The U.S. Department of Labor (DOL) has issued its 31st FAQ on the implementation of the Patient Protection and Affordable Care Act (ACA), dedicated to coverage of preventive services, rescissions of coverage, out-of-network emergency services, clinical trial coverage, cost-sharing limitations, the Mental Health Parity Act, and the Women’s Health and Cancer Rights Act. Some highlights are provided below.
The ACA requires health plans to offer evidence-based services with a rating of A or B in the current recommendations provided by the United States Preventive Services Task Force (USPSTF), as well any additional coverage for women provided in guidelines supported by the Health Resources and Services Administration (HRSA). Numerous FAQs in the series have covered preventive services, and the most recent one covers questions relating to colonoscopies and contraceptives. The FAQ confirmed that if a colonoscopy is scheduled and performed as a screening procedure, the plan cannot impose cost sharing for the bowel preparation medications. In regard to contraception, the FAQ confirms that, although plans and issuers must ensure access to a full range of FDA-approved contraception methods, plans may utilize reasonable medical management techniques within a specified method of contraception, and may develop and use a standard exception form and instructions for participants. The Medicare Part D Coverage Determination Request Form may serve as a model for plans and issuers when developing a standard exception form.
Rescissions of Coverage
The ACA prohibits group health plans and individuals from having coverage rescinded with a retroactive effect, unless the individual with coverage commits fraud, or certain premiums are not paid on time. The FAQ stated that a group health plan may not terminate coverage with a retroactive effect when an individual paid the premium but resigns from his or her position of employment. The example provided involved a school teacher who terminated employment at the end of the contract but paid the insurance premium in full.
Non-grandfathered group health plans and health insurance issuers offering non-grandfathered group or individual health insurance coverage cannot impose cost sharing on out-of-network emergency services in a greater amount than what is imposed for in-network emergency services. Balance billing is not included in the statutory definition of cost sharing, which is the practice of providers billing patients for the difference between the provider’s billed charges and the amount collected from the plan or issuer, plus the amount collected from the patient in the form of a copayment or coinsurance amount. Agencies have determined that a reasonable amount be paid by a plan or issuer before a patient becomes responsible for a balance billing amount.
A plan or issuer satisfies the out-of-network emergency care copayment or coinsurance limitations in the statute if it provides benefits for out-of-network emergency services in an amount at least equal to the greatest of the following three amounts (adjusted for in-network cost sharing):
- The median amount negotiated with in-network providers for the emergency service.
- The amount for the emergency service calculated using the same method the plan generally uses to determine payments for out-of-network services (such as the usual, customary, and reasonable amount).
- The amount that would be paid under Medicare for the emergency service (collectively, minimum payment standards).
The latest FAQ states that plans or issuers must disclose how they calculate these minimum payment standards and the “usual, customary, and reasonable amount.” Documentation of this must be included in plan documents, and provided to participants within 30 days of request.
Originally published by United Benefit Advisors – Read More