PCORI Fee Increase for Plan Years Beginning on or After October 1, 2015

The applicable dollar amount to determine PCORI fees will increase from $2.08 to $2.17 for plan years ending after September 30, 2015 and before October 1, 2016 according to Notice 2015-60 issued by the Internal Revenue Service (IRS) on October 9th.

Health insurance issuers and self-funded health plans are required to pay PCORI fees for Plan Years ending on or after October 1, 2012 and on or before September 30, 2019. These fees help fund the Patient-Centered Outcomes Research Institute (PCORI). The fee amount is calculated by multiplying the average number of covered lives during the Plan Year by the applicable dollar amount for that Plan Year.

The applicable dollar amount for each Plan Year is:

Plan Year ending between October 1, 2012 and September 30, 2013 $1.00
Plan Year ending between October 1, 2013 and September 30, 2014 $2.00
Plan Year ending between October 1, 2014 and September 30, 2015 $2.08
Plan Year ending between October 1, 2015 and September 30, 2016 $2.17

Draft Guide for Electronically Filing ACA Information Returns Released

Beginning in 2016, group health plans and large employers will be required to file annual health coverage information returns under Internal Revenue Code Sections 6055 and 6056, which were added by the Affordable Care Act (ACA). Although all filers are encouraged to file information returns electronically, those who file 250 or more information returns are required to file electronically through the Affordable Care Act (ACA) Information Returns (AIR) system. To assist in developing software for use with the AIR system, the Internal Revenue Service (IRS) released Draft Publication 5165. This guide has information regarding the communication procedures, transmission formats and other rules for the following annual information returns filed electronically:

  • Form 1094-B, Transmittal of Health Coverage Information Returns
  • Form 1095-B, Health Coverage
  • Form 1094-C, Transmittal of Employer-Provided Health Insurance Offer and Coverage Information Returns
  • Form 1095-C, Employer-Provided Health Insurance Offer and Coverage

The IRS will publish a final Publication 5165 at a later date.

ACA FAQ Part XXV Addresses Wellness Programs

The Departments of Labor (DOL), Health and Human Services (HHS) and the Treasury released FAQ XXV addressing the compliance of wellness programs with the Affordable Care Act.

Highlights of FAQ XXV:

  • Compliance with the wellness program regulations under ACA does not determine compliance with other laws nor does it determine the tax treatment of rewards provided by the wellness program.
  • A wellness program will comply with the requirement to be “reasonably designed” if it:
    has a reasonable chance of improving the health of, or preventing disease in, participating individuals;

    • is not overly burdensome;
    • is not a subterfuge for discrimination based on a health factor;
    • is not highly suspect in the method chosen to promote health or prevent disease; and
    • provides a reasonable alternative standard to qualify for the reward for anyone who does not meet the initial standard that is related to a health factor.

HHS Extends Deadline for Reinsurance Enrollment Counts to December 5, 2014

The Department of Health and Human Services has provided an extension of the deadline for contributing entities to submit their 2014 enrollment counts for the transitional reinsurance program contributions. The deadline has now been extended until December 5, 2014. The January 15, 2015 and November 15, 2015 payment deadlines have not been changed.

ACA FAQ Part XXII Addresses Premium Reimbursement Arrangements

The Departments of Labor (DOL), Health and Human Services (HHS) and the Treasury released FAQ Part XXII addressing the compliance of premium reimbursement arrangements with the Affordable Care Act. Sponsors of health reimbursement arrangements (HRAs), health flexible spending arrangements (health FSAs) or other arrangements that reimburse health premiums should confirm that reimbursements are not being made for individual coverage premiums.

Specifically, the guidance provided in this set of three questions states that:

  • Employers cannot offer employees cash to reimburse the purchase of an individual policy.
  • Employers cannot offer employees at risk of high claims a choice between the group health plan or cash to obtain individual insurance.
  • Employers cannot cancel group policies, setup a Code section 105 reimbursement plan using brokers to help employees select individual policies and allow employees to access premium tax credits.

Final Regulations Issued on Excepted Benefits

Final rules were released by the Departments of Labor (DOL), Health and Human Services (HHS) and the Treasury addressing limited scope vision and dental benefits and employee assistance programs (EAPs) as excepted benefits. These regulations should be reviewed so that plans may make any necessary changes effective for plan years beginning on or after January 1, 2015.


Excepted benefits are generally excluded from the Affordable Care Act’s (ACA’s) requirements. There are four categories of excepted benefits:

  1. Benefits that are generally not health coverage (workers compensation, accidental death and dismemberment)
  2. Limited excepted benefits (some limited scope* vision or dental benefits, long-term care, home health care, health FSAs)
  3. Non-coordinated excepted benefits (coverage for a specific disease or illness, hospital indemnity insurance)
  4. Supplemental excepted benefits (Medicare Supplement plans)

*Limited scope means that benefits are limited to treatment of the eye (vision) or mouth (dental).

In December 2013, proposed rules were issued regarding excepted benefits. The rules proposed changes in the requirements affecting limited scope vision and dental coverage and recognition of both employee assistance programs and coverage that wraps around individual coverage as new forms of limited excepted benefits. The final rule is silent on wraparound coverage and makes minor modifications to the other proposals. Additional guidance on wraparound coverage is expected in the future.

Vision and Dental Benefits

The final rules clarify that limited scope vision and dental benefits are excepted benefits if they (1) are offered under a separate policy or insurance contract or (2) are not considered to be an integral part of the group health plan. These benefits are not an integral part of the group health plan if either (1) participants may decline coverage or (2) claims for the benefits are administered under a separate contract. The regulations eliminate the requirement that an additional premium be charged in order to qualify as an excepted benefit.

Employee Assistance Programs (EAPs)

The final rule also allows employee assistance programs to be recognized as excepted benefits if they:

  • Do not provide significant medical care benefits.
  • Do not coordinate their benefits with group health plan benefits.
  • Do not require employee premiums or contributions for participation.
  • Do not impose cost-sharing requirements.

Next Steps

These regulations apply to group health plans and group health insurance issuers for plan years beginning on or after January 1, 2015. Plans should review the regulations and determine that benefits have been designed and are being administered appropriately to meet the definition of excepted benefits. If these requirements are not met, plans may face additional compliance under HIPAA, Mental Health Parity and the ACA as well as potential penalties for noncompliance.

PCORI Fee Announced for Year 3 of Program

The Internal Revenue Service (IRS) issued Notice 2014-56 announcing the PCORI fees applicable to health plans for plan and policy years ending on or after October 1, 2014 and before October 1, 2015 is $2.08. These fees are calculated using an average number of covered lives and an annually announced applicable dollar amount. The applicable dollar amount for plan and policy years ending on or after October 1, 2012 and before October 1, 2013 was $1.00. This dollar amount was increased to $2.00 for plan and policy years ending on or after October 1, 2013 and before October 1, 2014.

For policy years and plan years ending October 1, 2015, through September 30, 2019, the adjusted applicable dollar amount will be published in future guidance in the Internal Revenue Bulletin.

Plans Must Obtain Health Plan Identifier (HPID)

As part of the effort to standardize health plans’ electronic transactions, all group health plans are required to obtain a health plan identifier (HPID). The HPID is a 10-digit number assigned to health plans and will be used to identify the plan in standard transactions. Proposed regulations about the HPID were issued by HHS on April 27, 2012. Final regulations followed shortly after on September 5, 2012. Large health plans must obtain a HPID by November 5, 2014. Small health plans with less than $5 million in benefits per year have a one year extension and must obtain a HPID by November 5, 2015.

If a plan is fully insured, the insurance carrier is responsible for obtaining the HPID. If a plan is self-insured, the plan sponsor must obtain the HPID. If a plan sponsor’s health plan has both fully-insured and self-insured options, or has multiple self-insured options, the plan sponsor may obtain one HPID as the controlling health plan. Plans must apply for HPIDs at https://portal.cms.gov/wps/portal/unauthportal/home/. CMS has resources available to assist plans through the application process. For assistance in determining whether your plan is required to apply for an HPID or for assistance with the application process, please contact The McKeogh Company.   Continue reading

IRS Releases 2015 HSA and HDHP Amounts

The Internal Revenue Service (IRS) published Revenue Procedure 2014-30 outlining the annual health savings account (HSA) contribution limitation, the minimum deductible for a high-deductible health plan (HDHP) and the maximum out-of-pocket expense limits for an HDHP in 2015. For calendar year 2015, the annual contribution limitation to an HSA is $3,350 for self-only coverage and $6,650 for family coverage. The minimum deductible under an HDHP is $1,300 for self-only coverage or $2,600 for family coverage. The maximum out-of-pocket expense limit is $6,450 for self-only coverage or $12,900 for family coverage.

HHS Releases Data on Physician Medical Services Payments

“As part of the Obama administration’s work to make our health care system more transparent, affordable, and accountable, Health and Human Services (HHS) Secretary Kathleen Sebelius announced the release of new, privacy-protected data on services and procedures provided to Medicare beneficiaries by physicians and other health care professionals. The new data also show payment and submitted charges, or bills, for those services and procedures by provider.”  Read more here.