The DOL recently released
Part 18 in its set of Frequently Asked Questions ("FAQs")
regarding the Patient Protection and Affordable Care Act
("PPACA"). FAQ Part 18 addresses a variety of questions
related to the implementation of PPACA, including PPACA's interaction
with the Mental Health Parity and Addiction Equity Act ("MHPAEA").
The following is a summary of some of the points covered in FAQ Part
Coverage of Preventive
Services. For plan years beginning
on or after September 24, 2014, non-grandfathered group health plans
must cover certain medications that reduce the risk of breast cancer,
without imposing cost-sharing.
Cost-sharing Limits. For
plan years beginning in 2014, the out-of-pocket maximums for
essential health benefits ("EHBs") provided under a
non-grandfathered plan are $6,350 for self-only coverage and $12,700
for coverage other than self-only coverage.
In a prior FAQ, the DOL
provided transition relief for plans that use more than one service
provider. The relief applies only to the first plan year beginning on
or after January 1, 2014. For that plan year only, a plan using
multiple service providers will satisfy the out-of-pocket maximums
if: (i) major medical coverage remains subject to the maximum
out-of-pocket limits; and (ii) out-of-pocket limits that are
separately imposed under coverage provided by other service providers
do not exceed the maximum out-of-pocket limits.
Wellness Programs. If,
at the time of enrollment or re-enrollment, a participant is offered
a reward for joining a tobacco cessation program but does not join,
he need not be eligible for the reward if he joins the program at a
later date. However, tobacco cessation programs may provide the
reward on either a full or pro-rated basis to a participant who joins
the program mid-year.
Where a physician advises
the plan that a standard under an outcome-based, health-contingent
wellness program is medically inappropriate for a participant, plan
sponsors may retain discretion regarding the reasonable alternative
standard that is used, but must engage in a meaningful discussion
with the participant and physician about different options available
to the participant.
PPACA's Interaction with
MHPAEA. EHBs include mental
health and substance use disorder services, and PPACA extends mental
health parity protections to both grandfathered and non-grandfathered
coverage. Non-grandfathered, small-group market coverage must
generally include mental health and substance use disorder coverage
for plan years beginning on or after January 1, 2014, and the
coverage must comply with the MHPAEA rules. Grandfathered small group
market coverage, however, is not required to comply with the EHB or
MHPAEA rules. Nevertheless, to the extent that a grandfathered plan
does provide mental health or substance use disorder coverage, such
coverage must comply with the MHPAEA rules.
A copy of FAQ Part 18 can
be accessed at: http://www.dol.gov/ebsa/pdf/faq-aca18.pdf