New Rules Lay Down Law for Group Plans in 2019

In the final rules that the Centers for Medicare and Medicaid Services released for 2019, it also covered annual cost-sharing limits for group plans, rules on SHOP exchanges, and grandfathered plans, among other items we’ve covered earlier.

Here we break down some of the focuses of the 2019 rules:

 

Annual cost-sharing limits for group plans –  The maximum annual limit on cost-sharing for 2019 will jump to $7,900 for self-only coverage and $15,800 for other than self-only coverage. That’s up from $7,350 and $14,700, respectively, for this year.

 

New rules for SHOP –  Starting in 2019, the Small Business Health Options Program will no longer be required to provide employee eligibility determinations or appeals, premium aggregation or online enrollment. The SHOP scheme was created as a way for small employers to shop on an exchange much like individuals buying Affordable Care Act plans on marketplaces do.

SHOPs will still be required to determine employer eligibility for the SHOP and certify each qualified health plan available through the SHOP. However, enrollment will not be done online, but rather through agents and brokers who have registered with SHOP or an insurer offering a qualified health plan.

Notably, the small business health care tax credit will remain in place for eligible employers. SHOP will still have a website that includes information on the plans in all geographical areas, a premium calculator and access to customer service where SHOP personnel can answer questions.

One other item that will stay in place is the “rolling enrollment” rule that allows employers to buy SHOP coverage at any point during the year if they meet certain criteria.

The main reason for these changes is that SHOP enrollment has been well shy of expectations, so CMS is looking for ways to continue offering the administration functions required by the ACA.

That said, state-based SHOPs will still have leeway to maintain their current operations as they see fit. But for the most part, starting with the 2019 policy year, federal and state SHOPs will mainly rely on brokers and insurers to take on more of the responsibility for determining employee eligibility, conducting enrollment and collecting premiums.

 

Another grandfather extension –  CMS has extended the transitional policy that allows  states to permit insurers in small group markets to renew health insurance policies they would otherwise have to cancel because they don’t comply with parts of the ACA.

This means that states may allow insurers that have continually renewed eligible non-grandfathered individual and small group policies since Jan. 1, 2014, to again renew those policies, provided that the policies end by Dec. 31, 2019.

Health insurers that use the transitional policy will be required to send informational notices to affected individuals and employers.