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New FAQs Address Cost-Sharing Limits, Wellness Programs, and Other Reforms

FAQs Clarify Key Compliance Issues  

A new set of FAQs addresses various issues related to coverage of preventive services, limitations on cost-sharing, and wellness program rules, among other reforms under the Affordable Care Act.

Coverage of Preventive Services
Pursuant to new agency recommendations, the FAQs explain that non-grandfathered group health plans will be required in plan years beginning on or after September 24, 2014 to cover certain medications for risk reduction of primary breast cancer in women without cost sharing.

Limitations on Cost-Sharing
Beginning in 2014, non-grandfathered group health plans must ensure that any annual cost-sharing under the plan does not exceed certain limitations, including limits on out-of-pocket maximums. The FAQs clarify a number of issues related to this requirement:

  • For plan years beginning on or after January 1, 2015, non-grandfathered group plans must have an out-of-pocket maximum which limits overall out-of-pocket costs on all essential health benefits or EHBs. (Prior FAQs provided limited transition relief for plans utilizing more than one service provider for the first year of applicability.)
  • Plans are permitted to structure a benefit design using separate out-of-pocket limits across multiple categories of benefits (rather than reconcile claims across multiple service providers), provided the combined amount of any separate out-of-pocket limits applicable to all EHBs under the plan does not exceed the annual limitation on out-of-pocket maximums for that year.
  • A plan that includes a network of providers may, but is not required to, count out-of-pocket spending for out-of-network and non-covered items and services towards the plan’s annual maximum out-of-pocket limit.

Wellness Programs
The FAQs also provide guidance on several issues related to wellness program rules, including providing rewards for mid-year enrollment and the requirement that plans provide a notice of the availability of reasonable alternative standards.

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