2014 Health Care Reform Requirements

Many health care reform requirements become effective in 2014.  As we start the year, see below for a look at new obligations under the Affordable Care Act.

  • Individual Mandate.  Virtually all U.S. citizens must have appropriate health coverage in 2014 or pay a penalty.
  • Elimination of Preexisting Condition Limitations.  Almost all plans must eliminate exclusions from coverage based on pre-existing conditions.  There are certain exceptions for previously established “grandfathered” individual health plans.
  • Annual Dollar Limits.  Plans must no longer apply an annual dollar limit on essential health benefits.  There is an exception for certain grandfathered individual health plans.
  • Exchanges.  The health insurance Marketplace is open for health plan enrollment.
  • Tax Credits.  The small business health tax credit is increased and premium tax credits/cost sharing is available to qualifying individuals who purchase coverage through an Exchange.
  • Medicaid Expansion.  A few states have opted to expand Medicaid coverage.
  • Out of Pocket Maximums.  Out of pocket maximum payments for essential health benefits must be limited.
  • Community Rating.  Insurers may rate by geographic area, family demographics, age and tobacco use.  Community rating is applicable to only individual and small group plans.
  • Waiting Period.  A plan cannot impose a waiting period of more than 90 days.
  • PCORI Fee.  The Patient Centered Outcomes Research Institute Fee is $2.00 times the average number of covered lives.

Other health care reform requirements are already in effect.  These include

  • Preventive Services.  Plans must cover preventive services for women.
  • Summary of Benefits and Coverage.  Plans must summarize their coverage in a 4-page format.
  • Age 26 coverage.  Plans must cover children up to age 26 regardless of dependency status.
  • Lifetime Limits.  Plans may not pace lifetime limits on coverage.
  • Retroactive Rescission of Coverage.  Retroactive cancellation of coverage is permitted in only very limited circumstances.
  • Essential Health Benefits.  Coverage that is deemed “essential” must be offered and covered by health plans (some not effective until 2015).
  • Appeal Rights.  Plans must offer certain rights in connection with appealing a denial of coverage.

Health care reform seems to be continually evolving, and more changes are likely in the coming years.

2 Responses

  1. Murph Casey says:

    So we have a client asking us if they have to offer coverage to their employees’ dependents. They would like to only make plan available to the employee. From what I’ve read above, they MUST – it is mandatory that they offer employees’ dependent children coverage. No spouses – just children to age 26. Is that correct? This is an Aetna Small Group Plan (have about 58 people covered).

    I’ll wait to hear back from you on this. Thanks so much.


    • mroshkoff@basusa.com says:

      An employer is not required to offer health coverage to dependents. However, if the employer does cover children under its health plan, the employer must extend coverage to all children up to age 26.

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