ACA News & Publications

ACA Pathways: HSS Issues Notice of Benefit and Payment Parameters for 2015 Final Rule

March 12, 2014

On March 5, 2014, the Department of Health and Human Services (HHS) released its 2015 Notice of Benefit and Payment Parameters Final Rule. The Final Rule describes payment parameters applicable to the 2015 benefit year and standards relating to the:

  • Transitional reinsurance program;
  • 2015 open enrollment period; and
  • 2015 annual limitations on cost-sharing

Among other provisions, the Final Rule also implements patient safety standards for qualified health plans (QHPs) offered in the Health Insurance Marketplace (Marketplace) and includes standards related to the employee choice and premium aggregation provisions in federally-facilitated Small Business Health Options Programs (SHOPs).

Reinsurance Program

Beginning in 2014, the Affordable Care Act (ACA) requires a three-year transitional reinsurance program to be established in each state. This program is intended to help stabilize premiums for coverage in the individual market during the first three years of Marketplace operation (2014 through 2016) when individuals with higher-cost medical needs gain insurance coverage. This program imposes a fee on health insurance issuers and self-insured group health plans.

Key highlights of the Final Rule with respect to the reinsurance program include the following:

  • The definition of "contributing entity" is modified for the 2015 and 2016 benefit years to exempt certain self-insured, self-administered group health plans from the reinsurance contribution requirement;
  • There is a two-installment contribution schedule for the payment of reinsurance fees.For example, the $63 per capita reinsurance contribution for the 2014 benefit year will be collected in two installments: $52.50 in January 2015 and $10.50 late in the fourth quarter of 2015;
  • The Final Rule refines the definition of "major medical coverage" to prevent more than one payment per enrollee; and
  • The 2015 annual reinsurance contribution rate will be $44 per enrollee

Open Enrollment Period for 2015

The Final Rule finalizes the Marketplace's annual open enrollment period for the 2015 benefit year, which will begin on November 15, 2014, and extend through February 15, 2015. According to HHS, this schedule gives issuers additional time before they need to set their 2015 rates and submit their QHP applications, gives states and HHS more time to prepare for open enrollment, and gives consumers until February 15, 2015, to shop for coverage. The Final Rule does not change the schedule for the Marketplace's initial open enrollment period, which began on October 1, 2013, and goes until March 31, 2014.

Annual Limitations on Cost-sharing

Effective for plan years beginning on or after January 1, 2014, the ACA requires certain non-grandfathered health plans to comply with cost-sharing limits with respect to their coverage of essential health benefits. The cost-sharing limits include both an overall annual limit, or an out-of-pocket maximum, and an annual deductible limit.

The ACA requires that these limits be updated annually based on the percent increase in average premiums per person for health insurance coverage. The Final Rule establishes the cost-sharing limits for 2015, which are lower than the limits HHS originally proposed. For 2015:

  • The annual deductible for a health plan in the small group market may not exceed $2,050 for self-only coverage and $4,100 for family coverage; and
  • The annual out-of-pocket maximum for all health plans is $6,600 for self-only coverage and $13,200 for family coverage

The Final Rule is available at:

For More Information
For more information about this ACA Pathways or about any other health care reform-related provisions, please contact your Burnham Benefits consultant or Burnham Benefits at:

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This ACA Pathways is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers should contact legal counsel for legal advice. The information contained in this ACA Pathways includes emerging health care news from a limited perspective and does not encompass all views. The information was selected from a wide range of sources selected on the basis of their potential impact on employers and/or their employee benefit plans. For more information, please contact Burnham Benefits.

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