2. Apply to Apply to Apply to
Apply to Apply to Apply to
Large Small Very Small Additional
Fully Self- Grand-
Requirement Effective Date Employers Employers Employers Guidance Action Needed Comments Penalties
Insured Funded fathered
(>100 (50 - 100 (<50 Needed
Plans Plans Plans
employees) employees) employees)
If receive rebate,
must share
prorata with Precise method
participants; if no of determining
rebate received, each Failure to
Minimum for first year of participant's distribute
Medical Loss rebate only, share of rebate appropriately
7/12/2012 Yes Yes Yes Yes No Yes No
Ratio (MLR) include notice is not may be a
Rebates with first plan prescribed; prohibited
materials (e.g. must use transaction
open enrollment "reasonable"
materials) approach
provided after
7/1/12
Insurer will
provide for
insured
First open
coverage and
Summary of enrollment Prepare SBC and
TPA likely will $1,000/ failure
Benefits or plan year Yes Yes Yes Yes Yes Yes No distribute by due
help with self- to provide
Coverage after date
funded, but
9/23/2012
plan sponsor
ultimately
responsible
Update
Maximum enrollment
This is a longer Plan disqualifi-
Health FSA First day of materials, verify
time to amend cation (all
Contribution of 2013 plan Yes Yes Yes Yes Yes Yes No administration is
than is usually benefits become
$2,500 year updated, amend
given taxable)
(indexed) plan by
12/31/2014
3. Apply to Apply to Apply to
Apply to Apply to Apply to
Large Small Very Small Additional
Fully Self- Grand-
Requirement Effective Date Employers Employers Employers Guidance Action Needed Comments Penalties
Insured Funded fathered
(>100 (50 - 100 (<50 Needed
Plans Plans Plans
employees) employees) employees)
Ensure W-2
system has Report total
W-2 Reporting Yes, if
needed data on value
of Value of issued
1/31/2013 No No Yes Yes Yes No value of GHP (employer + Likely $50/ W-2
Group Health >250 W-
coverage and can employee
Benefit 2's in 2011
correctly populate contributions)
Box 12
Employee owes
an additional
0.9% Medicare
withholding if
Update pay filing married
Additional FICA withholding to with combined
withholding on collect additional wages Likely 20% of
employee's 1/1/2013 Yes Yes Yes Yes Yes Yes Yes 0.9% FICA for >$250,000 or amount under-
share of wages employees filing single withheld
> $200,000 earning > with wages >
$200,000 $200,000.
Employer
responsibility
limited as
described
Only affects
employers
receiving
subsidy for
Loss of First day of Consider subsidy
providing Rx to
Deductibility for 2013 tax Yes Yes Yes Yes Yes Yes No taxable income for
retirees;
Part D subsidy year 2013 and later
change also
likely impacts
financial
reporting
4. Apply to
Apply to Apply to
Very Small Apply to Apply to Apply to
Large Small Additional
Employers Fully Self- Grand-
Requirement Effective Date Employers Employers Guidance Action Needed Comments Penalties
(<50 Insured Funded fathered
(>100 (50 - 100 Needed
employees Plans Plans Plans
employees) employees)
)
Exchange
Create and send contact details
Notice of notices re are not
3/1/2013 Yes Yes Yes Yes Yes Yes Yes
Exchanges availability of available yet;
exchanges model notices
are expected
Fee increases
to $2/covered
life for
following year,
then $2
(indexed)/
covered life;
fee applies to
Calculate fee
plan/ policy
($1/covered life)
Patient 7/31/2013 years ending
and pay on IRS
Centered for plan after
Form 720 if self-
Outcomes/ years 9/30/2012
Yes Yes Yes Yes Yes Yes Yes funded; insurer
Comparative ending through
calculates and
Effectiveness 10/1/12 - plan/policy
pays for insured
Fee Due 12/31/12 years ending
plans but likely
on or before
will pass fee along
9/30/2019; fee
is due by 7/31
of the calendar
following the
plan year;
applies to
retiree only
plans
Yes (unless
Open state has If eligible, decide
enrollment chosen a whether to
10/1/2013 No Yes Yes No Yes Yes
begins for 50- participate in
exchanges employee exchange/SHOP
threshold
5. Apply to
Apply to Apply to
Very Small Apply to Apply to Apply to
Large Small Additional
Employers Fully Self- Grand-
Requirement Effective Date Employers Employers Guidance Action Needed Comments Penalties
(<50 Insured Funded fathered
(>100 (50 - 100 Needed
employees Plans Plans Plans
employees) employees)
)
Guidance was
Report to HHS
due prior to
and participants Report as required HHS will
TBD Yes Yes Yes Yes Yes No Yes 3/23/12, but
on quality of once rules set determine
none has been
care
issued yet
$100/ discrimin-
TBD for ated-against
Determine
insured employee if
No if whether meet
plans; insured; loss of
Nondiscrimin- insured, discrimination
existing tax preference
ation Yes Yes Yes Yes Yes yes if Yes requirements and
requiremen for unduly
requirements self- make needed
t for self- benefited highly
funded adjustments if do
funded compensated
not
plans individual if self-
funded
Auto-enroll
employees who do Unclear if will
not affirmatively use same
Automatic 2014 or Yes (if > enroll in or decline definition of
No No Yes Yes Yes Yes
enrollment later 200 EEs) coverage, most employee as
likely in lowest will for "play or
cost plan, once pay"
rules are set
6. Apply to
Apply to Apply to
Very Small Apply to Apply to Apply to
Large Small Additional
Employers Fully Self- Grand-
Requirement Effective Date Employers Employers Guidance Action Needed Comments Penalties
(<50 Insured Funded fathered
(>100 (50 - 100 Needed
employees Plans Plans Plans
employees) employees)
)
If no coverage is
Employer to
offered, penalty
pay a penalty
is # of FT EEs -
for each FT
30 EEs x
(30+
$166.67/ mo; if
hours/week) EE
coverage is
Begin to consider who is not
offered but it's
Employer whether to play or offered
unaffordable or
shared pay (i.e., offer coverage that
1/1/2014 Yes Yes No Yes Yes Yes Yes below minimum
responsibility compliant meets
essential,
("play or pay") coverage or pay minimum
penalty is
the penalty) essential (60%)
$250/mo. for
level & is
each FT EE who
affordable
gets a premium
(<9.5% of
credit or cost
household
share through
income)
an exchange
Not
Yes (unless
available If eligible, begin to Exchanges/
state
until at consider whether SHOP will
restricts to
Exchanges/ least to provide provide online
1/1/2014 employers Yes Yes No Yes Yes
SHOP 2017; coverage inside or resource to
with 50 or
state by outside of elect health
fewer
state exchange/SHOP coverage
lives)
decision
Elimination of Determine if
Annual Dollar First day of current plan Up to $100/
Limits on 2014 plan Yes Yes Yes Yes Yes Yes Yes design complies; if affected
Essential year not, revise participant/ day
Benefits plan/policy
Elimination of Determine if
Pre-Ex Limits for First day of current plan Up to $100/
adults (as well 2014 plan Yes Yes Yes Yes Yes Yes No design complies; if affected
as children year not, revise participant/ day
under age 19) plan/policy
7. Apply to
Apply to Apply to
Very Small Apply to Apply to Apply to
Large Small Additional
Employers Fully Self- Grand-
Requirement Effective Date Employers Employers Guidance Action Needed Comments Penalties
(<50 Insured Funded fathered
(>100 (50 - 100 Needed
employees Plans Plans Plans
employees) employees)
)
Agencies have
not yet
determined if
Determine if first of month
Waiting period First day of Up to $100/
current eligibility after 90 days is
cannot exceed 2014 plan Yes Yes Yes Yes Yes Yes Yes affected
rules comply; if permissible,
90 days year participant/ day
not, revise how to address
those who
move between
PT and FT, etc.
Determine if
No Minimal
First day of current plan Up to $100/
discrimination change from
2014 plan Yes Yes Yes Yes Yes No Yes design complies; if affected
based on health current HIPAA
year not, revise participant/ day
status rules
plan/policy
Maximum
deductible of
Determine if
$2,000 for
Limits on cost- First day of current plan Up to $100/
single and
sharing and 2014 plan Yes Yes Yes Yes Yes No Yes design complies; if affected
$4,000 family;
deductibles year not, revise participant/ day
maximum OOP
plan/policy
based on HDHP
limits
Determine if
Mandated First day of current plan Up to $100/
coverage of 2014 plan Yes Yes Yes Yes Yes No Yes design complies; if affected
clinical trials year not, revise participant/ day
plan/policy
8. Apply to
Apply to Apply to
Very Small Apply to Apply to Apply to
Large Small Additional
Employers Fully Self- Grand-
Requirement Effective Date Employers Employers Guidance Action Needed Comments Penalties
(<50 Insured Funded fathered
(>100 (50 - 100 Needed
employees Plans Plans Plans
employees) employees)
)
Agencies have
authority to
increase
If have permissible
HIPAA/PPACA- reward to 50%
compliant of cost of
First day of
Wellness wellness program, coverage;
2014 plan Yes Yes Yes Yes Yes N/A Yes N/A
Incentives may increase compliance
year
incentive to 30% with
of cost of single HIPAA/PPACA
coverage does not
guarantee
compliance
with ADA
These are the
10 listed
Only for Only for
Only for Yes If this applies, categories of
First day of lifetime lifetime
Essential health lifetime & (varies determine if benefits; this is
2014 plan Yes Yes & annual & annual Yes
benefits applies annual by group offered coverage not the same
year maximu maximu
max. size) is adequate as "minimum
ms ms
essential
benefits"
Begins with
coverage
Report to IRS provided on or
and participants after 1/1/14;
Report as required Likely $50/
on minimum 1/31/2015 Yes Yes Yes Yes Yes Yes Yes insurers likely
once rules set employee
essential to be
coverage responsible for
reporting for
insured plans
9. Apply to
Apply to Apply to
Very Small Apply to Apply to Apply to
Large Small Additional
Employers Fully Self- Grand-
Requirement Effective Date Employers Employers Guidance Action Needed Comments Penalties
(<50 Insured Funded fathered
(>100 (50 - 100 Needed
employees Plans Plans Plans
employees) employees)
)
Begins with
coverage
provided on or
after 1/1/14;
Report to IRS
IRS has
and participants
Report as required requested
on coverage 1/31/2015 Yes Yes No Yes Yes Yes Yes
once rules set comments on
offered by large
combining
employers
minimum
essential and
large employer
reporting
Employer pays
excise tax if
total cost of
medical
benefits (EE
and ER
Determine if contributions
current design combined)
40% non-
Excise tax on falls below exceeds
1/1/2018 Yes Yes Yes Yes Yes Yes Yes deductible
high cost plans threshold; if not, $10,200
excise tax
consider design (single) or
changes $27,500
(family)
[indexed]for
medical, HRA
and Section
125 (pre-tax &
health FSA)
10. ALREADY IN EFFECT
Apply to
Apply to Apply to
Very Small Apply to Apply to Apply to
Large Small Additional
Employers Fully Self- Grand-
Requirement Effective Date Employers Employers Guidance Action Needed Comments Penalties
(<50 Insured Funded fathered
(>100 (50 - 100 Needed
employees Plans Plans Plans
employees) employees)
)
In 2014,
grandfathered
plans must
Verify plan/SPD cover
Cover First day of has been dependent Up to $100/
dependent to 2011 plan Yes Yes Yes Yes Yes Partly No amended and even if affected
age 26 year administration is dependent has participant/ day
correct employer-
provided
coverage
available
Verify plan/SPD
Elimination of First day of has been Up to $100/
Lifetime Dollar 2011 plan Yes Yes Yes Yes Yes Yes No amended and affected
Limit year administration is participant/ day
correct
Restriction on Verify plan/SPD
Annual Dollar First day of has been Up to $100/
Limits on 2011 plan Yes Yes Yes Yes Yes Yes No amended and affected
Essential year administration is participant/ day
Benefits correct
Verify plan/SPD
Elimination of
First day of has been Up to $100/
Pre-Ex Limits for
2011 plan Yes Yes Yes Yes Yes Yes No amended and affected
children under
year administration is participant/ day
age 19
correct
Generally may
not terminate
First day of Verify ineligible Up to $100/
Limits on
2011 plan Yes Yes Yes Yes Yes Yes No administration is covered affected
Rescissions
year correct persons retro participant/ day
to ineligibility
date
11. Apply to
Apply to Apply to
Very Small Apply to Apply to Apply to
Large Small Additional
Employers Fully Self- Grand-
Requirement Effective Date Employers Employers Guidance Action Needed Comments Penalties
(<50 Insured Funded fathered
(>100 (50 - 100 Needed
employees Plans Plans Plans
employees) employees)
)
HHS may
Verify plan/SPD periodically
Up to $100/
First dollar First day of has been revise definition
affected
coverage for 2011 plan Yes Yes Yes Yes Yes No No amended and of preventive
participant/
Preventive Care year administration is care, such as they
day
correct have done with
women's care
Verify plan/SPD
Up to $100/
First day of has been
Enhanced affected
2011 plan Yes Yes Yes Yes Yes No Yes amended and
Appeals Rules participant/
year administration is
day
correct
No Verify plan/SPD
reimbursement First day of has been
Applies to FSA's,
of OTC drugs 2011 plan Yes Yes Yes N/A N/A Yes No amended and
HRA's and HSA's
w/o a year administration is
prescription correct
Verify plan/SPD
has been
Up to $100/
First day of amended,
Primary care affected
2011 plan Yes Yes Yes Yes Yes No No participants
physician choice participant/
year advised and
day
administration is
correct
Verify plan/SPD
has been
Up to $100/
OON First day of amended,
affected
emergency care 2011 plan Yes Yes Yes Yes Yes No No participants
participant/
coverage year advised and
day
administration is
correct
12. Apply to
Apply to Apply to
Very Small Apply to Apply to Apply to
Large Small Additional
Employers Fully Self- Grand-
Requirement Effective Date Employers Employers Guidance Action Needed Comments Penalties
(<50 Insured Funded fathered
(>100 (50 - 100 Needed
employees Plans Plans Plans
employees) employees)
)
Notes:
Controlled
Under PPACA,
group rules
cutoff for a
generally "Fully
“small
apply insured"
employer" may
when de- includes
be 50 or 100,
termining HMO's
depending on
employer
provision
size
This chart reflects UBA's understanding of the available guidance as of the date shown and is subject to change.
It is provided as general information and should not be considered legal or tax advice.
Damon H. Lee, Vice President
Horizon Agency, Inc.
6500 City West Parkway
Eden Prairie, MN 55344
damon@horizonagency.com
952-914-7187