Monthly Archives: September 2015

Affordable Care Act Cost-Sharing and High Deductible Health Plan Limits for 2016

Starmark® self-funded plan designs’ in-network out-of-pocket limits have been updated to incorporate the 2016 ACA cost-sharing and high-deductible health plan changes. The in-network out-of-pocket limits for 2016 plan years are:

  • PPO plans (Not HSA Qualified)
    • Individual: $6,850
    • Family: $13,700
  • CDHPs
    • Individual: $6,550
    • Family: $13,100
  • The ACA individual out-of-pocket limit of $6,850 will apply to individuals covered under family coverage with an HDHP (this is a new requirement in 2016).
  • For plans with a calendar-year benefit period, services received during the calendar year prior to the start of the new 2016 plan year may exceed the $6,850 cost-sharing limit.

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Filed under Cost sharing, Healthcare reform

Downgraded Preventive Services

The federal Departments of Health and Human Services, Labor and the Treasury have released final regulations that address coverage and cost sharing for preventive services that are downgraded by the U.S. Preventive Services Task Force.

The task force assigns each service a letter grade based on the strength of the evidence and the balance of benefits and harms of a preventive service. For example, a service with an A or a B is recommended by the Task Force. By assigning a D, the Task Force is recommending against the service and discouraging its use.

As part of the final regulations, the departments clarified that when a recommendation or guideline for preventive services from the task force is downgraded in the middle of a plan year, generally group health plans and insurers must continue to cover the services without cost sharing through the end of the plan year, even if the recommendation or guideline changes or is eliminated during the plan or policy year.

However, there is no requirement under the final regulations to cover certain items and services through the last day of the plan or policy year if, during a plan or policy year:

  • An A or B recommendation or guideline of the task force that was in effect on the first day of a plan or policy year is downgraded to a D rating (meaning the task force has determined that there is strong evidence that there is no net benefit, or that the harms outweigh the benefits, and therefore discourage the use of this service), or
  • Any item or service associated with any preventive service recommendation or guideline specified in federal regulations that was in effect on the first day of a plan or policy year is the subject of a safety recall or is otherwise determined to pose a significant safety concern by a federal agency authorized to regulate that item or service.

Other requirements of federal or state law may apply in connection with ceasing to provide coverage or changing cost-sharing requirements for any item or service. For example, if a group health plan or issuer makes any material modification in any of the term of the plan or coverage involved that would affect the content of the Summary of Benefits and Coverage (SBC), which is not reflected in the most recently provided SBC, and that occurs other than in connection with a renewal or reissuance of coverage, the plan or issuer must provide notice of the modification to enrollees not later than 60 days prior to the date on which the notification will become effective.

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Filed under Preventive Care

Upcoming Reinsurance Assessment Fee Webinars

The Centers for Medicare and Medicaid Services will host three free webinars in September explaining how to complete and submit the 2015 ACA Transitional Reinsurance Program Annual Enrollment and Contributions Submission Form and providing information about how to pay the fee. The form is expected to be made available at on Oct. 1, 2015.

Staff who are completing the form for employers with self-insured group plans may want to consider attending one of the training sessions.

The free webinars are scheduled for:

  • Sept. 23, 2015 from 1pm to 2:30pm Eastern
  • Sept. 28, 2015 from 1pm to 2:30pm Eastern
  • Sept. 30, 2015 from 1pm to 2:30pm Eastern

Log on to for registration and additional information on the webinars.

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Filed under Healthcare reform, Reinsurance Fee

MLR Rebate Checks Being Mailed to Employers

In accordance with the Patient Protection and Affordable Care Act (PPACA) regulations, the week of September 7, 2015, Trustmark will mail Medical Loss Ratio (MLR) rebate checks with letters to eligible groups as shown below. The size of the group is based on eligible employees.

Small group (based on state definitions, but generally groups with 50 or fewer employees): AR, AZ, GA, IL, IN, KS, MO, MT, NE, NV, OH, TN, TX, UT, VA, WV, WY

Large group (based on state definitions, but generally groups with 51+ employees): AZ, IL, IN, MO, TX, WY

Sample cover letter

Sample letter

Regulations under the Patient Protection and Affordable Care Act require health insurers to spend at least 80 percent of their premiums on medical expenses for small groups, and at least 85 percent for large groups, or rebate the difference to customers.  A lower Medical Loss Ratio (MLR) percentage means a higher potential rebate to the employer. This requirement does not apply to self-funded plans.

Click here to view the MLR rebates Q&A.

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Filed under Medical Loss Ratio