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What are your thoughts on maximum deductibles for large group, come 2014? Will the $2,000 limit apply to large group too, or only small group?
Deductibles After 2014
- Thread starter Sam
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Here is my understanding of the issue.
The IFP and Small Group market has Actuarial Value (AV) which are the metal tiers of bronze, silver, gold & platinum. In that market the maximum deductible is $2,000 ($4,000 for families) unless a higher deductible is needed to fit it into one of the metal tiers. The max out-of-pocket is $6,250 ($12,500 per family), and that includes all member costs except premium (for instance, copays, Rx, and deductibles are included in the OOP max).
The large group market has Minimum Value (MV) and Minimum Essential Coverage (MEC). They aren't required to use the metal tiers, and they don't have to include all 10 Essential Health Benefits (EHBs). They don't have to meet a maximum $2,000 deductible. However, they are subject to the maximum out-of-pocket limits of $6,250 and $12,500 just like IFP and Small Group.
Like I said, that's my understanding, but I was proven wrong at least one time before (it makes my husband laugh when I admit to that!)
The IFP and Small Group market has Actuarial Value (AV) which are the metal tiers of bronze, silver, gold & platinum. In that market the maximum deductible is $2,000 ($4,000 for families) unless a higher deductible is needed to fit it into one of the metal tiers. The max out-of-pocket is $6,250 ($12,500 per family), and that includes all member costs except premium (for instance, copays, Rx, and deductibles are included in the OOP max).
The large group market has Minimum Value (MV) and Minimum Essential Coverage (MEC). They aren't required to use the metal tiers, and they don't have to include all 10 Essential Health Benefits (EHBs). They don't have to meet a maximum $2,000 deductible. However, they are subject to the maximum out-of-pocket limits of $6,250 and $12,500 just like IFP and Small Group.
Like I said, that's my understanding, but I was proven wrong at least one time before (it makes my husband laugh when I admit to that!)
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Wait, co-pays and Rx are included in the $6,250 OOP limit? How did I miss that?
Yes. Here is a quote from a Towers Watson article:
Beginning generally with their 2014 plan year, non-grandfathered employer group health plans will need to comply with a single OOP maximum applicable to all coverage under the plan (e.g., medical, prescription drug and mental health and substance use disorder benefits).
Twenty New PPACA FAQs Clarify the Out-of-Pocket Maximum Mandate and Numerous Preventive Services Issues - Towers Watson
Sam, the same article also answers your question about the $2,000 deductible. Please note that it refers to large group as being 100+ in that reference, and if I remember correctly, some of the "large group" provisions don't hit the 50-99 space, and this might be one of them.
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Thanks Ann, I appreciate that. The most recent Wolters Kluwer benefits management briefing paper suggests that it is not applicable over 50, but they say it is based on their best interpretation, but nothing concrete.
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There is an excellent write-up here ACA Guidance on Cost-Sharing Limits, Preventive Care and More | E is for ERISA
"“Small group market” is defined under applicable state rate filing laws, but in states that do not have a definition, the ACA definition will apply. In California, small group will mean up to and including 50 employees for 2014 and 2015; the ACA definition is up to and including 100 employees. Some small group coverage may exceed the annual deductible limit if doing so is necessary to reach a given “metal tier” level of coverage."
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There is an excellent write-up here ACA Guidance on Cost-Sharing Limits, Preventive Care and More | E is for ERISA
"“Small group market” is defined under applicable state rate filing laws, but in states that do not have a definition, the ACA definition will apply. In California, small group will mean up to and including 50 employees for 2014 and 2015; the ACA definition is up to and including 100 employees. Some small group coverage may exceed the annual deductible limit if doing so is necessary to reach a given “metal tier” level of coverage."
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