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Mandate Exemptions

Retiree-Only Plans are Exempt from the Following Mandates:

  • Sections 1001(5) and 10101 – No lifetime or annual dollar limits on essential benefits
  • Section 1001(5) – Prohibition on rescission
  • Section 1001(5) – Coverage of certain preventive health services provided in network
  • Section 1001(5) – Extension of dependent coverage
  • Section 1001(5) – Development and utilization of uniform explanation of coverage documents and standardized definitions (Summary of Benefits and Coverage)
  • Section 1001(5) – Provision of additional information
  • Section 1001(5) – Prohibition on discrimination in favor of highly compensated individuals for insured plans
  • Section 1001(5) – Ensuring the quality of care reporting
  • Section 1001(5) 8 – Medical loss ratio requirements
  • Section 1001(5) – Required appeals process and various requirements in the claims and appeals rules
  • Section 1001(5) – Patient protections (choice of provider, emergency services requirements)
  • Section 1003 – Rate review
  • Section 1201 – Prohibition of preexisting condition exclusions or other discrimination based on health status for children under age 19
  • Section 1201 – Restrictions on what criteria can be used in rating and rate band limits
  • Section 1201 – Guaranteed issue
  • Section 1201 – Guaranteed renewability
  • Section 1201 – Prohibiting discrimination against individual participants and beneficiaries based on health status
  • Section 1201 – Non-discrimination towards health care providers
  • Section 1201 – Cost-sharing requirements and essential benefit requirements
  • Sections 1201 and 10103 – Prohibition on waiting periods of more than 90 days
  • Section 10103 – Coverage for individuals participating in approved clinical trials

Premium-Only HRA Plans are Exempt from The Following Mandates in Addition to Those Above:

  • Section 1103 – Web portal reporting requirements
  • Section 1341 – Reinsurance
  • Section 1311(e) – Risk pooling (applies to small group retiree-only plans, with the exception of grandfathered plans)
  • Section 3141 – Reinsurance
  • Section 1342 – Risk corridors (applies to retiree-only qualified health plans)
  • Section 1343 – Risk adjustment (applies to small group retiree only plans)
  • Section 9022 – W-2 reporting (applies to employers that sponsor retiree only plans, but only if the retiree otherwise is receiving a Form W-2 from the employer.)
  • Section 6005 – Pharmacy benefit managers transparency
  • Section 9010 – Annual fee on health insurance providers

Retiree-Only, Premium-Only HRA Plans Must Still Comply with the Following Mandates:

  • Section 6301 – Research Trust Fund Health Plan Fee (PCORI)
  • Sections 9001 and 10901 – Excise tax on high-cost employer-sponsored health coverage
  • Section 1502 – Reporting of health insurance coverage
  • Section 9003 – Exclusion of over-the-counter drugs for group health plans, FSAs, HRAs, HSAs
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Erin Woulfe
Erin Woulfe
Erin Woulfe likes to write about things that matter. Keeping her finger on the pulse of what’s happening in the public sector world, she blogs about the latest legislative news and employee benefit trends that affect our school, city and county clients. She’s been with NIS since 2002. “I love connecting to our clients and providing them with the tools they need in order to administrate their plan,” says Erin. “Whether that be materials to educate their employees on certain benefits, how to effectively communicate change within an organization or just providing tips and how-to’s to help them make their job easier.”

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