• Benefit Provision Changes

    Small Group Metallic Plans 

    The new metallic plans offer benefit changes that go into affect in 2014. Here are some highlights of these changes:

    • Individual in-network out-of-pocket maximums cannot exceed $6,350
    • Family in-network out-of-pocket maximums cannot exceed $12,700
    • No regulations for out-of-network out-of-pocket maximum
    • All medical copays accrue to the medical out-of-pocket maximum
    • Annual maximum will be unlimited
    • Dependent children covered to age 26 (does not include spouses)
    • Elimination of pre-existing condition limitations

    Large Group Plans (Non-Grandfathered) 

    • A variety of new plan options meeting the minimum value rules with out-of-pocket maximums expenses not exceeding $6,350
    • All medical copays accrue to the medical out-of-pocket maximum
    • In specific situations, prescription copays do not need to accrue to out-of-pocket costs until January 1, 2015 (transitional safe harbor)
    • Annual maximum will be unlimited
    • Dependent children covered to age 26 (does not include spouse)
    • No annual limits on essential health benefits
    • Maximum 90 day probationary period - The Premera standard will be 1st of the month following 30 days, 60 days or date of hire
    • Elimination of pre-existing condition limitations

    Grandfathered Plans 

    Grandfathered plans will also have new plan rules and offerings due to healthcare reform. The following are required rules and benefits:

    • New limits on waiting periods
    • Notice regarding exchanges
    • Lifetime dollar limit prohibitions on essential health benefits
    • Phase-out of annual dollar limits on essential health benefits
    • Dependent child coverage to age 26
    • Elimination of pre-existing condition limitations
    • Employer shared responsibility beginning in 2015 (200+ employees)

    The following are not required for grandfathered plans 

    • Coverage of preventive care without employee cost-sharing
    • Limitations on out of pocket maximums
    • Guaranteed issue and renewal
    • Additional patient protections, such as OB/GYN access without a referral
    • Coverage of routine costs for clinical trials

    For more information on grandfathered plan benefits.