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Healthcare Reform - Understanding Who Must Comply

PPACA applies to the majority of employer-sponsored health plans. However, there are few exceptions to this rule, such as retiree coverage and certain stand alone “Excepted Benefit” plans (described further below). Below is a snapshot of which plans must comply, and which plans are generally exempt from compliance (unless otherwise noted). The distinction between whether a plan is ERISA or Non-ERISA does not apply here, as PPACA applies to both ERISA and Non-ERISA plans.


Plans That Must Comply


• Medical Plans (both self-funded and insured)


• Non-ERISA Plans (Church and Governmental Plans)


• Employer Plans that are deemed a single employer under the common-ownership rules


• Multiple Employer Welfare Arrangements (MEWAs) that provide medical benefits


• Plans governed by a Collectively Bargained Agreement (CBA) that provide medical benefits


• Mini-Med Plans


• Dental and Vision Plans that are bundled with Medical


• Stand-Alone Prescription Drug Plans


• Employee Assistance Programs or EAPs (whether insured or self-funded) if part of the group health plan (or subject to Knox-Keene requirements)


• Executive Medical Plans


Plans That Do Not Need To Comply


• Stand-Alone Excepted Benefit Plans such as:


  o Stand-alone dental and vision benefits


  o Most health Flexible Spending Accounts


  o Medigap policies


  o Accidental death and dismemberment coverage


  o Specified disease (e.g., cancer) and limited hospital indemnity (i.e., $100 per day in hospital) coverage


• Stand-Alone Retiree Plans that operate separate from a medical plan (offered through a separate plan document) and treated as separate for applicable reporting requirements (Form 5500). One exception here is that stand-alone retiree plans must comply with the PCORI fee.


Stand-alone dental and vision benefits are considered Excepted Benefits if they are: (i) provided under a separate plan or (ii) otherwise not "an integral part" of an employer’s group health plan (or a collectively bargained multiemployer plan). Benefits which are not an integral part of a plan if participants have the right to waive coverage for the benefits, meaning individuals can elect separately or opt-out.


This content is being provided as an informational tool. It is believed to be accurate at the time of posting and is subject to change. It is recommended that plans consult with their own experts or counsel to review all applicable federal and state legal requirements that may apply to their group health plan. By providing this information, Meritain Health is not exercising discretionary authority or assuming a plan fiduciary role, nor is Meritain Health providing legal advice.