Blue Cross and Blue Shield of Illinois

 

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:

  • Non-grandfathered standard (pre-packaged) fully insured and self-insured plans (51+)
  • Non-grandfathered custom fully insured and self-insured plans (151+)
  • Non-grandfathered small group metallic plans (1-50)

Non-grandfathered Standard (pre-packaged) Plans, 51+ (Both Fully Insured and Self-insured)
There will be no changes on how BCBSIL loads the out-of-pocket maximum bucket for pharmacy, dental and vision benefits for standard (pre-packaged) health plans that are non-grandfathered for the 2014 plan year. This mirrors the OOPM structure used for these benefits for the 2013 plan year.

Here’s a recap of our standard approach to OOPM for pharmacy, dental and vision benefits that are not currently embedded in the medical plan for the 2014 plan year.1    

  • Prime Therapeutics pharmacy benefits will not have a separate OOPM under the 2014 OOPM safe harbor.2
  • For plans with a drug card, the member cost share will not go toward OOPM under the 2014 OOPM safe harbor.
  • For plans with Integrated BlueScriptSM,3 member liability will count toward the OOPM.
  • Dental and vision coverage will remain unchanged.4 For example, if the pediatric dental benefits are embedded in the medical plan, they will load the OOPM as they do today. If the pediatric dental benefits are stand-alone benefits and meet the definition for “excepted” benefits, they are not subject to the ACA OOPM requirement. Therefore, they would remain the same as the 2013 benefit structure. 

Non-grandfathered Custom Accounts, 151+ (Both Fully Insured and Self-insured)
The BCBSIL approach on OOPM for pharmacy, dental and vision benefits for the 2014 plan year will remain as it has been for 2013 for non-grandfathered large group accounts.

Here’s a recap of our standard approach to OOPM for pharmacy, dental and vision benefits that are not currently embedded in the medical plan for the 2014 plan year.1  

  • A separate OOPM for pharmacy is not required as long as the plan does not have a pharmacy OOPM in 2013. 
  • BCBSIL will support a separate OOPM for Prime Therapeutics upon request. To request this option, contact your BCBSIL representative.
  • BCBSIL will consider requests to support a separate OOPM for other Pharmacy Benefits Managers (PBMs) based on current system integration capabilities with the PBM. We currently have system integration capabilities for this purpose with the following PBMs: Caremark, ESI (now merged with Medco) and Prime Therapeutics. To request this option, contact your BCBSIL representative.
  • For plans with Integrated BlueScript,3 member liability will go toward the OOPM.
  • Dental and vision coverage will remain unchanged.4 For example, if the pediatric dental benefits are embedded in the medical plan, they will load the OOPM as they do today. If the pediatric dental benefits are stand-alone benefits and meet the definition for “excepted” benefits, they are not subject to the ACA OOPM requirement. Therefore, they would remain the same as the 2013 benefit structure. 

Non-grandfathered Small Group Metallic Plans, 1-50 (Both On and Off the Exchange)
There will be a single OOPM for the 2014 plan year for small group metallic plans that are non-grandfathered. This applies to those plans both on and off the health insurance exchange (also known as the health insurance marketplace).

  • For plans with a drug card, the member cost-share will load the OOPM.
  • For plans with Integrated BlueScript,3 member liability will go toward the OOPM.
  • Pediatric dental will load a separate OOPM not to exceed $700 for coverage of one child and $1,400 for coverage of two or more children.
  • Pediatric vision will be included with no member cost sharing. Therefore, there is no member liability to be applied to the OOPM.

1 Plans that integrate pharmacy with medical benefits in 2013 can maintain that integration for the 2014 plan year.
 
2 While Prime Therapeutics is considered a separate service provider for the purposes of the OOPM safe harbor, our standard approach will not include a separate OOPM for pharmacy benefits administered by Prime.
 
Other examples of organizations that BCBSIL considers separate service providers include (but are not limited to): Catamaran PBM, CVS Caremark, Davis Vision, DNOA, Express Scripts, MaxCare PBM and Walgreens.

3 BCBSIL plans that include BlueScript will transition to Integrated BlueScript policies on Jan. 1, 2014.

4 The ACA out-of-pocket maximum requirement does not apply to dental and vision discount programs.

For more information, contact your BCBSIL representative.

This information does not constitute legal or tax advice and it may be subject to change.

 
 
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