Employers with fewer than 50 employees are not required to offer health insurance. However, those who choose to offer coverage will have new options through Oregon’s online marketplace, Cover Oregon.
Benefit changes: Individual and small group plans sold after Jan.1, 2014, must include essential benefits in 10 categories:
- Ambulatory (outpatient) services
- Emergency services
- Maternity and newborn care
- Mental health and substance abuse disorder services, including behavioral health treatment
- Prescription drugs
- Rehabilitative and habilitative services and devices
- Laboratory services
- Preventive and wellness services and chronic disease management
- Pediatric services, including oral and vision care
Knowing how much your plan covers: Plans will be labeled to help consumers understand the level of coverage they are buying. The levels of coverage are:
- Bronze – The plan must cover 60 percent of expected costs for the average individual
- Silver – The plan must cover 70 percent of expected costs for the average individual
- Gold – The plan must cover 80 percent of expected costs for the average individual
- Platinum – The plan must cover 90 percent of expected costs for the average individual
Insurers can sell more than one plan in each of the categories although Oregon requires all insurers to sell one standardized bronze plan and one standardized silver plan. These plans will have identical benefits, making it easier for consumers to compare different companies based on price, provide networks, customer service and other factors.
Limiting out-of-pocket costs: All plans sold or renewed in 2014, must limit consumers’ annual out-of-pocket costs (such as co-pays) to approximately $6,350 for individual and $12,700 for families. These limits will be indexed to average premium growth in future years.
Health Savings Accounts (HSA): Nothing in the law prevents individuals from contributing to a Health Savings Account (HSA), or discourages an individual from doing so. The minimum level of coverage required to meet the individual mandate was specifically designed to allow for the purchase of a qualified high-deductible health plan that would complement the HSA.
* Lifetime coverage limits: Insurance companies cannot place a dollar limit on how much they will cover over the lifetime of a member.
* Annual coverage limits: Rules are phasing out annual limits on any “essential benefits” although some employers/insurers received waivers from this requirement. The requirement applies to all but grandfathered individual plans. For plans issued or renewed on or after Jan. 1, 2014, annual dollar limits on coverage of essential benefits will be prohibited.
Small business tax credits: Businesses with fewer than 25 full-time equivalent employees (FTE) and average annual wages less than $50,000 per employee may qualify for tax credits available now. To receive the tax credit, an employer must have a group health plan and must pay at least 50 percent of the premium. The tax credit is equal to a percentage of what the employer pays and is based on the average premium in the small group market in the state.
For tax years 2010 through 2013, the maximum credit in each year is 35 percent of the employer’s contributions (25 percent for nonprofit employers). Beginning tax year 2014, the maximum credit is 50 percent of the employer’s contribution (35 percent for nonprofit employers).
The full 50 percent tax credit is available for a business with:
- 10 or fewer full time equivalent workers and
- average annual wages of $25,000 or less.
The tax credit phases out completely for employers with 25 full time equivalent workers or average wages of $50,000. The IRS administers this program. For details, consult your tax advisor or review the IRS information.
Buying insurance through Cover Oregon: On Oct. 1, 2013, Cover Oregon will launch an online central marketplace where individuals and small employers can compare health coverage options. Small employers may choose a level of coverage and then allow each employee to select his or her own insurer and plan. Cover Oregon can also collect the employer and employee contributions and direct those payments to the chosen insurers. See the fact sheet for small employers.