Alert / Employee Benefits
Feds Clarify Health Reform’s Cost-Sharing Limits, Preventive Care Mandates, Taxes and More
  • The wellspring of health reform-related regulatory guidance continues to gush, with federal authorities issuing rules at a near crushing pace. Recent releases include regulations clarifying that the reform law's limits on health plan deductibles apply only in the individual and small-group market, but limits on out-of-pocket maximums apply to all non-grandfathered plans. However, the limit on out-of-pocket maximums does not apply to out-of-network care.
  • Regulators have made available a calculator that employer-sponsored plans may use to determine whether their coverage satisfies the 60-percent actuarial value requirement under the employer play or pay mandate. Employer contributions to health savings accounts and health reimbursement accounts may be considered in assessing a medical plan's actuarial value.
  • Final regulations on the Transitional Reinsurance Program fee on insurers and sponsors of self-funded plans affirm the estimated amount of the fee ($5.25 per month, per enrollee, for 2014). But the fee will not be assessed with respect to health savings accounts, health flexible spending accounts, or most health reimbursement arrangements. Also excused are most dental and vision plans, employee assistance plans, disease management programs, wellness programs and stand-alone prescription drug plans.
  • Regulators have clarified many aspects of the reform law's preventive care mandate on non-grandfathered plans, and will allow plans to limit cost-free coverage of preventive drugs and contraceptive drugs and devices to the generic versions, unless there's a clinical reason why the insured needs the brand name version.
  • Federal authorities have noted that some insurance products being sold as "indemnity" (and thus outside the scope of the health reform law) are actually health plans in disguise, and thus subject to the reform law's mandates and penalties.
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