ACA Final Rules Issued in Bulk. 12 Changes You Need to Know.

Over the years, federal agencies have issued a plethora of ACA proposed and interim rules, as well as regulatory guidance. But none of it was officially finalized — until now. The feds just issued final rules in bulk, solidifying those earlier efforts. In addition, the rules contain a few surprises you need to know about. 

The final rules were just published as part of a 104-page addition to the Federal Register. They cover a wide swath of the healthcare reform law — including dependent coverage, patient protection rules, lifetime and annual limits, claims appeals, rescissions, HRA integration with Medicare, and grandfathered plan provisions.

For the most part, the rules don’t contain many substantial changes from the regulatory paperwork the feds have issued over the years. But there were a few modifications that employers and insurers will need to know about.

Here’s a breakdown of the most substantial changes and those that will affect the most plans:

Dependent coverage

  • Service area restrictions. Eligibility restrictions requiring plan participants to work, live or reside in a service area (as is typically the case with HMOs) cannot be applied to dependent children until they reach age 26. However, plans can continue to provide coverage only within a designated service area.
  • Variations in coverage. Terms of plan coverage cannot vary based on the age of a dependent child, except for children age 26 and older.

Patient protections

  • Individual primary care designation. If a plan requires participants to designate a primary care provider, each participant must be permitted to designate his or her own provider.
  • Children’s primary care providers. If a plan requires the designation of a primary care provider for a child, the plan must allow any physician who specializes in pediatrics (including subspecialties in pediatrics) — and who is in-network and available to accept the child — to be designated as the child’s primary care provider.
  • OB/GYN access. All women, no matter their age, must be ensured direct access to OB/GYN care. That means no authorizations or referrals can be required to seek OB/GYN care.

Lifetime and annual limits

  • General prohibition on limits. Lifetime and annual dollar limits on coverage for “essential health benefits” are generally prohibited, regardless of whether those benefits are provided by in-network or out-of-network providers.

Claims appeals

  • Evidence. Plans must provide claimants with any new or additional evidence that is being relied upon or used in anyway in connection with a claim, as well as any new or additional rationale for a denial of an internal appeal. This must be provided free of charge automatically. Merely providing a notice of the availability of such information is not enough.


  • Non-payment of COBRA premiums. A retroactive termination of COBRA coverage is permissible if the participant has failed to pay the required premium.

HRA integration

  • Medicare. Employers with fewer than 20 employees that are not required to offer their group health plan coverage to employees who are eligible for Medicare coverage can integrate an HRA with Medicare Part B or D.

Grandfathered plans

  • Multi-employer plans. New contributing employers can join a multi-employer plan for the express purpose of taking advantage of the plan’s grandfathered status without violating anti-abuse rules.
  • Plan changes. One plan’s status change doesn’t change the status of all benefits packages. Example: The loss of grandfathered status for a PPO plan won’t impact the status of an HDHP plan.
  • Generic alternatives. Plans can move brand-name drugs to a higher cost-sharing tier when a generic alternative becomes available without losing grandfathered status.

Disability benefits claims appeals

Published along with the final rules were proposed rules on the claims and appeals rules applicable to plans providing disability benefits.

In a nutshell, the rules would apply the claims and appeals procedure rules for standard healthcare claims to disability benefits claims.

Survey reveals Employer family health premiums rise 4% to $17,545 in 2015.

Single and family premiums for employer-sponsored health insurance rose an average of 4% in 2015, according to the recently released Kaiser Family Foundation/Health Research & Educational Trust

This annual survey, now in its 17th year, of nearly 2,000 small and large employers provides a detailed snapshot of trends in employer-sponsored health insurance, costs, and coverage—including employers’ responses to provisions of the Affordable Care Act.

The average annual premium for single coverage is $6,251, of which workers on average pay $1,071. The average family premium is $17,545, with workers on average contributing $4,955.

The survey also finds that 81% of covered workers are in plans with a general annual deductible, which average $1,318 for single coverage this year. Covered workers in smaller firms (three to 199 workers) face an average deductible of $1,836 this year. That’s 66% more than the $1,105 average deductible facing covered workers at large firms (at least 200 workers).

Since 2010, both the share of workers with deductibles and the size of those deductibles have increased sharply. These two trends together result in a 67% increase in deductibles since 2010, much faster than the rise in single premiums (24%) and about seven times the rise in workers’ wages (10%) and general inflation (9%).

“With deductibles rising so much faster than premiums and wages, it’s no surprise that consumers have not felt the slowdown in health spending,” foundation president and CEO Drew Altman says.

“Employees are benefiting from stable employer health benefits coverage and modest premium growth,” says Maulik Joshi, president of HRET, an affiliate of the American Hospital Association. “Also noteworthy is that many employers are tying financial incentives to employee participation in health and wellness programs.”