1/10/14 DOL posted the 18th set of Frequently Asked Questions (FAQs) regarding the implementation of various provisions of the ACA. The FAQs have been prepared by the DOL, HHS, and the Treasury. This set of FAQs addresses coverage of preventive services, limitations on cost-sharing, expatriate health plans, wellness programs, fixed indemnity insurance, and the Mental Health Parity and Addiction Equity Act of 2008.

According to the FAQs, non-grandfathered group health plans and non-grandfathered health insurance coverage offered in the individual or group market will be required to cover certain medications without cost sharing for women who are at increased risk for breast cancer and at low risk for adverse medication effects. Under ACA §1001, all of the services recommended by the U.S. Preventive Services Task Force (USPSTF) receiving grades of "A" or "B" must be provided without cost-sharing when delivered by an in-network health insurance provider in the plan years (or, in the individual market, policy years) that begin on or after September 23, 2010. The USPSTF is an independent panel of non-federal government experts that conduct reviews of scientific evidence of preventive health care services. The USPSTF then develops and publishes recommendations for primary care clinicians and health systems in the form of recommendation statements. As part of their recommendations process, the USPSTF will assign definitions to the services they review based on the certainty that a patient will receive a substantial benefit from receiving the service. Services that are graded "A" and "B" are highly recommended and the USPSTF believes there is a high certainty that patient will receive a substantial or moderate benefit. Because this recommendation received a "B" rating the medication will be required to be covered without cost-sharing under the ACA.

The FAQs also address limitations on cost sharing. As required by §1302, beginning on or after January 1, 2015 annual cost sharing imposed by health plans on members must have an out-of-pocket maximum which limits overall out-of-pocket costs on all essential health benefits (EHB). According to the FAQ, plans and insurers are permitted to structure a benefit design using separate out-of-pocket limits, dividing the annual limit on out-of-pocket costs across multiple categories of benefits, provided that the combined amount of any separate out-of-pocket limits applicable to all EHBs under the plan does not exceed the annual limitation on out-of-pocket maximums for that year under §1302.

Among other topics, the agencies describe the impact of the ACA on the Mental Health Parity and Addiction Equity Act (MHPAEA). The ACA builds on MHPAEA and requires coverage of mental health and substance use disorder services as one of ten essential health benefits (EHB) categories. Under the EHB rule, individual and small group health plans are required to comply with these parity regulations. As required under ACA §1302(b), EHBs are a package of medical services and treatments which includes ambulatory and emergency care, maternity care, prescription drugs and other comprehensive health care services in ten statutory benefit categories, and are equal in scope to a typical employer health plan. Effective January 1, 2014, all plans sold in the exchanges and through the small group and individual markets were required to be equal in scope to the benefits covered by a typical employer plan and offer an EHB package of medical services and treatments in the ten prescribed categories.

Read a fact sheet about the MHPAEA rules at: CMS

Read the FAQ's at: http://www.dol.gov/ebsa/faqs/faq-aca18.html

1/10/14 CMS/HHS issued a final rule called "Medicaid Program; State Plan Home and Community-Based Services, 5-Year Period for Waivers, Provider Payment Reassignment, and Home and Community-Based Setting Requirements for Community First Choice and Home and Community-Based Services (HCBS) Waivers." The final rule sets forth new requirements for several Medicaid authorities under which states may provide and pay for home and community-based long-term services and supports. According to CMS, the regulations enhance the quality of home and community-based services (HCBS) programs, provide additional protections to individuals that receive services under these Medicaid authorities and ensure that individuals receiving services and supports through Medicaid's HCBS programs have full access to the benefits of community living and are able to receive services in the most integrated setting.

The final rule amends the Medicaid regulations to outline state plan section 1915(i) home and community-based services (HCBS) under the Social Security Act as amended by the ACA. According to CMS, under the rule states have new flexibility in providing necessary and appropriate services to elderly and disabled populations. The final rule describes Medicaid coverage of the optional state plan benefit to furnish HCBS and draw federal matching funds. Consistent with the requirements of ACA §2601, the rule allows states to use a five-year renewal cycle to align concurrent waivers and state plan amendments that serve individuals eligible for both Medicaid and Medicare. In addition, the final rule also amends Medicaid regulations to provide home and community-based setting requirements related to ACA §2401 for section 1915(k) of the Act, the Community First Choice State plan option.

Other key features of the rule: allows states to combine target groups within one 1915(c) waiver, establishes characteristics of home and community based settings across the various authorities the rule addresses ( 1915(c) (i) and (k)), and establishes person centered planning requirements.

HCBS became available in 1983 when Congress added section 1915(c) to the Social Security Act, giving states the option to receive a waiver of Medicaid rules governing institutional care. In 2005, HCBS became a formal Medicaid State plan option and now several states include HCBS services in their Medicaid State plans.

Read the final rule (which was published in the Federal Register on January 16, 2014) at: http://www.gpo.gov/fdsys/pkg/FR-2014-01-16/pdf/2014-00487.pdf

For more information regarding the Home and Community-Based Services available under Medicaid, please visit: http://www.medicaid.gov/HCBS 

Prior guidance can be found at: http://www.hhs.gov/healthcare/index.html 

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