Question: If a company has a fully insured medical benefit with a self-insured prescription benefit, are they required to pay Patient Centered Outcome Research Institute (PCORI) fees for both plans?
Answer: According to the IRS regulations, this situation would require payment of two PCORI fees because the fully insured plan is subject to the fees under § 4375 of the Affordable Care Act, and self-insured plans are subject to the fee under § 4376. The final regulations specifically note that these two fees are intended to be separate.
However, the final regulations permit “…an applicable self-insured health plan that provides accident and health coverage through fully-insured options and self-insured options to determine the fee imposed by section 4376 by disregarding the lives that are covered solely under the fully-insured options…”
In this way, plans may be able to reduce the amount of the fee which must be paid for the self-insured portion of the plan.