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The Wagner Law Group

The Wagner Law Group, A Professional Corporation, is a nationally recognized ERISA & employee benefits, estate planning, employment, labor & human resources practice. 


Established in 1996, The Wagner Law Group has 22 attorneys engaged exclusively in employee benefits, estate planning and employment law. Six of our attorneys are AV rated by Martindale-Hubbell as having very high to preeminent legal abilities and ethical standards. The firm is among the largest ERISA boutiques in the country. Our practice is national in scope, with clients in more than 40 states and several foreign countries.





Contact Info

The Wagner Law Group


  Integrity | Excellence



Tel: (617) 357-5200 

Fax: (617) 357-5250 

99 Summer Street 

13th Floor

Boston, MA 02110

Palm Beach Gardens 

Tel: (561) 293-3590
Fax: (561) 293-3591
7108 Fairway Drive
Suite 125
Palm Beach Gardens, FL 33418



Tel: (813) 603-2959

Fax: (813) 603-2961

101 East Kennedy Boulevard

Suite 2140
Tampa, FL  33602 


San Francisco

Tel: (415) 625-0002

Fax: (415) 358-8300

315 Montgomery Street

Suite 904

San Francisco, CA 94104


St. Louis

Tel: (314) 236-0065

Fax: (314) 236-5743
100 South 4th Street, Suite 550
St. Louis, MO  63102 







November 20, 2015


 Health and Welfare Law Alert




 Agencies Issue Final Regulations Implementing

Certain ACA Provisions




The DOL, HHS and IRS have jointly issued final regulations for many of the Affordable Care Act's ("ACA's") provisions, including: (1) preservation of the right to maintain existing coverage; (2) prohibition on preexisting condition exclusions as well as lifetime and annual limits; (3) rescission of coverage; (4) extension of dependent coverage to age 26; (5) internal claims and appeals and external review process; and (6) patient protections. For the most part, these final regulations merely incorporate the earlier interim regulations with the subsequent, additional interpretive guidance issued by agencies. The final regulations are effective for plan years beginning on or after January 1, 2017.


Final Regulations. The following are some of the highlights from the final regulations:


Grandfathered Plans. ACA provides that certain group health plans existing on March 23, 2010 (i.e., grandfathered plans) are not required to comply with some ACA provisions. The final regulations define grandfathered plans and establish rules for maintaining this status.


Preexisting Condition Exclusions. The regulations finalize the ACA's prohibition on group health plans imposing preexisting condition exclusions.


Lifetime and Annual Limits Prohibition. The regulations also finalize the rules regarding the prohibition of group health plans imposing annual and lifetime dollar limits on essential health benefits.


Prohibition on Rescissions. The ACA prevents group health plans from rescinding coverage unless an individual commits fraud or intentionally misrepresents a material fact. The final regulations explain that a retroactive cancellation is not a rescission if: (i) it is initiated by the individual and the employer, plan, or sponsor does not take action to influence the decision or take adverse action (i.e., retaliate) against the individual, or (ii) it is initiated by an Exchange in accordance with applicable HHS requirements. The final regulations also clarify that the exception for failure to timely pay required premiums also applies to COBRA coverage.


Coverage for Dependents to Age 26. The ACA requires that group health plans offering dependent coverage for children must make coverage available for dependent children up to age 26. The final regulations provide that eligibility restrictions under a group health plan that require an individual to work, live, or reside in a service area are prohibited to the extent that they apply to dependent children up to age 26.


Internal Claims and Appeals and External Reviews. The ACA establishes standards for group health plans regarding internal claims and appeals and external reviews. The final regulations generally prohibit the imposition of filing fees on claimants seeking external reviews. However, because several states' external review processes currently allow nominal filing fees, the final regulations permit group health plans subject to such states' laws to impose nominal filing fees.


Patient Protection. The ACA sets forth certain requirements for emergency services benefits and the designation of primary care providers. The final regulations provide that group health plans are allowed to apply reasonable and appropriate geographic limitations regarding which participating primary care providers are available for designation. The final regulations also explain that there are no age restrictions for the ACA requirement that women may receive obstetrical and gynecological care without prior authorization or referral by a group health plan.


The final regulations are available at: http://www.gpo.gov/fdsys/pkg/FR-2015-11-18/pdf/2015-29294.pdf





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This Newsletter is provided for information purposes by The Wagner Law Group to clients and others who may be interested in the subject matter, and may not be relied upon as specific legal advice.  This material is not to be construed as legal advice or legal opinions on specific facts. Under the Rules of the Supreme Judicial Court of Massachusetts, this material may be considered advertising.