The Affordable Care Act1 requires non-grandfathered health plans to provide certain preventive services in network without charge to the participant or beneficiary.2 On October 23, 2015, the Departments of Labor, Treasury, and Health and Human Services (the “Departments”), which are responsible for implementing group health plan standards under the Affordable Care Act, published a series of answers to Frequently Asked Questions (FAQs) clarifying certain issues.3 This Update summarizes these new answers to FAQs.
The preventive services that must be provided without cost sharing fall into four different categories: services with an “A” or “B” recommendation from the U.S. Preventive Services Task Force (USPSTF), vaccines recommended by the Centers for Disease Control and Prevention (CDC), the Bright Futures guidelines developed by the American Academy of Pediatrics with support from the Health Resources and Services Administration (HRSA), and certain women’s services listed in HRSA guidelines (supplementing some of the USPSTF recommendations).
The HRSA guidelines mentioned above require plans to provide coverage of comprehensive lactation support, counseling and equipment rental. Lactation support generally helps mothers learn how to feed babies and address the medical problems that may arise. The new answers to FAQs clarify several issues relating to these requirements:
Non-grandfathered plans are not permitted to have a general exclusion for weight-management services for obese adults that would encompass required preventive services. However, precisely what services plans must offer without cost sharing is not clear. Plans must cover screening for obesity for adults. In addition, the USPSTF recommends intensive, multicomponent behavioral interventions for adults with a body mass index of 30 kg/m2 or higher.
While plan sponsors are permitted to use reasonable medical-management techniques to determine the frequency, method, treatment or setting for these interventions, the Departments set out this example of an intensive, multicomponent behavioral intervention for weight management:
A screening colonoscopy must be covered without cost sharing. However, certain services are integral to receiving the colonoscopy. Consequently, non-grandfathered plans may not charge cost sharing for the following:
This guidance is effective for plan years beginning on or after December 22, 2015 (January 1, 2016 for calendar-year plans). Previous guidance had clarified that anesthesia services related to the screening colonoscopy must be covered without cost sharing.4
Women found to be at increased risk using a screening tool designed to identify a family history that may be associated with an increased risk of having a potentially harmful gene mutation must receive, without cost sharing, coverage for genetic counseling, and, if indicated, testing for mutations of BRCA genes.5 This requirement also applies to a woman previously diagnosed with cancer, as long as she is not currently symptomatic or being treated for breast, ovarian, tubal or peritoneal cancer.
Sponsors of non-grandfathered plans should review both plan documents and plan operations to assure that they are in compliance with the latest answers to FAQs. With respect to weight-management counseling, plan sponsors may want to develop custom programs with discounted provider network services, clear clinical management rules, and protocols and reporting tools to make sure care is appropriate and help manage costs. In addition to implementing the preventive services benefits operationally, it is important to have documentation of the benefit, both so that plan participants can understand their coverage and that the plan sponsor can demonstrate the benefit if audited by the Department of Labor or Centers for Medicare & Medicaid Services. Failure to properly implement a non-grandfathered benefit could lead to excise tax penalties of $100 per day for each affected individual and/or the imposition of a requirement to re-process claims under the correct standards.
1 The Affordable Care Act is the shorthand name for the Patient Protection and Affordable Care Act (PPACA), Public Law No. 111-48, as modified by the subsequently enacted Health Care and Education Reconciliation Act (HCERA), Public Law No. 111-152.
2 For background on the preventive services requirements, see Sibson Consulting’s March 12, 2013 Capital Checkup, “New Guidelines on Preventive Care Benefits for Non-Grandfathered Plans.”
3 These answers to FAQs are available on the DOL website. For information on previous recent answers to FAQs on required preventive services (addressing some of the same topics), see Sibson’s May 28, 2015 Update, “Additional Coverage Required for Preventive Services Under the Affordable Care Act.”
4 That guidance is summarized in Sibson’s May 28, 2015 Update, “Additional Coverage Required for Preventive Services Under the Affordable Care Act.”
Update is Sibson Consulting’s electronic newsletter summarizing compliance news. Update is for informational purposes only and should not be construed as legal advice. It is not intended to provide guidance on current laws or pending legislation. On all issues involving the interpretation or application of laws and regulations, plan sponsors should rely on their attorneys for legal advice.
If you would like additional information about this news, please contact your Sibson consultant or the Sibson office nearest you. Sibson can be retained to work with plan sponsors and their legal counsel on compliance issues.
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