ACA short briefing


There are a lot of people who ask me the question, what is an aca compliant plan? ACA stands for the affordable care act. There are four areas of plans.

1. Individual plans, open enrollment began Oct 1, 2013 and ended 03-31-2014 for coverage for

2014. For coverage for 2015 the open enrollment begins 11-15-2014 and ends 01-15-2015. There are special exceptions where one can enroll outside of the open enrollment period. Such as moving to another state, childbirth, and loss of coverage through an employer.

2. What is a qualified Aca plan? An ACA plan must include essential benefits which are maternity and newborn care, pediatric care such as dental and vision screenings, preventative screenings covered at 100% with no co-pay such as colonoscopies, cholesterol screenings, mammograms, pap smears, and prostate exams. There is a list on of some 80 screenings. Do not visit a provider for any of these screening and have another condition treated, do them separately. Most carriers also require you to use a network provider for these screenings to be covered at 100%. Emergency services are covered even if you visit a non-network hospital. Hospitalization after deductibles if applicable, prescription medications, mental and behavioral Health, rehabilitative services and devices, lab services. There are limits on how often you can use preventative services and deductibles and co-pays will apply. All charges one incurs applies to an annual cap which varies by carrier. There are no pre-existing condition exclusions and all plans are guaranteed issue. All fully insured plans must include essential benefits.

3. Small group plans form 2 employees to 49 employees- All plans are guaranteed issue with no pre-existing condition waiting periods. Standard industry classification codes cannot be used for rating purposes. Association discounts cannot be given. Volume discounts cannot be applied, sex rates cannot be given. Some carriers are now using composite rating which is the same cost for any employee, employee and spouse, employee and children, family. The rates are determined on the original enrollment. All plans have an annual open enrollment, most are at renewal.

4. Large groups with more than 50 eligible employees. All plans must include essential benefits. All taxes for not offering coverage are postponed to 2015, the tax for not offering coverage is $2,000 per employee and $3,000 for each employee who goes through an exchange and receives a subsidy. A large group can be underwritten by a carrier and can be rated as high as the carrier chooses due to health conditions. The coverage however is guaranteed issue.

5. Partially self-funded plans. Many carriers are now offering this type of funding arrangement as an alternative to ACA plans. They are underwritten by asking health questions. Rates can go up based on medical conditions. After being underwritten there are no pre-existing condition limitations. They still provide wellness benefits just as ACA plans. There is a $5.25 per member per month tax but other than that does not contain many of the taxes that ACA plans have, and thus makes the cost much more affordable. The monthly premiums are all of the liability a group has other than the before mentioned tax. At the end of the plan year plus the claims run out period the portion of the claims portion of the premium that is not used is returned to the client. Each carrier does this differently and I am able to provide a breakdown at the inception and reports are available to clients during the plan year. There are many components of the legislation not included in this briefing such as the limited waiting period of 90 days and many other components. We have posted on our web site many updates and will continue to do so. We also post on twitter, Facebook, linked-in and google+, please go to our web site to follow us thanks!

Information contained in this briefing is not legal advice but is information that is available to the public but is narrowed down for a basic quick understanding. I can always answer questions no matter how complex they are on the subject so please feel free to contact me with them.

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