Coverage Mandates and Subsidies
- Individuals required to have health care coverage or face tax penalties.
- Tax credits and premium subsidies available on new public exchanges for individuals who fall below income thresholds.
- Applicable large employers that fail to provide health care coverage or provide coverage that is "unaffordable" or does not meet "minimum value" may be subject to a penalty starting in 2015.
- Small business tax credits expanded.
- Employers with more than 200 full-time employees offering health coverage must automatically enroll new full-time employees in a coverage option and continue existing elections for current full-time employees from year to year.*
Health Insurance Exchange & Insurance Reforms
- State-based "public" health insurance exchanges for individuals and small groups operational.
- Federal government-run exchange available for consumers in states without state-run exchange.
- Guaranteed issue, guaranteed renewability, modified community rating and minimum benefit standards ("essential health benefits") become effective.
- No more lifetime or annual dollar limits for essential health benefits.
- Coverage waiting periods of greater than 90 days eliminated for group health plans.
- No pre-existing condition exclusions for enrollees of any age.
- New disclosure and transparency rules apply, requiring health plans to publicly disclose a wide range of information including number of claims denied and data on rating practices.
- New uniform insurance rating rules apply, limiting rate bands for adults to a 3 to 1 ratio.
- Members may designate any participating primary care provider (or any participating pediatrician for child member). Direct access to participating ob/gyn care also required.
- New operating rules for electronic fund transfer and claim payment/remittance advice transactions.
New taxes and fees on health insurers and employers
- Health insurers pay an annual fee to offset premium subsidies and tax credits available on public exchanges. Industry assessed with $8 billion in fees in 2014, increasing to $14.3 billion in 2018.
- Insurers and self-funded plans start paying $25 billion over three years to help fund the new Transitional Reinsurance Contribution Program.
Medicaid and Medicare Reform
- States incented, but not required, to expand Medicaid to cover low-income individuals under age 65 up to 133% of the federal poverty level — about $28,300 for a family of four.
- Minimum medical loss ratio of 85% for Medicare Advantage plans.
* Guidance from the U.S. Department of Labor indicates that automatic enrollment guidance will not be ready in time to permit this provision to be effective for 2014. Employers are not required to comply until final regulations are issued and become applicable.