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.