ACA Guidance on Cost-Sharing Limits, Preventive Care and More

In FAQ XII on Affordable Care Act implementation, issued February 20, 2013, more helpful guidance was provided to plan sponsors and insurers (“issuers,” in ACA parlance) on a variety of topics.  The FAQ is the latest in a series issued by the three government agencies that administer the ACA (the Departments of Labor, Health and Human Services, and Treasury). The FAQs are “soft guidance” intended to clarify existing regulations under the ACA and provide temporary guidance on issues for which regulations have not yet been issued.  Here is a very brief summary of the key points in FAQ XII:

• Annual Limits on Cost-Sharing[1]
  • Annual Maximum Deductible:  Under the ACA, non-grandfathered health plans offered in the small group market (on or off the exchange) must limit annual deductibles to $2,000 single/$4,000 family for plan years starting on or after January 1, 2014.  These amounts will be indexed to the increase in U.S. health insurance premiums in subsequent years.  Large group and self-funded health plans do not need to limit deductible amounts until further regulations issue (no deadline is mentioned).  “Small group market” is defined under applicable state rate filing laws, but in states that do not have a definition, the ACA definition will apply.  In California, small group will mean up to and including 50 employees for 2014 and 2015; the ACA definition is up to and including 100 employees.  Some small group coverage may exceed the annual deductible limit if doing so is necessary to reach a given “metal tier” level of coverage.
  • Annual Maximum Out of Pocket Expense:  The FAQ makes clear that beginning in 2014, all non-grandfathered group health plans of any size (insured or self-funded) must limit out of pocket expenses to no more than the maximum limits allowed for high-deductible plans that are combined with HSAs ($6,250 single/$12,500 family in 2013).  Plans that use multiple providers (such as major medical carrier, pharmacy benefits manager, managed behavioral health organization), each of which may impose a separate deductible, have transition relief from the dollar limit only for the first plan year beginning on or after January 1, 2014.  The relief is available only if the major medical component plan complies with the maximum dollar limits, and any separate component also does not exceed the limits.  However the FAQ warns that mental health parity rules prevent prohibit separate annual OOP maximums just on mental health and substance use disorder benefits.
• General Preventive Services
  • If a preventive service that the ACA requires be provided “first-dollar” (i.e., with no cost sharing) is not available from a plan’s in-network providers, the plan’s out of network providers must offer the preventive service with no cost sharing.
  • Over the counter items recommended for preventive care (such as daily aspirin tablets to reduce heart attacks) will be covered without cost sharing only when prescribed by a health care provider.
  • No cost-sharing will apply to separate preventive services – such as polyp removal during a colonoscopy – that are an “integral part” of the preventive screening procedure.  The professional standards applicable to each preventive service will govern what is “integral” to the preventive service, and what is not.
  • When a woman’s family history suggests she is “high risk” for developing breast cancer, genetic counseling and testing for mutations in the BRCA 1 or BRCA 2 genes must be provided with no cost sharing.  Currently it is not uncommon for the patient co-pay for this testing to exceed $500.
  • Identification of “high risk” individuals eligible for genetic testing will be determined by clinical expertise based on doctor-patient communications.
  • When an immunization is recommended for certain individuals, rather than an entire age- or risk-based population, no cost-sharing will apply so long as the immunization is prescribed by a health care provider under terms that are consistent with recommendations by the Advisory Committee on Immunization Practices (ACIP).
  • First-dollar coverage of immunizations that newly are recommended by ACIP must begin with the plan year (or policy year, for individual coverage) that begins on or after the date that is one year after the date that ACIP makes the recommendation.  The FAQ contains details about when an ACIP recommendation is considered to have been “issued.”

• Women’s Preventive Services

By way of background, the ACA requires first-dollar coverage of women’s preventive services recommended by the Health Resources and Services Administration (HRSA) for plan years beginning on or after August 1, 2012.  Covered services include at least one annual “well-woman” visit, annual testing for HPV (human papillovirus), annual testing and counseling for HIV, annual counseling for sexually transmitted infections, contraceptive methods and counseling (as prescribed), breastfeeding support and supplies (per each birth), and annual screening and counseling for interpersonal and domestic violence.   This is in addition to the “general” preventive care rules which require first-dollar coverage of mammograms, screenings for cervical cancer, prenatal care, and other items, some of which may overlap with the “well woman” visits described below.  An exception from the requirement to provide no-cost contraception methods and counseling applies to certain religious employers, including churches and other houses of worship, as well as to non-profit organizations with religious objections to contraception.

• The FAQ provides that, although the HRSA guidelines list preventive services individually, they do not “promote” multiple visits for the separate preventive services, and permit the provision of multiple services at a single visit provided that it is consistent with reasonable medical management techniques.
• The FAQ defines a “well-woman” visit to include age- and developmentally appropriate preventive services listed in the HRSA guidelines as well as other “general” preventive services such as mammograms, and states that, if a health care provider determines that more than one well-woman visit is needed in a year to cover all preventive screening and counseling requirements, the second or subsequent visits must be covered without cost-sharing, subject to reasonable medical management.
• The FAQ describes where to find online assessment tools and other information that may be used to perform counseling for interpersonal and domestic violence.
• The FAQ provides that women age 30 or older with normal cytology results should be tested every three years for certain types of HPV DNA that are strongly linked to cancer, and that HIV testing must be made available yearly, with no cost-sharing.
• The FAQ provides that an employer that is not exempt from providing no-cost contraceptive methods must provide access to all FDA-approved contraceptive measures and cannot cover only birth control pills.  Plans may, however, provide first dollar coverage only of generic contraceptive drugs, except in cases where a generic is not available, or where generic substitution is not medically appropriate for a particular patient.
• The FAQ provides that over-the-counter (OTC) contraception methods can be provided with no cost sharing only if a health care provider prescribes the particular contraceptive method, and also states that the HRSA guidelines do not include contraception for men.
• The FAQ provides that services related to contraceptive measures, including follow-up visits, management of side effects, counseling for continued adherence, and intrauterine device/implant removal, must be provided without cost-sharing, subject to reasonable medical management.
• The FAQ provides that first-dollar coverage of breastfeeding counseling includes prenatal and postnatal lactation support, counseling, and equipment rental, subject to reasonable medical management (which may include equipment purchase instead of rental).  No-cost lactation support and benefits is available for the duration of breastfeeding, subject to subject to reasonable medical management techniques.