There's a lot to keep track of over the next six months, so let's get right to the list. Here are 15 Affordable Care Act requirements that will become effective on Jan. 1, 2014:
1. State Health Insurance Exchanges
Each state must establish a health insurance exchange (or HHS will do so) for use by the uninsured and small employers with 100 or fewer employees (states may set the cap at 50 employees). The exchanges will offer fully insured insurance contracts that provide essential health benefits at differing levels of coverage (bronze, silver, gold, and platinum). Employees of small employers who offer health insurance coverage through an exchange may pay their employee premiums for such coverage on a pre-tax basis through the employer’s cafeteria plan.
2. State Health Insurance Exchange Tax Subsidies
Individuals who do not have affordable minimum essential coverage from their employer will be eligible for tax credit subsidies for their health insurance purchase on a state exchange if their income is below 400 percent of federal poverty level. (In 2013 the federal poverty level for a household of 1 in the 48 contiguous states is $11,490, therefore 400% of that would be $45,960.
3. Individual Mandate Tax Penalty
Individuals are required to obtain minimum essential health coverage for themselves and their dependents or pay a monthly penalty tax for each month without coverage. The monthly penalty tax is one-twelfth of the greater of the dollar penalty or gross income penalty amounts. The dollar penalty is an amount per individual of:
- $95 for 2014 (capped at $285 per family
- $325 for 2015 (capped at $975 per family)
- $695 for 2016 (capped at $2085 per family)
These dollar penalties will be indexed for inflation starting in 2017.
The gross income penalty is a percentage of household income in excess of a specified filing threshold of:
- 1 percent for 2014
- 2 percent for 2015
- 2.5 percent for 2016 and later years
In no event will the maximum penalty amount exceed the national average premium for bronze-level exchange plans for families of the same size. Minimum essential coverage includes Medicare, Medicaid, CHIP, TRICARE, individual insurance, grandfathered plans, and eligible employer-sponsored plans. Workers compensation and limited-scope dental or vision benefits are not considered minimum essential health coverage.
4. Automatic Enrollment
Employers with more than 200 employees who maintain one or more health plans must automatically enroll new full-time employees in a health plan. The employer must give affected employees notice of this automatic enrollment procedure and an opportunity to opt out. State wage withholding laws are preempted to the extent that they prevent an employer from instituting this automatic enrollment program. The final effective date will be established by DOL regulations.
5. Pre-Existing Condition Exclusion Practices Eliminated
Pre-existing condition exclusions no longer will be allowed in group health plans or individual insurance policies, not even the limited exclusions previously allowed under HIPAA. This also applies to grandfathered plans.
6. Ninety-Day Maximum Waiting Period
Group health plans and health insurance issuers may not impose waiting periods of more than ninety days before coverage becomes effective. This also applies to grandfathered plans.
7. Cost-Sharing Limits
Group health plans, including grandfathered plans, may not impose cost-sharing amounts (i.e., copays or deductibles) that are more than the maximum allowed for high-deductible health plans (currently these limits are $5,000 for an individual and $10,000 for a family coverage). After 2014, these amounts will be adjusted for health insurance premium inflation.
8. Annual or Lifetime Limits
Group health plans, including grandfathered plans, may no longer include more than restricted annual or any lifetime dollar limits on essential health benefits for participants. Limits will possibly exist in and after 2014 for non-essential benefits.
9. Wellness Program Health Plan Discount
The maximum premium discount an employer can offer under its health plan for participation in a wellness program is 30 percent. (It is possible that this could increase this maximum discount to 50 percent in the future.)
10. Coverage for Those in Clinical Trials
Insurers and health plans, unless grandfathered, may not discriminate against an individual for participating in a clinical trial. If a plan covers a qualified individual, it may not deny or impose additional conditions for participation in a clinical trial.
11. Employer Minimum Essential Coverage Reporting
All employers providing minimum essential coverage must file information with the IRS and plan participants.
12. Large Employer Health Information Reporting
Large employers and employers with at least 50 full-time equivalent employees must submit annual health insurance coverage returns to the FTEs and the IRS. The returns must certify whether the employer offers health care insurance to its employees and, if so, describe the details regarding plan participation, applicable waiting periods, coverage availability, the lowest cost premium option under the plan in each enrollment category, and other information.
13. Medicaid Expansion
The U.S. Supreme Court in effect ruled that the requirement for states to offer Medicaid benefits to all persons with incomes at or below 133 percent of the federal poverty level is optional with each state. States that participate in the expansion will receive full reimbursement of their additional Medicaid costs from the federal government until 2017. At that time, reimbursement will gradually decline to 90 percent of extra costs in 2020 and thereafter.
14. Health Insurance Nondiscrimination Requirements
Code Section 105(h) currently taxes the benefits received by highly compensated employees (HCEs) under discriminatory self-funded health plans. PPACA has extended these nondiscrimination rules to insured plans. Employers with discriminatory insured arrangements will need to consider changing them. Grandfathered plans are exempt from this rule. This new requirement was originally intended to be effective for plan years beginning on or after September 23, 2010. The effective date was postponed in 2010 until IRS publishes a notice, which has not yet been issued. The provision may not be effective in 2014 but it most likely will be.