PCORI fee filings are due on July 31st each year. That means it is time to get a refresher on requirements and responsibilities.
What is PCORI?
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
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Per Human Not Per Employee: Counting for PCORI fees is based on number of covered persons (not just covered employees). As such, each employee and each dependent must be counted for PCORI fee payment purposes.
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Exception for Account-Based Plans (HRAs): The one exception is for 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 and funded or matched FSAs. The regulations provide this special rule where dependents are not counted for account-based plans only.
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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. This special rule eliminates “double-paying” for participants who are covered under more than one self-funded plan sponsored by the employer.
Who pays the fee?
Fully Insured Plans: Insurance carriers pay the fee on behalf of fully insured employers. The PCORI fee is baked into the fully insured premium. Therefore, no action is required for employers with only fully insured plans (and no account based plans).
Self-Funded Plans and HRAs: Plan sponsors/employers are required to pay the fee directly for all self-funded plans and any HRA plans. This includes the following plan types:
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Self-funded medical plans (including hybrid plans, such as level-funded, balance funded, or graded)
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Health Reimbursement Arrangements (HRAs) that are not considered excepted benefits (such as dental and vision only)
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Employer-funded Health Flexible Spending Accounts (FSAs) in excess of $500 or in excess of a $1:$1 match
Current PCORI Rate
The updated PCORI rate for 2024 filings (based on 2023 Plan Year data) is $3.22 per covered life (or per participant for HRA plans).
This rate applies for policy and plan years ending on or after October 1, 2023 (which includes calendar year plans ending on December 31, 2023).
PCORI Reporting
PCORI Fees are paid on the Q2 IRS Form 720.
The fees are reported in the first section of Part II, under the clump of rows numbered “133” on Form 720.
Fees paid on behalf of self-funded plans should be reported under the “Applicable self-insured plans” section of Form 720. (The “Specified health insurance policies” applies to health insurance carriers reporting on behalf of their fully insured populations.)
The Q2 Form 720 is due on July 31, 2024 (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.
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Plan
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Covered Employees
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Persons Counted for PCORI
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Persons for whom PCORI Payment is Due
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Who Pays PCORI Fee
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Self-Funded Plan
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400
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1,000
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1,000
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Employer
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Fully Insured Kaiser Plan
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100
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250
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250
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Kaiser
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Medical Travel HRA Plan
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500
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500
by special rule
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100
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Employer
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In this example, PCORI fees would be due as follows:
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Employer pays PCORI fees for the 1,000 humans on the self-funded health plan.
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Kaiser pays the PCORI fee for the 250 humans on the Kaiser plan.
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Employer also pays PCORI fees for the 100 “extra” employees that are covered under the self-funded HRA plan (but whose health plan PCORI fee was paid by Kaiser because they are covered under the fully insured Kaiser plan). The employer owes a PCORI fee for these 100 employees (but not their dependents because of the special rule for account-based plans).
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Employer would report 1,100 covered lives and pay the PCORI fee accordingly.
As an aside, if there was 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.
