Over the years, federal agencies have issued a plethora of ACA proposed and interim rules, as well as regulatory guidance. But none of it was officially finalized — until now. The feds just issued final rules in bulk, solidifying those earlier efforts. In addition, the rules contain a few surprises you need to know about.
The final rules were just published as part of a 104-page addition to the Federal Register. They cover a wide swath of the healthcare reform law — including dependent coverage, patient protection rules, lifetime and annual limits, claims appeals, rescissions, HRA integration with Medicare, and grandfathered plan provisions.
For the most part, the rules don’t contain many substantial changes from the regulatory paperwork the feds have issued over the years. But there were a few modifications that employers and insurers will need to know about.
Here’s a breakdown of the most substantial changes and those that will affect the most plans:
- Service area restrictions. Eligibility restrictions requiring plan participants to work, live or reside in a service area (as is typically the case with HMOs) cannot be applied to dependent children until they reach age 26. However, plans can continue to provide coverage only within a designated service area.
- Variations in coverage. Terms of plan coverage cannot vary based on the age of a dependent child, except for children age 26 and older.
- Individual primary care designation. If a plan requires participants to designate a primary care provider, each participant must be permitted to designate his or her own provider.
- Children’s primary care providers. If a plan requires the designation of a primary care provider for a child, the plan must allow any physician who specializes in pediatrics (including subspecialties in pediatrics) — and who is in-network and available to accept the child — to be designated as the child’s primary care provider.
- OB/GYN access. All women, no matter their age, must be ensured direct access to OB/GYN care. That means no authorizations or referrals can be required to seek OB/GYN care.
Lifetime and annual limits
- General prohibition on limits. Lifetime and annual dollar limits on coverage for “essential health benefits” are generally prohibited, regardless of whether those benefits are provided by in-network or out-of-network providers.
- Evidence. Plans must provide claimants with any new or additional evidence that is being relied upon or used in anyway in connection with a claim, as well as any new or additional rationale for a denial of an internal appeal. This must be provided free of charge automatically. Merely providing a notice of the availability of such information is not enough.
- Non-payment of COBRA premiums. A retroactive termination of COBRA coverage is permissible if the participant has failed to pay the required premium.
- Medicare. Employers with fewer than 20 employees that are not required to offer their group health plan coverage to employees who are eligible for Medicare coverage can integrate an HRA with Medicare Part B or D.
- Multi-employer plans. New contributing employers can join a multi-employer plan for the express purpose of taking advantage of the plan’s grandfathered status without violating anti-abuse rules.
- Plan changes. One plan’s status change doesn’t change the status of all benefits packages. Example: The loss of grandfathered status for a PPO plan won’t impact the status of an HDHP plan.
- Generic alternatives. Plans can move brand-name drugs to a higher cost-sharing tier when a generic alternative becomes available without losing grandfathered status.
Disability benefits claims appeals
Published along with the final rules were proposed rules on the claims and appeals rules applicable to plans providing disability benefits.
In a nutshell, the rules would apply the claims and appeals procedure rules for standard healthcare claims to disability benefits claims.