WPS Health Insurance

Health Care Reform

ACA subsidies will help struggling Americans afford health insurance

Beginning in 2014, if you are a single person making less than $44,680 annually (in 2012 dollars) or have a family of four that makes less than $92,200 per year (in 2012 dollars), and your employer doesn't offer affordable coverage, you may be able to get some help paying for your health insurance premium.
Find out more.

Consumer-friendly Health Care Reform Resources

Health care reform means big changes to health insurance and the health care system as a whole. One of the best resources available for individual health care consumers who want to understand this complex new law is the Henry J. Kaiser Family Foundation Health Reform Source. On this site you'll find a variety of consumer-friendly articles, videos, a glossary, even interactive tools that will help you get your arms around the coming transformation of health care.

WPS Members and Health Care Reform

We are working hard to ensure all necessary changes to our policies and procedures are implemented accurately and on time. We are currently assessing and evaluating the law's many provisions as they are finalized by the government, to determine how and when our products and members are affected. Rest assured, WPS will comply with all federal and state requirements by the required implementation dates.

If you are a current WPS customer, we will also be sending notifications via renewal letters and other communications, fully explaining your options and any plan changes mandated under the new legislation. Our priority is to ensure that you understand how you may be affected by each new provision.

Technical Health Care Reform Resources and Timeline

Many aspects of the legislation are still being finalized by federal and state regulatory bodies. The following chart lists the provisions of the law and the regulatory information that have been released. As new information becomes available, we will continue to post updates to this chart.

2010
Provision Topic: Annual Limits
Brief Description:
May only impose annual limits on "Essential" benefits, as determined by the Secretary, until they are completely eliminated in 2014. Applies to individual and group (including ASO). Applies to Group Grandfathered plans. Special rules apply in the case of collectively bargained plans.
Federal Regulations Related Resources
 
Provision Topic: Appeals Process
Brief Description:
A new health plan appeals process must be followed. New rules require external review in some situations. Does not apply to grandfathered plans.
Federal Regulations Related Resources
 
Provision Topic: Dependent Coverage of Children Who Have Not Attained Age 26
Brief Description:
Provide dependent coverage for children up to age 26 for all individual and group (including ASO) policies. Applies to Grandfathered plans. The coverage must be extended to married children, but not their dependents (spouse and children) if they are not eligible for other employer-sponsored coverage. But for plan years starting in 2014, you can no longer impose the ER-sponsored requirement. The plan will have to satisfy the federal requirements and any state law requirements that require the extension of adult dependent coverage. Plans will need to provide the better of the two requirements in each state. {Except, self-funded will follow federal requirement only.} Internal Revenue Code Section 105(b) is amended to permit an employee to exclude from gross income the value of employer-provided health coverage to any child of a taxpayer who has not reached age 27 as of the end of the tax year.
Federal Regulations Related Resources
 
Provision Topic: Early Retiree Reinsurance Program
Brief Description:
A temporary reinsurance program for employers providing health insurance coverage, whether the benefits provided are self-funded or delivered through the purchase of insurance, to retirees over age 55 who are not eligible for Medicare (and the eligible spouses, surviving spouses, and dependents of such retirees). Program will reimburse employers or insurers for 80% of retiree claims between $15K-$90K. Payments from the reinsurance program will be used to lower the costs for enrollees in the employer plan and can't be used for any other purposes. $5 billion will be appropriated to the Secretary to carry out this program.On April 5, 2011 (HHS) announced that the ERRP will stop accepting new applications effective May 6, 2011.
Federal Regulations Related Resources
 
Provision Topic: Lifetime Limits
Brief Description:
Prohibits individual and group (Including ASO) health plans from placing aggregate dollar lifetime limits on "Essential" coverage. Includes Applies to Grandfathered plans. Special rules apply in the case of collectively bargained plans.
Federal Regulations Related Resources
 
Provision Topic: Medical Loss Ratio Reporting
Brief Description:
Requires health plans to report the proportion of premium dollars spent on clinical services, quality, and other costs for the amount of premium spent on clinical services and quality that is less than 85% for plans in the large group market and 80% for plans in the individual and small group markets.
Federal Regulations Related Resources

Regulations

Guidance

Forms
 
Provision Topic: Medicare Expansion
Brief Description:
Medicare coverage will be expanded to include individuals who have been exposed to environmental health hazards from living in a subject area to an emergency declaration made as of 6/17/09 and have developed certain health conditions as a result.
Federal Regulations Related Resources
Not Yet Available  
 
Provision Topic: Nondiscrimination Rules for Insured Plans
Brief Description:
Insured group plans may not discriminate in favor of highly compensated employees. Self-funded plans are already subject to this rule under the Internal Revenue Code. Does not apply to Grandfathered plans.
Federal Regulations Related Resources
Based on public comments in response to the earlier notice, Notice 2011-1 was issued on December 22, 2010, which announced that insured plans are not required to comply with the rules until further guidance is provided. Until that time, sanctions for failure to comply with the rules will not apply. Furthermore, the agencies expect that when such guidance is issued, its effective date will be delayed until plan years beginning a certain time after its issuance.
 
Provision Topic: Part D $250 Rebate
Brief Description:
A $250 rebate will be provided to Medicare beneficiaries who reach the Part D coverage gap in 2010.
Federal Regulations Related Resources
No Guidance Expected  
 
Provision Topic: Phase I Tax Credits for Small Employers (25 or less EE's and average annual wages of less than $50K that purchase health insurance for employees with a tax credit)
Brief Description:
Phase I: For tax years 2010 through 2013, a tax credit of up to 35% of the employer's contribution toward the employee's health insurance premium if the employer contributes at least 50% of the total premium cost or 50% of a benchmark premium. The full credit is available to employers with 10 or fewer employees and average annual wages are less than $25K. The credit phases-out as firm size and average wage increases. Tax-exempt small businesses meeting these requirements are eligible for tax credits up to 25% of the employer's contribution toward the employee's health insurance premium.
Federal Regulations Related Resources
  • Tax provisions contained in §45R, Internal Revenue Code, Employee Health Insurance Expenses of Small Employers
    IRS notice 2010-44
 
Provision Topic: Pre-existing conditions for children
Brief Description:
Prohibits individual and group (including ASO) health plans from placing pre-existing condition exclusions on children under age 19. Applies to Group Grandfathered plans.
Federal Regulations Related Resources

Additional Information
 
Provision Topic: Preventive Care
Brief Description:
Requires qualified health plans to provide at a minimum coverage without cost-sharing for preventive services rated A or B by the US Preventive Services Task Force, recommended immunizations, preventive care for infants, children, and adolescents, and additional preventive care and screenings for women. Does not apply to Grandfathered plans.
Federal Regulations Related Resources
 
Provision Topic: Rate Review
Brief Description:
The Secretary of DHHS, in conjunction with the states, will have new authority to monitor health insurance premium rates to prevent unreasonable increases. Carriers that have a pattern of unreasonable increases may be barred from participating in the Exchange.
Federal Regulations Related Resources
 
Provision Topic: Rescissions
Brief Description:
Prohibits individual and group (including ASO) insurers from rescinding coverage, except in cases of fraud or when enrollees make an intentional misrepresentation of material fact as prohibited by the terms of the plan or coverage. Applies to Grandfathered plans.
Federal Regulations Related Resources

Patient Rights
 
Provision Topic: Temporary High-Risk Pool
Brief Description:
A temporary national high-risk pool will be established to provide health coverage to individuals with pre-existing medical conditions and who have been uninsured for at least six months. Premiums for the pool will be established for a standard population and may vary by no more than 4:1 due to age. Maximum cost-sharing will be limited to current law HSA limit ($5,950/individual and $11,900 family in 2010.)
Federal Regulations Related Resources
 
Provision Topic: HHS Web Portal
Brief Description:
Requires the establishment of a website through which individuals and small businesses can obtain information about the insurance coverage options that may be available to them in their State. Interim final rule adopts the categories of information that will be collected and displayed via the website, and the data required from issuers, states, associations, and high risk pools in order to create this content.
Federal Regulations Related Resources

Additional Resources
 
Provision Topic: Patient Protection Rules
Brief Description:
Patient Protection rules allow individual's to designate a primary care provider or designate a pediatrician as a primary care provider, improves patient access to obstetrical and gynecological care without a referral and allows individuals to designate an OB/GYN as a primary care provider, and requires coverage of emergency services.
Federal Regulations Related Resources
 
2011
Provision Topic: Administrative Simplification: Adoption of a Standard for a Unique Health Plan Identifier and ICD-10
Brief Description:
Simplify health insurance administration by adopting a single set of operating rules for eligibility verification and claims status. Health plans must document compliance with these standards or face a penalty of no more than $1 per covered life.
Federal Regulations Related Resources
 
 
Provision Topic: CLASS Program: Community Living Assistance Services and Support
Brief Description:
Establishes a national, voluntary insurance for purchasing CLASS services. Employers are expected, but not required, to allow for payroll deductions and automatically enroll employees. Employees have the option to opt-out.
Federal Regulations Related Resources
 
 
Provision Topic: Eliminate Cost-Sharing for Preventive Services in Medicare and Medicaid.
Brief Description:
Improve prevention by covering only proven preventive services and eliminating cost-sharing for preventive services in Medicare and Medicaid. Increase Medicare payments for certain preventive services to 100% of actual charges or fee schedule rates.
Federal Regulations Related Resources
 
 
Provision Topic: Expanded federal income tax requirements
Brief Description:
All business owners will be subject to new expanded federal income tax requirements on payments of fixed or determinable income or compensation.
Federal Regulations Related Resources

Regulations
 
Provision Topic: Form 5500 studies
Brief Description:
The Department of Labor will begin annual studies on self-funded plans using data collected from Form 5500.
Federal Regulations Related Resources

Regulations
 
Provision Topic: Health Risk Assessment for Medicare Beneficiaries
Brief Description:
Provide Medicare beneficiaries access to a comprehensive health risk assessment (HRA) and creation of a personalized prevention plan. Provide incentives to Medicare and Medicaid beneficiaries to complete behavior modification programs.
Federal Regulations Related Resources
 
 
Provision Topic: Over-the-counter drugs
Brief Description:
Prohibits reimbursement of over-the-counter drugs from FSAs, HRAs, and HSAs, except for insulin.
Federal Regulations Related Resources

Regulations

  • Part III - Administrative, Procedural, and Miscellaneous
    Notice 2010-59
  • Part III - Administrative, Procedural, and Miscellaneous
    Notice 2011-5
 
Provision Topic: Phase down of Part D Coverage Gap
Brief Description:
Phase down gradually the beneficiary coinsurance rate in the Medicare Part D gap from 100% to 25% by 2020. For brand-name drugs, require pharmaceutical manufacturers to provide a 50% discount on prescriptions filled in the Medicare Part D coverage gap beginning in 2011, in addition to federal subsidies of 25% of the brand-name drug cost by 2020 phased in beginning in 2013. For generic drugs, provide federal subsidies of 75% of the generic drug cost by 2020 for prescriptions filled in the Medicare Part D coverage gap phased in beginning in 2011. Between 2014 and 2019, reduce the out-of-pocket amount that qualifies an enrollee for catastrophic coverage.
Federal Regulations Related Resources
Not Yet Available  
 
Provision Topic: Reporting on W2's
Brief Description:
Requires all employers to include the aggregate cost of employer-sponsored health, vision and dental coverage, and contributions made to health savings accounts on each employee's W-2 tax form.
Federal Regulations Related Resources

Regulations

Related Resources
 
Provision Topic: "Simple Cafeteria" plans
Brief Description:
Small employers (less than 100 lives) will be allowed to adopt new "simple cafeteria plans." In exchange for satisfying minimum participation requirements, these plans would be treated as meeting the nondiscrimination requirements that would otherwise apply to the cafeteria plan.
Federal Regulations Related Resources
 
 
Provision Topic: Standard Uniform Explanation of Benefits and Coverage
Brief Description:
New standards will be developed for insurers (includes Grandfathered plans) to use in providing information on benefits and coverage. Changes some of ERISA's SPD requirements. Requires 4-page summary with 12 pt. type and is culturally/linguistically appropriate. [Insurer must comply with standards within 24 months following enactment.]
Federal Regulations Related Resources

Regulations
 
2012
Provision Topic: Adoption of operating rules for health insurance administration
Brief Description:
Electronic funds transfers and health care payment and remittance . Health plans must document compliance with these standards or face a penalty of no more than $1 per covered life.
Federal Regulations Related Resources
 
Provision Topic: New annual fees on Drug Manufacturers
Brief Description:
New annual fees will be imposed on the pharmaceutical manufacturing sector, according to this schedule:
  • $2.8 billion in 2012-2013
  • $3.0 billion in 2014-16
  • $4.0 billion  in 2017
  • $4.1 billion in 2018
  • $2.8 billion in 2019 and later.
Federal Regulations Related Resources
Not Yet Available  
 
Provision Topic: Part B rebates
Brief Description:
Prohibition on Part B rebates (MA plans)
Federal Regulations Related Resources
Not Yet Available  
 
Provision Topic: Preventable Hospital Admissions
Brief Description:
Reduces Medicare payments that would otherwise be made to hospitals by specified percentages to account for excess (preventable) hospital readmissions.
Federal Regulations Related Resources
Not Yet Available  
 
2013
Provision Topic: Consumer Operated and Oriented Plan [CO-OP]
Brief Description:
$6 billion will be appropriated to finance the program and to award loans and grants to establish CO-Ops. To be eligible to receive funds, an organization must not be an existing health insurer or sponsored by a state or local government, and substantially all of its activities must consist of the issuance of qualified health benefit plans in each state in which its licensed. Governance of the organization must be subject to a majority vote of its members, must operate with a strong member focus, and any profits must be used to lower premiums, improve benefits, or improve the quality of health care delivered to its members.
Federal Regulations Related Resources
 
Provision Topic: Employer notice requirement
Brief Description:
All employers must provide notice to their employees informing them of the existence of the state-based exchanges.
Federal Regulations Related Resources
Not Yet Available  
 
Provision Topic: Employer subsidy for Medicare Part D ends
Brief Description:
The tax deduction for employers who receive Medicare Part D retiree drug subsidy payments ends.
Federal Regulations Related Resources
Not Yet Available  
 
Provision Topic: Health Care Choice Compacts and national plans
Brief Description:
Permits states to form health care choice compacts and allow insurers to sell individual policies in any state participating in the compact no earlier than 1/1/2016.
Federal Regulations Related Resources
Not Yet Available  
 
Provision Topic: Medicare Part A payroll tax increase
Brief Description:
The hospital insurance tax on wages will increase 0.9% (from 1.45% to 2.35%) for those earning more than $200K ($250K couple filing jointly) and it includes net investment income. It also imposes a 3.8% assessment on unearned income for higher-income taxpayers ($120K individual or $250K couple filing jointly). The tax would be applied to investment income including interest, dividends, rents, royalties, annuities and capital gains. (Thresholds not indexed.)
Federal Regulations Related Resources
Not Yet Available  
 
Provision Topic: New Federal premium tax ("Comparative Effectiveness Fee")
Brief Description:
New federal premium tax on fully-insured and self-insured group health plans to fund comparative effectiveness research program. It imposes an annual fee on private plans equal to $1for each individual covered for first plan year ending after 9/30/2012; $2 per participant following year; adjusted thereafter.
Federal Regulations Related Resources
Not Yet Available  
 
Provision Topic: Salary reductions for FSAs
Brief Description:
The amount of contributions to a flexible medical spending account will be limited to $2500 per year and will increase annually, based on the cost of living adjustment starting on 1/1/2014.
Federal Regulations Related Resources
Not Yet Available  
 
Provision Topic: Tax change for unreimbursed medical deductions.
Brief Description:
The threshold for the itemized deduction for unreimbursed medical expenses will increase from 7.5% of AGI to 10% AGI for regular tax purposes. Those 65 and older can claim the 7.5% deductible through 2016.
Federal Regulations Related Resources
Not Yet Available  
 
Provision Topic: Taxable medical devices
Brief Description:
A 2.3% excise tax will be imposed on the sale of any taxable medical device.
Federal Regulations Related Resources
Not Yet Available  
 
2014
Provision Topic: Abortion coverage (Requires separation of tax dollars from premiums.)
Brief Description:
Permits states to prohibit plans participating in the Exchange from providing coverage for abortions. If a plan chooses to offer coverage for abortions beyond those for which federal funds are required, allocation accounts for segregating premium payments must be implemented. Plans must also estimate the actuarial value of covering abortions by taking into account the cost of the abortion benefit [valued at no less than $1 per enrollee, per month] and cannot take into account any savings that might be reaped as a result of the abortions.
Federal Regulations Related Resources
Not Yet Available  
 
Provision Topic: Adoption of operating rules for health insurance administration
Brief Description:
Health claims or equivalent encounter information, enrollment and disenrollment in a health plan, health plan premium payments, and referral certification and authorization. Health plans must document compliance with these standards or face a penalty of no more than $1 per covered life.
Federal Regulations Related Resources
Not Yet Available  
 
Provision Topic: Annual limits are eliminated
Brief Description:
Prohibits individual and group (including ASO) health plans from placing annual limits on the dollar value of coverage. Applies to Grandfathered plans.
Federal Regulations Related Resources
Not Yet Available  
 
Provision Topic: Automatic Enrollment , Employer Shared Responsibility
Brief Description:
Requires employers with more than 200 employees to automatically enroll employees into health insurance plans offered by the employer. Employees may opt out of coverage.
Federal Regulations Related Resources
 
 
Provision Topic: Basic Health Plan (For uninsured individuals with incomes between 133-200% FPL)
Brief Description:
Permits states the option to create a Basic Health Plan for uninsured individuals with incomes between 133-200% FPL who would otherwise be eligible to receive premium subsidies in the Exchange. States opting to provide this coverage will contract with one or more standard plans to provide at least the essential health benefits and must ensure that eligible individuals do not pay more in premiums than they would have paid in the Exchange and that the cost-sharing requirements do not exceed those of the platinum plan for enrollees with income less than 150% FPL or the gold plan for all other enrollees. States will receive 95% of the funds they would have been paid as federal premium and cost-sharing subsidies for eligible individuals to establish the Basic Health Plan. Individuals with incomes between 133-200% FPL in states creating Basic Health Plans will not be eligible for subsidies in the Exchanges.
Federal Regulations Related Resources
Not Yet Available  
 
Provision Topic: Cost-Sharing Reductions
Brief Description:
Cost-sharing credits will be provided to eligible individuals and families to reduce the cost-sharing amounts and limits on plans.  It has the effect of increasing the actuarial value of the basic benefit plan to the following percentages of the full value of the plan for the specified income level:
  • 100-150% FPL:  94%
  • 150-200% FPL:  87%
  • 200-250%  FPL:  73%
  • 250-400%FPL:  70%
Federal Regulations Related Resources
Not Yet Available  
 
Provision Topic: Creation of state-based exchange for small businesses and individuals.
Brief Description:
Health insurance exchanges will open in each state to individuals and small employers to comparison shop for standardized health plans. Require the Office of Personnel Management to contract with insurers to offer at least two multi-state plans in each Exchange. At least one plan must be offered by a non-profit entity and at least one plan must not provide coverage for abortions beyond those permitted by federal law. Each multi-state plan must be licensed in each state and must meet the qualifications of a qualified plan. If a state has a lower age rating requirement than 3:1, the state may require multi-state plans to meet the more protective age rating rules. These multi-state plans will be offered separately from the FEHBP and will have a separate risk pool.
Federal Regulations Related Resources
Not Yet Available  
 
Provision Topic: Eligibility for premium tax credits and cost-sharing reductions through the Exchange
Brief Description:
Limited to US citizens and legal immigrants who meet income requirements. Employees who are offered coverage by an employer are not eligible for premium credits unless the employer plan does not have an actuarial value of at least 60% or if the employee share of the premium exceeds 9.5% of income. Legal immigrants who are barred from enrolling in Medicaid during their first five years in the US will be eligible for premium credits.
Federal Regulations Related Resources
Not Yet Available  
 
Provision Topic: Employer Penalty for those who offer coverage
Brief Description:
An employer with more than 50 employees that offers coverage but has at least one FTE receiving the premium assistance tax credit will pay a penalty of $3,000 for each employee receiving subsidized Exchange coverage with an aggregate limit of $2,000 times the total number of employees. FTE is defined as 30 or more hours/week.
Federal Regulations Related Resources
Not Yet Available  
 
Provision Topic: Employer Penalty if they don't offer coverage
Brief Description:
Employers with 50 or more workers who do not offer coverage, face a fine of $2,000, (Indexed) for each employee, if any worker receives subsidized insurance on the exchange. FTE is defined as 30 or more hours/week. The first 30 employees are excluded from the assessment.
Federal Regulations Related Resources
Not Yet Available  
 
Provision Topic: Essential Benefits Package
Brief Description:
Create an Essential health benefits package that provides at least 60% of the actuarial value of the covered benefits, limits annual cost-sharing to the current law HSA limits $5950/Ind. And $11,900/Family in 2010 and is equal to the scope of benefits provided under a typical employer plan. Require the Secretary to define and periodically update the benefit package through a transparent and public process.
Federal Regulations Related Resources
 
Provision Topic: Essential Plan/Abortion coverage
Brief Description:
Prohibit abortion coverage from being required as part of the Essential health benefits.
Federal Regulations Related Resources
Not Yet Available  
 
Provision Topic: Exchange plans
Brief Description:
Four separate benefit categories of plans will be created plus a separate catastrophic plan.
  • Bronze Plan: Represents minimum creditable coverage and provides the essential health benefits, covers 60% of the benefit costs of the plan, with an OOP limit equal to the HSA law limit [$5950 for individuals and $11,900 for families in 2010]
  • Silver Plan: Provides the essential health benefits, covers 70% of the benefit cost of the plan, with the HSA OOP limits.
  • Gold Plan: Provides the essential health benefits, covers 80% of the benefits costs of the plan, with the HSA OOP limits. 
  • Platinum:  Provides the essential health benefits, covers 90% of the benefits costs of the plan, with the HSA OOP limits. 
  • Catastrophic Plan:   Restricted to Individual market only.  Available to those up to age 30 or are exempt from the mandate to purchase coverage and provides catastrophic coverage with the coverage level set at the HSA current law levels, except that preventive benefits and coverage for three primary care visits would be exempt from the deductible. 
Federal Regulations Related Resources
 
 
Provision Topic: Exchange Reinsurance Program
Brief Description:
$25B tax on insurers and TPAs from 2014 through 2016 for Exchange reinsurance program.
Federal Regulations Related Resources
Not Yet Available  
 
Provision Topic: "Free Choice" Vouchers to Qualified Employees
Brief Description:
Employers who offer minimum essential coverage to its employees through an eligible employer-sponsored plan and who pay a portion of the costs of such plan will be required to provide a free choice voucher to employees with incomes less than 400% FPL whose share of premium exceeds 8%, but is less than 9.8%, of their income and who choose to enroll in a plan in the Exchange. The voucher amount is equal to what the employer would have paid to provide coverage to the employee under the Employer's plan and will be used to offset the premium costs for the plan in which the employee is enrolled. Employers providing free choice vouchers will not be subject to penalties for employees that receive premium credits in the Exchange.
Federal Regulations Related Resources
Not Yet Available  
 
Provision Topic: Health Insurance Exchanges
Brief Description:
Beginning in 2014, individuals may enroll in a plan through the Exchange of the state where they reside. Only lawful residents may obtain coverage in an Exchange. Unauthorized aliens will be prohibited from obtaining coverage through an Exchange.  Beginning in 2014, small employers can offer coverage to their employees through an Exchange. A "small employer" is an employer that employed an average of at least one but not more than 100 employees on business days during the preceding calendar year, and employs at least one employee on the first day of the plan year.
Federal Regulations Related Resources

Regulations
 
Provision Topic: Health Insurance Industry Tax
Brief Description:
An annual fee will be imposed on the health insurance sector, according to the following schedule:  
  • $8 billion in 2014
  • $11.3 billion in each of 2015-16
  • $13.9 billion in 2017
  • $14.3 billion in 2018
For subsequent years, the fee shall be the amount from the previous year increased by the rate of premium growth. For non-profit insurers, only 50% of net premiums are taken into account in calculating the fee.  Exemptions are granted for non-profit plans that receive more than 80% of their income from government programs targeting low-income or elderly populations, or people with disabilities and VEBAs not established by an employer.
Federal Regulations Related Resources
Not Yet Available  
 
Provision Topic: Individual insurance mandate
Brief Description:
Requires U.S. citizens and legal residents to have qualifying health coverage. Those without coverage pay a tax penalty of the greater of $695 per year, up to a maximum of three times that amount [$2,085] per family or 2.5% of household income. The penalty will be phased-in according to the following schedule: $95 in 2014, $325 in 2015, and $695 in 2016 for the flat fee or 1.0% of taxable income in 2014, 2.0% of taxable income in 2015, and 2.5% of taxable income in 2016. Beginning after 2016, the penalty will be increased annually by the cost-of-living adjustment. Exemptions will be granted for financial hardship, religious objections, American Indians, those without coverage for less than three months, undocumented immigrants, incarcerated individuals, those for whom the lowest cost plan option exceeds 8% of an individual's income, and those with incomes below the tax filing threshold [in 2009 the threshold for taxpayers under age 65 was $9,350 for singles and $18,700 for couples].
Federal Regulations Related Resources
Not Yet Available  
 
Provision Topic: Insurance Market and Rating Rules (For all fully insured individual and small groups up to 100 ees.)
Brief Description:
Requires guarantee issue and renewability and allow rating variation based only on age [limited to 3:1], premium rating area, family composition, and tobacco use [limited to 1.5:1] in the individual and small group market and in the Exchange. Requires risk adjustment in the individual and small group markets and in the Exchange. Applies to non-grandfathered fully-insured small group and individual plans. Also will apply to fully insured large group plans in states that allow them to purchase through the Exchange.
Federal Regulations Related Resources
Not Yet Available  
 
Provision Topic: Merging Individual/Small Group Markets
Brief Description:
Each state can have a separate exchange for employers and individuals or merge their exchanges to include both markets. State can also apply for a waiver on their exchange design from DHHS, and currently operational state exchanges are exempt.
Federal Regulations Related Resources
Not Yet Available  
 
Provision Topic: Operating In/Out of Exchange
Brief Description:
Requires all new policies (except stand-alone dental, vision, and long-term care insurance plans), including those offered through the Exchanges and those offered outside of the Exchanges, to comply with one of the four benefit categories. Existing individual and employer-sponsored plans do not have to meet the new benefit standards.
Federal Regulations Related Resources
Not Yet Available  
 
Provision Topic: Out of Pocket Limits with Exchange plans
Brief Description:
Reduce the OOP limit for those with incomes up to 400% FPL to the following levels:
  • 100-200% FPL:  1/3 of the HSA limit
  • 200-300% FPL:  1/2 of the HSA limit
  • 300-400% FPL:  2/3 of the HSA limit
These OOP reductions are applied within the actuarial limits of the plan and will not increase the actuarial value of the plan.
Federal Regulations Related Resources
Not Yet Available  
 
Provision Topic: Part D OOP reduction
Brief Description:
The law will reduce the out-of-pocket amount that qualifies an enrollee for catastrophic coverage between 2014 and 2019. In 2020, the level would revert to that which it would have been absent the reductions in the intervening years.
Federal Regulations Related Resources
Not Yet Available  
 
Provision Topic: Phase II: Tax Credits for small employers (25 or less full time equivalent employees with average annual wages of less than $50K that purchase health insurance for employees with a tax credit)
Brief Description:
Phase II: For tax years, 2014 and later, a tax credit of up to 50% of the employer's contribution toward the employee's health insurance premium if the employer contributes at least 50% of the total premium cost through the state exchange. The credit is available for two years. The full credit will be available of employers with 10 or less employees and its average annual wages are less than $25K. The credit phases out as firm size and wages increase. Tax-exempt small businesses meeting these requirements are eligible for tax credits of up to 35% of the employer's contribution toward the employee's health insurance premium.
Federal Regulations Related Resources
Not Yet Available  
 
Provision Topic: Pre-existing condition exclusion eliminated
Brief Description:
Pre-existing exclusions prohibited for all enrollees. Applies to Group Grandfathered plans.
Federal Regulations Related Resources
Not Yet Available  
 
Provision Topic: Premium Credits
Brief Description:
Eligible individuals and families with incomes between 133-400% FPL will receive refundable and advanceable premium tax credits to purchase insurance through the Exchange.  The premium tax credits are tied to the second lowest cost Silver plan in  the area and will be set on a sliding scale:
  • Up to 133% FPL: 2% of income
  • 133-150% FPL: 3-4% of income
  • 150-200% FPL: 4-6.3% of income
  • 200-250% FPL: 6.3-8.05% of income
  • 250-300% FPL: 8.05-9.5% of income
  • 300-400% FPL: 9.5% of income
Increase the premium contributions for those receiving subsidies annually to reflect the excess of the premium growth over the rate of income growth for 2014-2018.  Beginning in 2019, further adjust the premium contributions to reflect the excess of premium growth over CPI if aggregate premiums and cost sharing subsidies exceed .504% of GDP.
Federal Regulations Related Resources
Not Yet Available  
 
Provision Topic: Prevention/Wellness
Brief Description:
Permits employers to offer employees rewards up to 30%, increasing to 50% if appropriate, of the cost of coverage for participating in a wellness program and meeting certain health-related standards. Establish 10- state pilot programs to permit participating states to apply similar rewards for participating in wellness programs in the individual market.
Federal Regulations Related Resources
Not Yet Available  
 
Provision Topic: Qualification of participating health plans
Brief Description:
Required qualified health plans participating in the Exchange to meet marketing requirements, have adequate provider networks, contract with essential community providers, contract with navigators to conduct outreach and enrollment assistance, be accredited with respect to performance on quality measures, use a uniform enrollment form and standard format to present plan information.

Requires participating health plans to report information on claims payment policies, enrollment, disenrollment, number of claims denied, cost-sharing requirements, out-of-network policies, and enrollee rights in plain language.
Federal Regulations Related Resources
Not Yet Available  
 
Provision Topic: Qualified Benefit Plans/"Essential" plan
Brief Description:
All qualified health benefit plans, including those offered through the Exchange and those offered outside the exchange, except grandfathered individual and employer-sponsored plans, are required to offer at least the "Essential" health benefits package.
Federal Regulations Related Resources
Not Yet Available  
 
Provision Topic: Reinsurance program ends for Retirees Age 55 to 64.
Brief Description:
Reinsurance program ends for Retirees Age 55 to 64.
Federal Regulations Related Resources
Not Yet Available  
 
Provision Topic: Small Group deductible limit of $2K
Brief Description:
Limit deductibles for health plans in the small group market to $2K for individuals and $4K for families, subject to annual indexing increases, unless contributions are offered that offset deductible amounts above these limits. This deductible limit will not affect the actuarial value of any plans.
Federal Regulations Related Resources
Not Yet Available  
 
Provision Topic: Temporary high-risk pool ends
Brief Description:
Temporary high-risk pool ends.
Federal Regulations Related Resources
Not Yet Available  
 
Provision Topic: Waiting Periods
Brief Description:
Waiting periods in excess of 90 days are prohibited for all group (including ASO) plans. Applies to Group Grandfathered plans.
Federal Regulations Related Resources
Not Yet Available  
 
2015
Provision Topic: Hospital penalty for hospital-acquired conditions
Brief Description:
Reduces Medicare payments to certain hospitals for hospital-acquired conditions by 1%.
Federal Regulations Related Resources
Not Yet Available  
 
2016
Provision Topic: Health Care Choice compacts and national plans
Brief Description:
Permits states to form health care choice compacts and allow insurers to sell policies in any state participating in the compact. Compacts may only be approved if it is determined that the compact will provide coverage that is at least as comprehensive and affordable as coverage provided through the state Exchanges.
Federal Regulations Related Resources
Not Yet Available  
 
2017
Provision Topic: Expanding Exchange
Brief Description:
States have the option of expanding the exchange to larger employers. "Large employer" generally means more than 100 employees, but for plan years beginning before 1-1-16, a state may define it as more than 50 employees.
Federal Regulations Related Resources
Not Yet Available  
 
Provision Topic: Waiver for State Innovation
Brief Description:
Permit states to obtain a five-year waiver of certain new health insurance requirements if the state can demonstrate that it provides health coverage to all residents that is at least as comprehensive as the coverage required under an Exchange plan and that the state plan does not increase the federal budget deficit.
Federal Regulations Related Resources
Not Yet Available  
 
2018
Provision Topic: "Cadillac" plan tax
Brief Description:
A 40% excise tax will be imposed on high-cost, employer-provided health plans beyond $27,500 for family coverage and $10,200 for individuals. These threshold values will be indexed to CPI for urban consumers for years beginning in 2020. The threshold amounts will be increased for retired individuals age 55 and older who are not eligible for Medicare and for employees engaged in high-risk professions by $1,650 for individual coverage and $3,450 for family coverage. The threshold amounts may be adjusted upwards if health care costs rise more than expected prior to implementation of the tax in 2018. The threshold amounts will be increased for firms that may have higher health costs because of the age or gender of their workers.

The tax is equal to 40% of the value of the plan that exceeds the threshold amounts and is imposed on the issuer of the health insurance policy, which in the case of a self-funded plan is the plan administrator or, in some cases, the employer. The aggregate value of the health insurance plan includes reimbursements under a flexible spending account for medical expenses [health FSA] or health reimbursement arrangement [HRA], employer contributions to a health savings account [HSA], and coverage for supplementary health insurance coverage, excluding dental and vision coverage.
Federal Regulations Related Resources
Not Yet Available  
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Wisconsin Physicians Service (WPS Health Insurance) is a Medicare-approved Part D sponsor. S5753_25342_021_1112 CMS approved: 01/03/2012