A lot of employers and advisers might want a simple, at-a-glance way to see all the Affordable Care Act requirements that apply to their business(es). This is no easy task given group size, SHOP exchanges and self-funding variables. Let’s take a look at a few provisions that are effective for the plan year beginning on or after January 1.

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

If you have 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

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

Linda Rowings is director of compliance at United Benefit Advisors. Any questions should be referred to UBA marketing officer Bill Olson at bolson@ubabenefits.com.


This Legal Alert is intended for educational purposes and should not be taken as specific legal advice.

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