Blue Cross and Blue Shield of Illinois

 

 

March 1, 2013

Legislative Update: Federal Government Releases FAQs on Out-of-Pocket Maximum, Deductible Limits, Preventive Services

On Feb. 20, 2013, the U.S. Departments of Labor, Health & Human Services (HHS) and Treasury released FAQs providing guidance on a number of Affordable Care Act (ACA) provisions. Note that these FAQs include new requirements for all health plans, even self-insured, that may have both financial and operational implications.

Out-of-Pocket Maximum
ACA requires that for plan years beginning on or after Jan. 1, 2014, annual cost sharing (i.e., coinsurance, deductibles, copayments and similar charges) for non-grandfathered plans cannot exceed 2014 limits under the Internal Revenue Code for HSA [health savings account] out-of-pocket limits. For example, the 2013 limits are $6,250 for self-only coverage and $12,500 for family coverage; these amounts will be indexed annually.

The final rule released by HHS on Feb. 25, 2013, and addressed in the FAQs, clarifies ACA's out-of-pocket maximum limit provision applies to all group health plans, including large group and self-insured. The out-of-pocket maximum is limited to in-network services.

The out-of-pocket maximum will also include copays/coinsurance across all benefit categories, including benefit categories that are carved out to other service providers (i.e., prescription drug, mental health and substance abuse, etc.). However, HHS provides for a safe harbor to allow time for coordination between providers that help administer benefits. For the first plan year beginning on or after Jan. 1, 2014, a group plan or group health insurance issuer that uses more than one service provider to administer benefits that are subject to the out-of-pocket limit will be able to maintain separate out-of-pocket maximum limits for each benefit category that is carved out to a service provider (with the exception of mental health and substance use disorder benefits) under the following two conditions:

a) The group plan or group health insurer complies with the out-of-pocket maximum limit (the 2014 limits under the Internal Revenue Code for HSA out-of-pocket limits) for its major medical coverage; and

b) If a group plan or group health insurer includes an out-of-pocket maximum on coverage outside major medical coverage (for example, an out-of-pocket maximum on prescription drug coverage), that separate maximum cannot exceed the out-of-pocket limit as well (the 2014 limits under the Internal Revenue Code for HSA out-of-pocket limits).

Deductible Limits
The FAQs also address deductible limits under ACA. For plan years beginning on or after Jan. 1, 2014, ACA stated that non-grandfathered, fully insured small group plans could not have a deductible higher than $2,000 for individuals and $4,000 for families. The final rule provides flexibility by allowing issuers to exceed the deductible limit if it cannot reasonably reach a given level of coverage (metallic level) without doing so.

The FAQs also confirm that self-insured and large insured group health plans do not have to comply with the deductible limits.

Preventive Services
ACA requires non-grandfathered group health plans to cover preventive services recommendations rated A or B by the U.S. Preventive Services Task Force (USPSTF) without member cost-share – meaning with no deductible, copayment or coinsurance. In most cases, this applies when the member uses a network provider for the service. The FAQs from the federal government also addressed several points related to preventive services.

Question 3 in the newly released FAQs provides guidance on how a plan must cover out-of-network preventive services when a plan does not have a network provider who can administer a specific service. Question 4 notes “Aspirin and other OTC [over-the-counter] recommended items and services must be covered without cost-sharing only when prescribed by a health care provider.” Question 5 speaks to colorectal cancer screening via colonoscopy. It notes that health plans, “may not impose cost-sharing” for “polyp removal during a colonoscopy performed as a screening procedure.” Question 6  indicates, “HHS believes the scope of the recommendation” related to genetic testing and counseling for routine breast cancer susceptibility gene (BRCA) includes both BRCA testing and genetic counseling, “if appropriate, for a woman as determined by her health care provider.”

Question 7 provides guidance about how a plan determines whether a service is covered without cost-sharing for preventive services recommended for high-risk individuals. It notes that the “attending provider” determines whether an individual is at high risk. In this instance, the provider would identify and submit the service as preventive care according to ACA requirements.

ACA preventive care also includes vaccines recommended by the Advisory Committee on Immunization Practices (ACIP). Question 8 in the FAQs clarifies which ACIP recommendations must be covered as preventive care without member cost-sharing. It also spells out the timeline for adopting new ACIP immunization recommendations.

Women’s Preventive Services
In addition, the document clarifies some questions about ACA’s employer contraception coverage requirement. Health Resources and Services Administration (HRSA) guidelines outline the full range of FDA-approved contraceptive methods, not just oral contraceptives for women to access.

The FAQs also discuss HRSA guidelines regarding lactation support to include counseling, supplies and equipment. These guidelines include coverage for lactation support and counseling, and costs of renting or purchasing breastfeeding equipment — for the duration of breastfeeding. However, plans can use reasonable medical management techniques to determine frequency, method, treatment or setting with respect to lactation counseling and breastfeeding equipment and supplies under the HRSA guidelines.

Blue Cross and Blue Shield of Illinois is reviewing the additional guidance provided by the FAQs to determine whether additional actions or changes to coverage are needed. We will continue to keep you updated.   

 

 
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