New FAQs Published
On Friday, October 23, 2015 the Department of Labor published a new set of FAQs regarding requirements under the Affordable Care Act. This is the 29th set of FAQs published by the agency, and can be found at http://www.dol.gov/ebsa/faqs/faq-aca29.html.
These 13 questions deal primarily with preventive service, wellness programs, and compliance with the Mental Health Parity and Addiction Equity Act of 2008. Generally, these requirements are effective for plan years beginning on or after January 1, 2016, and given their relatively late publication, employers with calendar year plans are highly encouraged to do a quick review of their plans to ensure they are compliant with these clarifications in the law.
The first 5 FAQs deal with coverage of expenses related to lactation counseling and limitations on the rental of breastfeeding equipment. The guidance reiterates that lactation counseling is a preventive care expense that is required to be covered at no cost sharing to the employee, including scenarios where there are no “in-network” and/or licensed lactation counselors available. Additionally, lactation counseling must be covered when it is performed on an out-patient basis as well as on an in-patient basis.
The last FAQ on breastfeeding indicates that plans must cover the rental or purchase of breastfeeding equipment for the duration of breastfeeding, providing the individual remains continuously covered by the plan.
Next, the Preventive Care FAQs then move to address a variety of issues. First up is the coverage of weight management services for adult obesity. Plans are not permitted to exclude screening for obesity in adults, as well as intensive, multicomponent behavioral interventions for individuals meeting certain criteria.
The focus then moves to colonoscopy coverage, where the FAQs indicate that expenses related to the colonoscopy that have to be covered without cost sharing include both pre-screening specialist expenses, as well as pathology exams on polyp biopsies.
The last FAQ for Preventive Care is a reminder on the process of opting out of providing contraceptive coverage for non-profit or closely held for-profit employers who hold sincere religious objections to providing contraceptive coverage.
FAQ #10 briefly describes which women must receive coverage without cost share for genetic counseling, and if indicated, testing for harmful BRCA mutations – essentially, women who are found to be at an increased risk using a screening tool that examines family history are entitled to this coverage without cost sharing.
One FAQ is dedicated to clearing up a question on wellness programs, clarifying that non-cash rewards that are tied to a wellness program are subject to the wellness program regulations published by the various agencies. This would include items such as gift cards, sports gear, thermoses, and other non-cash rewards from satisfying a standard related to a health factor.
The final two FAQs clarify what documentation may be presented to plan participants regarding medical necessity criteria as it applies to mental health and substance use disorder (MH/SUD) benefits. If requested, plans must disclose to participants the criteria for making medical necessity determinations, as well as any processes, strategies, evidentiary standards, or other factors used to determine medical necessity. Plans may also provide a summary description of medical necessity that is written in terms understandable to a layperson, however, such a document is not required, nor is it a substitute for providing the actual necessity criteria.
Again, employers should review their plans for plan years starting on and after January 1, 2016 to make sure they are complying with the items addressed in this FAQ. Please contact your Assurance representative with any questions.