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Master Health Reform Guide, 2016 Edition

Master Health Reform Guide, 2016 Edition



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This concise yet authoritative guide highlights everything employers need to know about health reform, explaining complex concepts in plain English and clarifying even the most complicated requirements. This invaluable resource simplifies everything, from the employer mandate, to the Cadillac tax to contraceptive coverage, private health exchanges, reporting requirements, and much more.

Master Health Reform Guide includes:

  • Fast Facts at the start of each chapter, providing an instant overview of the most crucial areas of health reform
  • Forms for all relevant requirements (see Table of Contents)
  • A handy reference card that can be removed from the book and used as convenient references
  • An extensive Glossary of health reform terms, making it easy to understand even the most unfamiliar concepts
  • Appendices that provide in-depth analysis of the most pressing topics (see Table of Contents)

Plus, Master Health Reform Guide delivers clear, concise, plain-English analysis of the most pressing issues facing employers, including:

  • Employer Mandate: Clarification of all facets, including minimum essential coverage, shared responsibility, and more
  • Cadillac Tax: Coverage of the limits and the excise taxes set to take effect in 2018
  • Contraceptive Coverage: Expert insights into the requirements and challenges regarding this area of coverage
  • Reporting: Practical guidance on forms 1094 and 1095, along with other employer reporting requirements

And this unique resource also provides exclusive articles, providing in-depth, expert analysis of the most critical developments and ongoing issues, including:

  • The impact of the King v. Burwell Supreme Court decision
  • The possibility of ERISA litigation being brought against companies that reduce employee hours to avoid ACA fines
  • The details involved in Private Health Exchanges and why interest remains high though employers are slow to adopt

Last Updated 12/09/2015
Product Line Wolters Kluwer Legal & Regulatory U.S.
ISBN 9781454874195
SKU 10038652-0001
Table of Contents


Chapter 1 – Health Insurance

  • Generally
  • Grandfathered plans
  • Retiree-only plans
  • Excepted benefits
  • Expatriate plans
  • MEWAs

Chapter 2 – Group Market Rules

  • Prohibition on lifetime or annual limits
  • Prohibition on rescissions
  • Required preventive health services coverage
  • Coverage for adult children
  • Prohibition on discrimination in favor of highly compensated individuals
  • Guaranteed availability and renewal
  • Prohibition on preexisting condition exclusions
  • Prohibition on discrimination based on health status
  • Prohibition on waiting periods
  • Selection of primary care provider
  • Coverage for clinical trials

Chapter 3 - Coverage Responsibilities

  • Individual mandate
  • Employer mandate
  • Automatic enrollment

Chapter 4 - Health Exchanges

  • Establishment of Exchanges
  • Basic requirements
  • Essential health benefits
  • Enrollment periods
  • Eligibility rules
  • Subsidy determination notices
  • Small Business Health Options Program (SHOP)

Chapter 5 - Account-Based Plans (FSAs, HSAs, HRAs)

  • Overview of account-based plans
  • Simple cafeteria plans
  • Maximum annual salary reduction for FSAs
  • Limitiations on reimbursements for over-the-counter medicines
  • Additional tax on HSA and Archer MSA distributions
  • Exchange-participating QHP offered through cafeteria plan
  • HRA compliance with market reforms
  • Employer payment plans

Chapter 6 - Reporting Rules

  • Summary of Benefits and Coverage
  • Cost of coverage on W-2
  • Information reporting on coverage
  • Annual report on medical loss ratio
  • Annual report on health care quality
  • Claims appeals process

Chapter 7 - Tax Rules

  • Small employer health insurance credit
  • Excise tax on high-cost coverage
  • Elimination of retiree drug subsidy
  • Premium tax credit for individuals
  • Additional Medicare tax on wages

Chapter 8 - Health Insurer Provisions

  • Medical loss ratio
  • Review of premium increases
  • Premium rate limitations
  • Fees (reinsurance, provider, PCORI)

Chapter 9 - Other Provisions and Issues

  • Breastfeeding requirements
  • Wellness programs
  • Whistleblowing
  • Elimination of creditable coverage certificate
  • Future of COBRA


  • Patient Protection Model Disclosure
  • Model Language Notice Lifetime Limit No Longer Applies and Enrollment Opportunity
  • Model Grandfathered Health Plan Disclosure Notice
  • Model Notice of Adverse Benefit Determination
  • Model Notice of Final Internal Adverse Benefit Determination
  • Model Notice of Final External Review Decision
  • Notice of Failure to Meet Minimum Annual Limits for Essential Benefits and Receipt of Waiver
  • Model Notice to Enrollees in a Self-Funded Nonfederal Governmental Group Health Plan For Plan Years Beginning On or After September 23, 2010
  • Summary of Benefits and Coverage (SBC) Template
  • Sample Completed SBC
  • What Your Plan Covers and What it Costs Draft Instruction Guide for Group Policies
  • What Your Plan Covers and What it Costs Draft Instruction Guide for Individually Purchased Policies
  • Why This Matters Language for “Yes” Answers
  • Why This Matters Language for “No” Answers
  • Guide for Coverage Examples Calculations — Diabetes
  • Guide for Coverage Examples Calculations — Maternity
  • Uniform Glossary of Coverage and Medical Terms
  • Management of Type 2 Diabetes
  • Maternity Care
  • Benefits Template SBC Addition
  • Benefits Template SBC, issued December 2014
  • New Health Insurance Marketplace Coverage Options and Your Health Coverage
  • New Health Insurance Marketplace Coverage Options and Your Health Coverage
  • Form 1094-B
  • Form 1094-C
  • Instructions for 1094-B and 1094-C
  • Form 1095-B
  • Form 1095-C
  • Instructions for 1095-B and 1095 -C


  • Navigating the small employer health insurance tax credit
  • What happens if one of your employees wants to blow the whistle?
  • Simple cafeteria plans- more to the ACA than just health benefits
  • Employers should implement cost-cutting strategies now to avoid ACA's excise tax in 2018, expert says
  • Companies that reduce employee hours to avoid ACA fines might face ERISA litigation risk
  • The end of creditable coverage: what you need to know
  • Even large group plans may have to know their EHBs
  • Will states gut the ACA with Section 1332 waivers?
  • A subsidy determination notice just arrived - now what?
  • Private Health Exchanges: Interest remains high but employers slow to adopt
  • SCOTUS rules in favor of ACA subsidies for federal Exchange enrollees
  • King v. Burwell: What the
  • Supreme Court ruling on ACA
  • subsidies means for employers