Previously we posted a 2014 health care reform timeline. Here’s an updated timeline that provides a snapshot of the major health care reform provisions taking effect in 2014, with links to more information. These health care reform provisions include essential health benefits, the health insurance exchanges, individual premium tax credits, ACA fees, and the elimination of pre-existing condition exclusions. Are you ready for 2014?
Health Care Reform Timeline – 2014
- Health Insurance Exchanges (“Marketplaces”) are operational January 1, 2014 (enrollment began October 1, 2013).
- Individual Requirement to Have Insurance (aka “Individual Mandate” or “Individual Shared Responsibility Payment”). Nearly all U.S. citizens and lawfully present individuals are required to maintain qualifying health coverage or pay a penalty.
- Guaranteed Availability and Renewability. All carriers in the individual and group markets will be required to offer all products approved for sale in a particular market and accept any individual or group that applies for any of those products. Plans and policies are guaranteed renewable.
- Pre-existing Conditions. Beginning on plan years on or after Jan. 1, 2014, pre-existing condition limitations will be eliminated for enrollees of all ages.
- Essential Health Benefits (EHBs). Certain health benefits that are deemed “essential” must be offered by non-grandfathered individual plans and non-grandfathered, fully insured small group plans offered both on and off the Marketplace in 2014.
- Medicaid Expansion in Some States. Medicaid expansion to individuals not eligible for Medicare with incomes up to 133% FPL takes effect. Medicaid expanision is optional for states (see this article for where states stand as of October 2013).
- Deductible Limits for EHBs. For plan years beginning on or after Jan. 1, 2014, non-grandfathered, fully insured small group plans must limit deductibles to $2,000 for individuals and $4,000 for families (in-network).
- Annual Dollar Limits. For plan years on or after Jan. 1, 2014, restricted annual dollar limits on EHBs are no longer permitted.
- Out-of-Pocket Maximums for EHBs. For plan years beginning on or after Jan. 1, 2014, all non-grandfathered plans that cover EHBs must limit annual out-of-pocket member expenses for in-network EHBs. Expenses for EHBs, including coinsurance, deductibles, copays and similar charges cannot exceed 2014 out-of-pocket limits set by the IRS for High Deductible Health Plans. The 2014 out-of pocket maximum for EHBs is $6,350 for self-only coverage and $12,700 for family coverage. Note: Some of the out-of-pocket limits have been delayed until 2015. See this article.
- Actuarial Value (Metallic Levels). Non-grandfathered individual and non-grandfathered, fully insured small group plans must fit within four metallic levels that correspond to plan actuarial value in 2014. These Bronze, Silver, Gold and Platinum “metallic plans” are meant to make it easier for consumers to compare plans with similar levels of coverage. All metallic plans offered in a state must cover at least the package of EHBs set by that state’s benchmark plan.
- Waiting Periods. A group health plan cannot apply any waiting period that exceeds 90 days for plan years starting on or after Jan. 1, 2014.
- PCORI Fee. The Patient-Centered Outcomes Research Institute Fee increases to $2 multiplied by the average number of lives covered under the plan or policy for plan or policy years ending on or after Oct. 1, 2013, and before Oct. 1, 2014.
- Provider Non-discrimination. Health care providers will not be prevented from participation in an insurer’s provider network if willing to abide by the terms and conditions for participation and are acting within the limits of their medical license or certification.
- Small Business Health Tax Credits. ACA increases the small business health tax credit. Small group employers with 25 or fewer employees (with an average wage of less than $50,000 a year) may be eligible for a tax credit. The tax credit will cover up to 50 percent of the employer’s cost (up to 35 percent for small nonprofit organizations) and is available for the first two years an employer offers coverage through the Small Business Health Options Program (SHOP Marketplace).
- Premium Tax Credits for Individuals. Premium tax credits and other cost-sharing assistance are available to qualifying individuals and families purchasing coverage on the Marketplace.
- Community Rating. Health insurance issuers can only use the following rating factors: geographic area, family demographics, age and tobacco use. Community rating provisions apply only to individual plans and small group plans unless large group coverage is offered through the Marketplace.
- Insurer Fee. The Health Insurer Fee is designed to help fund premium tax credits and/or cost-sharing assistance for eligible individuals purchasing a qualified health plan through the Marketplace. This annual fee will be determined by the federal government and will be based on a health insurer’s premiums from the previous year.
- Dependent to Age 26 for Grandfathered Plans. ACA requires group health plans and insurers that offer health insurance for dependent children to make coverage available for children (married or unmarried) until age 26.
- Wellness Incentive Increases. ACA changes the maximum reward that can be provided under HIPAA’s health factor–based wellness program from 20 to 30 percent. The reward under such a program can be up to 30 percent of the cost of employee coverage.
- Transitional Reinsurance, Temporary Risk Corridors, and Risk Adjustment. Beginning in 2014, ACA will create three risk-mitigation programs (Transitional Reinsurance, Temporary
Risk Corridors and Risk Adjustment) intended to stabilize premiums in the market as insurance reforms and Marketplaces are implemented.
Delayed to 2015
- Employer Shared Responsibility (aka “Employer Mandate” or “ACA Play or Pay”). The provision requiring applicable large employers (generally employers with more than 50 full-time or full-time equivalent employees) to offer minimum essential coverage to full-time employees, or pay a fee, was delayed to 2015. See: Why the ACA Employer Mandate Delay is Great for Your Business.