The Patient-Centered Outcomes Research Institute (PCORI) is an independent, non-profit research organization created to help patients and providers make better-informed healthcare decisions. The organization commissions research within the framework of creating actionable, evidence-based medicine.
PCORI was created as part of the Affordable Care Act and is funded by a fee that was also included in the legislation. The fee is paid by all health plans, including fully insured health plans, self-funded health plans, and account-based plans.
PCORI Counting Rules
- Per Human, Not Per Employee: Counting for PCORI fees is based on the number of covered persons (not just covered employees). As such, each employee and each dependent must be counted for PCORI fee payment purposes.
- Exception for Account-Based Plans: The one exception is for the calculation of PCORI fees for account-based plans (such as HRA plans), which are counted on a per-employee basis even if dependent expenses are eligible for reimbursement under an account-based plan. This includes plans such as HRAs.
- Exception for More Than One Self-Funded Plan: There is also a special rule that PCORI fees are only payable for one self-funded plan, even if an employer has more than one self-funded plan and even if an individual may be covered under more than one self-funded plan.
Who Pays the Fee?
For fully insured plans, the insurance carriers pay the fee on behalf of employers. The actual fee is baked into the fully insured premium.
For self-funded plans, plan sponsors/employers are required to pay the fee directly.
2023 PCORI Rate
The updated PCORI rate for 2023 filings is $3.00 per covered life. This applies to plans with policy years ending on or after October 1, 2022.
PCORI Reporting
PCORI Fees are paid on the Q2 IRS Form 720. Currently, Form 720 still lists the 2022 rate under Row 133 of the form. However, we expect that the form will be updated in the next few weeks. The Q2 Form 720 is due on July 31, 2023 (one month after the last day of the quarter).
Complex Counting Example
The following is an example of an employer with 500 employees. Employees have a choice between a self-funded health plan and a Kaiser HMO plan. In addition, the employer provides a non-integrated medical travel HRA plan that covers all employees.
|
Plan
|
Covered Employees
|
Persons Counted for PCORI
|
PCORI Payments Due
|
Who Pays PCORI Fee
|
|
Self-Funded Plan
|
400
|
1,000
|
1,000
|
Employer
|
|
Fully Insured Kaiser Plan
|
100
|
250
|
250
|
Kaiser
|
|
Medical Travel HRA Plan
|
500
|
500
by special rule
|
100
|
Employer
|
In this example, PCORI fees would be due as follows:
- Employer pays PCORI fees for the 1,000 humans on the self-funded health plan
- Kaiser pays the PCORI fee for the 250 humans on the Kaiser plan
- Employer also pays PCORI fees for the 100 “extra” employees that are covered under the self-funded HRA plan (but who are covered under the fully insured Kaiser plan and for whom Kaiser paid the PCORI fee because the employer did not pay a PCORI fee under a self-funded plan). The employer owes a PCORI fee for these 100 employees (but not their dependents because of the special rule for account-based plans.
As an aside, if there were not a Kaiser plan in place, only one PCORI fee would be due for the 1,000 humans on the self-funded medical plan. In the above example, the 500 employees covered by the medical travel HRA plan would be a "gimme" because that would be a second self-funded plan.
