Benefit Mandates

The ACA requires that the following provisions are implemented for self-funded health plans.

  • 90-day waiting period1
  • No pre-existing exclusions
  • Removal of annual and lifetime dollar limits
  • Coverage for dependents to age 262
  • No pre-existing condition exclusions for persons younger than 19
  • Increased parity for out-of-network emergency services3
  • 100 percent coverage for certain in-network preventive services3 (See the Preventive Services section for more information.)
  • Additional claim and appeal rights3

The 90-day waiting period and elimination of pre-existing exclusions were mandated for plan years on or after Jan. 1, 2014, All other provisions were mandated for plan years on or after Sept. 23, 2010.

1Plans may not impose a waiting period of more than 90 days. For the 2014 plan year, employers may impose an “orientation period” not to exceed one calendar month less one calendar day.
2To avoid possible penalties, businesses subject to the employer mandate must provide health coverage to a dependent adult child through the end of the month in which he or she attains age 26. If coverage extends beyond the 26th birthday, the value of the coverage can continue to be excluded from the employee’s income for the full tax year (generally a calendar year) in which the adult dependent child turns 26.
3The provision does not apply to grandfathered plans.