December 9, 2015
Last month, the federal agencies
charged with implementing the Affordable Care Act (ACA) finalized a group of
market reform rules that were first released in 2010. These reform requirements
represented the first phase of the ACA to take effect following enactment of
the health reform law. This bulletin addresses the key
market reform rules and provides insight about special clarifying commentary
that the agencies have chosen to share.
Below is an executive summary of finalized rules. Download this bulletin to read more on market reform finalized rules.
Most guidance from earlier
regulations remains unchanged and finalized rules will not take effect until
the first plan year on or after January 1, 2017.
1. Grandfathered status: Employers with grandfathered plans should review their
programs under past and current rules for continued protection, especially as
may concern plan adoption of wellness incentives.
2. Applying dollar limits: If your plan is self-funded, check the plan document/summary
plan description (SPD) for any dollar limits. Make sure affected terms are not
essential benefits in the state you’ve selected as the plan standard.
3. Rescissions: Check to confirm that individuals can be removed from your plan
retroactively and if advance notice of doing so is required. Ideally, adopt
written procedures for this situation. If you impose a tobacco incentive, make
sure you do not terminate coverage retroactively — even if an employee has been
dishonest about tobacco use.
4. Children with HMO coverage: Determine how your managed care organization will
provide coverage to children who move outside of a limited service area (common
5. Claims procedures: Adopt claims procedures as an employer for eligibility
determinations. Be prepared to provide a medical review for certain wellness
plan conditions. Monitor your carrier’s or third party administrator’s (TPA’s)
claims and appeals procedures. Finally, make sure any external review fees are
as narrowly applied as required.
6. Choice of healthcare professionals: Anticipate that some plans require
designation of a primary care provider, and the law generally allows anyone
covered by a group health plan to select any in-network provider who is
“available” to accept that person. Although the regulations were not revised,
the agencies acknowledge a duly authorized representative can select a provider
for an incapacitated person
7. Emergency care: Be aware that the agencies note that out-of-network emergency
care providers can still issue patients a balance bill for emergency services;
plans need not pay the same amount as for in-network emergency care. Prior
rules on the reasonableness of out-of-network reimbursements continue to apply.
8. Special issues: The federal agencies reinforce rules precluding employer
reimbursement of individual health policies and examine Health Reimbursement
Arrangements (HRAs) in the context of Medicare integration.
Download this bulletin and contact an advisor today.