The recently released frequently asked questions (FAQs) provide more insight into the Affordable Care Act (ACA) rules around annual cost-sharing limits imposed for certain health plans. Once a participant reaches an annual cost share limit, the participant is supposed to have 100% coverage under the plan for in-network covered services or items. These limits are also referred to as maximum out-of-pocket limits (MOOP).
The MOOP for next year will be $6,600 for single coverage and $13,200 for family coverage (defined as anything but single coverage). Please note, Health Savings Accounts (HSAs) have separate rules on these limits.
The guidance focussed primarily on the application of referenced based pricing with the MOOP, but the guidance says it applies to "similar network designs." Reference based pricing is where a plan pays a fixed amount for a particular procedure (for example, a knee replacement), which certain providers will accept as payment in full. Previous guidance noted that there is a concern that this pricing method may run afoul of the MOOP, but allowed it for large group market and self-insured group health plans as long as the plan or issuer uses a reasonable method to ensure that it offers adequate access to quality providers.
This new guidance indicates that the departments will consider all the facts and circumstances when evaluating whether it is a reasonable method. This includes an analysis on the (1) types of service, not to be used for situations where participants do not have enough time to choose providers (2) access to an adequate number of providers, considering wait times and geographic limits (3) standards and procedures to ensure quality, (4) easily accessible exception process for participants who want to choose another provider, and (5) recommended disclosures (both automatic and on request) as detailed under this FAQ.
The agencies reserve the right to provide additional guidance after observing reference based pricing in the market and clarify that this guidance does not signify compliance with other ACA requirements (like, preventive care, emergency services and essential health benefits for non-grandfathered plans in the individual and small group markets). Similar network designs should also consider this guidance. Examples of similar designs may even include tiered-provider networks.
To view a list of FAQs on the ACA, the DOL has an ACA implementation page listing these at the following: