How Defined Contribution Health Plans Work

Defined Contribution Health Plans offer an alternative to “defined benefit” group health insurance. Just as employers have moved away from defined benefit retirement pensions and toward Defined Contribution 401(k)s, many employers are applying this model to their health benefits programs.

The general strategy of a Defined Contribution Health Plan is that:

  • The employer offers each employee a fixed monthly dollar amount  to spend on qualified medical expenses. This might be a direct contribution to a savings account or an allowance the employer agrees to reimburse employees after the expenses are incurred.
  • Employees select and purchase the individual or family health plan of their choice. Employees may purchase their own policy directly from any health insurance company, through a broker, or from the HealthCare.gov or state Health Insurance Marketplaces. Depending on the employee's plan documents, employees may also purchase a number of other health care products and services that qualify as eligible expenses.
  • The employer reimburses employees up to the amount of their Defined Contribution allowance or the employee submits a claim for reimbursement to their HSA provider.

Defined Contribution Health Plans by themselves are not health insurance plans. Defined Contribution plans give the employer control of benefits while giving employees choice and a great benefit. Note however, that if an applicable large employer uses an ICHRA, which requires employees purchase minimum essential coverage, the plan will meet the employer mandate. In addition, it’s important to note that employers must offer an affordable allowance. Learn more about calculating affordability HERE.

Learning Resources

how the hra works for employers

How it
works

Watch Webinar
guide to health benefits

Guide to
health benefits

Download Guide
ICHRA, individual coverage hra, guide

Guide to
offering ICHRA

Download Guide

The benefits of a Defined Contribution Health Plan

1. It’s a self-funded health plan

A common reason employers use a Defined Contribution Health Plan is it is a self-funded health plan, which gives them control over exactly how much they spend. With a fully-insured health plan, the costs are controlled by the insurance companies.

2. It’s a tax-free health benefit

Many employers who do not qualify for group health plans or simply can’t afford them often resort to offering taxable wage increases. A Defined Contribution Health Plan is free of payroll taxes for both the employer and employee. As long as the employee uses money to purchase minimum essential coverage, it is also free of income taxes. This makes employers’ benefit dollars stretch a lot farther.

On top of it all, a Defined Contribution Health Plan doesn’t have to be a standalone benefit. Employers who are already offering a group health plan can offer a group coverage HRA (GCHRA) alongside the group plan, and there are a few ways to do that, depending on your needs. The best way to figure out which type of Defined Contribution Health Plan to offer is by taking our quiz below.

Find out which HRA fits your organization's needs best: take the quiz.

Learning Resources

hra, health reimbursement arrangement, software

Software
overview

See How It Works
hra hsa fsa comparison chart CTA icon

HRA vs
HSA vs FSA

Download Comparison
CTA Icon - nonprofits guide to health benefits

Guide to
health benefits

Download Guide

Comparing the PeopleKeep health reimbursement arrangements

PeopleKeep offers Section 105 Plans that meet nearly every employer need, including: a Qualified Small Employer HRA (QSEHRA), an Individual Coverage HRA (ICHRA), and a Group Coverage HRA (GCHRA). Choosing the one that is right for you can feel complicated, so we’ve broken it all down with our HRA comparison chart.

Compare our three HRAs using the chart below:

HRA Comparison Chart

Feature

QSEHRA

ICHRA

Group Coverage HRA

Business size restrictions

Limited to businesses with fewer than 50 FTE employees

None

None

Allowance amount restrictions

Limited to $5,250 for self-only employees and $10,600 for employees with a family in 2020. Businesses cannot give different employees different allowance amounts based on criteria other than family status.

None

No minimum or maximum contribution requirements. Businesses can give different employees different allowance amounts based on job-based criteria.

Group health policy requirements

Can’t be offered with a group health policy

Can be offered with a group health policy, but employees cannot have a choice between the group policy and the HRA.

Must be offered with a group health policy

Individual health policies permitted

Yes

Yes; in fact, they're required for participation in the HRA.

No

Premium tax credit coordination requirements

Employees must reduce their premium tax credit by the amount of their HRA allowance.

Employees cannot collect premium tax credits and participate in the ICHRA. However, if the ICHRA allowance is considered unaffordable, employees may waive the HRA and collect the credits.

N/A. These HRAs can’t reimburse employees for individual premiums.

Annual rollover permitted

Yes

Yes

Yes

Medical expenses available for reimbursement

Any or all items listed in IRS Publication 502

Any or all items listed in IRS Publication 502

Any or all items listed in IRS Publication 502 with the exception of individual insurance premiums

Employee eligibility guidelines

All full-time employees are eligible. Businesses can decide on part-time employee eligibility.

Businesses can decide on eligibility based on 11 different employee classes.

None

Why Defined Contribution Health Plans Work

Defined Contribution Health Plans work for employers and employees because:

  • Individual health insurance cost 20% - 60% less than comparable group health coverage. The employer’s healthcare dollars go farther.
  • Contributions are tax-deductible to the employer, and employees receive reimbursements tax-free.
  • The employer gains fiscal control and predictability over their health benefits budget.
  • There are no minimum or maximum contribution amounts—depending on the HRA— and no minimum participation requirements.
  • Employees have options in health insurance plans and make consumer-driven choices.
  • Depending on the plan and their income level, employees may have access to the premium  tax subsidies through the HealthCare.gov marketplace and/or their state exchange.

Design Requirements for Defined Contribution Health Plans

There are three key questions to ask when designing your Defined Contribution Health Plan.

These two questions will help you customize a plan that achieves your employee health benefit goals (and meets your budget):

  1. When will the plan year start?

    Your organization will decide when your Defined Contribution Health Plan will start.

  2. How much will you provide each month?

    You probably already have a budget in mind for health benefits. Within this budget, how will you divide up employees' monthly allowances? If you offer an HRA, you will come up with a monthly allowance that employees can use toward health expenses.

    With an HRA, you can provide the same monthly allowance amount to all employees, or you can provide different monthly allowances to different types/classes of employees. If you offer an ICHRA, the employee classes must be based on bona-fide job criteria such as job title, location, etc. You can also vary the allowance amounts by family status (single, married, etc.) within an employee class.

    See: The individual coverage HRA (ICHRA)'s employee classes: How do they work?

Learning Resources

cancel group health insurance

Cancelling group
health insurance

Download Guide
group health insurance, health reimbursement arrangement, comparison

Group health
vs. HRAs

Download Comparison
hra compliance

HRA
compliance

Download Tool Kit

Compliance Requirements for Defined Contribution Health Plans

Defined Contribution Health Plans that use a Section 105 Plan as the foundation are considered group health plans. As such, they must comply with IRS, HIPAA, COBRA, ERISA, and the Affordable Care Act (ACA) rules.

This section details compliance requirements that may impact your Defined Contribution Health Plan.

Internal Revenue Service (IRS)

  • Plan Documents: The IRS requires that written Plan Documents are established and maintained. Plan Documents define what expenses are eligible for reimbursement, the amount of employer contribution, and other required details about the reimbursement plan.
  • Documentation: The IRS requires that employees submit proper documentation verifying their claim for reimbursement, and that supporting documentation is saved on file for ten years.
  • Non-Discrimination: Defined Contribution Health Plans must comply with IRS nondiscrimination rules. The rules state the plan must not discriminate in favor of highly compensated individuals (HCIs) with respect to eligibility to participate in the plan or benefits provided under the plan.

Health Insurance Portability and Accountability Act (HIPAA)

  • HIPAA Privacy Rules: Defined Contribution Health Plans are governed by HIPAA Privacy Rules. In order to administer a Plan correctly, the entity processing employee reimbursement claims receives Protected Health Information (PHI) that is required to be held confidentially under HIPAA.

Consolidated Omnibus Budget Reconciliation Act (COBRA)

(Only for plans with 20 or more participants)

  • COBRA Compliance: Employers must give terminated employees the option to continue their participation in the Defined Contribution Health Plan for a period after termination, and may charge an employee up to 102% of the value of their allowance if COBRA is elected.

Employee Retirement Income Security Act (ERISA)

  • Summary Plan Description: Defined Contribution Health Plans are employee welfare plans under ERISA. ERISA requires every [welfare] plan to have a Summary Plan Description (SPD) and to furnish copies to each participant.
  • ERISA Compliance: The U.S. federal government has specific regulations employers must comply with in order to reimburse employees for individual health insurance premiums without triggering ERISA plan status for the individual health insurance policies. For example, the employer must not endorse specific individual health insurance policies or pay directly for them.

Patient Protection and Affordable Care Act (ACA)

  • Annual Limit Compliance: Section 2711 of the Public Health Services (“PHS”) Act, as added by the ACA, provides that no annual or lifetime limits may be placed on essential health benefits (“EHB”). PHS Act 2711 provides that annual limits and lifetime limits may be placed on benefits that are not EHB, such as health insurance premiums. Defined Contribution Health Plans must be designed to comply with PHS 2711.
  • Preventive Care Compliance: Section 2713 of the PHS Act, as added by the ACA, requires group health plans (including Defined Contribution Health Plans) to cover basic preventive health services without cost-sharing.
  • 90-Day Waiting Period Compliance: The ACA prohibits waiting periods over 90 days for eligible employees.
  • Internal and External Claims Appeal Process: The ACA added new requirements to the internal and external appeal process including how and when procedures are communicated to plan participants.
  • Dependent Coverage for Adult Children up to Age 26: Section 2714 of the PHS Act, as added by the ACA, provides that group health plans (including Defined Contribution Health Plans) that make available dependent coverage of children must make such coverage available for children until 26 years of age.
  • Uniform Explanation of Coverage and Definitions: The ACA requires that group health plans, participants, and beneficiaries receive a standardized summary of benefits and coverage (“SBC”) and a set of uniform definitions (“Uniform Glossary”), both of which must conform to requirements outlined in the ACA and existing regulations.
  • Form 720 Comparative Effectiveness Research (CER) Fee: The ACA includes a "research fee" that plan sponsors must pay on an annual basis annually via Form 720.

60-Day Notice of Material Modification: The ACA requires employers to provide 60 days advance notice to participants when making material modifications to their group health plan (including Defined Contribution Health Plans).

Interested in seeing how our HRA software works?

Watch an on-demand demo today

WATCH DEMO

Frequently Asked Questions

Can you offer health insurance to only certain employees?

Depending on the HRA, you have the ability to make the health benefit to certain classes of employees. To learn more, see our article on employee eligibility


What is the difference between an HRA and an HSA?

The biggest difference between health reimbursement arrangements (HRAs) and health savings accounts (HSAs) is that the business owns the HRA while the employee owns the HSA. In addition, an HRA is a reimbursement arrangement between an employer and employee, whereas an HSA is a savings account that is owned by the employee. To learn more, see our article on HRAs vs. HSAs.


Can I have an HRA and an HSA at the same time?

Yes! And you should take advantage of both. Unique rules apply to users, especially regarding what items are available for reimbursement when an HSA is in place. To learn more, read our article on using HRAs and HSAs.


What health insurance premiums can an HRA reimburse?

HRAs can reimburse many health care products and services, including the following types of insurance premiums, provided they were not already paid with pre-tax dollars: Major medical individual health insurance premiums; Dental care and vision care premiums; Qualified ancillary premiums (e.g., accident policies); Medicare Part A or B, Medicare HMO, and employer-sponsored health insurance premiums; Medicare Advantage and Supplement premiums; and COBRA premiums. To learn more, read our article on reimbursing premiums with an HRA.