United Benefit Advisors Insight and Analysis Blog

Preventive Services Final Rules

Posted by: Danielle Capilla    Aug 6, 2015 12:00:00 PM

Federal agencies released final regulations on the preventive services mandate of the Patient Protection and Affordable Care Act (ACA) that requires non-grandfathered group health plans to provide coverage without cost-sharing for specific preventive services, which for women include contraceptive services.

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Topics: ACA, PPACA Affordable Care Act, contraception coverage, religious opposition to contraception, Cost-Sharing, group health insurance, preventive services, Danielle Capilla

Cost Sharing Limits Changing for 2016

Posted by: Danielle Capilla    Apr 7, 2015 12:00:00 PM

In the Benefit and Payment Parameters for 2016 Final Rule issued in February 2015, federal agencies included a clarification that annual cost-sharing limitations for self-only coverage apply to all individuals, regardless of whether the individual is covered by a self-only plan or is covered by another kind of plan. Cost sharing refers to out-of-pocket expenses and deductibles that are paid by the beneficiary. In both self-only and other plans, an individual’s cost sharing for essential health benefits (EHBs) may never exceed the self-only annual limitation. The information was only included in the preamble of the Final Rule, and was not included into the regulatory language. As a result, the benefits industry was left unsure of the implications.

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Topics: Cost-Sharing

Reference-Based Pricing and Cost-Sharing Limits

Posted by: Linda Rowings    Nov 11, 2014 10:19:00 AM

The Department of Labor (DOL), the IRS, and the Department of Health and Human Services (HHS) have jointly issued a FAQ that addresses how "reference-based pricing" works with the Patient Protection and Affordable Care Act's (PPACA) restrictions on out-of-pocket maximums. PPACA limits the out-of-pocket maximum a non-grandfathered plan may impose, and generally requires that co-pays, coinsurance, and deductibles be counted toward this limit. However, premiums, balance billed amounts for non-network providers, and non-covered services do not need to be applied to the out-of-pocket limit. (For 2015, the limits are $6,600 per individual or $13,200 per family.) The new FAQ explains how the out-of-pocket limit applies to plans that use reference-based pricing--i.e., a design under which the plan pays a fixed amount for a particular procedure (such as a knee replacement), which certain providers have agreed to accept as full payment.

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Topics: Linda Rowings, IRS, HHS, DOL, Reference-Based, Pricing, Cost-Sharing, Limits, Department of Labor, Department of Health and Human Services