Upcoming PPACA Requirements

The Affordable Care Act mandates the creation of a temporary reinsurance program to help stabilize premiums for coverage in the individual market.  This program will be used to provide reinsurance payments to individual market issuers that cover high risk individuals. Payments will be based on claims incurred above an attachment point and below a reinsurance cap.

For plan years beginning on or after January 1, 2014, health care plans may not discriminate against health care providers so long as they acted within the scope of their license under applicable state law.  At its most basic, this prevents health care plans from denying a benefits claim for a service outside a provider’s typical specialty area.

Beginning on January 1, 2014, the Affordable Care Act (ACA) requires that all non-grandfathered individual and small group health insurance plans cover certain essential health benefits (EHBs). This includes insurance plans sold through Exchanges. The Department of Health and Human Services issued proposed regulations on November 26, 2012, that defined EHBs. The entire text of the proposed rule can be viewed in Federal Register Vol. 77 No. 227.

One of the aims of the Affordable Care Act was to provide a resource to assist patients, clinicians, purchasers, and policy-makers in making informed health decisions. The law created a private, nonprofit corporation known as the Patient-Centered Outcomes Research Institute (PCORI). PCORI intends to achieve this goal by creating and managing a wide variety of effectiveness studies regarding the delivery of health care.

For plan years beginning on or after January 1, 2014, a group health plan or health insurance issuer offering group health insurance coverage shall not impose a waiting period for eligibility in excess of 90 days. This mandate applies to all eligible employees and dependents.

The Affordable Care Act (ACA) creates new incentives and builds on existing wellness program policies to promote employer wellness programs and encourage opportunities to support healthier workplaces. Currently, employers can offer up to 20% of the cost of the health plan coverage as an incentive to achieve certain wellness goals.  In 2014, the 20% cap is increased to 30%.  There will also be an additional 20% that can be added to the cap to reward success with tobacco cessation programs.  Thus, up to 50% of the cost of the health plan coverage will be available as an incentive to stop smoking.