2016 Cost-Sharing Limits, Reinsurance Fee, and Other Changes Related to the Exchange

In late February, the Department of Health and Human Services (“HHS”) changed cost-sharing and transitional reinsurance program fee limits and released standards for health insurers and the Exchange (a.k.a., the Health Insurance Marketplace). Below identifies a few items of note for employers.

For 2016, the maximum annual out-of-pocket limits for non-grandfathered plans are $6,850 for individual coverage and $13,700 for family coverage. These limits generally apply with respect to any essential health benefits (EHBs) offered under the group health plan. The final regulations established that starting in the 2016 plan year, the self-only annual limitation on cost sharing applies to each individual, regardless of whether the individual is enrolled in other than self-only coverage, including in a family HDHP.[1]

The reinsurance fee for 2016 is $27 per covered individual. 2016 is the final year for the transitional reinsurance program.
Generally enrollment counts for the reinsurance fee are due by November 15 of the benefit year. Payment is due by January 15 of the following year (and November 15 of the following year, if paying in two installments). The regulations make clear that when these dates fall on a Saturday, Sunday or holiday, submission of this information and/or payment is due by the next business day.

For benefit year January 1, 2016, the annual enrollment period for the Exchange begins November 1, 2015 and extends through January 31, 2016.
For the benefit year beginning on January 1, 2016, the Exchange must ensure coverage is effective:
– January 1, 2016 for plan selections received by the Exchange on or before December 15, 2015;
– February 1, 2015 for plan selections received by the Exchange from December 16, 2015 through January 15, 2016; and
– March 1, 2016 for plan selections received by the Exchange from January 16, 2016 through January 31, 2016.

For the regulations, visit: http://www.gpo.gov/fdsys/pkg/FR-2015-02-27/pdf/2015-03751.pdf

For the fact sheet, visit: http://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/2016-PN-Fact-Sheet-final.pdf
[1] In a subsequently-issued FAQ, HHS addressed how this change may affect qualified high deductible health plans (HDHPs). However, it appears HHS may have pulled that guidance as the information is no longer available on the HHS website.

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