Impacts large fully insured plans with 50 or more employees:
Large group insured plans are not required to provide the ten “essential health benefits” or coverage at a “metal level” as small plans will be required to do. (The essential health benefits are coverage within these categories – ambulatory/outpatient, emergency, hospitalization, maternity and newborn care, mental health and substance use, prescription drugs, rehabilitative and habilitative services and devices – e.g., speech, physical and occupational therapy, laboratory services, preventive and wellness services and chronic disease management, and pediatric services, including pediatric dental and vision care. Under the “metal level” requirements, a plan must be designed to cover 90 percent of covered costs – a “platinum” plan, 80 percent of covered costs – a “gold” plan, 70 percent of covered costs – a “silver” plan or 60 percent of covered costs – a “bronze” plan).
However, large plans cannot impose lifetime or annual limits on essential health benefits and to avoid the employer-shared responsibility/play or pay penalty they must provide minimum value (an actuarial value of at least 60 percent). A proposed minimum value calculator has been released; it is at:
Regulations and Guidance | cciio.cms.gov
Current year employer contributions to health reimbursement arrangements and health savings accounts are included in the minimum value calculation.
The agencies had said they planned to provide safe harbor minimum value plan designs, but there is still no time table for issuing those plan designs.
