The new provisions in the health care law can be complex and difficult to understand, especially in how they relate to employer-sponsored group health plans. It is important for employers to understand and plan for the changes in their obligations under the new plan, as failure to do so can mean fines or penalties for any violations.
Grandfathered Plans - Health Care Reform allows plans that were in effect on 3/23/10 to have grandfathered status. This means that these plans can delay implementation of certain required provisions. These existing plans can change only very slightly to maintain their grandfathered status. This means no increases to participant costs or decreases in benefits.
Coverage for Adult Children up to Age 26 – Plans beginning on or after 9/23/10 must provide dependent coverage for members with adult children until they reach age 26. Children no longer have to be full-time students, reside with parents, or be unmarried.
Pre-existing Conditions for Children under Age 19 – Plans beginning after 9/23/10 may not impose pre-existing conditions on children less than 19 years of age.
Lifetime Limits and Restrictions on Annual Limits – All plans after 9/23/10 are prohibited from imposing lifetime limits on essential health benefits, and are restricted in the dollar amount of annual limits imposed. After 1/1/14, these limits will be banned. Currently, these essential benefits include ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, including behavioral health treatment, prescription drugs, rehabilitative services and devices, laboratory services, preventive and wellness services and chronic disease management, and pediatric services.
Equal Treatment of In-network Versus Out-of-network Emergency Services – After 9/23/2010, plans must treat out-of –network emergency services like visits to the E.R. the same as they do for in-network emergencies. Plans will no longer be able to pre-authorize emergency services.
Provide Preventive Care Benefits without Costs to Participants – After 9/23/10, plans may not impose cost-sharing requirements on preventative care services and benefits. This means plans cannot impose co-pays, deductibles, or co-insurance on services like annual physicals, immunizations, and mammograms.
Rescissions Allowed Only in Limited Circumstances – After 9/23/10, plans may not rescind existing coverage or terminate existing plans except with notice to enrollees and then, only in the case of fraud or misrepresentation.
New Appeals Processes – After 9/23/10, plans must have written internal and external appeals procedures. The law stipulates specific methods and structure for these appeals.
Reimbursement of Over-the-Counter Medications Without a Prescription – Beginning 1/1/11, a health care flexible spending plan, health savings account, or health reimbursement arrangement may no longer reimburse over-the-counter medication without a prescription.
Health FSA Contributions Are Capped effective January 1, 2013 – Regardless of plan year, employees may only defer up to $2,500 into a health flexible spending account plan.
Tax Credits for Small Employers – For tax years 2010 through 2013, small employers (those employing fewer than 25 full-time equivalents with average annual wages of less than $50,000) who purchase health insurance for their employees may receive a sliding scale tax credit. Small employers with 10 or fewer workers with an average wage of $25,000 or less may receive the full value of the credit. To qualify for a tax credit, an employer must contribute at least 50 percent of the total premium cost of a benchmark premium.
Subsidy for Retiree Coverage – Effective immediately and available until 1/1//14, group health plans may be reimbursed for certain expenses they incur for early retiree medical coverage. Early retirees are between age 55 and the age at which they become eligible for Medicare.
Provide Breast-Feeding Breaks to Nursing Mothers – Effective in March of 2010, employers must give employees who are nursing mothers reasonable break times to express milk for their children during the one-year period after birth. A private space, other than a bathroom, must be made available.
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