Individuals will be required to obtain coverage under a qualified health insurance plan or pay a tax penalty, in some cases. Employers will be required to offer qualified health insurance to their employees or pay a penalty, in some circumstances. Small businesses with fewer than 50 employees will be exempt from this requirement.
Failure to Provide Coverage
If an employer is subject to the penalty and fails to offer any full-time employee health coverage, and if any full-time employee enrolls in the exchange and receives a tax subsidy to purchase coverage, the employer is subject to a penalty equal to the number of the business’ full-time employees, minus 30, times $2,000 per year. If an employer offers its employees health insurance, but that coverage does not provide a “minimum value” as required by the law, or if the employee's contribution for self-only coverage is greater than 9.5% of the employee’s household income, the employee is eligible to receive a tax subsidy to purchase coverage through the exchange. The employer must pay a penalty tax of $3,000 per year for each of these employees.
Extension of Dependent Coverage
Plans that cover dependent children must cover all children (married and unmarried) of the insured until the child reaches age 26.
End of Pre-Existing Condition Limitations — Children Under 19
Health insurance companies are required to make their policies available to individuals with no pre-existing condition exclusions applied. This mandate took effect for people under age 19 for plan years beginning on or after September 28, 2010. It will apply to all individuals in 2014.
Coverage must be offered on a “guaranteed issue” basis, as well as on a “guaranteed renewal” basis. “Guaranteed issue” requires issuers to offer all products approved for sale in a particular market segment to any individual or fully insured small or large group within that market segment, other than grandfathered plans. Enrollment may be restricted to open or special enrollment periods. However, in the small group market, enrollment will be open continuously, unless the employer fails to meet minimum participation requirements, in which case there may be a restricted open enrollment period (November 15 through December 15). “Guaranteed renewability” is the requirement for a plan to renew or continue in-force individual coverage at the option of the policyholder, or renew or continue in-force group coverage at the option of the plan sponsor/employer. The effective date is plan or policy years beginning on or after January 1, 2014.
Maximum deductibles and OOP expenses/cost-sharing
The out-of-pocket (OOP) limits on cost-sharing in 2014 are $6,350 Single / $12,700 Family and apply to all Essential Health Benefits (EHBs) offered by a group. Cost-sharing includes the plan’s annual deductible and any other out-of-pocket expenses the insured is required to pay, such as co-payments and coinsurance.
- The cost-sharing and deductible maximums for years after 2014 will be increased based on increases in average per capita premiums for health insurance coverage in the U.S.
- For plans that have networks, only cost-sharing for in-network services will count toward the out-of-pocket limits and annual deductible limits.
- The out-of-pocket and deductible maximums do not apply to grandfathered plans.
- Deductibles cannot exceed $2,000 for single coverage or $4,000 for other coverage in 2014. The deductible maximums only apply to plans and issuers in the small group market (< 100 employees), and not to self-insured plans or large group plans.
What do you need to do? Ensure your coverage complies with these new requirements, and make sure your employees are aware of these changes.
How we can help: We can help you understand what these changes mean to your business and educate your employees through our 1-to-1 meetings with them.
Reporting and Communication
W-2 Forms – Employer Reporting of Health Coverage Costs
Beginning in 2012, employers who file more than 250 W-2 forms must disclose the value of their employer-provided health benefits for each employee on the employee’s annual W-2 form. The IRS will issue guidance in the future that may expand the requirement to affect more employers.
What do you need to do? Ensure you have a means to provide these cost values on your employees’ W-2 forms if and when this requirement applies to you.
How we can help: We have tools to help simplify your W-2 reporting for our products.
Summary of Benefits and Coverage Documents
Beginning with the first open enrollment period on or after September 23, 2012, health insurers and group health plans were required to provide a summary of the provisions of their plan, to applicants and enrollees, following the format specified by the U.S. Department of Health and Human Services (HHS). This requirement may be enforced with a substantial fee for each day of non-compliance.
What do you need to do? Ensure your employees receive a copy of each Summary of Benefits and Coverage, as required and appropriate.
How we can help: We cannot deliver these statements, but we can review them to help educate your employees on the value of their benefits during 1-to-1 benefits counseling sessions.
Exchanges will create an open but highly regulated marketplace where individuals and small business employees can purchase health insurance coverage through an online portal. Exchange health plans will be offered in four tiers (Platinum, Gold, Silver, Bronze) that adjust premiums according to the level of cost-sharing. The exchanges are designed to:
- Use a competitive marketplace to lower health insurance premiums.
- Make health insurance benefits affordable and accessible outside the workplace.
- Make it easy to “comparison shop” online.
- Deliver insurance subsidies to low-wage workers.
What will you need to do? If you are an eligible small employer, you may use the exchanges to help your employees obtain health insurance.
How we can help: We can help your employees prepare for exchanges during 1-to-1 benefits counseling sessions.
Why Choose Colonial Life?
Through our nearly 75 years of experience, we have the expertise to provide benefit solutions tailored to meet the needs of your business and your employees. Communicating benefit changes and explaining financial protection options to employees is what we do best.
No matter what path you take, we can help you navigate through health care reform and make sure you understand your requirements and options.
To help each employee understand and appreciate benefits available at work.
That save time and money.
Tailored to personal needs and designed to help provide financial protection.
...all at no direct cost to you.