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New ACA Guidance Issued on Preventives Services, Wellness Programs and MentalHealth Parity
December 3, 2015
On Oct. 23, the Departments of Labor (DOL), Health and Human Services (HHS), and the Treasury released frequently asked questions (FAQ)that provided clarification on the implementation of coverage of preventive services, non-financial incentives given to wellness program participants, and disclosure requirements under the Mental Health Parity provision.
UnitedHealthcare is currently reviewing the FAQ and will be communicating at a future date any updates to coverage once determined. Below is a summary of the questions addressed in the FAQ Part XXIX.
Coverage of Preventive Services
Health reform law requires non-grandfathered group health plans and health insurance coverage offered in the individual or group market to cover certain preventive care services without cost-sharing. The FAQ Part XXIX provides clarity on the standards used to determine which services are required to be covered in network without cost-sharing.
- Question 1 – Plans and issuers are required to provide a list of the lactation counseling providers available within the network under the plan or coverage.
- Question 2 –If a non-grandfathered health plan’s network does not have network options for lactation counseling services, the plan cannot impose cost-sharing on the member if services are received out-of-network.
- Question 3 – If a member’s state does not license lactation counseling providers and a plan only covers services received from providers licensed by the state, the lactation counseling must be covered without cost sharing when it is performed by any provider acting within the scope of his or her license or certification under state law.
- Question 4 – Plans cannot limit coverage for lactation counseling without cost-sharing to services provided on an inpatient basis, while imposing cost-sharing for lactation counseling on an outpatient basis. Additionally, coverage for lactation support services without cost-sharing must extend for the duration of the breastfeeding.
- Question 5 – The requirement to cover the rental or purchase of breastfeeding equipment without cost-sharing extends for the duration of breastfeeding and cannot be limited to a set number of months, provided the individual remains continuously enrolled in the plan or coverage.
- Question 6 – Non-grandfathered health plans cannot impose general exclusions that would encompass recommended preventive services. For example, non-grandfathered health plans cannot contain a general exclusion for weight management services for adult obesity. Non-grandfathered health plans must cover without cost-sharing, screening for obesity in adults, in addition to behavioral interventions for weight management for certain populations.
- Question 7 – If a colonoscopy is scheduled and performed as a screening procedure based on USPSTF recommendation, a plan or issuer may not impose cost-sharing with respect to a required consultation prior to the colonoscopy, if the provider determines that the pre-procedure consultation would be medically appropriate.
- Question 8 – After colonoscopy is performed as a screening procedure based on USPSTF recommendation, the plan or issuer must cover any pathology exam on a polyp biopsy without cost-sharing.
- Question 9 – If a qualifying non-profit or closely held for-profit ERISA employer that sponsors a self-insured plan wishes to exclude coverage of contraceptive services due to a religious objection, there are two ways to do so:
- Complete the EBSA Form 700 and submit it to appropriate third-party administrator(s). In this case, the EBSA Form 700 will be a plan instrument that has the legal effect of designating the third-party administrator as the ERISA plan administrator responsible for separately providing payments for those services.
- Provide appropriate notice of the objection to the Department of HHS. HHS will forward the information to the DOL, which will send a notification to the third-party administrator, designating it as the ERISA plan administrator responsible for separately providing coverage for any contraceptive services to which the sponsor objects.
- Question 10 – Women found to be at increased risk using a screening tool designed to identify a family history that may be associated with an increased risk of having a potentially harmful gene mutation must receive coverage without cost-sharing for genetic counseling, and, if indicated, testing for harmful BRCA mutations. This is true regardless of whether the woman has previously been diagnosed with cancer, as long as she is not currently symptomatic of or receiving active treatment for breast, ovarian, tubal, or peritoneal cancer.
Under health reform law, group health plans and health insurance issuers in the group and individual market are prohibited from discriminating against participants, beneficiaries, and individuals when establishing eligibility, benefits, or premiums based on a health factor. There is an exception for group health coverage, but not individual market coverage, if the group adheres to certain programs of health promotion and disease management (wellness programs). On June 3, the Departments released a final rule which set the maximum permissible reward under a health-contingent wellness program that is part of a group health plan. The FAQ Part XXIX notes that a group health plan providing a “reward” as part of adherence to a wellness program is subject to the Departments wellness regulations.
- Question 11 – If a group health plan provides a “reward” based on an individual satisfying a standard that is related to a health factor, the wellness program is subject to the Departments wellness regulations. A reward may be financial or non-financial (or in-kind – such as gift cards and sports gear).
Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) and Disclosure
MHPAEA final rule requires that the financial requirements and treatment limitations imposed on mental health and substance use disorders (MH/SUD) benefits cannot be more restrictive than the predominant financial requirements and treatment limitations that apply to substantially all medical/surgical benefits. The FAQ Part XXIX clarifies previous guidance in which the DOL rejected arguments that ERISA plans could refuse to provide such information on the basis it was proprietary. Information must be disclosed even where the source of such information is a third-party commercial vendor.
- Question 12 – With respect to both MH/SUD benefits (including anorexia), a plan cannot deny a member access to the criteria it uses to make medical necessity determinations, as well as any processes, strategies, evidentiary standards or other factors used to develop the underlying non-quantitative treatment limitation (NQTL) and applying it, regardless of the proprietary nature or commercial value of such information.
- Question 13 – Group health plans and issuers may choose, but are not required, to provide a document that provides a description of the medical necessity criteria in layperson’s terms. However, providing such a summary document is not a substitute for providing the actual underlying medical necessity criteria, if such documents are requested.
January 1, 2018 PDL Updates
The following updates will take effect for the OptumRx direct Prescription Drug Lists (PDLs) on January 1, 2018. Learn more
New Sales Automation Management Tool
Check out our new Sales Automation Management (SAM). Learn more
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