The PACE Act and What it Means to California Employers: October 2015

President Obama has signed into law the Protecting Affordable Coverage for Employees (PACE) Act.  On September 28, 2015, the House of Representatives passed H.R. 1624 through voice vote and on October 1, the Senate passed the legislation through unanimous consent.


How Will PACE Act Affect the Affordable Care Act (ACA)?

Small group is currently defined as employers with 2-50 employees.  As of January 1, 2016 under the ACA, the definition of small group was set to expand 1-100 employees.  The PACE Act repeals the mandated small group expansion and it gives the individual states the flexibility to determine the small group market definition, rather than being forced to the national standard.

Several states, including California, have already enacted legislation that expands the small group market definition to 100 employees.  However, for those states that have not taken any action to date regarding the definition of small group, we are awaiting confirmation form the departments of insurance and legislators as to whether the states will accept the new federal standards or if they will take action of their own to expand the small group market definition of up to 100.


How Does PACE Affects the California Employer?

Unless further guidance is issued by California, we are moving forward with the small group expansion for employers with 1-100 employees with new business or renewals beginning January 1, 2016.  For employers who have 51-100 employees, there will be significant changes in their benefits, rating, and administrative process.  The most significant changes will be as follows:

  •  Rates in small group are age-banded, whereas large group premium rates are composite rates.  In age-banded rates, older employees pay a higher premium than younger employees.
  • ACA rates in small group are “member-level” rating (also known as “community rating”), whereas large group premium rates have a family rate for the plan, regardless of number of dependents.  With member-level rating in small group, larger families will pay a significantly higher premium as they are individual rated (some limits apply).
  • Small group plans are required to cover the 10 Essential Health Benefits, including pediatric dental and vision.
  • Small group plans are required to meet specified actuarial values +/- 2 percent (60%, 70%, 80%, or 90%, also referred to as the metal tiers), whereas large group plans can provide any actuarial value as long as they meet the minimum value of 60% requirement.


Action Items for Employers with 51-100 Employees:

  • Evaluate your plan  options in 2015.
  • Consider an Early Renewal option.
  • Market alternative carriers for 11/1 or 12/1/15 effective dates or extended renewal periods.
  • Compare current composite rates to age-banded, member-level rates in 2015 to see how the new rating will impact your company.
  • If you are an employer with 50 or more full-time equivalent and do not currently have coverage, evaluate your plan with a 2015 effective date versus age-banded rates in small group.


Please contact MNJ Insurance Solutions at (714) 716-4303 for more information.


This content is provided for informational purposes only.  While we have attempted to provide current, accurate and clearly expressed information, this information is provided “as is” and MNJ Insurance Solutions makes no representations or warranties regarding its accuracy  and completeness.  The information provided should not be construed as legal or tax advice or as a recommendation of any kind.  External users should seek professional advice form their own attorneys and tax and benefit plan advisers with respect to their individual circumstances and needs.

Help…I Lost my Job…Should I Take COBRA or an Individual Policy?

COBRA is a federal law that requires employers of 20 or more employees with group health plans to offer employees, their spouse and dependents a temporary period of continued health care coverage if they lose coverage through the employer’s group health plan.  Employers who have not continuously had 20 employees are covered if they had at least 20 employees on more than 50% of  the typical business day in the previous calendar year.  Both full-time and part-time employees are counted to determine whether the plan is subject to COBRA.


Individuals are not obligated to participate in COBRA after leaving an employer or having a reduction in hours.  However, if an individual declines the initial offer of COBRA, he/she may qualify for “special enrollment” in Covered California health insurance or an “off-exchange plan” outside of the annual Open Enrollment period for Individual/Family coverage.  An “off-exchange plan” are plans that are offered by the carrier direct, rather than through Covered California.  In order t take advantage of the special enrollment in Covered California or “off-exchange plan,” the individual/family losing group coverage must apply for coverage no later than 60 days after their employer-sponsored plan ends.  It is also important to note that if an individual were to terminate their COBRA coverage during Open Enrollment of Covered California or elect an off-exchange plan, he/she cannot change their mind to go back to COBRA.


If an individual were to elect COBRA and loses his/her coverage (i.e. due to non-payment), he/she will NOT be eligible for special enrollment through Covered California, nor opt to an off-exchange individual plan at that time.  Outside of Open Enrollment, individuals qualify for special enrollment with Covered California or off-exchange individual plans if one of the following apply:

  • If former employer was responsible for remitting payments for the COBRA premium and fails to do so in a timely manner, therefore participant is cancelled due to group non-payment;
  • The COBRA participant moves out of the plan coverage area and there is not another option available (i.e. former employer offers HMO only plan and COBRA participant moves out of state and the HMO would no longer be a good option);
  • If the former employer cancels the group plan, therefore, COBRA is no longer available; or
  • The beneficiary has maximized their COBRA duration available under the plan.


Listed below are pros and cons of Electing COBRA vs. Enrolling in Covered California after an individual and qualified beneficiaries have had a qualifying event.


  • The network of doctors and hospitals available in each plan and individual can continue the current benefits.
  • Covers more Rx than individual plans.
  • Transition and electing COBRA is typically an easier process than enrolling in Covered California.
  • If you are currently seeking treatment or under the care of a physician, it is easier to continue care under COBRA.
  • The total monthly premiums for the individual and qualified beneficiaries (family members previously enrolled on the plans) are paid by individual.
  • If the individual and qualified beneficiaries enrolled in COBRA, they cannot drop their COBRA plan and enroll in Covered California plan unless it is Open Enrollment for Covered California.
  • Depending on the level of benefits previously provided by the employer, the COBRA monthly premiums may be more expensive than desired coverage through Covered California (i.e. if employee or dependents may not need the rich covered previously offered by the employer).


  • Depending on income, the individual and qualified beneficiaries may qualify for tax credit and/or subsidy (depends on household income – chart for 2015) with Covered California.
  • Copays and deductibles may vary with options for Covered California or “off-exchange plans.”
  • Individual has options to move to another carrier (plans for 2015) than what may be provided through their former employer.


  •  Doctors and hospitals may not be in the network for the Covered California or “off-exchange” plan option.  It is important to confirm preferred doctors before selecting a plan to ensure they are in the network.
  • Prescription plans offered through Covered California individual plans or “off-exchange” plans often cover a smaller list of formulary drugs than group plans.


Note: If you have a qualifying event, your spouse has other group coverage offered through his/her employer, you may also want to explore adding onto their group plan as an additional alternative.  If this is an option through his/her employer, it must be done within 30 days of the loss of coverage.

If you have questions regarding your personal situation, MNJ Insurance Solutions are able to assist and can be reached at (714) 716-4303.


More Resources:

COBRA vs. Exchange Coverage – Covered CA


Disclaimer:  The views and opinions expressed are those of the author and do not necessarily reflect the official policy or position of Covered California.  Any content provided by our bloggers or author is of their opinion and are not intended to malign any organization, company, government entity, anyone or anything.

This document is for general information only.  While we have attempted to provide current, accurate and clearly expressed information, this information is provided “as is” and MNJ Insurance Solutions makes no representations or warranties regarding its accuracy or completeness.  The information provided should not be construed as legal or tax advice or as a recommendation of any kind.  External users should seek professional advice from their own attorneys and tax advisors with respect to their individual circumstances.