a) Cost-Sharing
Under Group Health Plans
A group health plan shall ensure that any annual cost-sharing
imposed under the plan does not exceed the limitations provided for under
subsections (a)(1) and (2). (See
42 USC
300gg - 6(b).) Requirements relating to
cost-sharing are:
1) Annual Limitation
on Cost-Sharing
A) 2014
The cost-sharing incurred under a health plan with respect to
self-only coverage or coverage other than self-only coverage for a plan year
beginning in 2014 shall not exceed the dollar amounts in effect under
26 USC
223(c)(2)(A)(ii) for
self-only and family coverage, respectively, for taxable years beginning in
2014.
B) 2015 and Later
In the case of any plan year beginning in a calendar year
after 2014, the limitation under this subsection (a)(1)(B) shall:
i) in the case of self-only coverage, be
equal to the dollar amount under subsection (a)(1)(A) for self-only coverage
for plan years beginning in 2014, increased by an amount equal to the product
of that amount and the premium adjustment percentage under subsection (a)(4)
for the calendar year; and
ii) in
the case of other coverage, twice the amount in effect under subsection
(a)(1)(B)(i).
C) If the
amount of any increase under subsection (a)(1)(B)(i) is not a multiple of $50,
such increase shall be rounded to the next lowest multiple of $50.
2) Annual Limitation on
Deductibles for Employer-Sponsored Plans
A)
In General
i) In the case of a health plan
offered in the small group market, the deductible under the plan shall not
exceed $2,000 in the case of a plan covering a single individual and $4,000 in
the case of any other plan.
ii) The
amounts under subsection (a)(3)(A)(i) may be increased by the maximum amount of
reimbursement that is reasonably available to a participant under a flexible
spending arrangement described in
26 USC
106(c)(2) (determined
without regard to any salary reduction arrangement).
B) Indexing of Limits
In the case of any plan year beginning in a calendar year
after 2014:
i) the dollar amount under
subsection (a)(1)(A)(i) shall be increased by an amount equal to the product of
that amount and the premium adjustment percentage under subsection (a)(4) for
the calendar year; and if the amount of any increase under subsection
(a)(2)(B)(i) is not a multiple of $50, such increase shall be rounded to the
next lowest multiple of $50.
ii)
the dollar amount under subsection (a)(1)(A)(ii) shall be increased to an
amount equal to twice the amount in effect under subsection (a)(1)(A)(i) for
plan years beginning in the calendar year, determined after application of
subsection (a)(2)(B)(i).
C) Actuarial Value
The limitation under this subsection (a) shall be applied in
such a manner so as to not affect the actuarial value of any health plan,
including a plan in the bronze level.
D) Coordination with Preventive Limits
Nothing in this subsection (a) shall be construed to allow a
plan to have a deductible under the plan apply to benefits described in section
2713 of the federal Public Health Service Act ( 45 CFR 130).
3) Cost-Sharing
A) In general, the term "cost-sharing" in
this Section includes:
i) deductibles,
coinsurance, copayments or similar charges; and
ii) any other expenditure required of an
insured individual that is a qualified medical expense (within the meaning of
26 USC
223(d)(2)) with respect to
EHB covered under the plan.
B) Exceptions
The term "cost-sharing" in this Section does not include
premiums, balance billing amounts for non-network providers, or spending for
non-covered services.
4) Premium Adjustment Percentage
For purposes of subsections (a)(1)(B)(i) and (a)(2)(B)(i),
the premium adjustment percentage for any calendar year is the percentage (if
any) by which the average per capita premium for health insurance coverage in
the United States for the preceding calendar year (as estimated by the
Secretary no later than October 1 of such preceding calendar year) exceeds such
average per capita premium for 2013 (as determined by the Secretary). (See
42 USC
18022(c).)
b) Levels of Coverage
The levels of coverage described in this subsection (b) are
as follows:
1) Bronze Level
A plan in the bronze level shall provide a level of coverage
that is designed to provide benefits that are actuarially equivalent to 60
percent of the full actuarial value of the benefits provided under the
plan.
2) Silver Level
A plan in the silver level shall provide a level of coverage
that is designed to provide benefits that are actuarially equivalent to 70
percent of the full actuarial value of the benefits provided under the
plan.
3) Gold Level
A plan in the gold level shall provide a level of coverage
that is designed to provide benefits that are actuarially equivalent to 80
percent of the full actuarial value of the benefits provided under the
plan.
4) Platinum Level
A plan in the platinum level shall provide a level of
coverage that is designed to provide benefits that are actuarially equivalent
to 90 percent of the full actuarial value of the benefits provided under the
plan. (See
42 USC
18022(d).)
c) Actuarial Value (AV)
Calculation for Determining Level of Coverage
1) Calculation of AV
Subject to subsection (c)(2), to calculate the AV of a health
plan, the issuer must use the AV Calculator developed and made available by
HHS.
2) Exception to the
Use of the AV Calculator
If a health plan's design is not compatible with the AV
Calculator, the issuer must meet the following:
A) Submit the actuarial certification from an
actuary, who is a member of the American Academy of Actuaries, on the chosen
methodology identified in subsection (c)(2)(B) or (C).
B) Calculate the plan's AV by:
i) Estimating a fit of its plan design into
the parameters of the AV Calculator; and
ii) Having an actuary, who is a member of the
American Academy of Actuaries, certify that the plan design was fit
appropriately in accordance with generally accepted actuarial principles and
methodologies.
C) Use
the AV Calculator to determine the AV for the plan provisions that fit within
the calculator parameters and have an actuary, who is a member of the American
Academy of Actuaries, calculate and certify, in accordance with generally
accepted actuarial principles and methodologies, appropriate adjustments to the
AV identified by the calculator, for plan design features that deviate
substantially from the parameters of the AV Calculator.
D) The calculation methods described in
subsections (c)(2)(B) and (C) may include only in-network cost-sharing,
including multi-tier networks.
3) Employer Contributions to Health Savings
Accounts and Amounts Made Available Under Certain Health Reimbursement
Arrangements
For plans other than those in the individual market that at
the time of purchase are offered in conjunction with a Health Savings Account
(HSA) or with integrated Health Reimbursement Accounts (HRAs) that may be used
only for cost-sharing, annual employer contributions to HSAs and amounts newly
made available under such HRAs for the current year are:
A) Counted towards the total anticipated
medical spending of the standard population that is paid by the health plan;
and
B) Adjusted to reflect the
expected spending for health care costs in a benefit year so that:
i) Any current year HSA contributions are
accounted for; and
ii) The amounts
newly made available under such integrated HRAs for the current year are
accounted for.
4) Use of State-Specific Standard Population
for the Calculation of AV
Beginning in 2015, if submitted by the State and approved by
HHS, a State-specific data set will be used as the standard population to
calculate AV in accordance with subsection (c)(1). The data set may be approved
by HHS if it is submitted in accordance with subsection (c)(5) and:
A) Supports the calculation of AVs for the
full range of health plans available in the market;
B) Is derived from a non-elderly population
and estimates those likely to be covered by private health plans on or after
January 1, 2014;
C) Is large enough
that:
i) The demographic and spending
patterns are stable over time; and
ii) It includes a substantial majority of the
State's insured population, subject to the requirement in subsection
(c)(4)(B);
D) Is a
statistically reliable and stable basis for area-specific calculations;
and
E) Contains claims data on
health care services typically offered in the then-current market.
5) Submission of State-Specific
Data
AV will be calculated using the default standard population
described in subsection (c)(6), unless a data set in a format specified by HHS
that can support the use of the AV Calculator as described in subsection (c)(1)
is submitted by a State and approved by HHS consistent with subsection (c)(4)
by a date specified by HHS.
6) Default Standard Population
The default standard population for AV calculation will be
developed and summary statistics, such as in continuance tables, will be
provided by HHS in a format that supports the calculation of AV as described in
subsection (c)(1). (See
45 CFR
156.135.)
d) Actuarial Value Levels of Coverage
1) General Requirement for Levels of Coverage
AV, calculated as described in subsection (c), and within a
de minimis variation as defined in subsection (d)(3), determines whether a
health plan offers a bronze, silver, gold or platinum level of coverage.
2) The levels of coverage are:
A) A bronze health plan is a health plan that
has an AV of 60 percent.
B) A
silver health plan is a health plan that has an AV of 70 percent.
C) A gold health plan is a health plan that
has an AV of 80 percent.
D) A
platinum health plan is a health plan that has as an AV of 90
percent.
3) De Minimis
Variation
The allowable variation in the AV of a health plan that does
not result in a material difference in the true dollar value of the health plan
is ±2 percentage points. (See 45 CFR 146.140.)
e) Determination of Minimum Value
1) Acceptable Methods for Determining Minimum
Value
An employer-sponsored plan provides minimum value (MV) if the
percentage of the total allowed costs of benefits provided under the plan is no
less than 60 percent. An employer-sponsored plan may use one of the following
methods to determine whether the percentage of the total allowed costs of
benefits provided under the plan is not less than 60 percent:
A) The MV Calculator to be made available by
HHS and the Internal Revenue Service. The result derived from the calculator
may be modified under subsection (e)(2).
B) Any safe harbor established by HHS and the
Internal Revenue Service.
C) If the
plan is a group health plan, it may seek certification by an actuary to
determine MV if the plan contains non-standard features that are not suitable
for either of the methods described in subsections (e)(1)(A) or (B). The
determination of MV must be made by a member of the American Academy of
Actuaries, based on an analysis performed in accordance with generally accepted
actuarial principles and methodologies.
D) If the plan is in the small group market
that meets any of the levels of coverage, as described in subsection (d), it
satisfies MV.
2)
Benefits that May Be Counted Towards the Determination of MV
A) In the event that a group health plan uses
the MV Calculator and offers an EHB outside of the parameters of the MV
Calculator, the plan may seek an actuary, who is a member of the American
Academy of Actuaries, to determine the value of that benefit and adjust the
result derived from the MV Calculator to reflect that value.
B) For the purposes of applying the options
described in subsection (e)(1) in determining MV, a group health plan will be
permitted to take into account all benefits provided by the plan that are
included in any one of the EHB benchmarks.
3) Standard Population
The standard population for MV determinations described in
subsection (e)(1) is the standard population developed by HHS for such use and
described through summary statistics issued by HHS. The standard population for
MV must reflect the population covered by self-insured group health
plans.
4) Employer
Contributions to Health Savings Accounts and Amounts Made Available Under
Certain Health Reimbursement Arrangements
For employer-sponsored self-insured group health plans and
insured group health plans that at the time of purchase are offered in
conjunction with an HSA or with integrated HRAs that may be used only for
cost-sharing, annual employer contributions to HSAs and amounts newly made
available under such HRAs for the current year are:
A) Counted towards the total anticipated
medical spending of the standard population that is paid by the health plan;
and
B) Adjusted to reflect the
expected spending for health care costs in a benefit year so that:
i) Any current year HSA contributions are
accounted for; and
ii) The amounts
newly made available under such integrated HRAs for the current year are
accounted for. (
45 CFR
156.145)
f) Application
In determining the percentage of the total allowed costs of
benefits provided under a group health plan or health insurance coverage that
are provided by such plan or coverage, this Section shall apply. (See
42 USC
18022(d)(2)(C).)
g) Allowable Variance
There may be a de minimis variation in the actuarial
valuations used in determining the level of coverage of a plan to account for
differences in actuarial estimates. (See
42 USC
18022(d)(3).)
h) Plan Reference
In this Section, any reference to a bronze, silver, gold or
platinum plan shall be treated as a reference to a qualified health plan
providing a bronze, silver, gold or platinum level of coverage, as the case may
be. (See
42 USC
18022(d)(4).)
i) Catastrophic Plan
1) In General
A health plan not providing a bronze, silver, gold or
platinum level of coverage shall be treated as meeting the requirements of
subsection (b) with respect to any plan year if:
A) the only individuals who are eligible to
enroll in the plan are individuals described in subsection (c)(2);
and
B) the plan provides:
i) except as provided in subsection
(c)(1)(B)(ii), the essential health benefits determined under Section
2001.11(c),
except that the plan provides no benefits for any plan year until the
individual has incurred cost-sharing expenses in an amount equal to the annual
limitation in effect under subsection (a)(1) for the plan year (except as
provided for in
PHS Act section 2713); and
ii) coverage for at least three primary care
visits.
2)
Individuals Eligible for Enrollment
An individual is described in this subsection (i)(2) for any
plan year if the individual:
A) has
not attained the age of 30 before the beginning of the plan year; or
B) has a certification in effect for any plan
year under this Part that the individual is exempt from the requirement under
26 USC
5000 A by reason of:
i)
26 USC
5000 A(e)(1) (relating to individuals without
affordable coverage); or
ii)
26 USC
5000 A(e)(5) (relating to individuals with
hardships).
3) Restriction to Individual Market
If a health insurance issuer offers a health plan described
in this subsection (i), the issuer may only offer the plan in the individual
market. (See
42 USC
18022(e).)
j) Child-Only Plans
If a qualified health plan is offered through the Health
Benefits Exchange in any level of coverage specified under subsection (c), the
issuer shall also offer that plan through the Health Benefits Exchange in that
level as a plan in which the only enrollees are individuals who, as of the
beginning of a plan year, have not attained the age of 21, and such plan shall
be treated as a qualified health plan. (See
42 USC
18022(f).)
k) Payments to Federally Qualified Health
Centers
If any item or service covered by a qualified health plan is
provided by a Federally Qualified Health Center (as defined in
42 USC
1396 d(l)(2)(B)) to an enrollee of the plan,
the offeror of the plan shall pay to the center for the item or service an
amount that is not less than the amount of payment that would have been paid to
the center under
42 USC
1396 a(bb)) for such item or service. (See
42 USC
18022(g).)
l) Mutually Agreed Payment Rates
Nothing in subsection (k) precludes a Qualified Health Plan
issuer and a Federally Qualified Health Center from mutually agreeing upon
payment rates other than those that would have been paid to the center under
42 USC
1396 a(bb), as long as the mutually agreed
upon rates are at least equal to the generally applicable payment rates of the
issuer indicated in
45 CFR
156.235(d). (See
45 CFR
156.235(e).)
