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Life Health > Health Insurance > Health Insurance

Feds answer cost-sharing questions

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Health plans can leave out spending on liposuction and massage therapy when deciding whether an enrollee has reached the annual out-of-pocket spending limit.

A plan also can leave out spending on out-of-network products and services, or any amounts that out-of-network providers charge that exceed the plan’s reimbursement level.

Officials from the Center for Consumer Information & Insurance Oversight, the Employee Benefits Security Administration and the Internal Revenue Service have given that advice in a collection of answers to questions about the Patient Protection and Affordable Care Act.

The new batch of guidance includes details about the new decision by CCIIO’s parent, the U.S. Department of Health and Human Services, to require all non-grandfathered major medical plans to include coverage for breast cancer prevention drugs in their basic preventive services package.

The officials also discuss the expatriate plans that cover overseas workers, wellness programs, and mental health parity rules.

The officials repeat earlier statements, for example, that grandfathered individual and small group plans need not provide mental health or substance abuse benefits.

Any grandfathered individual policies that do provide mental health or substance abuse benefits will have to comply with the federal parity requirements in policy years beginning on or after July 1, officials said.

Beginning with plan or policy years that start July 1 or later, all non-grandfathered individual and small-group plans must provide mental health and substance abuse benefits that meet the parity requirements, officials said.

In answers to questions about expat plans, officials promised not to apply any new rules that could cause headaches until 2017, at the earliest.

In the section on out-of-pocket spending maximums and other individual and small-group plan cost-sharing provisions, officials said a plan can count enrollees’ spending on out-of-network spending and non-covered services if they want to.

Carriers also can keep covered services that are outside the government’s official “essential health benefits” package out of the out-of-pocket spending total, officials said. 

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