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Specifics to Self-Insurance
The Patient Protection and Affordable Care Act (PPACA) of 2010
An Overview of the Health Care Reform Bill as it relates to the Self Insurance Industry.
The Patient Protection and Affordable Care Act of 2010 will bring about direct impacts on the self-insurance industry. The below bullet points summarize some of the implementations specific to self-funded health care plans.
The following changes are effective for all plans as they renew on September 23, 2010 and thereafter:
A.)Coverage of Emergency Services: All non-grandfathered self insured health plans (SIHP) must cover emergency services without the need for prior authorization; if services are out-of-network, cost sharing is the same as in-network.
B.)Restricted annual limits for essential benefits.
C.)Prohibition of Lifetime Limits: SIHP are prohibited from establishing lifetime limits on the dollar value of benefits. Exclusion: SIHP may place restrictions on non-essential health benefits.
D.)Prohibition of Pre-existing conditions: SIHP may not impose any pre-existing condition exclusions on enrollees under age 19. Effective January 1, 2014, all SIHP are prohibited from imposing pre-existing exclusions on any enrollee.
E.)Prohibition of rescinding coverage from any employee beneficiary except in instance of fraud or misrepresentation.
F.)Requires hospitals to publicize a list of standard charges for the items and services they provide.
G.)States provided with grants to establish Medical Reimbursement Data Centers to collect reimbursement information and to make information available to all.
H)Employers are required to disclose costs of employer-sponsored health coverage on W-2.
I)Requires that non-taxable reimbursements from Health Savings Accounts (HSA’s) and Health Reimbursement Accounts (HRA’s) are limited to prescribed medicine or insulin.
J)Extension of Dependent Coverage: All SIHP that cover dependent children must extend coverage to their 26th birthday. Prior to 2014, grandfathered SIHP are only required to offer coverage to dependent children without access to a plan through their own employer. Marriage or student status is not a factor in dependent eligibility. Plans are not required to cover a child of a child dependent.
Additional changes for SIHP, beginning in 2014:
· Prohibited from establishing rules for eligibility based upon the health status, claims experience, medical history, genetic info, disability or evidence of insurability.
· Permits employers to vary insurance premiums by as much as 30% for employee participation in certain health promotion and disease promotion programs. Certain requirements apply.
· Prohibited from maintaining waiting periods longer than 90 days
· Health Information Technology Standards: All SIHP will have to adopt procedures that comply with Federal procedures.
· Cost-sharing: All SIHP will require cost sharing to be limited to the maximum out of pocket expenses allowable for High Deductible Health Plans.
For additional information, click here to read a Summary of the PPACA.
