ACA UPDATE: Overview of PCORI Fee for 2020
Senior Compliance Attorney
The Patient-Centered Outcomes Research Institute (PCORI) fee is a temporary fee on both fully-insured and self-insured health care benefits that apply for the policy years between 2012 and 2029. The fees are intended to fund the Patient Centered Outcomes Research Institute, which is an independent, non-profit organization created under the Affordable Care Act to conduct research for patients and caregivers on enhancing health care outcomes.
The PCORI fee is paid annually and is due by July 31st. For a plan year ending between January 1, 2019 and September 30, 2019, the $2.45 fee is due July 31, 2020. For a plan year ending between October 1, 2019 and December 31, 2019, the $2.54 fee is due by July 31, 2020. Fees are due on July 31 of the year following the last day of the policy or plan year. Please see attached schedule for specific due dates as it relates to the plan year.
Please note that the 2019 spending bill reinstated PCORI fees for the 2020-2029 fiscal years. As a result, specified health insurance policies and applicable self-insured health plans must continue to pay PCORI fees through 2029.
Every year the applicable dollar amount is further adjusted to reflect inflation in national health expenditures, as determined by the Secretary of Health and Human Services.
OVERALL RULES FOR THE FEES
PCORI fees are generally imposed on either the issuer of a specified health insurance policy (i.e., fully insured plans carriers) or plan sponsors (employers) of an applicable self-insured health plan. For self-insured plans maintained by two or more employers, the plan sponsor responsible for paying the fee is the entity identified as the plan sponsor by the terms of the document under which the plan is operated. If no plan sponsor is identified, the plan sponsor responsible for the fee is each employer that maintains the plan.
HOW THE FEES APPLY TO DIFFERENT PLANS
- Fully Insured Plans: The fees are imposed on “specified health insurance” policies. “Specified health insurance” policies include any prepaid health coverage arrangement if fixed payments or premiums are received as consideration for a person’s agreement to provide or arrange for the provision of accident or health coverage to residents of the United States.
- Self-Insured Plans: The fees are imposed on “plan sponsors”. The “plan sponsor” is the employer in the case of a plan established or maintained by a single employer and the employee organization in the case of a plan established or maintained by an employee organization. In the case of a plan established or maintained by two or more employers or jointly by one or more employers, a MEWA (Multiple Employer Welfare Arrangement) or a VEBA (Voluntary Employee Beneficiary Association), the plan sponsor is the association, committee, joint board of trustees or other similar group of representatives of the parties who wish to establish or maintain the plan.
- Excepted Benefits: Certain benefits are not subjected to the PCORI fee, because they are “excepted” or non-essential health benefits. Examples would include workers’ compensation insurance and stand-alone dental or vision programs.
- HRAs & FSAs: A Health Reimbursement Account (HRA) is not subject to a separate fee if the HRA is integrated with another applicable self-insured health plan that provides major medical coverage, provided that the HRA and the other plan are established and maintained by the same plan sponsor. However, an HRA that is integrated with a fully insured plan is treated as an “applicable self-insured health plan” and the plan sponsor (employer) would be subject to the fee on the HRA. The issuer of the fully insured plan that is integrated with the HRA would be subject to the PCORI fee on the fully insured health plan.“Flexible Spending Accounts” (FSAs) that satisfy the requirements of an “excepted benefit” are excluded from the definition of “applicable self-insured plan” and are NOT subject to the fees. FSAs that are not excepted benefits are subject to the fees.Because it is difficult to determine the number of “covered lives” under FSAs and HRAs, the regulations allow the plan sponsor to assume one covered life for each employee with an HRA and for each employee with a health FSA that is not an excepted benefit.
- EAPs, Disease Management & Wellness Programs: Employee Assistance Programs (EAPs), disease management programs and wellness programs are excluded from the definition of “applicable self-insured plan” and the fee would not apply, but only if these programs do not provide significant benefits in the nature of medical care or treatment.
DETERMINING FEE AMOUNTS
Fees are assessed on the number of covered lives on the plan for the plan year. The regulations provide different methods for determining the number of covered lives as outlined below. Please be sure to run numbers based on each method as one method might be more advantageous than the others.
- Actual count: Count the number of covered lives each day for the plan year and divide by the number of days.
- Snapshot: Pick one day each quarter for the first three quarters of the plan year and divide by 3.
- Snapshot Factor: In the case of self-only and other than self-only coverage (family, employee + one or employee + children) determine the sum of: (1) the number of participants with self-only coverage, and (2) the number of participants with other than self-only coverage multiplied by 2.35.
- Form 5500: Use the counts from your Form 5500 by adding the number of participants at the beginning of the year and the number of participants at the end of the year.
PCORI PAYMENT SCHEDULE
|Plan Year||Payment Amount||Due Date|
|February 1, 2018 – January 31, 2019||$2.45||July 31, 2020|
|March 1, 2018 – February 28, 2019||$2.45||July 31, 2020|
|April 1, 2018 – March 31, 2019||$2.45||July 31, 2020|
|May 1, 2018 – April 30, 2019||$2.45||July 31, 2020|
|June 1, 2018 – May 31, 2019||$2.45||July 31, 2020|
|July 1, 2018 – June 30, 2019||$2.45||July 31, 2020|
|August 1, 2018 – July 31, 2019||$2.45||July 31, 2020|
|September 1, 2018 – August 31, 2019||$2.45||July 31, 2020|
|October 1, 2018 – September 30, 2019||$2.45||July 31, 2020|
|November 1, 2018 – October 31, 2019||$2.54||July 31, 2020|
|December 1, 2018 – November 30, 2019||$2.54||July 31, 2020|
|January 1, 2019 – December 31, 2019||$2.54||July 31, 2020|
Updated: 6/12/2014; 6/23/16; 5/30/17; 5/17/18, 3/19/19; 6/9/2020
The information above is a summary of laws and regulations regarding provisions relating to provisions in the Patient Protection and Affordable Care Act (PPACA). The information should not be construed as legal or tax advice. In all cases, employers should be advised to consult with tier accountant or legal counsel for assistance.