SECOND OPINIONS: ACA Checklist: 2014 Plan Amendments

November 6, 2013 ( - For the past few years, we have put together an annual list of ACA plan amendments that are required for the upcoming plan year.  Back by popular demand, below is our ACA checklist for 2014.

For the past few years, we have put together an annual list of ACA plan amendments that are required for the upcoming plan year.  Back by popular demand, below is our ACA checklist for 2014.

What plan amendments are required for 2014 for both grandfathered and non-grandfathered plans?

The following plan changes are required for all plans (grandfathered and non-grandfathered) for plan years starting on or after 1/1/4:

·                     Waiting Periods – Plans may not have an eligibility waiting period of more than 90 days.

·                     Annual Limits – Plans may no longer have annual dollar limits on essential health benefits (up until this time, plans were able to have some restricted annual limits).

·                     No Pre-Existing Condition Exclusions (PCEs)–  Plans are no longer able to impose PCEs, regardless of age.  Note that regulations provide that plans still must provide certificates of creditable coverage through 12/31/14.


What plan amendments are required for 2014 non-grandfathered plans only?

The list below only applies to non-grandfathered plans.  As a practical matter, most plans that were grandfathered at one time have given up their grandfathered plan status by now.  However, if your plan still is grandfathered, you will not have to make the following changes yet, but will when you decide to lose grandfathered status:

·                     Clinical Trials – Plans must cover certain routine patient costs related to approved clinic trials.  However, the plan is not required to cover the cost of the research itself, such as the device being tested.  Many plans list clinical trials as part of an experimental treatment exclusion.  So, plans should add coverage for the required clinical trial costs and also check their experimental treatment exclusion to make sure their language is consistent.

·                     Wellness – Plans should review their wellness programs to make sure they comply with the new HIPAA wellness regulations that were mandated by the ACA.  For example, plans are able to provide a health-based incentive of up to 30% of the cost of coverage, or even 50% for tobacco programs.  Previously the limit was 20%.  There are also new rules regarding reasonable alternatives.

·                     Out-of-Pocket Limits – A plan’s out-of-pocket limits may not exceed $6,350 for individuals / $12,700 for families.  

·                     Deductible Limits – Insured plans in the small group market must limit deductibles to $2,000 for individuals / $4,000 for families (not applicable to large group market plans or self-funded plans).

·                     Essential Health Benefits – Insured plans in the small group market must cover essential health benefits (not applicable to large group market plans or self-funded plans).

We are a grandfather plan that is losing grandfathered plan status starting January 1, 2014.  What additional amendments will we need? 

When a plan loses grandfathered status, they must remember to go back and add any prior plan changes from which they were previously grandfathered.  Grandfathered plans should be careful not to make mid-year changes that could inadvertently trigger loss of grandfathered status.  Instead, grandfathered plans should deliberately decide when they may want to lose grandfathered status so that they can adopt the required plan amendments accordingly.  Prior ACA requirements that will apply when a plan loses grandfathered status include:

·                     Appeals / External Review - Plans must follow additional claims and appeals rules (on top of existing ERISA claims procedure requirements), plus have an additional layer of external review.

·                     Preventive Care - Plans must cover certain recommended preventive care services, including women’s preventive care, at 100% with no cost-sharing (may limit to in-network).

·                     Emergency - Plans must cover out-of-network emergency services under the same terms as network emergency services and may not require prior authorization.

·                     Choice of Provider - Plans that require designation of a primary care provider (PCP) must allow an individual to choose their PCP, including allowing a child to name a pediatrician as their PCP.

·                     OB-GYN – Plans may not require prior authorizations or referrals for OB-GYN visits.

Now is the time to get ready for 2014.  Make sure your plan has made the required amendments and that these changes have been incorporated into your SPD or other communications materials. 

Note that another good resource for information on these required changes is the DOL website, particularly the ACA Q&As – see  


Got a health-care reform question?  You can ask YOUR health-care reform legislation question online at  

You can find a handy list of Key Provisions of the Patient Protection and Affordable Care Act and their effective dates at   


Christy Tinnes is a Principal in the Health & Welfare Group of Groom Law Group in Washington, D.C.  She is involved in all aspects of health and welfare plans, including ERISA, HIPAA portability, HIPAA privacy, COBRA, and Medicare.  She represents employers designing health plans as well as insurers designing new products.  Most recently, she has been extensively involved in the insurance market reform and employer mandate provisions of the health-care reform legislation.

Brigen Winters is a Principal at Groom Law Group, Chartered, where he co-chairs the firm's Policy and Legislation group. He counsels plan sponsors, insurers, and other financial institutions regarding health and welfare, executive compensation, and tax-qualified arrangements, and advises clients on legislative and regulatory matters, with a particular focus on the recently enacted health-reform legislation.

PLEASE NOTE:  This feature is intended to provide general information only, does not constitute legal advice, and cannot be used or substituted for legal or tax advice.