As always,
contact your BlueCross field agency support representative or your sales or
account executive for more information.
Annual
Limits
One of the near-term provisions of
the Patient Protection and Affordable Care Act (“PPACA”) to be implemented for
group plans and newly-sold individual policies beginning on or after Sept. 23,
2010 is the prohibition of annual limits on the dollar value of essential health
benefits, which applies to non-grandfathered individual policies and self-funded
and fully insured group plans, including grandfathered group
plans1. The full
prohibition goes into effect in 2014, with restricted annual limits permitted
until that time. Allowable restricted annual limits are as
follows:
What is an
Essential Benefit?
While regulations elaborating on
what benefits are considered essential have not been issued, PPACA defines
essential health benefits to, ‘‘…include at
least the following general categories and the items and services covered within
the categories:”
Regulations for annual limits
indicate that these rules do not require a group health plan or insurer to
provide coverage for all benefits considered essential benefits. But, if
benefits viewed as essential are provided for a condition, then these
requirements apply. Group health plans and insurers may continue applying
annual dollar limits to benefits that are not considered
essential.
Excluded Plan
Types
Certain types of benefit plans are
exempt from this provision of PPACA including, but not limited to, most dental
and vision ancillary products, life, disability, individual short-term medical,
Medicare supplement or Medicare Advantage. In addition, certain types of
indemnity plans such as cancer policies are also exempt from this provision.
For more information regarding the impact to products provided by Group
Insurance Services, contact your GIS representative.
Possible Waiver
Program
Prior to the prohibition of annual
dollar limits in 2014, regulations provide that the Secretary of Health and
Human Services (“HHS”) may establish a program under which the requirements
relating to annual limits may be waived (for such period as is specified by the
Secretary). A waiver would apply to a group health plan or health
insurance coverage that has an annual dollar limit on benefits below the
restricted annual limits if compliance would result in a significant decrease in
access to benefits under the plan or health insurance coverage or would
significantly increase premiums for the plan or health insurance
coverage.
On Sept. 3,
2010, HHS issued guidance on the process for requesting a waiver of the annual
limits requirements on health plans and policies that were in effect on Sept.
22, 2010 or earlier. The request process includes submitting an
application to HSS – electronically or through U.S. Mail – with plan-specific
information. The full text of the guidance can be found by going to
www.hhs.gov./ociio/regulations/patient/ociio_2010-1_20100903_508.pdf.
Removal of
Annual Dollar Limits on Standard Plans
In order to comply
with this provision, BlueCross will be removing the following annual limits from
non-grandfathered individual policies and all group health plans, including
grandfathered group plans:
The limited travel benefit
associated with transplants is not considered essential and the dollar limit
will remain on this benefit.
Regulations indicate that only the
annual dollar limits on essential benefits are prohibited (restricted).
Visit limits, such as day limits or utilization limits (e.g., provide a
service every three years), are still permitted and BlueCross will not remove
these types of limitations.
Annual Dollar
Limits on Non-Standard Benefits
Some large group
health plans have unique benefits that include coverage of services and devices
that are not commonly included in standard BlueCross group offerings. For
example, some fully insured plans cover hearing aids with a dollar and
utilization limit. Absent further regulations, BlueCross will consider
this an essential benefit and remove the dollar limit, but the utilization limit
will remain. There is also a limited wig benefit that some fully insured groups
have purchased. BlueCross is not considering this an essential benefit;
therefore the dollar limit will remain.
If fully insured group plans impose
dollar limits on other benefits, please contact your BlueCross sales or account
executive to determine if the limits will have to be
removed.
Self-funded groups will need to
review their non-standard benefits that impose dollar limits and determine if
these limits need to be removed. Common non-standard benefits that may
include a dollar limit are fertility services, bariatric surgery, transplants
and chiropractic care. Ultimately, self-funded groups are responsible for
their plan’s compliance with PPACA.
1
This provision will be implemented on
Jan. 1, 2011 for individual policies effective prior to Sept. 23, 2010 that are
not grandfathered; grandfathered policies will retain annual dollar
limits.
Coverage of
Stepchildren
The regulations for the PPACA
provision extending dependent coverage of children to age 26 have resulted in
questions regarding the coverage of stepchildren.
PPACA Regulations
vs. BlueCross Policy
Regulations indicate that, “…a plan or issuer may not define dependent for
purposes of eligibility for dependent coverage of children other than in terms
of a relationship between a child and the participant…” “Child” is
not defined in PPACA or the applicable regulation, but some have suggested that
the best practice would be to use the IRS definition, which includes
stepchildren.
Generally speaking, since PPACA and
its regulations are silent, a group could choose not to cover stepchildren and
accept the risk that future clarification from HHS could force the group to
modify its definition. The current regulations are considered interim.
Final regulations, once issued, could provide a definition of
child.
The policy of BlueCross is and will
continue to be to cover stepchildren the same as other children for individual
policies and fully insured and self-funded groups. If a self-funded group
does not want to cover stepchildren as an exception to this standard policy, it
will be up to the group to monitor compliance and validate that requests for
dependent enrollment do not include stepchildren (and provide only valid
dependents to BlueCross to be enrolled). The Evidence of Coverage (“EOC”) will
also have to be amended to remove stepchild as a valid dependent.