Retiree-Only Plans are Exempt from the Following Mandates:
- Sections 1001(5) and 10101 - No lifetime or annual dollar limits on essential benefits
- Section 1001(5) - Prohibition on rescission
- Section 1001(5) - Coverage of certain preventive health services provided in network
- Section 1001(5) - Extension of dependent coverage
- Section 1001(5) - Development and utilization of uniform explanation of coverage documents and standardized definitions (Summary of Benefits and Coverage)
- Section 1001(5) - Provision of additional information
- Section 1001(5) - Prohibition on discrimination in favor of highly compensated individuals for insured plans
- Section 1001(5) - Ensuring the quality of care reporting
- Section 1001(5) 8 - Medical loss ratio requirements
- Section 1001(5) - Required appeals process and various requirements in the claims and appeals rules
- Section 1001(5) - Patient protections (choice of provider, emergency services requirements)
- Section 1003 - Rate review
- Section 1201 - Prohibition of preexisting condition exclusions or other discrimination based on health status for children under age 19
- Section 1201 - Restrictions on what criteria can be used in rating and rate band limits
- Section 1201 - Guaranteed issue
- Section 1201 - Guaranteed renewability
- Section 1201 - Prohibiting discrimination against individual participants and beneficiaries based on health status
- Section 1201 - Non-discrimination towards health care providers
- Section 1201 - Cost-sharing requirements and essential benefit requirements
- Sections 1201 and 10103 - Prohibition on waiting periods of more than 90 days
- Section 10103 - Coverage for individuals participating in approved clinical trials
Premium-Only HRA Plans are Exempt from The Following Mandates in Addition to Those Above:
- Section 1103 - Web portal reporting requirements
- Section 1341 - Reinsurance
- Section 1311(e) - Risk pooling (applies to small group retiree-only plans, with the exception of grandfathered plans)
- Section 3141 - Reinsurance
- Section 1342 - Risk corridors (applies to retiree-only qualified health plans)
- Section 1343 - Risk adjustment (applies to small group retiree only plans)
- Section 9022 - W-2 reporting (applies to employers that sponsor retiree only plans, but only if the retiree otherwise is receiving a Form W-2 from the employer.)
- Section 6005 - Pharmacy benefit managers transparency
- Section 9010 - Annual fee on health insurance providers
Retiree-Only, Premium-Only HRA Plans Must Still Comply with the Following Mandates:
- Section 6301 - Research Trust Fund Health Plan Fee (PCORI)
- Sections 9001 and 10901 - Excise tax on high-cost employer-sponsored health coverage
- Section 1502 - Reporting of health insurance coverage
- Section 9003 - Exclusion of over-the-counter drugs for group health plans, FSAs, HRAs, HSAs
National Insurance Services is not a law firm and no opinion, suggestion, or recommendation of the firm or its employees shall constitute legal advice. Readers are advised to consult with their own attorney for a determination of their legal rights, responsibilities and liabilities, including the interpretation of any statute or regulation, or its application to the readers’ business activities.
