files-720612_1920The “tri agencies”–which includes the Internal Revenue Service (IRS), the Employee Benefits Security Administration (EBSA), and the U.S. Department of Health and Human Services (HHS)–are getting ready to release their final regulations for the Patient Protection and Affordable Care Act of 2010 (PPACA) and its companion Health Care and Education Reconciliation Act of 2010 (HCERA).

If you think that’s a lot of acronyms, then just wait until you read the full packet. It addresses popular provisions like grandfathering, coverage for dependent children up to age 26, and the appeal process, to name a few. A recent article on LifeHealthPro addresses many of the key provisions. Here’s a snapshot of a few of their findings, which will take effect starting January 1, 2017.



  • Plans that make significant changes will lose their “grandfathered” status, unless that change is only adding a new tier. Such as adding family coverage to what was previously a self-only plan.
  • Losing “grandfathered” status is irreversible. The tri agencies plan to show no mercy to plans that mess up and lose their status.

Essential Health Benefits (EHB) Package

  • Non-EHB coverage issuers aren’t allowed to use as many EHB benchmarks for PPACA compliance purposes. While they could once choose from a list of over 500 benchmarks, that number will be reduced to 51.

Health Reimbursement Arrangements (HRAs)

  • HRAs are exempt from the PPACA ban on annual lifetime and benefits limits, but the tri agencies are essentially banning individual health-HRA packages by requiring the HRAs they contain to provide unlimited benefits for EHB services.



  • Individuals affected by an “adverse benefit determination” will be permitted to use both internal appeal and external review programs, regardless of whether the rescission of health coverage affects any particular benefit.


Coverage for dependent children up to age 26

  • Plans whose provider networks are only local will be required to cover service for out-of-area dependent children, like those who attend college or work in another town.


Internal Appeals and External Review

  • Insurers must allow individual policy owners to appeal coverage eligibility decisions within the internal appeal process, and only one level of internal appeal is permitted.
  • A maximum external review filing fee of $25 per filing and $75 per claimant per plan year will be implemented. No fee will apply in states without filing fee rules.


General Patient Protection Provisions

  • The tri agencies are still figuring out how to handle balance billing. They neither require plans or providers to cover balance billed amounts, nor do they prohibit balance billing.
  • They’re also still working on how to implement the Expatriate Health Coverage Clarification Act of 2014 (EHCCA) under the Consolidated and Further Continuing Appropriations Act of 2015. In the meantime employers and issuers should continue to use the interim guidance.