Feds Provide Answers to Frequently Asked Questions

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The Labor (DOL), Health and Human Services (HHS), and the Treasury Departments have published a new batch of Frequently Asked Questions (FAQ) about the Affordable Care Act (ACA). These questions come from ACA stakeholders and the DOL publishes them to facilitate compliance with certain ACA mandates. Among the issues highlighted:

  • A general overview of COBRA requirements and hyperlinks to the newest DOL model COBRA and CHIPRA notices.
  • How a plan may count or exclude out-of-network expenses towards out-of-pocket maximums. As one example, if a member elects a brand name drug over a less expensive and medically appropriate generic drug, the difference between the two does not have to be counted towards that individual’s out-of-pocket maximum. Plans must use a reasonable method for excluding expenses from the out of pocket maximum, and ERISA requires that such provisions be explained in the summary plan description.
  • Under a plan which uses reference-based pricing, only those providers who accept the reference amount will be considered as being in-network for the plan, so long as there is adequate access to quality providers.
  • Elaboration of compliance requirements for coverage of preventive services and tobacco use screening/ cessation.
  • Unused health FSA carry over amounts remaining at the end of a plan year that satisfy the modified “use-or-lose” rule should not be used to determine how the excepted benefits regulations apply to the health FSA.
  • The Summary of Benefits and Coverage (SBC) template which was made available in April 2013 for the second year of applicability should be used until further guidance is issued.


Click here to view the FAQ