Beginning January 1st, 2015 the employer shared responsibility requirements of the Affordable Care Act mandates that most employers with 50 or more full-time employees or full-time equivalents must offer minimum essential coverage to their employees and their dependents that meets a two part test.
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Shared Responsibility Requirement: Beginning January 1, 2015, Employers with 50 or more full-time employees (or equivalent full-and part-time workers) generally will be required to offer 95% of their full-time employees and their dependents minimum essential coverage or pay a penalty if any full-time employee receives a premium tax credit or cost sharing subsidy in an exchange. The penalty varies depending on if the employer offers coverage or does not offer coverage.
Maximum Out-of-Pocket Limits (MOOP): Starting in 2014 there will be a federally mandated maximum out-of-pocket (MOOP) limit that health insurance coverage cannot exceed. All health insurance plans with non-grandfathered status, both fully insured and self-funded must have the MOOP include all member cost sharing for medical and pharmacy (excluding premiums, balance billing amounts for non-network providers, or spending for non-covered services). Cost-sharing includes all copayments, deductibles, and coinsurance amounts for medical, behavioral health and pharmacy amounts. The inclusion of copayments in the MOOP will likely be a change to your plan.
Summary of Benefits Communications (SBC): The Summary of Benefits & Coverage ("SBC") document is intended to provide consumers with consistent and comparable information regarding health plan benefits and coverage across health insurance carriers. The SBC will include key features of the plan or coverage such as the covered benefits, cost-sharing provisions, and coverage limitations and exceptions. In addition, it will include a new, standardized health plan comparison tool for consumers called "coverage examples."
Preventative Coverage: As of August 1st, 2012, preventive services are covered at 100% (no copays, deductible or coinsurance), with in-network providers.
Participation and Eligibility: Beginning January 1st, 2014 all individual and group health plans must guarantee issue policies to all applicants, regardless of health status or other factors.
Minimum Value, Minimum Essential Coverage: Most employers with 50 or more full-time equivalent employees must offer minimum essential coverage that meets a two part test to employees and their dependent children.
Annual limits – Annual limits on essential health benefits are prohibited (this does not apply to grandfathered plans).
Waiting periods – Waiting periods for coverage cannot exceed 90 days.