On Nov. 18, 2015, the Departments of Labor, Health and Human Services and the Treasury (Departments) issued final regulations regarding a number of ACA market reform requirements, including annual limits, dependent coverage up to age 26 and patient protections.
While this final rule largely reaffirms proposed interim final rules, there are a few measures to be aware of. For example, the final rule clarifies that lifetime and annual dollar limits on essential health benefits (EHBs) are generally prohibited, regardless of whether care is provided in network or out of network.
In regards to dependent coverage, the final rule confirms that a plan or issuer cannot deny or restrict coverage based on a child’s financial dependency, residency, student status or employment. The term “child” refers to a son, daughter, stepson, stepdaughter, adopted child or eligible foster child. Plans are not required to make coverage available to grandchildren.
The final rule also addresses patient protection requirements, including clarifying that a plan or issuer may not require a female participant (of any age) to obtain an authorization or referral for obstetric or gynecological care provided in network. Plans and issuers, however, are allowed to apply reasonable and appropriate geographic limitations with respect to participating primary care providers.
In the final rule, the IRS declined to define the term “primary care provider.” Instead, this term should be determined under the terms of an employer’s plan or coverage and in accordance with state law.
These are just a few of the provisions outlined in the final rule. Other topics covered include grandfathered plans, pre-existing condition exclusions, rescissions, and internal and external appeals.
The final rule is effective for plan years beginning on or after Jan. 1, 2017.
For a more complete understanding of the final rule and what it means for you, contact Emery Benefit Solutions today at firstname.lastname@example.org.