IRS Logo
Print - Click this link to Print this page

Application of the Patient-Centered Outcomes Research Trust Fund Fee to Common Types of Health Coverage or Arrangements

Type of insurance coverage or arrangement

Subject to the fee?

Person responsible for paying and reporting the fee

Accident and health coverage or major medical insurance coverage

Yes

  • The issuer if insured
  • The plan sponsor if self-insured

 

Retiree-only health or major medical coverage

Yes

  • The issuer if insured
  • The plan sponsor if self-insured

 

Health or major medical coverage under multiple policies or plans

Yes

  • Each issuer or plan sponsor
  • See below for special rules for coverage under multiple applicable self-insured health plans

COBRA coverage

Yes

  • The issuer if insured
  • The plan sponsor if self-insured

 

Health Reimbursement Arrangement (HRA), including a premium-only HRA

 

 

Yes, unless the arrangement satisfies the requirements for being treated as an excepted benefit

  • The plan sponsor
  • See below for special rules for coverage under multiple applicable self-insured health plans and special counting rules for HRAs

Flexible Spending Arrangement (FSA)

Yes, unless the arrangement satisfies the requirements for being treated as an excepted benefit

  • The plan sponsor
  • See below for special counting rules for FSAs

 

 

 

State & local government health or major medical plans for employees and/or retirees

Yes

  • The issuer if insured
  • The plan sponsor if self-insured

Stand-alone dental or vision coverage

No

 

Group insurance policy designed and issued specifically to cover primarily employees working and residing outside the United States

No

 

Self-insured health plan designed specifically to cover primarily employees who are working and residing outside the United States

No

 

Medicare (the insurance program established under title XVIII of the Social Security Act)

No

 

Medicaid (the medical assistance program established by title XIX of the Social Security Act)

No

 

Children’s Health Insurance Program (CHIP) (the medical assistance program established under title XXI of the Social Security Act)

No

 

Military health plans (programs established by Federal law for providing medical care (other than through insurance policies) to individuals (spouses or dependents) by reason of the individual being (or having been) a member of the Armed Forces of the United States)

No

 

Certain Indian tribal government health plans (programs established by Federal law for providing medical care (other than through insurance policies) to members of Indian tribes (as defined in section 4(d) of the Indian Health Care Improvement Act))

No

 

Health Savings Arrangements (HSAs)

No

 

Archer Medical Savings Accounts (MSAs)

No

 

Hospital indemnity or specified illness benefits

No

 

Stop-loss or indemnity reinsurance

No

 

Employee assistance programs, disease management programs, or wellness programs

No, provided the program does not provide significant benefits in the nature of medical care or treatment

 

Accident-only coverage (including accidental death and dismemberment)

No

 

Disability income coverage

No

 

Automobile medical payment coverage

No

 

Workers’ compensation or similar coverage

No

 

On-site medical clinic

No

 

 

Special rule for coverage under multiple applicable self-insured health plans:

  • Generally, separate fees apply for lives covered by each specified health insurance policy or applicable self-insured health plan.
  • However, two or more applicable self-insured health plans may be combined and treated as a single applicable self-insured health plan for purposes of calculating the PCORI fee but only if the plans have:
    • The same plan sponsor; and
    • The same plan year.

For example, if amounts in an HRA may be used to pay deductibles and copays under a specified health insurance policy, the HRA (an applicable self-insured health plan) and the policy would be subject to separate PCORI fees. However, an HRA that may be used to pay deductibles and copays under the applicable self-insured health plan is not subject to a separate fee (and the fee will apply only to the applicable self-insured health plan) if both the HRA and the applicable self-insured health plan have the same plan sponsor and the same plan year.

  • There is no similar rule for lives covered by more than one insurance policy subject to the PCORI fee.

Special counting rule for HRAs and FSAs:

  • Plan sponsors are permitted to assume one covered life for each employee with an HRA.
  • Plan sponsors are permitted to assume one covered life for each employee with an FSA.

Related Item: Patient-Centered Outcomes Research Trust Fund Fee: Questions and Answers

 

 

Page Last Reviewed or Updated: 16-May-2013