Key reform provisions for businesses with 1-50 employees
For 2014 and 2015, a small-group employer will be defined in Oregon as a business with between one and 50 employees. Small groups are not required to provide group health coverage for employees. If a small-group employer does choose to provide coverage, however, the employer must offer coverage to all of its eligible employees.
For those employers who wish to provide group health coverage, many benefit changes required by the Affordable Care Act, or ACA, already have occurred. The information that follows is an update on what is required in 2014 and 2015.
Providence Health Plan offers this information on some of the laws applicable to health care reform so that employers can understand the general legal landscape and seek their own counsel. Where possible, we provide tips for how to find additional information from regulators. This guide is offered for general educational purposes only and should not be taken as legal advice. Employers should consult with their benefit advisors about the specific legal considerations of their benefit programs.
More comprehensive benefits
All health plans will be required to cover a comprehensive package of items and services known as essential health benefits. These essential health benefits include services such as outpatient care, emergency services, mental health and substance abuse care, rehabilitation services and devices, and preventive care.
New health plans will be required to pay for a greater percentage of your health care costs
Your premiums will cover more benefits and services, and your out-of-pocket expenses - such as copays and deductibles - will be capped starting in 2014. Under the ACA, qualified health plans must cover a minimum of 60 percent of average health care costs. Actuarial value is defined as the percentage of total average costs for covered benefits that a plan will cover. For example, if a plan has an actuarial value of 70 percent, on average, the member would be responsible for 30 percent of the costs of all covered benefits. In 2014 and 2015, all small group plans will be categorized based on one of four actuarial value levels, know as "metal levels" as follows: bronze, silver, gold or platinum, with platinum plans offering the richest level of benefits.
90-day probationary waiting period
Eligibility waiting periods for group health insurance cannot exceed 90 days.
Changes to FSAs
There is a $2,500 maximum contribution to healthcare flexible spending accounts.
Mandatory coverage for clinical trials
Group health insurance plans are required to provide coverage of routine patient costs associated with approved clinical trials of life-threatening diseases.
Medical loss ratio
If insurers fall below a specific medical loss ratio limit - 80 percent for small groups - they are required by law to refund policy holders.
The ACA medical loss ratio is unique and is defined as the sum of incurred claims plus expenses to improve health care quality divided by earned premiums minus federal and state taxes and licensing fees. The calculation is done yearly, beginning Jan. 1 through Dec. 31.
In 2011, 2012 and 2013, Providence Health Plan met the medical loss ratio requirements established by the ACA. This means that we demonstrated fiscal responsibility and are not required to issue member rebates.
We understand there is a lot to consider. Use this guide to understand how health care reform affects you and your business and to prepare for the upcoming changes.