New DOL Guidance on Cost-Sharing Limitations

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The Department of Labor (DOL) recently issued FAQS about Affordable Care Act Implementation (Part XXVII) that provides additional guidance on the limitations on cost-sharing under the Affordable Care Act (ACA).  The ACA sets annual limits on a plan participant’s out-of-pocket costs for in-network services for essential health benefits.  These out-of-pocket costs include deductibles, co-insurance, and co-payments but not premiums, balance billing amounts for out-of-network services or costs for services not covered under the plan.

All non-grandfathered group health plans were required to comply with the out-of-pocket limits for plan years beginning on or after January 1, 2014.  The limits for 2015 are $6,600 for self-only coverage and $13,200 for family coverage.  For 2016, the limits are $6,850 for self-only and $13,700 for family coverage.

The FAQ clarifies that for plan years beginning on or after January 1, 2016, the self-only annual limit on cost-sharing applies to each individual, regardless of whether the individual is enrolled in self-only or in family coverage.  In other words, the self-only coverage limit applies to an individual even if enrolled in family coverage or in other coverage that is not self-only coverage.  The FAQ includes a detailed example of how this would apply to a family of four enrolled in a group health plan.  Note, this applies to all non-grandfathered group health plans, including non-grandfathered high-deductible health plans.

In addition to cost-sharing limitations, the FAQ addresses provider non-discrimination under the ACA.  Non-grandfathered group health plans and issuers may not discriminate against any provider, with respect to participation under the plan, who is acting within the scope of their license to practice.  While this applied to plan years beginning on or after January 1, 2014, the FAQ explains that no enforcement action will be taken against a group health plan until further guidance is issued so long as the plan is using a good faith, reasonable interpretation of the statutory requirement.