New ACA Guidance Addresses Cost Sharing, Wellness, Mental Health

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By Kristen Ricaurte Knebel  

Jan. 9 --Beginning in 2015, health plans and issuers are required to apply all out-of-pocket maximums across all essential benefits, the federal government said in a new set of frequently-asked-questions and answers on implementation of the Affordable Care Act.

Because the cost-sharing limits included in the ACA only apply to essential health benefits, “plans are not required to apply the annual limitation on out-of-pocket maximums to benefits that are not” essential health benefits, the departments of Labor, Treasury and Health and Human Services said in their 18th set of FAQs and answers on ACA implementation, released Jan. 9.

The agencies also said in the guidance that plans are able to divide the annual limits on out-of-pocket costs over multiple categories of benefits.

“Plans and issuers are permitted to structure a benefit design using separate out-of-pocket limits, provided that the combined amount of any separate out-of-pocket limits applicable to all [essential health benefits] under the plan does not exceed the annual limitation on out-of-pocket maximums for that year,” the FAQs said.

The FAQs also said that a plan with a provider network isn't required to count a participant's out-of-pocket expenses for items and services obtained outside of the plan's network toward the annual out-of-pocket limits for the plan. Additionally, plans aren't required to count costs for services that aren't covered by the plan toward the out-of-pocket maximum for the year, the guidance said.

In addition to cost-sharing limitations, the FAQs tackle a host of other ACA-related issues, including the health-care law's impact on the Mental Health Parity and Addiction Equity Act, wellness programs and the definition of “insured expatriate health plan.”

Wellness Programs

If participants in a group health plan decline the chance to avoid a “tobacco premium surcharge” by enrolling in a smoking cessation program at the beginning of a plan year, the plan isn't obligated to offer the participants the discount if they decide to join the program in the middle of the year, the guidance said.

“If a participant is provided a reasonable opportunity to enroll in the tobacco cessation program at the beginning of the plan year and qualify for the reward (i.e., avoiding the tobacco premium surcharge) under the program, the plan is not required (but is permitted) to provide another opportunity to avoid the tobacco premium surcharge until renewal or reenrollment for coverage for the next plan year,” the agencies said.

The guidance also addressed the reasonable alternative standard that plans must provide for participants in health-contingent wellness programs.

“If an individual's personal physician states that the outcome-based wellness program is not medically appropriate for that individual and recommends a weight reduction program (an activity-only program) instead, the plan must provide a reasonable alternative standard that accommodates the recommendations of the individual's personal physician with regard to medical appropriateness. Many different weight reduction programs may be reasonable for this purpose, and a participant should discuss different options with the plan,” the guidance said.

Other Issues

The guidance also explained the impact the ACA had on the MHPAEA, saying that the ACA “builds on MHPAEA and provides that mental health and substance use disorder services are one of ten [essential health benefits] categories.”

The agencies also provided further clarification on the definition of an insured expatriate health plan, saying it is “an insured group health plan with respect to which enrollment is limited to primary insureds for whom there is a good faith expectation that such individuals will reside outside of their home country or outside of the United States for at least six months of a 12-month period and any covered dependents, and also with respect to group health insurance coverage offered in conjunction with the expatriate group health plan.”

The FAQs said the agencies are considering further guidance on insured expatriate group health plans but that any guidance wouldn't be effective for plan years ending on or before Dec. 31, 2016. Insured expatriate health plans can continue to rely on the temporary relief given in FAQs issued in March 2013 (31 HRR 259, 3/18/13) through at least 2016, the guidance said.

In addition, the guidance addressed the coverage of preventive services in light of recommendations by the U.S. Preventive Services Task Force, saying that the recommendations regarding medications for reducing the risk of breast cancer in women must be implemented by non-grandfathered group health plans for plan or policy years starting Sept. 24, 2014.


To contact the reporter on this story: Kristen Ricaurte Knebel in Washington at

To contact the editor responsible for this story: Phil Kushin at

Text of the FAQs is available at

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