DOL answers more questions on ACA: 5 highlights
New Obamacare guidance from the agencies responsible for implementing the ACA includes a lot of important info on health plans and cost-sharing.
The feds’ (DOL, HHS and IRS) 31st FAQ on healthcare reform answers a lot of important questions for employers about the ACA.
But it also delves into other federal laws such as the Mental Health Parity Act and the Women’s Health and Cancer Rights Act (WHCRA).
Some of the highlights employers should know from the 12-question FAQ:
Preventive services
The first few questions in the FAQ deal with the preparation for a common preventive procedure: a colonoscopy.
According to the feds, the preparation is an integral part of the actual procedure and, generally, must be covered without any cost-sharing. Specifically, the feds mentioned bowel preparation medications given before the colonoscopy.
However, when utilizing reasonable medical management techniques, plans can create a standard exception form – which can be modeled after the Medicare Part D Coverage Determination Request Form – so providers can prescribe specific services or FDA-approved items.
Out-of-network ER services
When asked, plans generally must disclose how the payments for out-of-network ER services were calculated to comply with ERISA’s disclosure rules and the ACA’s appeals process and external review requirements.
Clinical trials and cancer
The FAQs tackled how cancer treatment coverage applies to clinical trials. Specifically, if a plan covers chemotherapy, it generally can’t limit that coverage when it’s connected with an individual’s participation in an approved clinical trial for a new anti-nausea medication.
Plus, plans can’t deny coverage of items or services to diagnose or treat side effects that are part of a clinical trial if the plan generally covers those things for non-clinical trial treatment.
Mental health parity
The feds dedicated three questions to clarifying some issues surrounding the Mental Health Parity Act, specifically how to perform certain tests — “substantially all” and “predominant” — for financial requirements and quantitative limits.
Those testing requirements apply to any benefits a plan offers for medication-assisted treatment of an opioid use disorder.
Reconstructive surgery following a mastectomy
Finally, the feds clarified that under the WHCRA, plans must provide coverage for nipple and areola reconstruction — including repigmentation to restore the physical appearance of the breast — as a required stage of breast reconstruction.
A version of this article was published previously on our sister website, CFO Daily News.
