The Departments of Health and Human Services, Labor and the Treasury have collectively issued another set of Frequently Asked Questions (FAQs) addressing a cornucopia of Affordable Care Act (ACA) issues. This, the 31st set of FAQs issued since the ACA was signed into law, runs the gamut from the coverage of preventive services to rescissions.
- Coverage of Preventive Services – Colonoscopies: A plan may not impose cost-sharing requirements for bowel preparation medications prescribed in connection with a scheduled preventive screening colonoscopy that is performed pursuant to USPSTF recommendations because the medications are an integral part of the procedure.
- Coverage of Preventive Services – Contraceptives: A plan that utilizes reasonable medical management techniques for a specified method of contraception may develop a standard form and instructions for providers to use for prescribing a particular method of contraception that is based on a determination of medical necessity. The Medicare Part D Coverage Determination Request Form may be used as a model template for plans and issuers to draft their forms and instructions.
- Rescissions: A teacher working under a 10-month (August 1 – May 31) contract who pays the full 12-month (August 1 – July 31) premium during those 10 months, and who informs the District during summer recess that he/she will not return for the next school year, cannot have his/her coverage retroactively terminated to May 31 unless he/she committed fraud or made an intentional misrepresentation of material fact.
- Out-of-Network Emergency Services: Plans subject to the Employee Retirement Income Security Act (ERISA) must disclose the documentation and data used to calculate payments for out-of-network emergency services, including the usual, customary and reasonable amount, in order to comply with ERISA’s disclosure requirements and the ACA’s internal claims and appeals and external review requirements.
- Clinical Trials: A plan may not deny, limit or impose additional conditions on the coverage of routine patient costs for items and services furnished in connection with participation in an approved clinical trial. For example, if a plan generally covers chemotherapy to treat cancer, it cannot limit coverage for chemotherapy when it is provided in connection with an individual’s participation in an approved clinical trial. Similarly, if a plan typically covers items or services to diagnose or treat certain complications or side effects, then it cannot limit such overage when the individual is participating in an approved clinical trial.
- Out-of-Pocket Limits: Prior guidance, FAQ XXI, addressed how cost-sharing limits apply to plans using reference-based pricing (i.e., providers accept a fixed amount as payment in full from the plan for a particular procedure). The current FAQ clarifies that if a plan utilizing a reference-based pricing design uses a reasonable method to ensure adequate access to quality providers at the reference price, then it may treat the providers accepting the reference-based price as the only in-network providers and does not have to apply an individual’s out-of-pocket expenses for services rendered by other providers toward the maximum out-of-pocket limit.
- Mental Health Parity and Addiction Equity Act: The guidance provides clarification on several issues under the Act, including (1) application of the “substantially all” and “predominant” tests for financial requirements and treatment limitations, (2) disclosure requirements and (3) application of the law to any benefits a plan offers for Medication-Assisted Treatment for opioid use disorder.
- Women’s Health and Cancer Rights Act: If a group health plan or issuer offering group or individual coverage provides medical or surgical mastectomy benefits, then the plan or issuer must also provide coverage for all stages of breast reconstruction in a manner determined during consultation between the attending physician and the patient. Deductibles and coinsurance for these benefits may be imposed only if they are consistent with those established for other covered benefits.