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Clarification on Certain Affordable Care Act Provisions

The Departments of Labor, Health and Human Services and the Treasury (collectively, the Departments) issued Frequently Asked Questions (FAQs) on April 20, 2016 related to various provisions of the Affordable Care Act.


To whom do the FAQs apply? 
The FAQs apply to group health plans that must comply with the Affordable Care Act. 


Do these FAQs provide clarification or new guidance that will require changes?
The FAQs provide clarification. Please note, Meritain Health’s systems are currently built to comply with these clarifications, as are those of Scrip World.


When must plans comply with the clarifications in the FAQs?
Plans should comply with these clarifications now as they do not impose new requirements, but rather clarify existing ones.  


What do the FAQs say?
Below is a summary, by topic, of the clarifications provided in the FAQs:


FAQ Summary
Preventive Services

Cost sharing may not be imposed on any bowel preparation medication that is prescribed in advance of a colonoscopy procedure.


Health plans may develop a standard contraception exception form if using reasonable medical management techniques and if a provider has identified the need for a specific product. Groups may use the Medicare Part D Coverage Determination Request Form as a model for this exception form, which can be found here: Medicare Example

Plans are not permitted to retroactively terminate coverage for teachers on a 10-month contract (August to May) when resignation is provided in advance of the next contract. Coverage is terminated as of the resignation date.
Out-of-network Emergency Services
Plans must disclose—free of charge—how they calculate any amount under minimum payment standards (i.e., Usual & Customary [U&C] amounts), if requested from a plan participant, within thirty (30) days from the request.
Clinical Trials

Plans may not limit coverage of anti-nausea medication of a participant who is included in a clinical trial.  If the medication is typically covered for individuals not in a clinical trial, coverage must be provided. 


Plans may not deny coverage for complications or adverse events of a participant who is included in a clinical trial. If the treatment is typically covered for individuals not in a clinical trial, coverage must be provided.

Out-of-Pocket (OOP) Maximums
Plans that use referenced-based pricing designs may treat providers who accept the referenced-based prices as the only in-network providers, as long as there is ample access to such providers, the plan has implemented an exceptions process, and the plan has followed disclosure requirements informing plan participants of how the pricing structure works and the exceptions process. Plans do not have to count a participant’s OOP expenses toward the maximum OOP limit if they utilize a physician who does not accept the referenced-based price.
Mental Health Parity (MHP)

A plan may not base their analysis for substantially all and predominant tests for financial requirements and quantitative treatment limitations on their business for the entire year. If a group has specific health plan data available, such data must be used.


The following documents must be provided to providers acting as an individual’s authorized representative who request proof of compliance with MHP when asked about pre-authorizations:

    • Summary Plan Description (SPD)
    • Plan Language specific to NQTL (Non-Quantitative Treatment Limits)
    • Processes and standards in determining if NQTL will apply to benefits
    • Information regarding the application of NQTL to specific benefits
    • Analyses performed by the plan regarding NQTL compliance with MHPAEA

Plans must provide criteria for determining medical necessity with respect to mental health/substance use benefits to any enrollee or potential enrollee upon request.


Medication Assisted Treatment (MAT) is any treatment for opioid use disorder that includes medication that is FDA-approved for detoxification or maintenance treatment in combination with behavioral health services. 


Opioid use disorder is a type of substance use disorder and MAT is a substance use disorder benefit within the meaning of the term as defined by MHP. Group health plans that offer MAT benefits must do so in accordance with the requirements of MHP.
Women’s Health and Cancer Rights Act (WHCRA)
Plans are required to provide coverage for nipple and areola reconstruction as part of breast reconstruction under WHCRA. Plans may impose deductibles and coinsurance for benefits if consistent with other benefits in the plan. 


If you have any questions, please contact your Client Solutions team.

This content is being provided as an informational tool. It is believed to be accurate at the time of posting and is subject to change. It is recommended that plans consult with their own experts or counsel to review all applicable federal and state legal requirements that may apply to their group health plan. By providing this information, Meritain Health is not exercising discretionary authority or assuming a plan fiduciary role, nor is Meritain Health providing legal advice.