January 14, 2014
Authored by: benefitsbclp
Last week, the Departments of Labor, HHS and Treasury issued their 18th set of FAQs intended to answer a smattering of questions regarding the implementation of ACA. Issues addressed in those FAQs include, among other things:
- Risk-Reducing Breast Cancer Drugs Must Be Provided Without Copay. On September 24, 2013, the United States Preventive Services Task Force (USPSTF) revised its “B” recommendation with respect to medications for risk reduction of primary breast cancer in women. The recommendation now provides that, for women who are at increased risk for breast cancer and at low risk for adverse medication effects, clinicians should offer to prescribe risk-reducing medications, such as tamoxifen or raloxifene. Given that evidenced-based items or services that have in effect a rating of “A” or “B” must be provided by non-grandfathered group health plans and health insurance coverage without cost-sharing, this means that risk-reducing medications prescribed by clinicians will need to be covered with no cost-sharing under these plans. This change is effective for plan or policy years beginning on or after September 24, 2014 (one year after the date of the revision to the USPSTF recommendation) – generally January 1, 2015 for calendar year plans/policies.
- The Annual Limit on Out-of-Pocket Costs May Be Divided Across Multiple Categories of Benefits. ACA provides an annual limitation on out-of-pocket maximums (for 2014, $6,350 for self-only coverage and $12,700 for coverage other than self-only). In this FAQ, the Departments recognize that plans with multiple service providers may benefit from structuring a benefit design using separate out-of-pocket limits to avoid needing to reconcile claims across multiple providers. The Departments have officially approved this approach, subject to the caveat that the combined amount of any separate out-of-pocket limits applicable to all benefits under the plan may not exceed the annual limitation on out-of-pocket maximums for that year.
- One Opportunity At the Beginning of the Year to Participate in a Tobacco Cessation Program to Avoid Tobacco Use Surcharge is Permissible. The FAQs confirm that when a group health plan charges participants a tobacco premium surcharge unless, at the time of enrollment or annual reenrollment, the participant agrees to participate in (and subsequently completes within the plan year) a tobacco cessation educational program, then a participant who declines the opportunity to participate in the tobacco cessation program, but joins in the middle of the plan year, need not be excused from the surcharge for that plan year. Rather, a plan need only provide a reasonable opportunity to enroll in the tobacco cessation program at the beginning of the plan year.