Treasury released FAQs on Cost-Sharing Limitations under the ACA
Who must comply with the $2,000 deductible limit?
For now, small groups (under 50) need to comply with the $2,000 deductible maximum. However, there is a provision that allows insurers to offer a plan with a deductible larger than $2,000 if it cannot reasonably reach a given level of coverage on the exchange.
Who must comply with the annual out-of-pocket maximums?
All non-grandfathered group health plans must comply with this provision. Beginning with the plan year in 2014, a plan cannot have the member's total expenses (ie. deductibles, coinsurance, co-payments) exceed the HSA limits for that year. It only applies to in-network expenses. The limits can change annually, for 2013 they are $6,250 for single coverage and $12,500 for a family. 2014 limits have not been announced yet.
Preventive Services
ACA requires that many preventive services be covered in-network at 100% without any cost-sharing by the employee. This additional guidance closes a few gaps in this coverage:
- Out-of-network preventive must be covered at 100% when there aren't any network providers who can administer the service(s)
- Certain preventive over-the-counter recommended items(ie. aspirin) must be covered at 100%, but only when prescribed by a health care provider
- Colonoscopy including any polyp removal must be covered at 100% if done as a part of the preventive procedure
- Genetic testing and counseling (specifically the breast cancer susceptibility gene BRCA test) should be covered at 100%
- Preventive services for high risk individuals as determined by their health care provider covered at 100%
- All immunizations recommended by the Advisory Committee on Immunization Practices (ACIP) the plan year after the recommendation is made covered at 100%
- Clarifies that a full range of FDA-approved contraceptives must be covered at 100%, not just oral contraceptives
- Additional guidance on breastfeeding counseling
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