August 9, 2013
Legislative Update
Affordable Care Act Out-of-Pocket Maximum (OOPM) Rules and Safe Harbor
BCBSIL’s 2014 Approach to OOPM for Pharmacy, Vision and Dental Benefits
This article recaps how Blue Cross and Blue Shield of Illinois (BCBSIL) will approach the out-of-pocket maximum (OOPM) requirement and related safe harbor when it comes to pharmacy, vision and dental benefits for the 2014 plan year. We also address benefits administered by Prime Therapeutics and others considered separate service providers.
Non-grandfathered group health plans that offer essential health benefits (EHBs) must comply with annual out-of-pocket expense limits for any in-network EHBs and out-of-network emergency services they cover starting with the group’s 2014 plan year, according to the federal government’s interpretation of the Affordable Care Act (ACA).
Important Note: Large group self-funded plans and groups that are grandfathered do not have to cover EHBs in 2014. However, non-grandfathered groups that cover EHBs are required by ACA to follow OOPM rules starting with the 2014 plan year. ACA’s OOPM requirements do not apply to grandfathered plans and limited-scope dental and vision coverage structured as “excepted benefits.”
A special workgroup is addressing BCBSIL’s implementation of EHBs and OOPMs. We will share relevant information on this topic as it becomes available.
OOPM Safe Harbor for 2014 Plan Year Only
There is an OOPM safe harbor for the 2014 plan year. It applies to non-grandfathered group health plans when benefits under the plan are administered by more than one service provider. The federal government issued this safe harbor because it recognized the challenges that insurers and self-funded plan sponsors face as they work to comply with the OOPM requirements by 2014.
Generally, behavioral health vendors cannot be considered separate service providers for the purposes of the OOPM safe harbor. Why? Because benefit plans that are required to comply with mental health parity must have their medical and behavioral health benefits cross-accumulate to a single OOPM. Examples of behavioral health vendors include (but are not limited to): Cigna Behavioral Health, ComPsych Managed Behavioral Health, Magellan Behavioral Health Services and Mesa.
How Will BCBSIL Load the OOPM for Pharmacy, Vision and Dental Benefits in 2014?
BCBSIL has reviewed the OOPM rules and safe harbor for 2014. Our approach to loading the out-of-pocket maximum for pharmacy, vision and dental benefits for the 2014 plan year is based on the following:
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