Proposed Regulations on 2015 Benefit and Payment Parameters
November 26, 2013
On November 25, the Department of Health and Human Services (HHS) issued proposed regulations that address a variety of Patient Protection and Affordable Care Act (PPACA) benefit provisions for 2015. There is a 30-day comment period on these proposed regulations.
Here is an overview of some of the key provisions.
Reinsurance Assessment Contributions
The Reinsurance Assessment is a fee applicable to insured and self-funded major medical plans for calendar years 2014 through 2016. It will primarily be used to help cover the cost of high-dollar claims occurring within the individual market. The 2014 fee is $63 per person, which the updated regulation proposes to collect in two installments: $52.50 in January 2015, and $10.50 late in the fourth quarter of 2015. For 2015, the proposed fee is $44 per person.
The updated regulation also proposes to exempt certain self-funded group health plans from paying the fee for 2015 and 2016. Specifically, self-funded group health plans that do not use a third-party administrator for claims processing would be exempt.
Stabilizing Individual Market Premiums
To promote stable individual market premiums, the regulations propose modifications to the amount that the reinsurance program will pay to an insurer for a given policyholder in the individual market based on that person’s cumulative claim total over an applicable calendar year. The changes invest more of the reinsurance fee funds into the program sooner than originally planned.
2015 Marketplace Enrollment Period
The 2015 Health Insurance Marketplace open enrollment period will be held from November 15, 2014 – January 15, 2015.
Adjustments for Current Individual Policies Extended into 2014
Earlier this month, the federal government announced that states may allow individuals whose policies were in effect on October 1, 2013 to continue those policies through the end of the policy year that begins on and after January 1, 2014 even if they do not meet all PPACA requirements. In states that choose to permit insurers to extend these policies, the risk pool in the state’s Marketplace could be impacted. The regulations propose a number of state-by-state adjustments to address this impact.
States Moving from Federal to State-Run Marketplaces
States that are participating in the federal Marketplace for 2014 but want to establish a state-run Marketplace in the future will now have more time to prepare for the transition. The January 1 conditional approval deadline will be moved to June 15.
2015 Cost-Sharing Limits
The 2015 maximum annual out-of-pocket limits for all non-grandfathered plans will increase to $6,750 for individual coverage and $13,500 for family coverage. The maximum deductibles will increase to $2,150 individual and $4,300 family for insured non-grandfathered small group plans. For standalone child dental plans, the annual out-of-pocket maximum will be limited to $300 for one covered child and $400 for two or more children.
Protecting Privacy Information
Changes may be made to the eligibility and enrollment information collected by the Marketplace, but individual information will still be protected.
Patient Safety Standards
Plans offered on the Marketplace must meet certain patient safety standards. The initial standards will require that hospitals meet the Medicare Hospital Condition of Participation requirements related to quality assessment, performance improvement and discharge planning.
To be offered on the federal Marketplace, a plan must be “meaningfully different” from all other plans offered by the same insurer in the same service area and metal level. Meaningful difference requires that a consumer would be able to identify two or more material differences between plans in factors such as cost-sharing, provider networks and covered benefits.
2015 Federal Marketplace User Fee
The user fee paid by insurers that offer plans on the federal Marketplace will be 3.5% of premiums. Adjustments will be made to reimburse third-party administrators that provide payment for contraceptive services for self-funded group plans.
Small Business Health Options Program (SHOP) Plans
The proposed regulations include several new requirements related to premium payments and plan offerings that will take effect once employee choice becomes available in federal Marketplace SHOP plans.
For More Information
We encourage you to bookmark our health care reform website, InformedOnReform.com.
SEE ALL NEWS ALERTS
Stay up-to-date with health care reform announcements and breaking news. Read our news articles and discover how rules may affect you or your business.
Read answers to frequently asked questions about health care reform.