a. Notice to Employees - Beginning March 1, 2013 (and thereafter, for new hires), employers are required to notify their employees about the Exchange, the potential for premium tax credits for eligible employees, the cost-sharing subsidies that may be available to purchase coverage through the Exchange, and the potential loss of coverage and employer contribution if the employee decides to purchase insurance through an Exchange.
b. Uniform Summary of Benefits - The Secretary of HHS will develop, for use by group health plans and health insurers that offer group or individual health insurance coverage, standards for benefit summaries and coverage explanations utilizing a uniform format with standardized definitions. Beginning not later than twenty-four months after enactment of the PPACA, a health insurance issuer or the plan sponsor, in the case of a self-funded group health plan, must furnish the summary of benefits and coverage explanation to enrollees to an applicant, at the time of application; to an enrollee, prior to the time of enrollment or reenrollment; and to a policyholder, at the time of issuance of the policy. If material modifications are made in any of the terms of the plan or coverage that are not reflected in the most recently issued summary of benefits, the plan or issuer must also provide notice of such modifications no later than 60 days prior to the date on which such modification is to become effective. Failure to provide information can result in a penalty of not more than $1,000 for each failure.
c. Reporting Requirements - Group health plans and health insurance issuers that offer group or individual health insurance coverage also will need to comply with certain quality reporting requirements established by the Secretary of HHS. For calendar years beginning after 2013, each person that provides minimum essential coverage to an individual must report to the Secretary of HHS information about a covered individual and coverage levels and provide a copy of such information to the covered individual.
d. Prohibition of Discrimination in Favor of Highly Compensated Individuals. Effective for plan years beginning on or after the date that is six months after enactment of the PPACA, the plan sponsor of a group health plan (other than a self-insured plan) must satisfy the requirements of IRC Section 105(h)(2), which prohibits a plan from discriminating in favor of highly compensated individuals as to eligibility to participate as well as to benefits offered under the plan. This provision will prohibit the common practice among employers of purchasing fully-insured supplemental plans for key or highly paid employees only.
e. Appeal Process – Effective for plan years beginning on or after the date that is six months after enactment of the PPACA, a group health plan or health insurance issuer that offers group or individual health insurance coverage must comply with enhanced appeal process requirements, including making available internal and external claims processes and notifying enrollees of such rights. The plan and issuer must also inform enrollees of the availability of the to be created office of health insurance consumer assistance to assist them with appeals.
f. Fair Premium Rating – Effective for plan years beginning on or after January 1, 2014, a health insurance issuer for health insurance coverage offered in the individual or small group market may vary the premium rate with respect to a particular plan or coverage involved only based on single/family coverage tiers, premium rating areas, certain age bands, and certain tobacco use. These rating restrictions also will apply to any insurance offered in the Exchange in the large group market.
g. Reporting of Cost of Employer-Sponsored Health Coverage – Effective for tax years beginning after January 1, 2011, employers are required to disclose the value of an employee’s medical, dental, vision, prescription drug, and health savings accounts benefits (but excluding pre-tax salary contributions to a flexible spending account) on IRS Form W-2.