In light of the Affordable Care Act and Health Care Reform, regulations, plans, and coverage have changed and developed significantly since 2010. Moving forward, many more adjustments to health care for individual and corporations will be seen, making it even more important that you are aware of where you stand currently in health care reform. ERM Insurance brokers are privy to the ACA regulations in the past, and those forthcoming, and are glad to keep you up to date on them. Below is a list of changes to health care in a year-to-year compilation from 2010-2014.
- Children age 19 and younger cannot be denied coverage due to preexisting conditions. In addition, teens and young adults can stay on their parent’s health insurance plans until the age of 26.
- If a health care claim is denied, you may now challenge this final decision in hopes for an adjustment. Limits on a member’s health care coverage because of a dollar-amount is no longer allowed annually or in a lifetime.
- Generally, preventive care is now covered entirely. Checkups, shots, generic medications, and tests necessary to prevent illness are now covered at no cost to the member.
- Medical Loss Ratios (MLR) is the percentage of member paid premiums that insurers spend on medical care. Health insurance companies are required to spend 85% of premiums on MLR in the fully insured large group market. Fully insured small group and individual markets require 80% of premiums to be spent on MLR. Self-funded plans, also known as Administrative Services Only, are exempt.
- Members no longer need prior authorization, or special authorization, for emergency care. Out of network emergency room care will no longer result in a higher copay.
- A standard Summary of Benefits and Coverage statement has been created, and all insurance companies must use this to best inform people of health care benefits in a simplistic and uniform manner.
- Insurers, sponsors of health plans, and self-insured individuals must now pay a Comparative Effectiveness Research fee. This will aid in the research needed to determine effectiveness, risks and benefits of medical treatments through the Patient-Centered Outcomes Research Institute.
- Limits have been imposed on Flexible Spending Accounts, which are used to cover health insurance expenses per plan throughout one year. The new limit of $2,500 prevents workers from adding more than that to their accounts for estimated annual medical expenses. You may only roll over $500 from these accounts at the end of the year if they are left unused, unless you have a grace period.
- In compliance with the ACA, businesses are now required to inform their workers of the Health Insurance Marketplace, also know as the Exchange. They must also assist in their employees knowledge of how to gain cost assistance through subsidies and tax credits.
- Though optional in 2012, businesses must now report the value of their health care plans on W-2 forms if they have more than 250. Employers with less than 50 W-2s can hold off on reporting until 2014.
- In compliance with the individual mandate, all individuals who can afford it must have basic health coverage.
- Employers must offer minimum essential coverage to their employees if they have more than 50 workers. If your business has between 50 and 99 employees, offering minimum value coverage to employees may be postponed until 2016. A penalty calculator has been devised to determine if your business is qualified to offer this, and it also calculates the penalty you could incur if you don’t.
- Health insurance providers now incur an annual tax called the insurer fee that funds premium subsidies and Medicaid expansion. This does not apply to self-funded plans. The reinsurance fee, also new, applies to both providers and self-funded plans.
- All taxes and fees as a result of the Affordable Care Act can be viewed on this chart.
- For fully insured plans. higher paid workers are not allowed to receive better health coverage. Plans may not be based on eligibility, level of benefits, or a worker’s wage.
If you have any questions or concerns in regard to this information, feel free to reach out to an ERM Insurance Agent on our site or over the phone at (949 )222-0444.