On March 6, the Department of Health and Human Services (HHS) provided the 2015 actuarial value calculator and issued final regulations on the 2015 Notice of Benefit and Payment Parameters. While HHS changed a few items from the proposed rule – namely the open enrollment period and cost-sharing limits – many provisions remain the same.
Open Enrollment Period
The 2015 open enrollment period for individual and family plans has been extended by 30 days and will be held November 15, 2014 – February 15, 2015.
2015 Cost-Sharing Limits
The 2015 maximum annual out-of-pocket limits for all non-grandfathered plans will increase by 4.21 percent, lower than originally proposed. The confirmed 2015 amounts are $6,600 for individual coverage and $13,200 for family coverage. The maximum 2015 deductibles for insured non-grandfathered small group plans are $2,050 individual and $4,100 family.
The out-of-pocket limits for 2015 stand-alone pediatric dental Marketplace plans have increased from the proposed limits. The 2015 confirmed annual out-of-pocket maximum will be limited to $350 for one covered child and $700 for two or more children.
Reinsurance Assessment Fee
The Reinsurance Assessment Fee is applicable to insured and self-funded major medical plans for calendar years 2014 through 2016. It will primarily be used to help lessen the impact of high-dollar claims occurring within the individual market. The 2014 fee is $63 per person, with scheduled collection in two installments: $52.50 in January, 2015, and $10.50 late in the fourth quarter of 2015.
The 2015 fee is confirmed at $44 per person. It was also confirmed that self-funded group health plans that are also self-administered, e.g. that do not use a third-party administrator for claims processing, will be exempt from making reinsurance contributions for 2015 and 2016.
States Moving from Federal to State-Run Marketplaces
States currently participating in the federal Marketplace will now have more time to transition to a state-run Marketplace. The final regulations confirmed the January 1 conditional approval deadline has been extended to June 15.
2015 Federal Marketplace User Fee
The user fee paid by insurers that offer plans on the federal Marketplace is confirmed at 3.5% of premiums. This is the same rate as in 2014.
Small Business Health Options Program (SHOP) Plans
Several standards have been finalized for the federally-facilitated SHOP, including allowing certain flexibilities with employee selection of dental-plans and employer contribution options after 2015 for full-time and non-full-time employees. The rule also confirms that a small employer participating in the SHOP that becomes a large employer would continue to be rated as a small employer.
The final rule permits states to allow SHOP enrollment through an agent or broker website as long as state law coincides. Modifications are being considered that would allow states flexibility in offering employees to choose any plan within a coverage level.
2015 Actuarial Value Calculator
The 2015 actuarial value calculator and methodology are available on The Center for Consumer Information & Insurance Oversight (CCIIO) website. This calculator is used for individual and family plans, as well as SHOP plans.
See the calculator and methodology
There are many other details confirmed in this final rule that impact insurers and governments. A fact sheet on the final rule is available on the Centers for Medicare and Medicaid Services (CMS) website.
Read the CMS fact sheet
