Grandfathering Under Affordable Care Act by zVLwbf0

VIEWS: 0 PAGES: 4

									                                                                                                          Grandfathered Plans         Non-Grandfathered Plans
                Insurance Reform Changes that Apply
                                                                                                        Fully                          Fully
   (this list is not meant to be legal advise nor to cover every                Effective Date
                                                                                                      Insured   Self-Insured Plans   Insured Self-Insured Plans
                  aspect of the Affordable Care Act)
                                                                                                       Plans                          Plans
Coverage of Dependents to age 26:- plans that offer dependent
coverage as long as dependent (married or not) is not eligible for             First renewal after
                                                                                                        X               X
employer coverage (prior to 2014 this only applies to dependent who           September 23, 2010
cannot secure employer-sponsored coverage)
Coverage of Dependents to age 26:- plans that offer dependent                  First renewal after
                                                                                                                                       X             X
(married or not) coverage.                                                    September 23, 2010

Elimination of Lifetime Benefit Limits: The limits on the dollar
value of benefits must be eliminated. Although certain limits may be           First renewal after
                                                                                                        X               X              X             X
allowed on specific benefits if they are not considered "Essential            September 23, 2010
health Benefits" (not defined yet).

Restriction on Annual Benefit Limits: Under these regulations,
annual limits on the dollar value of benefits that are "essential benefit"
may not be less then the following amounts for plan years beginning
before January 1, 2014.
For plan or policy years beginning on or after September 23, 2010 but          First renewal after
                                                                                                        X               X              X             X
before September 23, 2011, $750,000                                           September 23, 2010
For plan or policy years beginning on or after September 23, 2011 but
before September 23, 2012, $1.25 million
For plan or policy years beginning on or after September 23, 2012 but
before January 1, 2014, $2 million

No Rescission of Coverage: Prohibited from rescinding coverage
                                                                               First renewal after
once coverage has already been in place for that person (except in                                      X                              X
                                                                              September 23, 2010
the event of fraud or misrepresentation)

Cost Ratio Requirements: Health insurers must provide an annual
rebate to each enrollee if the minimum loss ratio (MLR) is not met.
The MLR is 85% for 100+ employee and 80% for less then 100
                                                                                   1-Jan-11             X                              X
employees. Requirements to report medical loss ratio is effective with
plan years in 2010. The requirements then, to provide rebates based
on not needing the loss ratio perimeters is effective Jan 1, 2011.

                                                                               First renewal after
Elimination of Pre-Existing Coverage for Children                                                       X               X              X             X
                                                                              September 23, 2010

Elimination of Pre-Existing Coverage for Adults                                      2014               X               X              X             X

Waiting Period Restriction: no waiting period in excess of 90 days           Plan years on or after
                                                                                                        X               X              X             X
for an employee to go on the health plan                                        January 1, 2014




                                                                                       Jeff Petro Vice President
                                                                             Employee Benefit Plan and HR Systems Advisor
                                                                                             847-699-1400
                                                                                                       Grandfathered Plans        Non-Grandfathered Plans
                Insurance Reform Changes that Apply
                                                                                                   Fully                           Fully
   (this list is not meant to be legal advise nor to cover every            Effective Date
                                                                                                 Insured    Self-Insured Plans   Insured Self-Insured Plans
                  aspect of the Affordable Care Act)
                                                                                                  Plans                           Plans
Coverage of Dependents to age 26:- plans that offer dependent
Vouchers: Employers who offer coverage to their employees will be
coverage as long as dependent (married or not) is not eligible for         First renewal after
required to provide a voucher for purchasing health care to                                                         X
employer coverage (prior to 2014 this only applies to dependent who       September 23, 2010
employees with incomes less than 400% of Federal Poverty Level
cannot secure employer-sponsored coverage)
whose share of the premium exceeds 8% but does not exceed 9.5%
of the employee's income. Any technical changes will be reported.                2014              X                X              X             X
These vouchers are for enrolling in a plan in the Exchange. The
voucher amount is equal to the premium amount for coverage of the
employee under the employer's plan and will be used to offset the
premium costs for the plan in which the employee is enrolled

Penalties for Businesses with 50+ Employees: The Employer is
only penalized if any employees goes on the exchanges and receives
a credit or subsidy. In determining any penalties, the first 30                  2014              X                X              X             X
employees are ignored. Such employers could face fine to $2,000 per
full-time employee, with some exceptions.

Automatic Enrollment by Large Business Offering Health
Coverage: Employers with more than 200 full-time employees that
                                                                           To be Determined        X                X              X             X
off health coverage must automatically enroll employees in a plan.
Employees will be able to opt out of enrollment.

Excise Tax on High Cost Employer-Provided Health Coverage:
Insurers and plan administrators will pay a 40% tax for any health
insurance plan that is above the threshold of $10,200 for singles and            2018              X                X              X             X
$27,500 for families. This excise tax would apply to the amount of
the premium that is above these thresholds.

New Requirement on Form W-2 to Report Cost of Employer-
Provided Health Coverage: Employers must report on Form W-2
the aggregate cost of employer-sponsored health coverage. This
                                                                             2011 tax year         X                X              X             X
reporting requirement will not apply to salary reduction contributions
to FSA's, or the amount contributed to any HSA or Archer MSA of an
employee or employee's spouse.



FSA Contribution Limits: The law limits the amount of contributions
                                                                                 2013              X                X              X             X
to a flexible spending account (FSA) to $2,500 annually




                                                                                   Jeff Petro Vice President
                                                                         Employee Benefit Plan and HR Systems Advisor
                                                                                         847-699-1400
                                                                                                         Grandfathered Plans            Non-Grandfathered Plans
                Insurance Reform Changes that Apply
                                                                                                      Fully                              Fully
   (this list is not meant to be legal advise nor to cover every             Effective Date
                                                                                                    Insured    Self-Insured Plans      Insured Self-Insured Plans
                  aspect of the Affordable Care Act)
                                                                                                     Plans                              Plans
Coverage of of Uniform Notice of Coverage: Plan administrators,
Distribution Dependents to age 26:- plans that offer dependent
plan sponsors and insurers must provide a not) is not eligible for
coverage as long as dependent (married or summary of benefits and           First renewal after
                                                                                                                        X
coverage explanation thatto 2014 this only appliescoverage to who
employer coverage (prior describes benefits and to dependent               September 23, 2010
cannot secure employer-sponsored coverage)addition to a Summary
participants prior to enrollment. This will be in                                                    Unclear
Plan Description.                                                                                   as there
The Secretary of HHS will provide specific standards for the                                           is no  Unclear as there is no
                                                                           Unclear at this time
summary. The summary must state if the plan provides Minimum                                        guidance guidance at this time
Essential Coverage (not yet defined) and if it pays less than 60% of                                  at this
the total cost of benefits provided under the plan. In addition,                                        time
modification to the group health plan must be summarized and sent
to participants no later the 60 days prior to the change. There will be
a penalty for willful non-compliance.

Information to the Secretary of HHS: Group Health Plans must
provide information regarding claims payment, enrollment data,              First renewal after
                                                                                                                                         X             X
number of claims denied, rating practices, non-network cost sharing,       September 23, 2010
enrollee and participant rights and other data

Employer Annual Reporting Requirements regarding Quality of
Care: Annual report must be supplied to participants at Open
Enrollment that describes health care provider reimbursement rates
that improve quality of care, including wellness activities. The
                                                                          Unclear at this time as
Secretary of HHS is to collect this data and make it available on the
                                                                           regulation have not                                           X             X
internet. The Secretary is required to “develop” the reporting
                                                                              been issued
requirements no later than March 23, 2012. By the same date, the
Secretary must also issue regulations that provide criteria for
determining whether a “reimbursement structure” is subject to the
reporting rule.

First Dollar Coverage of Preventive Services: Plans required to
                                                                            First renewal after
provide first dollar benefits for Preventative Care Services, such as                                                                    X             X
                                                                           September 23, 2010
immunizations, screening and routine care for adults and children

Mandated Patient Protection: PCP's, OB-GYN's, and Emergency
Care: Health plans that require the designation of a Primary Care           First renewal after
                                                                                                                                         X             X
Physician (PCP) member must be allowed to select any participating         September 23, 2010
provider as their PCP

OB-GYN, ER and Pediatricians: Women must be granted direct
access to OB-GYN care with out a referral and emergency service
                                                                            First renewal after
offered in a health plan must provide coverage at the in-network                                                                         X             X
                                                                           September 23, 2010
level, regardless of facility used and without need for prior
authorization


                                                                                    Jeff Petro Vice President
                                                                          Employee Benefit Plan and HR Systems Advisor
                                                                                          847-699-1400
                                                                                                            Grandfathered Plans         Non-Grandfathered Plans
                 Insurance Reform Changes that Apply
                                                                                                          Fully                          Fully
    (this list is not meant to be legal advise nor to cover every                 Effective Date
                                                                                                        Insured   Self-Insured Plans   Insured Self-Insured Plans
                   aspect of the Affordable Care Act)
                                                                                                         Plans                          Plans
Coverage of Dependents to age 26:- plans that offer dependent
Non-Discrimination Requirements for Fully-Insured Plans:
Required as long as dependent (married or not) is not eligible for
coverage to satisfy Section 105(h) non-discrimination requirements               First renewal after
                                                                                                                          X
employer coverage (prior to 2014 this only applies to dependent who
stating that employers must not establish any eligibility rules for
                                                                                 First renewal 2010
                                                                                September 23,after                                       X       Already applies
cannotcare coverage, or levels of coverage that has the effect of               September 23, 2010
health secure employer-sponsored coverage)
discriminating in favor of higher-wage employees
Mandated Claims Appeals Process: In addition to the existing
ERISA internal claims appeals process for disputed claims, a new                 First renewal after
                                                                                                                                         X             X
external claims procedure must be implemented in group health plans             September 23, 2010
that will assure the review of disputed claims by a third party.
Guaranteed Availability and Renewability of Coverage: This
requires insurance companies to make available health coverage for
employers to purchase for their employees. It does not address or              Plan years on or after
                                                                                                                                         X
guarantee that this coverage will be affordable. This prevents health             January 1, 2014
insurers from canceling an employer's group plan in the event the
plan has poor claims experience in a given year.
No Discrimination Based on Health Status: Group plans may not                  Plan years on or after
                                                                                                                                         X             X
establish rules for eligibility to enroll based on health status factors.         January 1, 2014
Mandated Cost-Sharing Limits: Group health plans must limit cost-
sharing amounts (deductibles, co-insurance and co-pays) to the limit
applicable to high deductible health plans under Code Section 223.             Plan years on or after
                                                                                                                                         X             X
(For example: in 2010, the out of pocket limits on high-deductible                January 1, 2014
plans are $5,950 for single and $11,900 for family). Also, deductible
cannot exceed $2,000 per single and $4,000 per family.
Mandated Coverage for Clinical Trials: Health plans must provide
coverage for routine costs of clinical trials. An individual is eligible for
                                                                               Plan years on or after
coverage for clinical trails if the physicians deems it appropriate with                                                                 X             X
                                                                                  January 1, 2014
respect to the protocols of treatment of cancer or other life
threatening diseases or conditions.

        What notice and record retainer of records requirements must a plan sponsor or insurance company meet to retain its grandfather status of it health plans?

To maintain status as a grandfathered health plan, a plan sponsor or an insurance company must include a statement, in any plan materials provided to participants or beneficiaries
(Summary Plan Description) describing the benefits provided under the plan or health insurance coverage, that the plan or health insurance coverage believes it is a grandfather health
plan and providing contact information for question and complaints.
In addition, to maintain status as a grandfathered health plan, a plan sponsor or insurance company must maintain records documenting the terms of the plan or health insurance
coverage that were in effect on March 23, 2010, and any other documents necessary to verify, explain, or clarify its status as a grandfather health plan. Such documents could include
intervening and current plan documents health insurance policies, certificate or contracts of insurance, summary plan descriptions, documentation of premiums or the cost of
coverage, and documentation of required employee contribution rates.
In addition, the plan or issuer must make such records available for examination The plan sponsor or insurance company must also make such records available for examination.
Accordingly, a participant, beneficiary, State or Federal agency official would be able to inspect such documents to verify the status of the plan or health insurance coverage as a
grandfathered health plan.


                                                                                         Jeff Petro Vice President
                                                                               Employee Benefit Plan and HR Systems Advisor
                                                                                               847-699-1400

								
To top