New FAQs Confirm Embedded Out Of Pocket Limits

New FAQs Confirm Embedded Out Of Pocket Limits

Our Thinking / Healthcare /

New FAQs Confirm Embedded Out Of Pocket Limits
Calendar27 May 2015

The latest Affordable Care Act (ACA) FAQs from the Labor Department, IRS, and the Department of Health and Human Services confirm that self-insured and large-group insured nongrandfathered health plans must "embed" individual in-network out-of-pocket (OOP) limits in family coverage. The guidance gives health plans until the 2016 plan year to comply. This means that plans whose family annual OOP maximum for in-network essential health benefits exceeds $6,850 must have an embedded individual OOP limit of $6,850 or less for 2016.

The new guidance also withdraws a previous FAQ on the ACA's provider nondiscrimination provision that took effect in 2014. While the ACA says this provision is not an "any willing provider" requirement, the Senate Appropriations Committee criticized the prior FAQ as inconsistent with the provision's purpose. Instead of providing plan members broad access to licensed providers, the FAQ mistakenly allowed plans to consider market factors in addition to quality and performance in deciding which providers to include in their networks, the Senate committee said. That critique in turn prompted ACA regulators to issue a request for information on the topic.

The new FAQ essentially repeats the ACA's provider nondiscrimination language and states that, given the breadth of views expressed in comments, the agencies won't take any enforcement action against a group health plan using a good-faith, reasonable interpretation of the law until further guidance is issued.

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