Blue Cross and Blue Shield of Illinois

 

 

May 10, 2013

Legislative Update
Federal Government Releases FAQs on Annual Limit Waivers, Provider Non-Discrimination and Clinical Trials

On April 29, 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.

Expiration Date for Annual Dollar Limit Waivers
Question 1 applies to health plans or issuers that have received a waiver or waiver extension to allow them to set restricted annual dollar limits on essential health benefits (EHBs). The guidance notes that the effective dates of coverage listed in a plan’s or issuer’s original waiver application determine the expiration date for the waiver on annual dollar limits. 

In other words, if a health plan changes its plan or policy year, this will not change the waiver expiration date. For example, if a group health plan was granted a waiver based on a June 1, 2013 plan/policy year, the waiver expires on May 31, 2014 – even if the plan or issuer changes its plan/policy year. A group may terminate its annual dollar limits waiver any time before its approved expiration date. For example, a group with a May 31, 2014 expiration date can choose to terminate its waiver on Dec. 31, 2013.  

The FAQ indicates that HHS can review a group’s waiver to determine whether the plan or issuer is in compliance with HHS's policy on annual limit waivers. See more information about annual limits and waivers.

Provider Non-Discrimination
With regard to the provider non-discrimination provision, the departments do not expect to issue regulations in the near future. Health care providers will not be prevented from participation in an insurer’s provider network if willing to abide by the terms and conditions for participation and are acting within the limits of their medical license or certification. Plans and issuers should use a good faith, reasonable interpretation to implement the law. The provision is applicable to non-grandfathered group health plans and health insurance issuers offering group or individual health insurance coverage for plan years beginning on or after Jan. 1, 2014.

Clinical Trials
The departments also noted they do not anticipate issuing further guidance regarding coverage for individuals participating in approved clinical trials in the near future. If a “qualified individual” is in an “approved clinical trial,” the plan cannot deny coverage for related services. This provision of health care reform applies to non-grandfathered group health plans and health insurance issuers offering individual or group coverage for policy or plan years beginning on or after Jan. 1, 2014. Until further guidance is issued, the departments expect health insurance issuers to implement the requirements of the law “using a good faith, reasonable interpretation of the law.”

We will keep you updated if further guidance is issued on these provisions.


 
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an Independent Licensee of the Blue Cross and Blue Shield Association.