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The Wagner Law Group Description 

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

  

Massachusetts Office 

Tel: (617) 357-5200 

Fax: (617) 357-5250 

99 Summer Street 

13th Floor

Boston, MA 02110


Florida Office 

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

   

San Francisco Office

Tel: (415) 625-0002

Fax: (415) 358-8300

315 Montgomery Street

Suite 904

San Francisco, CA 94104

 

www.wagnerlawgroup.com

 

 

 

 

October 16, 2014

 

 Health and Welfare Law Alert

 

 

 

 

Agencies Issue Final Rules for Excepted Benefits  

 

 

 

DOL, HHS and IRS have jointly issued final regulations amending those originally promulgated under the Health Insurance Portability and Accountability Act ("HIPAA") regarding the classification of limited-scope dental and vision benefits as excepted benefits. The final regulations also expand the definition of excepted benefit to cover certain employee assistance programs ("EAPs"). Notably, these excepted benefits are exempt from meeting certain PPACA requirements that apply to group health plans and other health insurance.

 

Background. Excepted benefits are benefits that are considered limited or ancillary to comprehensive group health coverage. Notably, excepted benefits are exempt from HIPAA's portability and nondiscrimination requirements as well as other legislative mandates such as mental health parity and PPACA's marketplace mandates and insurance reforms. (This includes PPACA's restrictions on annual and lifetime limits and the requirement that preventive services be provided with no cost sharing.) Individuals with excepted benefits may enroll in health insurance coverage through one of PPACA's Health Insurance Marketplaces and obtain premium tax credits to pay for such coverage.

 

Dental and Vision Benefits. To qualify as excepted benefits, limited-scope dental and vision benefits must not be deemed as being an integral part of a group health plan. Under the final regulations, vision and dental benefits are not considered to be an integral part of a group health plan if participants may decline coverage or if claims for the benefits are administered under a separate contract from other group health plan benefits.

 

The final regulations explain that limited-scope dental and vision coverage need not be offered separately from the plan providing group health coverage in order to qualify as excepted benefits. In addition, the final regulations clarify that participants need not pay an additional premium or contribution for limited-scope dental or vision benefits to qualify as an excepted benefit.

 

EAPs. The final regulations amend current regulations to include EAPs that meet certain conditions as excepted benefits. The final regulations provide that for an EAP to be considered an excepted benefit, it cannot:

 

  • Provide significant benefits in the natue of medical care.
  • Be coordinated with the group health benefits.
  • Require any employee premiums or contributions as a condition for participation.
  • Impose cost-sharing requirements.

To determine whether an EAP provides significant benefits in the nature of medical care, the amount, scope and duration of the covered services are to be taken into account. For example, an EAP that provides only limited, short-term outpatient counseling for substance abuse disorders (without covering inpatient, residential, partial residential or intensive outpatient care) without requiring prior authorization or review for medical necessity does not provide significant benefits. Conversely, an EAP that provides disease management services (such as laboratory testing, counseling and prescription drugs) for individuals with chronic conditions, such as diabetes, does provide significant benefits.

 

Effective Date. The final regulations apply to group health plans for plan years beginning on or after January 1, 2015.

 

Action Steps. Employers that offer limited-scope dental or vision or EAP benefits are advised to carefully review the final regulations to ensure that benefits have been properly designated and are being properly administered by service providers. Failure to meet the applicable requirements may result in penalties for noncompliance.

 

 

 

 

This Newsletter is protected by copyright. Material appearing herein may be reproduced with appropriate credit.

 

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.