Health Care Reform
The 2010 Patient Protection and Affordable Care Act (also known as health care reform) provided mandates that have expanded health coverage and benefits in a number of ways, including those under the DoD NAF health program. Some of the changes over the last few years are outlined below:
Out-of-pocket maximum/limit The Out-of-pocket maximum (OOPM) is the most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance, your health plan pays 100% of the costs of covered benefits. For the Choice POSII plan, there is an in-network OOPM and an out-of-network OOPM. For the indemnity plans for both CONUS and OCONUS, the OOPM matches the in-network OOPM of the Choice POSII plan.
The out-of-pocket limit doesn't include your monthly premiums. It also does not include anything you spend for services your plan doesn't cover. Beginning in 2014, in-network member cost sharing, including copayments, must accumulate to the plan's out-of-pocket maximum. Out-of-pocket maximums include deductibles, coinsurance and copays. Out-of-Pocket maximums do not include prescription eyewear, 'Choose Generics' penalties, expenses covered at 50%, expenses above the maximum allowable amount, and non-covered expenses.
The Affordable Care Act requires plans to establish limits on member cost sharing for essential health benefits. These out-of-pocket maximum (OOPM) limits are the maximum a plan can have and are updated on a yearly basis.
In 2019, those limits are as follows:
- $7,900 for self-only coverage. Note that the self-only OOPM applies to each individual, regardless of whether he or she is enrolled in self-only or family coverage. In 2019, the DoD NAF HBP in-network employee only coverage OOP max is $4,000 (which is less than the individual OOPM of $7,900).
- $15,800 for other than self-only (family) coverage. In 2019, the DoD NAF HBP in-network family OOP max is $8,000. Note that the self-only OOPM of $7,900 applies to each individual, regardless of whether he or she is enrolled in self-only or family coverage. Therefore, if one individual under family coverage has $7,900 applied toward in-network OOP max, this individual will have 100% plan paid for covered services for the remainder of the plan year.
As of January 1, 2016, your employer is required to furnish a tax form for health care coverage. This form will be provided along with your annual W2 form, and will need to be submitted with your annual tax filing – consult your personal tax advisor.
Due to reporting requirements under the Affordable Care Act, certain information such as social security numbers and dates of births are required for all dependents enrolled in the DoD NAF health plan. Please update your records with your local HR office. Failure to provide SSNs and DoBs could result in IRS imposed penalties. Consult your local tax advisor.
Beginning in 2014, the Affordable Care Act required that all Americans have minimum essential health insurance. If you don’t, you may have to pay a tax penalty. If you don’t get insurance through your DoD NAF employer, you can buy it on your own through a public exchange or marketplace, through a broker or directly from an insurance company. Currently, the DoD NAF health plan meets the criteria of minimum essential health coverage and affordability required by the health care reform law per the TRICARE Affirmation Action (P.L.111-159)
Another health care reform mandate is called the Employer Responsibility Penalty. This penalty includes a provision that employers must offer coverage to all employees that work an average of 30 or more hours in a 12-month period or pay a penalty.
For general information about health care reform, visit www.healthcare.gov.