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individual coverage health reimbursement arrangement (ICHRA)

What is an individual coverage health reimbursement arrangement (ICHRA)?

An individual coverage health reimbursement arrangement (ICHRA) is a new type of health reimbursement arrangement in which employers of any size can reimburse employees for some or all of the premiums that the employees pay for health insurance that they purchase on their own. ICHRAs were created under regulations issued by the Trump administration in 2019, and became available as of 2020.

ICHRAs represent a departure from previous ACA implementation rules that forbid employers from reimbursing employees for individual market premiums. QSEHRAs, which became available in 2017, allow small employers to reimburse employees for individual market premiums. But ICHRAs allow this for employers of any size, and they offer more flexibility in terms of how much an employer is allowed to reimburse an employee.

  • Large employers can use an ICHRA to satisfy the employer mandate as long as the ICHRA benefit is substantial enough to make an individual health insurance plan affordable. (Note that the affordability determination under ICHRAs uses the same percentage of income that applies to employer group plans, but is calculated based on the price of the lowest-cost Silver plan in the marketplace, after the ICHRA benefit is subtracted from the total cost. This is different from the benchmark plan in the marketplace, which is the second-lowest-cost Silver plan. The interaction between ICHRAs and premium subsidies in the marketplace is discussed below).
  • There are no limits on how much an employer can reimburse under an ICHRA (unlike a QSEHRA, which does have limits).
  • An employer cannot offer an employee a choice between a group health plan and an ICHRA; it has to be one or the other. An employer can offer both a group health plan and an ICHRA, but they have to be offered to different classes of employees so that no employee has an option to choose between the group plan and the ICHRA.
  • Employees who become eligible for reimbursement of premiums under an ICHRA (or QSEHRA) are eligible for a special enrollment period during which they can enroll in an individual market health plan.
  • Employees must be enrolled in an individual market health plan (or Medicare) in order to receive the ICHRA benefit. In most cases, this will mean fully ACA-compliant coverage, but the rules do allow people with grandmothered and grandfathered plans to utilize an ICHRA benefit if it’s available to them.
  • ICHRAs can be used to reimburse qualified medical expenses in addition to individual market health insurance premiums if the employer opts to allow this. But if ICHRA reimbursement is available for pre-deductible expenses, the employee would not be eligible to contribute to an HSA, even if they enroll in an individual market HSA-qualified health plan.
  • If the ICHRA benefit covers some, but not all, of the employee’s premium in the individual market, the employer can allow the employee to use a pre-tax salary reduction (via a cafeteria plan) to pay the employee’s share of the premium, but only if the plan is purchased outside the exchange. If the employee purchases on-exchange coverage with the ICHRA funds, the employee cannot use a pre-tax salary reduction to fund the remainder of the premium (assuming the ICHRA benefit doesn’t cover the full premium).
  • If, after applying the ICHRA benefit, the employee would have to pay more than 9.61% (in 2022) of their household income for self-only coverage (not counting family members) under the lowest-cost silver plan in the exchange, the ICHRA does not constitute affordable employer-sponsored insurance. In that case, the employee can reject the ICHRA and claim a premium subsidy in the exchange instead, assuming they’re eligible for one. But if the employee accepts the ICHRA benefits and/or if the ICHRA benefit results in the lowest-cost self-only plan in the exchange having an after-ICHRA premium that doesn’t exceed 9.61% of the employee’s 2022 household income, the employee is not eligible for premium subsidies in the exchange. In this regard, an ICHRA is treated in exactly the same manner as employer-sponsored health insurance.

How many people are utilizing ICHRA benefits?

As of 2022, HealthSherpa estimates that there are between 100,000 and 200,000 people with ICHRA benefits. HealthSherpa is an enhanced direct enrollment entity that processes half of all HealthCare.gov’s broker-assisted enrollments, so they have a meaningful amount of data on this topic.

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