DOL – PPACA Implementation FAQs Part 14 and 15

DOL – PPACA Implementation FAQs Part 14 and 15

The month of April saw two more sets of PPACA-related FAQs (Frequently Asked Questions) from the Department of Labor.

Part 14 / Part XIV

This part deals with the new SBC requirements.  As we look to the 2nd year of applicability (that is for plans beginning on or after January 1, 2014 and before January 1, 2015), we are all expected to use the new SBC templates.  Those templates are available here (HHS) and here (DOL).  The only change to the SBC template and sample completed SBC is the addition of statements of whether the plan or coverage provides MEC (Minimum Essential Coverage as defined under Section 5000A(f) of the Internal Revenue Code) and whether the plan or coverage meets the MV (Minimum Value) requirements (that is, the plan’s or coverage’s share of the total allowed costs of benefits provided under the plan or coverage is not less than 60 percent of such costs).

Template and Sample

On page 4 of the SBC template (and illustrated on page 6 of the sample completed SBC), a plan or issuer should indicate in the designated entry on the SBC template that the plan or coverage “does” or “does not” provide MEC and whether the plan or coverage “does” or “does not” meet applicable MV requirements.  This will assist your employees and plan participants with their decisions.  In order to avoid individual mandate penalties, taxpayers must have coverage that does meet these standards.

Also, there were no changes to the uniform glossary, nor where there any changes to the instructions for completing the SBCs.

Part 15 / Part XV

Annual Limit Waiver Expiration Date based on a Change to Plan or Policy Year

Certain plans (such as mini-med plans) offer, by design, benefits that do not comply with PPACA’s prohibition on annual or lifetime limits on essential health benefits.  Many of these plans obtained waivers from HHS, waivers which expire in 2014.  This new FAQ clarifies that waiver expiration dates cannot be extended by making a plan or policy year amendment.  So, for example, a waiver approval letter that was granted for a March 1, 2013 plan or policy year will expire on February 28, 2014 even if the plan or carrier amends either the plan or policy year.

Good Faith Standard

PPACA requires non-grandfathered group health plans (and insurance carriers) to not discriminate against providers based upon their licenses or certification under applicable state law.  So, if a provider is licensed by a state to perform certain procedures, a plan or a carrier may not discriminate against that provider.  (A commonly used example would be where a health plan will pay $X for Y procedure if performed by an orthopedic physician, but will only pay $Z for the same procedure if a chiropractor or physical therapist performed the same procedure).

The Good Faith Standard also applies to the requirement that non-grandfathered health plans provide coverage to individuals participating in approved clinical trials.

Both of these requirements are considered “self-implementing”, meaning there will not be any regulations/guidance issued in the immediate future.  As such, any good faith efforts and reasonable interpretation of the law in this area will suffice for compliance.

Transparency Requirements for Carriers/Health Insurance Issuers in/through Exchange

PPACA requires that health insurance issuers seeking to offer QHP (Qualified Health Plans) (i.e., individual or small group policies that meet various exchange standards) through an exchange, must submit specified information to the exchange and other entities in a timely and accurate manner. FAQ-15 clarifies that these issuers need only begin providing that information after a QHP has been certified as a QHP for one benefit year.  The FAQs also clarify that certain related reporting requirements will become applicable to non-grandfathered group health plans and health insurance issuers offering group or individual coverage no sooner than when the transparency reporting requirements with respect to QHPs become applicable.