The Departments of Labor, Health and Human Services, and the Treasury have issued more Frequently Asked Questions (FAQs) regarding implementation of various provisions of the Affordable Care Act (ACA). A complete set of the FAQs is available here. Below is a summary of the recently issued guidance.
Summary of Benefits and Coverage. Summaries of Benefits and Coverage (SBCs) must be amended to indicate whether or not the sponsor’s medical plan qualifies as an eligible medical plan (i.e., provides “minimum essential coverage”) for purposes of satisfying the individual mandate and meeting the “play-or-pay” requirement and to indicate whether the plan provides minimum value. Updated SBC templates are available at cms.gov and dol.gov. These documents may be used for plan years beginning on or after January 1, 2014, and before January 1, 2015. Plan sponsors that have already prepared (or are in the process of preparing) SBCs for the new year may use the prior template without fear of enforcement action if it would be an administrative burden to modify the SBC to accommodate these new requirements. If the prior SBC is used, the sponsor must include a cover letter or similar disclosure stating whether the plan provides minimum essential coverage and whether the plan provides minimum value.
Health Reimbursement Account Waivers. The ACA prohibits insured and self-insured group health plans, such as Health Reimbursement Accounts (HRAs), from imposing lifetime or annual dollar limits on essential health benefits but allows ‘’restricted annual limits’’ with respect to essential health benefits for plan years beginning before January 1, 2014. Prior guidance provided a waiver process for eligible plans that would postpone compliance with these requirements through the end of the plan year that ends in 2014. Click here for a listing of relevant guidance regarding waivers. The FAQs warn sponsors that changing the plan year does not change the waiver expiration date. For example, if a waiver is granted for a plan year that begins January 1, 2013, the waiver will expire on December 31, 2014, regardless of whether the plan sponsor later amends its plan year.
Provider Non-Discrimination. Effective January 1, 2014, insured and self-insured medical plans may not discriminate against any health care provider that is acting within the scope of its license under applicable state law with respect to both participation and coverage. This provision does not require plans or health insurance issuers to accept all types of providers into a network and does not govern provider reimbursement rates, which may be subject to quality, performance, or market standards and considerations. The Departments of Labor, Health and Human Services, and the Treasury will not issue regulations prior to the effective date. Until regulations are issued, group health plans and health insurance issuers are expected to implement the requirements of this provision using a good faith, reasonable interpretation of the law.
Coverage for Individuals Participating in Approved Clinical Trials. Effective for plan years beginning on or after January 1, 2014, non-grandfathered insured and self-insured medical plans that provide coverage to “qualified individuals” may not (a) deny the qualified individual participation in an approved clinical trial with respect to the treatment of cancer or another life-threatening disease or condition, (b) deny (or limit or impose additional conditions on) the coverage of routine patient costs for items and services furnished in connection with participation in the trial, or (c) discriminate against the individual on the basis of the individual’s participation in the trial. A participant or beneficiary is a “qualified individual” if the participant or beneficiary meets the criteria for participation in the clinical trial and either (a) the referring health care professional is a participating provider and has concluded that the individual’s participation in such trial would be appropriate or (b) the participant or beneficiary provides medical and scientific information establishing that the individual’s participation in such trial would be appropriate. The departments will not issue regulations addressing this provision prior to its effective date. Until regulations are issued, group health plans and health insurance issuers are expected to implement the requirements of this provision using a good faith, reasonable interpretation of the law.