The end of the year is near: Health plan preparation for 2025
The focus for 2025 will be on continuing to comply with rules issued in prior years in which details are still being ironed out (or for which there are proposed changes).
While this is not an exhaustive list of compliance requirements, below is a summary of federal requirements affecting most self-insured health and welfare plans — subject to legislative or regulatory changes.
You will find a checklist of topics employers should review for their self-funded health plan and a comparison chart of various Affordable Care Act (ACA) and IRS High Deductible Health Plan (HDHP) limits for 2024 to 2025 (there are some numbers we are still waiting for the regulating bodies to release).
| Self-Funded Health Plan Checklist 2025 | Reviewed | |
| 1 | COVID-19 – National Emergency and Public Health Emergency have ended. Remove plan language related to the tolling of certain plan deadlines (maintain vaccines as preventive care requirement for Non-Grandfathered Plans). | |
| 2 | ACA Out-of-Pocket Limit for Non-Grandfathered Plans | |
| 3 | IRS Out-of-Pocket Limit for High Deductible Health Plans * Plans using embedded deductibles’ special rules | |
| 4 | IRS Minimum Deductible for High Deductible Health Plans *Plans using embedded out-of-pocket maximums have special rules | |
| 5 | New or Modified Preventive Care Recommendations for Non-Grandfathered Plans * Screening for breast cancer – revised to include biennial screening for those 40 to 74 years of age. Note: Plans need to confirm the desired frequency of the screenings for preventive care benefit coverage. HRSA guidelines are still slightly different indicating annual screenings; USPSTF guidelines provide for biennial screenings. | |
| 6 | Flexible Spending Account Limits – to be determined! | |
| 7 | Health Savings Account Telehealth Relief Currently set to sunset at the end of 2024. | |
| 8 | PCORI Fee – for plan years that end on or after 10/1/23 and before 10/1/24, the applicable fee amount is $3.22. | |
| 9 | Employer Shared Responsibility Mandate Reporting – use 2024 forms & penalty figures have changed. Affordability thresholds are still to be determined. | |
| 10 | Transparency in Coverage Requirements – Advanced EOB proposed regulations expected in March 2025. | |
| 11 | Prescription Drug and Health Care Spending Reporting – due June 1 annually for the prior reference year. | |
| 12 | Ongoing ACA Requirements – rules change if a plan loses grandfathered status. | |
| 13 | No Suprises Act (Surprise Medical Billing) & IDR Process – revised rules anticipated in November 2024. | |
| 14 | Reporting Data About Air Ambulance Services – currently delayed until March 2025. | |
| 15 | Mental Health Parity Expansion – final rules expected in September 2024. | |
| 16 | Mental Health Parity NQTL Comparative Analysis – plans should have an updated analysis annually. | |
| 17 | Gag Clause Attestations – Due 12/31/2024; instructions for 2024 provide minor clarifications about the number of attestations based on the number of individual plan filings. | |
| 18 | Copay Accumulator Programs – federal guidance issued after the court ruling in fall 2023 – plans should review and modify accordingly. All prescription drugs are treated as essential health benefits. | |
| 19 | Medicare Part D Creditable Coverage Determination – Part D has been redesigned for 2025 and the calculation rules are impacted for HDHPs. Many plans that were previously creditable will no longer be creditable. | |
| 20 | HIPAA and Reproductive Health – effective date June 25, 2024; Compliance dates begin December 23, 2024, except for the Notice of Privacy Practices (February 16, 2026). | |
| 21 | HIPAA Privacy and Cybersecurity – new regulations to improve measures for providers, health plans, and third parties handling PHI expected in December 2024. | |
Related: Cigna, Humana rekindle merger talks
| What’s the Limit for 2025? | 2024 | 2025 |
| ACA Individual Out-of-Pocket Maximum | $9,450 | $9,200 |
| ACA Family Out-of-Pocket Maximum | $18,900 | $18,400 |
| IRS HDHP Individual Out-of-Pocket Maximum | $8,050 | $8,300 |
| IRS HDHP Family Out-of-Pocket Maximum | $16,100 | $16,600 |
| IRS HDHP Individual Minimum Deductible | $1,600 | $1,650 |
| IRS HDHP Family Minimum Deductible | $3,200 | $3,300 |
| IRS HSA Individual Contribution Limit | $4,150 | $4,300 |
| IRS HSA Family Contribution Limit | $8,300 | $8,550 |
| ACA Affordability Threshold | 8.39% | TBD |
| 4980H(a) Penalties | $2,970 | $2,900 |
| 4980H(b) Penalties | $4,460 | $4,350 |
| IRS FSA Maximum Contribution | $3,200 | TBD |
| IRS FSA Rollover Maximum | $640 | TBD |
Kelly E. Dempsey is an attorney with The Phia Group, LLC. As the Vice President of Phia Group Consulting, Kelly’s specialization is an interesting mix of compliance matters impacting self-funded plans (such as issues relating to ERISA, ACA, COBRA, FMLA, MHPAEA, and MSP) and “outside-the-box thinking,” finding creative and innovative ways to help plans, brokers, and TPAs achieve their various self-funding goals. Kelly is admitted to the Bar of the State of Ohio and the United States District Court, Northern District of Ohio.