Agencies Issue ACA FAQs Addressing Annual Limit Waivers, Other Topics

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A change to a health plan or policy year will not impact the expiration date of an annual limit waiver, the federal government said April 29 in a new set of frequently-asked-questions and answers on implementation of the Affordable Care Act.

The 15th set of FAQs on ACA, issued by the Internal Revenue Service and the departments of Labor and Health and Human Services, also addressed questions regarding provider nondiscrimination, coverage provided to individuals participating in approved clinical trials, and “transparency in coverage reporting requirements.”

In response to a question about annual limit waivers, the departments said such waivers under Public Health Service Act Section 2711 “were approved by HHS for the plan or policy year in effect when the plan or issuer applied for the waiver. The same holds true for waiver extensions. They extended the waiver based on the date of the plan or policy year in effect when the initial application was submitted. As a result, waiver recipients that change their plan or policy years will not extend the expiration date of their waivers.”

PHSA Section 2711, added to the law by ACA, prohibits any group health plan or health insurance issuer in the group or individual market from imposing any lifetime or annual limit on the dollar value of “essential health benefits” provided to participants or beneficiaries. Essential health benefits include ambulatory patient services, emergency services, hospitalizations, maternity and newborn care, mental health and substance abuse services, prescription drugs, rehabilitative services and devices, laboratory services, preventative and wellness services, chronic disease management, pediatric services, and other services as defined by HHS.

Provider Nondiscrimination

The departments said they do not plan to offer formal guidance on provider nondiscrimination before its effective date because the “statutory language … is self-implementing and the Departments do not expect to issue regulations in the near future.”

PHSA Section 2706(a) addresses provider nondiscrimination, saying that a “group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider's license or certification under applicable state law.”

Section 2706(a) applies to “non-grandfathered group health plans and health insurance issuers offering group or individual health insurance coverage for plan years (in the individual market, policy years) beginning on or after January 1, 2014,” the departments said.

The departments also said they do not plan to issue guidance on PHSA Section 2709 before its effective date because the statute's language is “self-implementing.” Section 2709 addresses coverage for individuals participating in approved clinical trials.

Transparency Reporting

Plans and issuers do not have to comply with transparency in coverage reporting requirements under Section 1311(e)(3) of the Affordable Care Act and Section 2715A of the PHS Act until health plans have been certified as “qualified health plans” under the ACA for one benefit year, the FAQs said.

PHSA Section 2715A requires group health plans and health insurance issuers offering group or individual health insurance coverage to disclose the same information that carriers must disclose if they wish to certify their health insurance products on a state-based health insurance exchange. This information must be disclosed to the secretary of HHS and the relevant state insurance regulator, and be made available to the public.

“Similarly, because section 2715A of the PHS Act simply extends the transparency provisions set forth in section 1311(e)(3) of the Affordable Care Act to group health plans and health insurance issuers offering group and individual health insurance coverage, the Departments clarify that the reporting requirements under section 2715A of the PHS Act will become applicable to group health plans and health insurance issuers offering group and individual health insurance coverage no sooner than when the reporting requirements under section 1311(e)(3) of the Affordable Care Act become applicable,” the FAQs said.


The full set of FAQs is at http://www.dol.gov/ebsa/faqs/faq-aca15.html.