Finance chiefs should huddle with HR and Benefits pros as well as their benefits brokers to make sure everyone’s up to speed on the latest Obamacare guidance, because it includes a lot of important info on health plans and cost-sharing.
But it also delves into other federal laws such as the Mental Health Parity Act and the Women’s Health and Cancer Rights Act (WHCRA).
Here are some of the highlights from the 12-question guidance:
Prep, trials and ER costs
Preventive services. The first few questions in the FAQs deal with the preparation for a common preventive procedure: a colonoscopy.
According to the feds, the preparation is an integral part of the actual procedure and, subject to reasonable medical judgement, must be covered without any cost-sharing. Specifically, the feds mentioned bowel preparation medications given before the colonoscopy.
However, when utilizing reasonable medical management techniques, plans can create a standard exception form – which can be modeled after the Medicare Part D Coverage Determination Request Form – so providers can prescribe specific services or FDA-approved items.
Out-of-network ER services. When asked, plans generally must disclose how the payments for out-of-network ER services were calculated to comply with ERISA’s disclosure rules and the ACA’s appeals process and external review requirements.
Clinical trials and cancer. The FAQs tackled how cancer treatment coverage applies to clinical trials. Specifically, if a plan covers chemotherapy, it generally can’t limit that coverage when it’s connected with individual’s participation in an approved clinical trial for a new
Plus, plans can’t deny coverage of items or services to diagnose/treat side effects that are part of a clinical trial if the plan generally covers those things for non-clinical trial treatment.
Mental health parity, WHCRA
Mental health parity. The feds dedicated three questions to clarifying some issues surrounding the Mental Health Parity Act, specifically how to perform certain tests – “substantially all” and “predominant” – for financial requirements and quantitative limits.
Those testing requirements apply to any benefits a plan offers for medication-assisted treatment of an opioid use disorder.
Reconstructive surgery following a mastectomy. Finally, the feds clarified that under the WHCRA, plans must provide coverage for nipple and areola reconstruction – including repigmentation to restore the physical appearance of the breast – as a required stage of breast reconstruction.