United States: Final Regs On ACA Implementation

Last Updated: January 26 2016
Article by Ron M. Present, CALA, CNHA, LNHA, FACHCA

This past November, the IRS, Department of Labor and Department of Health and Human Services jointly issued final regulations covering a variety of topics related to the implementation of the Affordable Care Act (ACA). Effective for plan years beginning on or after January 1, 2017, these assorted nuggets incorporate agency guidance into a mixture of proposed and interim final regs dating back to 2010. Here are some highlights.

Grandfathered plans

The final regulations maintain the rule that grandfathered status is determined separately as to each "benefit package" under a group health plan. They also add new clarifying examples and adopt existing antiabuse rules that curtail attempts to retain grandfathered status through
indirect plan changes.

Considerable effort is also devoted to describing changes that would cause a plan to lose grandfathered status. The regs address, for instance, decreases in employer contribution rates and changes in co-payments for limited categories of services. Highlighting the continuing relevance of these issues, the agencies estimate that more than 40 million participants and beneficiaries are covered by grandfathered group health plans.

Pre-existing condition exclusions

The final regulations adopt previous guidance on pre-existing condition exclusions. Yet they also clarify that these rules don't prohibit plans or insurers from excluding all benefits for a condition if they do so regardless of when the condition arose relative to the effective coverage date. Nevertheless, the agencies note that other rules and laws — such as the essential health benefit (EHB) requirements — may preclude such exclusions.

Lifetime and annual limits

Group health plans (including self-insured plans) that aren't required to cover EHBs are nonetheless barred from imposing annual or lifetime dollar limits on the EHBs that they do offer. Under the regulations, these plans may define an EHB by reference to:

  • Any of the 51 benchmark plans identified by the states or the District of Columbia, or
  • One of the three largest Federal Employees Health Benefits Program plans.

The final regs address some, but not all, existing guidance for Health Reimbursement Arrangements and other account-based plans that are permitted only if "integrated" with a group health plan that complies with the ACA — including its prohibition on lifetime and annual dollar limits. Specifically, the regulations offer further clarifications and new guidance.

For instance, the regs explain that employers with fewer than 20 employees may be unable to meet the integration test for Medicare Part B and Part D premium reimbursement arrangements (PRAs) provided in previous guidance. The reason: Some insurers won't allow offers of coverage to employees who are eligible for Medicare.

The final regulations allow such PRAs to be integrated with Medicare if employees not offered other group health plan coverage would be eligible for that coverage except for their eligibility for Medicare. And the regs further clarify that a forfeiture of amounts or waiver of reimbursements under an HRA will comply with the integration requirements even if amounts may be reinstated on a future date or upon death (or the earlier of the two dates).

During periods when the HRA is considered forfeited or waived, the individual (for example, a retiree) is treated as not covered by the HRA. This may allow him or her to qualify for a premium tax credit for obtaining coverage from a Health Insurance Marketplace.

Rescissions

Although they don't break new ground, the final regulations remind employers that a rescission (that is, retroactive cancellation or discontinuation of coverage) is considered an adverse benefit determination subject to internal and external appeals procedures. Thus, coverage must remain effective until an internal appeal is completed.

In addition, the regs finalize previous guidance providing that the prohibition on rescissions isn't violated if a plan retroactively terminates coverage because of a failure to pay required contributions. This includes COBRA premiums.

Dependent coverage

Regarding the age 26 mandate, the final regulations clarify that adult children under age 26 must be offered coverage even if they don't live in a particular service area. This requirement, however, doesn't affect the extent to which plans and insurers are required to cover out-of-network services for adult children. Examples illustrate the requirement that coverage of children under age 26 can't vary based on age.

Claims and appeals

The regulations finalize "without substantial change" extensive rules on claims and appeal processes issued in interim and amended interim final regulations, incorporating a long list of clarifying technical guidance. Under the full and fair review rules, a plan that relies on new or additional evidence or a new rationale in making a benefit determination must automatically provide the evidence or rationale to the claimant and give the claimant a reasonable opportunity to respond.

Additionally, the final regulations extend the transitional period for using state "NAIC-similar" external review processes through 2017. (The NAIC acronym refers to the National Association of Insurance Commissioners.) Plans and insurers in a state without an NAIC-compliant external review process, as well as self-insured plans, must follow a process established through previous guidance and finalized in these regulations.

Also, the temporary rule applying the external review process to claims that involve medical judgment and rescissions has been made permanent. Two new items, however, have been added to the list of what's considered a medical judgment.

Patient protections

New clarifications allow health plans to require participants and beneficiaries to select in-network providers within specified geographic limits when designating a primary care provider. In addition, they clarify when and how "balance billing" is permitted for out-of-network emergency care. (Balance billing is billing patients for the excess of the providers' billed charges over benefits covered by the plan and other patient payments, such as co-payments or co-insurance.) Last, the final regs provide that emergency care doesn't have to be sought within a specific timeframe (for instance, within 24 hours of onset).

Breadth and depth

As you can see, these final regulations add both breadth and depth to the wealth of existing information on the ACA's compliance requirements. Fortunately, they largely incorporate previously issued guidance and, as mentioned, aren't effective until 2017.

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.

To print this article, all you need is to be registered on Mondaq.com.

Click to Login as an existing user or Register so you can print this article.

Authors
Ron M. Present, CALA, CNHA, LNHA, FACHCA
 
In association with
Related Video
Up-coming Events Search
Tools
Print
Font Size:
Translation
Channels
Mondaq on Twitter
 
Register for Access and our Free Biweekly Alert for
This service is completely free. Access 250,000 archived articles from 100+ countries and get a personalised email twice a week covering developments (and yes, our lawyers like to think you’ve read our Disclaimer).
 
Email Address
Company Name
Password
Confirm Password
Position
Mondaq Topics -- Select your Interests
 Accounting
 Anti-trust
 Commercial
 Compliance
 Consumer
 Criminal
 Employment
 Energy
 Environment
 Family
 Finance
 Government
 Healthcare
 Immigration
 Insolvency
 Insurance
 International
 IP
 Law Performance
 Law Practice
 Litigation
 Media & IT
 Privacy
 Real Estate
 Strategy
 Tax
 Technology
 Transport
 Wealth Mgt
Regions
Africa
Asia
Asia Pacific
Australasia
Canada
Caribbean
Europe
European Union
Latin America
Middle East
U.K.
United States
Worldwide Updates
Check to state you have read and
agree to our Terms and Conditions

Terms & Conditions and Privacy Statement

Mondaq.com (the Website) is owned and managed by Mondaq Ltd and as a user you are granted a non-exclusive, revocable license to access the Website under its terms and conditions of use. Your use of the Website constitutes your agreement to the following terms and conditions of use. Mondaq Ltd may terminate your use of the Website if you are in breach of these terms and conditions or if Mondaq Ltd decides to terminate your license of use for whatever reason.

Use of www.mondaq.com

You may use the Website but are required to register as a user if you wish to read the full text of the content and articles available (the Content). You may not modify, publish, transmit, transfer or sell, reproduce, create derivative works from, distribute, perform, link, display, or in any way exploit any of the Content, in whole or in part, except as expressly permitted in these terms & conditions or with the prior written consent of Mondaq Ltd. You may not use electronic or other means to extract details or information about Mondaq.com’s content, users or contributors in order to offer them any services or products which compete directly or indirectly with Mondaq Ltd’s services and products.

Disclaimer

Mondaq Ltd and/or its respective suppliers make no representations about the suitability of the information contained in the documents and related graphics published on this server for any purpose. All such documents and related graphics are provided "as is" without warranty of any kind. Mondaq Ltd and/or its respective suppliers hereby disclaim all warranties and conditions with regard to this information, including all implied warranties and conditions of merchantability, fitness for a particular purpose, title and non-infringement. In no event shall Mondaq Ltd and/or its respective suppliers be liable for any special, indirect or consequential damages or any damages whatsoever resulting from loss of use, data or profits, whether in an action of contract, negligence or other tortious action, arising out of or in connection with the use or performance of information available from this server.

The documents and related graphics published on this server could include technical inaccuracies or typographical errors. Changes are periodically added to the information herein. Mondaq Ltd and/or its respective suppliers may make improvements and/or changes in the product(s) and/or the program(s) described herein at any time.

Registration

Mondaq Ltd requires you to register and provide information that personally identifies you, including what sort of information you are interested in, for three primary purposes:

  • To allow you to personalize the Mondaq websites you are visiting.
  • To enable features such as password reminder, newsletter alerts, email a colleague, and linking from Mondaq (and its affiliate sites) to your website.
  • To produce demographic feedback for our information providers who provide information free for your use.

Mondaq (and its affiliate sites) do not sell or provide your details to third parties other than information providers. The reason we provide our information providers with this information is so that they can measure the response their articles are receiving and provide you with information about their products and services.

If you do not want us to provide your name and email address you may opt out by clicking here .

If you do not wish to receive any future announcements of products and services offered by Mondaq by clicking here .

Information Collection and Use

We require site users to register with Mondaq (and its affiliate sites) to view the free information on the site. We also collect information from our users at several different points on the websites: this is so that we can customise the sites according to individual usage, provide 'session-aware' functionality, and ensure that content is acquired and developed appropriately. This gives us an overall picture of our user profiles, which in turn shows to our Editorial Contributors the type of person they are reaching by posting articles on Mondaq (and its affiliate sites) – meaning more free content for registered users.

We are only able to provide the material on the Mondaq (and its affiliate sites) site free to site visitors because we can pass on information about the pages that users are viewing and the personal information users provide to us (e.g. email addresses) to reputable contributing firms such as law firms who author those pages. We do not sell or rent information to anyone else other than the authors of those pages, who may change from time to time. Should you wish us not to disclose your details to any of these parties, please tick the box above or tick the box marked "Opt out of Registration Information Disclosure" on the Your Profile page. We and our author organisations may only contact you via email or other means if you allow us to do so. Users can opt out of contact when they register on the site, or send an email to unsubscribe@mondaq.com with “no disclosure” in the subject heading

Mondaq News Alerts

In order to receive Mondaq News Alerts, users have to complete a separate registration form. This is a personalised service where users choose regions and topics of interest and we send it only to those users who have requested it. Users can stop receiving these Alerts by going to the Mondaq News Alerts page and deselecting all interest areas. In the same way users can amend their personal preferences to add or remove subject areas.

Cookies

A cookie is a small text file written to a user’s hard drive that contains an identifying user number. The cookies do not contain any personal information about users. We use the cookie so users do not have to log in every time they use the service and the cookie will automatically expire if you do not visit the Mondaq website (or its affiliate sites) for 12 months. We also use the cookie to personalise a user's experience of the site (for example to show information specific to a user's region). As the Mondaq sites are fully personalised and cookies are essential to its core technology the site will function unpredictably with browsers that do not support cookies - or where cookies are disabled (in these circumstances we advise you to attempt to locate the information you require elsewhere on the web). However if you are concerned about the presence of a Mondaq cookie on your machine you can also choose to expire the cookie immediately (remove it) by selecting the 'Log Off' menu option as the last thing you do when you use the site.

Some of our business partners may use cookies on our site (for example, advertisers). However, we have no access to or control over these cookies and we are not aware of any at present that do so.

Log Files

We use IP addresses to analyse trends, administer the site, track movement, and gather broad demographic information for aggregate use. IP addresses are not linked to personally identifiable information.

Links

This web site contains links to other sites. Please be aware that Mondaq (or its affiliate sites) are not responsible for the privacy practices of such other sites. We encourage our users to be aware when they leave our site and to read the privacy statements of these third party sites. This privacy statement applies solely to information collected by this Web site.

Surveys & Contests

From time-to-time our site requests information from users via surveys or contests. Participation in these surveys or contests is completely voluntary and the user therefore has a choice whether or not to disclose any information requested. Information requested may include contact information (such as name and delivery address), and demographic information (such as postcode, age level). Contact information will be used to notify the winners and award prizes. Survey information will be used for purposes of monitoring or improving the functionality of the site.

Mail-A-Friend

If a user elects to use our referral service for informing a friend about our site, we ask them for the friend’s name and email address. Mondaq stores this information and may contact the friend to invite them to register with Mondaq, but they will not be contacted more than once. The friend may contact Mondaq to request the removal of this information from our database.

Security

This website takes every reasonable precaution to protect our users’ information. When users submit sensitive information via the website, your information is protected using firewalls and other security technology. If you have any questions about the security at our website, you can send an email to webmaster@mondaq.com.

Correcting/Updating Personal Information

If a user’s personally identifiable information changes (such as postcode), or if a user no longer desires our service, we will endeavour to provide a way to correct, update or remove that user’s personal data provided to us. This can usually be done at the “Your Profile” page or by sending an email to EditorialAdvisor@mondaq.com.

Notification of Changes

If we decide to change our Terms & Conditions or Privacy Policy, we will post those changes on our site so our users are always aware of what information we collect, how we use it, and under what circumstances, if any, we disclose it. If at any point we decide to use personally identifiable information in a manner different from that stated at the time it was collected, we will notify users by way of an email. Users will have a choice as to whether or not we use their information in this different manner. We will use information in accordance with the privacy policy under which the information was collected.

How to contact Mondaq

You can contact us with comments or queries at enquiries@mondaq.com.

If for some reason you believe Mondaq Ltd. has not adhered to these principles, please notify us by e-mail at problems@mondaq.com and we will use commercially reasonable efforts to determine and correct the problem promptly.