10 frighteningly fast-approaching ACA mandates
Published October 30, 2013 3:34 PM
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Updated October 31, 2013 9:22 AM
1 Min Read
1. Waiting periods
Starting in January, once an employee hits eligibility requirements, the plan must offer health care coverage no later than the 90th calendar day. What proposed regulations about waiting periods allow, meanwhile, is that plans can require somebody to work 1,200 hours before they are eligible for coverage and then, at that point, they can apply the 90-day waiting period rule.
2. No annual dollar limits on essential health benefits
This applies to all plans, grandfathered or not. What remains unclear is whether day limits 120 days in hospital per year, for example are still allowed, explained Sharon Goodman, a principal with law firm Slevin & Hart, to attendees at the recent International Foundation of Employee Benefit Plans annual conference.
3. For non-grandfathered plans, out-of-pocket maximums on essential health benefits
Effective with the 2014 plan year, all non-grandfathered group health plans of any size and that use the same vendor for the administration of their medical and pharmacy benefits must comply with an annual limitation on out-of-pocket maximums on essential health benefits: $6,350 for single coverage, $12,700 for family coverage.
Open questions include whether the out-of-pocket maximums only apply to in-network benefits, as well as what is counted in the out-of-pocket limit, said Goodman.
4. Pre-existing condition exclusions
For plan years beginning on or after Jan. 1, 2014, pre-existing condition exclusions are prohibited for all participants and dependents, regardless of the age of the participant and the grandfathered status of the plan.
5. Dependent coverage to age 26
While grandfathered plans can currently exclude dependents up to age 26 if they are eligible for other employer-sponsored coverage, starting on Jan. 1, 2014, all plans must extend eligibility for dependents up to age 26 regardless of eligibility for other employer-sponsored coverage. This rule already applied to non-grandfathered plans.
6. Provider discrimination
Nongrandfathered plans with plan years beginning on or after Jan. 1, 2014, are not allowed to discriminate on a claim based on who the provider is.
7. Clinical trials
Non-grandfathered plans must cover clinical trials. Goodman noted that while drug costs in a clinical trial are free, starting in January employers must pay for other routine costs associated with the trial, such as blood work.
8. Preventive services
Non-grandfathered plans must provide coverage without cost-sharing for preventive treatments and services recommended by the U.S. Preventive Services Task Force.
9. Preventive services for women
Non-grandfathered plans must provide expanded preventive services without cost-sharing for women.
10. Wellness programs
Effective for plan years beginning on or after Jan. 1, 2014, the ACA allows for increased maximum reward (or penalty) to 30% of the cost of health coverage and up to 50% of the total cost of health coverage for tobacco cessation.
