Healthcare reform resources for agents & brokers

Whether you serve employers or individuals, the Affordable Care Act will impact your clients. Some provisions are already in effect. Dependent coverage, preventive care, appeals and external review, and pre-existing condition plans have been implemented. But changes due in 2014 may have the greatest impact.

Healthcare Reform Resources

Online Educational Webinars

Humana hosts webinars for small and large employers to offer education on the new requirements of healthcare reform and what you need to do to prepare for changes to your benefit programs.

Watch for upcoming webinars here and register in advance, or view our recently archived webinars on-demand.

Archived webinars
Healthcare Reform: What It Means to your large business clients (Recorded on Thursday, July 11, 2013; 1 Hour)
Healthcare Reform: What It Means to your small business clients (Recorded on Thursday, November 15, 2012; 1 Hour)

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Learn what is happening around the country on Health Reform. View highlights from coast to coast.

Review the Affordable Care Act provisions

The regulations defining how these provisions will work and be implemented are still being determined by federal and state agencies. These changes though will considerably alter the existing healthcare system.

Humana is committed to supporting brokers by helping you understand the key changes and providing you with tools to guide your customers. For detailed information on what Humana is doing to implement and support our customers on these key provisions, see our Health Reform Timeline.

Comparative effectiveness fee

Employers sponsoring group health plans started paying $1 per participant in 2012. This fee increases in 2013 to $2 per participant. Thereafter the amount will be indexed to national health expenditures. This fee phases out by 2019. Revenue from the fee will fund research to determine the effectiveness of various types of medical treatments.

Comparative Effectiveness Fee – the basics (99+ employees): Watch video | Download PDF

Medicare and Medicaid-related provisions

To learn more, see Medicare Healthcare Reform

Plan D donut hole

There is a manufacturers’ discount of 50% on brand name drugs in the coverage gap in 2013 and 2014. In addition, Part D plans cover an additional 2.5% giving the member a total discount of 52.5%. Members will pay less for generic drugs as well, with a discount in the donut hole of 21% in 2013 and 28% in 2014 (up from 14% in 2012).

Retiree drug subsidy

Beginning in 2013, employers may no longer deduct the retiree drug subsidy when offering qualified coverage under Medicare Part D.


Beginning in 2014, states are required to provide premium assistance and wrap-around benefits to any Medicaid beneficiary who is offered employer-sponsored coverage when it is cost-effective to do so.


The National Association of Insurance Commissioners will create new model plans for benefit packages C and F that include nominal cost sharing. The new models will be available in 2015.

Employer reporting requirements

Employers with 250 or more W-2s must show employees the total cost of their group health benefit plan coverage on their W-2 forms starting with the 2012 tax reporting year.

In 2013 employers will be required to notify employees:

  • About the availability of the Exchange
  • They may be eligible for a subsidy under the Individual Exchange if the employer’s plan’s share of the total allowed cost of benefits provided is less than 60% of such costs
  • If the employee purchases coverage in the Individual Exchange, he or she will lose the employer’s coverage contribution

All employees need to be notified by later summer or early fall of 2013 based on a recent update from the U.S. Department of Labor (DOL). It is expected that DOL will issue future guidance on complying with this requirement.
In 2014, large employers will be subjected to expanded 5500 reporting requirements to include information on the health insurance coverage of their employees.

Flexible spending account contributions

Contributions to FSAs for medical expenses are limited to $2,500 a year.

Flexible Spending Accounts (FSAs) - the basics (all businesses): Watch video | Download PDF

Cost-sharing limits

For 2014, the out-of-pocket maximums are the same as the maximum out-of-pocket limits applicable to HSA-compatible high deductible health plans under IRS Code (note that the 2012 maximums are $6,050 for self-only coverage and $12,100 for family coverage). For future years, the 2014 limits are increased by the premium adjustment percentage – the percentage increase in the average per capital premiums for health insurance coverage. These limits impact individual, small group and large group new business in 2014 and existing non-grandfathered business.

Employer Form 5500

Large employers will be subjected to expanded 5500 reporting requirements to include information on the health insurance coverage of their employees.

Essential benefits

Individual and small group plans offered inside/outside the exchange must provide the essential benefits package. The minimum benefit package applies to individual and small group new business in 2014 and non-grandfathered existing business. It includes: Ambulatory patient services, Emergency services, Hospitalization, Maternity and newborn care, Mental health & substance abuse, Prescription drug, Rehabilitative & habilitative services/devices, Lab services, Preventive/wellness, Disease management and Pediatric services including oral & vision care.

Deductibles are limited to $2,000 for individuals and $4,000 for families in the small group market, though proposed rules allow deductibles to be higher if needed to reach bronze status (self-funded plans and grandfathered plans are exempt from this requirement).

Guaranteed availability of insurance

Also known as "guaranteed issue," with this provision health insurers must accept every individual and employer who applies for coverage.

Guaranteed availability of insurance (guaranteed issue)

Health insurers must accept every individual and employer who applies for coverage.

Health insurance Exchanges

The act creates online marketplaces, or insurance Exchanges. It also creates Small Business Health Options Program (SHOP) Exchanges, administered by a governmental agency or non-profit organization. Individuals and small business with up to 100 employees can purchase health insurance on the Exchanges as of 2014. States can allow large employers to participate beginning in 2017.

Merged markets

States are allowed to merge the individual and small group markets if the state determines it is appropriate.

No annual limits on coverage

Annual limits on essential health benefits are prohibited. This does not apply to grandfathered individual plans.

Pre-existing conditions

Individual and group health plans can no longer impose pre-existing condition exclusions for any person of any age. This does not apply to grandfathered individual plans.

Rating restrictions

Rating restrictions go into effect for new individual and fully insured small group plans. Insurance companies cannot base premiums on health status, claims experience, or gender. Premiums can only vary by age, geography, family size, and tobacco use (no more than 1.5:1).

Adjusted Community Rating - the basics (1-99 employees): Watch video | Download PDF

Transitional reinsurance program

A temporary reinsurance program will be established for the individual market and funded by individual and group health plan assessments ($25 billion in total will be assessed between 2014 – 2016 on health insurers and employers with self-funded plans). This will provide payments to plans that cover high-risk individuals.

Transitional Reinsurance Fees - the basics (99+ employees): Watch video | Download PDF

Wellness programs

Employers can offer employees rewards of up to 30%, potentially increasing to 50%, of the cost of coverage for participating in a wellness program and meeting certain health-related standards.

Employer Shared Responsibility, or "Play or Pay"

PROVISION DELAYED. NOW Effective Jan. 1, 2015: Employers with 50 or more full-time employees or full-time equivalents will pay an assessment if they don’t offer adequate and affordable coverage. For more information, visit

What do employers need to do: Employers with 50 or more employees must “pay or play”:

If an employer DOES NOT offer coverage to at least 95% of its employees, and at least one full-time employee receives a subsidy to help pay for coverage on an Exchange*, the employer must pay $166.67 per month ($2,000 per year) for each of its full-time employees, excluding the first 30 employees.

If an employer DOES offer coverage but the coverage is not adequate or affordable*, and at least one full-time employee receives a subsidy to help pay for coverage on an Exchange, the employer must pay the lesser of, excluding the first 30 employees:

  • $250 per month ($3,000 per year) for each full-time employee receiving a subsidy
  • $166.67 per month ($2,000 per year) for all full-time employees

Non-discrimination rules for employers

The non-discrimination rules that currently apply to self-funded health plans are expanded to group fully insured health plans. Plans cannot base an employee's eligibility or continued eligibility for coverage on hourly or annual salary. Employer-provided insurance may not discriminate between employees. This will prevent employers from providing enhanced insurance benefits based on an employee's length of service. Under the new rules, plans may be subject to penalties of up to $100 per enrollee per day for violating the requirements.

Note: HHS has delayed application of the non-discrimination rules to fully insured health plans until additional regulations or other guidance are issued. The recent guidance makes clear that the Treasury Department will not apply the penalties until additional guidance or rules are issued on the nondiscrimination requirements.

Healthcare Reform eBook (1-99 employees): Download PDF
Healthcare Reform eBook (99+ employees): Download PDF

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