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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. Five 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) 829-4385

315 Montgomery Street

Suite 902

San Francisco, CA 94104





March 7, 2013 

 State and Federal Law Alert


Recently Released Health Care Reform FAQs Address Cost Sharing Limits and Coverage of Preventive Services


The DOL, HHS and IRS have issued the twelfth set of FAQs relating to the implementation of various provisions of the Patient Protection and Affordable Care Act ("PPACA"). In particular, these FAQs offer guidance on cost-sharing limits and coverage of preventive services mandated under PPACA.


Cost-sharing Limits. PPACA requires group health plans to ensure that any annual cost-sharing imposed by the plans does not exceed certain specified limits on out-of-pocket and annual deductible costs.


The FAQs confirm the following:

  • PPACA's annual deductible limits only apply to non-grandfathered health insurance coverage and qualified health plans offered in the small group market. Plans and insurers may exceed PPACA's annual deductible limits if they cannot "reasonably" reach a given level of coverage (e.g., bronze, silver, gold) without exceeding the limits.
  • Self-insured and large group health plans are not required to satisfy PPACA's deductible limits. While the DOL acknowledged that it intends to engage in future rulemaking to establish annual deductible limits for self-insured and large group health plans, for the time being these plans may rely on the DOL's expressed intention to only apply the annual deductible limits to plans and issuers in the small group market.
  • All non-grandfathered group health plans must comply with PPACA's annual limits on out-of-pocket maximums.
  • The Mental Health Parity and Equity Act of 2008 prohibits group health plans from imposing one annual out-of-pocket maximum on all medical/surgical benefits and a separate annual out-of-pocket maximum on all mental health and substance abuse disorder benefits. 

Transitional relief from PPACA's annual out-of-pocket maximums is available to plans that administer benefits using multiple service providers, which may impose different levels of out-of-pocket limits and use different methods to credit participants' out-of-pocket expenses. For the first plan year beginning on or after January 1, 2014, a group health plan with multiple service providers will be deemed to have satisfied the annual out-of-pocket maximums if:

  • the plan complies with the annual limit requirements with respect to its major medical coverage; and
  • any out-of-pocket maximums on coverage not consisting solely of major medical coverage (e.g., separate maximums for prescription drug coverage) do not exceed the limits on out-of-pocket maximums which apply to high-deductible health plans. 

Coverage of Preventive Services. PPACA requires non-grandfathered group health plans and health insurance coverage offered in the individual or group market to cover the following services without imposing cost-sharing requirements:

  • services recommended by the United States Preventive Services Task Force;
  • immunizations recommended by the Advisory Committee on Immunization Practices;
  • preventive care and screenings for infants, children, adolescents and women provided for in guidelines supported by HHS's Health Resources and Services Administration ("HRSA"); and
  • preventive care and screening for women supported by HRSA.  

If a plan does not have an in-network provider that can furnish the specified preventive service, it must cover the service when performed by an out-of-network provider and may not impose cost-sharing for the service.


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Pursuant to Internal Revenue Service Circular 230, we hereby inform you that any advice set forth herein with respect to US federal tax issues is not intended or written by The Wagner Law Group to be used and cannot be used, by you or any taxpayer, for the purpose of avoiding penalties that may be imposed on you or any other person under the Internal Revenue Code.


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.