The Departments of Labor (DOL), Health and Human Services (HHS), and the Treasury have released more answers to frequently asked questions about Affordable Care Act Implementation, addressing who must comply with limitations on cost-sharing and clarifying coverage of certain preventive services.
Limitations on Cost-Sharing under the Affordable Care Act
The Affordable Care Act, provides that a group health plan shall ensure that any annual cost-sharing imposed under the plan does not exceed certain limitations provided for out-of-pocket maximums and deductibles for employer-sponsored plans.
The Departments believe that only plans in the small group market are required to comply with the deductible limit (maximum of $2,000 for individuals and $4,000 for families). Until any future rulemaking is promulgated and effective, the Departments have determined that a self-insured or large group health plan can rely on the Departments’ stated intention to apply the deductible limits only on plans in the small group market.
The Departments require all non-grandfathered group health plans to comply with the annual limitation on out-of-pocket maximums, which will be announced later this year. The Departments recognize that plans may utilize multiple service providers to help administer benefits (such as one third-party administrator for major medical coverage and a separate pharmacy benefit manager). Separate plan service providers may impose different levels of out-of-pocket limitations and may utilize different methods for crediting participants’ expenses against any out-of-pocket maximums. These processes will need to be coordinated, which may require new regular communications between service providers.
The Departments have determined that, only for the first plan year beginning on or after January 1, 2014, where a group health plan utilizes more than one service provider to administer benefits that are subject to the annual limitation on out-of-pocket maximums, the Departments will consider the annual limitation on out-of-pocket maximums to be satisfied if both of the following conditions are satisfied:
a. The plan complies with the requirements with respect to its major medical coverage (excluding, for example, prescription drug coverage and pediatric dental coverage); and
b. To the extent the plan or any health insurance coverage includes an out-of-pocket maximum on coverage that does not consist solely of major medical coverage (for example, if a separate out-of-pocket maximum applies with respect to prescription drug coverage), such out-of-pocket maximum does not exceed the dollar amounts set forth.
Under the Mental Health Parity and Addiction Equity Act, plans and insurers are prohibited from imposing an annual out-of-pocket maximum on all medical/surgical benefits and a separate annual out-of-pocket maximum on all mental health and substance use disorder benefits.
Coverage of Preventive Services
The interim final regulations require non-grandfathered group health plans and health insurance coverage offered in the individual or group market to provide benefits for and prohibit the imposition of cost-sharing requirements with respect to, the certain preventive services.
This provision is premised on enrollees being able to access the required preventive services from in-network providers. Thus, if a plan does not have in its network a provider who can provide the particular service, then the plan must cover the item or service when performed by an out-of-network provider and not impose cost-sharing with respect to the item or service.
Aspirin and other over-the-counter (OTC) items and services must be covered without cost-sharing only when prescribed by a health care provider.
Polyp removal is an integral part of a colonoscopy. Accordingly, the plan may not impose cost-sharing with respect to a polyp removal during a colonoscopy performed as a screening procedure. On the other hand, a plan may impose cost-sharing for a treatment that is not a recommended preventive service, even if the treatment results from a recommended preventive service.
HHS believes that the scope of the recommendation for genetic counseling and evaluation for routine breast cancer susceptibility gene (BRCA) includes both genetic counseling and BRCA testing, if appropriate, for a woman as determined by her health care provider.
Identification of “high-risk” individuals is determined by clinical expertise. Decisions regarding whether an individual is part of a high-risk population, and should therefore receive a specific preventive item or service identified for those at high-risk, should be made by the attending provider. Therefore, if the attending provider determines that a patient belongs to a high-risk population and a recommendation applies to that high-risk population, that service is required to be covered without cost-sharing, subject to reasonable medical management.
In some circumstances, a recommendation applies for certain individuals rather than an entire population. In these circumstances, health care providers should determine whether the vaccine should be administered, and if the vaccine is prescribed by a health care provider consistent with the recommendations, a plan is required to provide coverage for the vaccine without cost-sharing.
Regulations allow plans to use reasonable medical management techniques to determine the frequency, method, treatment, or setting for a recommended preventive item or service, to the extent this information is not specified in a recommendation or guideline.
Although the guidelines list services individually, nothing in the regulations requires that each service be provided in a separate visit. Efficient care delivery and the delivery of multiple prevention and screening services at a single visit is a reasonable medical management technique, permissible under the regulations. For example, HIV screening and counseling and Sexually Transmitted Infections counseling could occur as part of a single well-woman visit. If the clinician determines that a patient requires additional well-woman visits for this purpose, then the additional visits must be provided without cost-sharing.
Contraceptive methods that are generally available OTC are only included if the method is both FDA-approved and prescribed for a woman by her health care provider. The guidelines do not include contraception for men.
Services related to follow-up and management of side effects, counseling for continued adherence, and device removal are included under the guidelines and required to be without cost-sharing.
Coverage of comprehensive lactation support and counseling and costs of renting or purchasing breastfeeding equipment extends for the duration of breastfeeding. Nonetheless, plans may use reasonable medical management techniques to determine the frequency, method, treatment, or setting for a recommended preventive item or service, to the extent not specified in the recommendation or guideline.
DMEC Legislative Updates 