklist


  • Communicate insurance reform changes to employees – “pay or play” for employers with an average of 50 F/T employees (working 30+ hours/week); individual mandates, employer mandates, subsidies for certain income levels and tax penalties
  • Determine applicability of free rider vouchers and provide to employees if necessary
  • Make all required plan design changes – all annual limits on essential benefits end:
    • No waiting periods greater than 90 days
    • No pre-existing conditions for anyone
    • Cost sharing amounts capped at levels allowed for high deductible plans
    • Employers in Small Group Market, deductibles capped at $2000 individual and $4000 family plus limit in health FSA plan
    • Cover routine costs for clinical trial participants
    • No discrimination against any provider in regard to plan participation
  • Report coverage of minimum essential benefits to IRS and covered individuals
  • Consider increasing wellness incentive to 30% of coverage cost
  • Update all employee communications, amend SPD Wraps and Cafeteria Plan documents and distribute to employees
  • If insured plan, obtain updated EOCs from Insurers and distribute to employees