HEALTH INSURANCE Management System FOR OUR TEAM MEMBERS

The ACA’s requirements for large-group plans and self-insured plans are different, so ACA compliance is measured in other ways for those plans. 

"Large group" means 51 or more employees in most states, but 101 or more employees in California, Colorado, New York, and Vermont.

For example, while individual and small-group health plans are required to cover the ACA’s essential health benefits, that’s not the case for large-group plans or self-insured plans of any size. 

Large-group and self-insured plans also don’t have to comply with the ACA’s 3:1 age-rating ratio, or 1.5:1 tobacco rating rule, as those are specific to individual and small-group plans.

But large-group plans do have to provide minimum value or else the employer faces a potential financial penalty. And as long as a large-group or self-insured plan is not grandfathered (meaning it took effect after the ACA was signed into law on March 23, 2010), it also has to cover recommended preventive care without cost-sharing, and for any essential health benefits that the plan does cover, it has to cap out-of-pocket costs for in-network care at no more than the level set each year by the federal government.

Large group plans have to comply with the ACA's MLR requirement, which means they have to spend at least 85% of premium revenue on claims and quality improvements, and no more than 15% on administrative expenses. Self-insured plans are not subject to MLR requirements.