The Wagner Law Group
Wagner Law Group, A Professional Corporation, is a nationally
recognized ERISA & employee benefits, estate planning,
employment, labor & human resources practice.
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.
Wagner Law Group
Fax: (561) 293-3591
7108 Fairway Drive
Palm Beach Gardens, FL 33418
East Kennedy Boulevard
Tampa, FL 33602
Francisco, CA 94104
100 South 4th Street, Suite 550
St. Louis, MO 63102
November 20, 2015
Health and Welfare Law
Agencies Issue Final
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.
Regulations. The following are
some of the highlights from the final regulations:
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.
Condition Exclusions. The
regulations finalize the ACA's prohibition on group health plans
imposing preexisting condition exclusions.
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.
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.
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.
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.
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.
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