Congress is likely to send a spending bill to President Barack Obama that delays funding for the Affordable Care Act. The draft bill delays by two years implementation of the law’s taxes on medical devices and high-cost health insurance plans, and delays by one year a tax on insurers. The delays are likely to be extended in future spending bills, creating a de facto repeal, former Obama administration budget director Peter Orszag said. The New York Times (free-article access for SmartBrief readers) (12/16), Modern Healthcare (tiered subscription model) (12/16), The Wall Street Journal (tiered subscription model) (12/16)
On Oct. 23, the Departments of Labor (DOL), Health and Human Services (HHS), and the Treasury released frequently asked questions (FAQ)that provided clarification on the implementation of coverage of preventive services, non-financial incentives given to wellness program participants, and disclosure requirements under the Mental Health Parity provision.
UnitedHealthcare is currently reviewing the FAQ and will be communicating at a future date any updates to coverage once determined. Below is a summary of the questions addressed in the FAQ Part XXIX.
Coverage of Preventive Services
Health reform law requires non-grandfathered group health plans and health insurance coverage offered in the individual or group market to cover certain preventive care services without cost-sharing. The FAQ Part XXIX provides clarity on the standards used to determine which services are required to be covered in network without cost-sharing.
- Question 1 – Plans and issuers are required to provide a list of the lactation counseling providers available within the network under the plan or coverage.
- Question 2 –If a non-grandfathered health plan’s network does not have network options for lactation counseling services, the plan cannot impose cost-sharing on the member if services are received out-of-network.
- Question 3 – If a member’s state does not license lactation counseling providers and a plan only covers services received from providers licensed by the state, the lactation counseling must be covered without cost sharing when it is performed by any provider acting within the scope of his or her license or certification under state law.
- Question 4 – Plans cannot limit coverage for lactation counseling without cost-sharing to services provided on an inpatient basis, while imposing cost-sharing for lactation counseling on an outpatient basis. Additionally, coverage for lactation support services without cost-sharing must extend for the duration of the breastfeeding.
- Question 5 – The requirement to cover the rental or purchase of breastfeeding equipment without cost-sharing extends for the duration of breastfeeding and cannot be limited to a set number of months, provided the individual remains continuously enrolled in the plan or coverage.
- Question 6 – Non-grandfathered health plans cannot impose general exclusions that would encompass recommended preventive services. For example, non-grandfathered health plans cannot contain a general exclusion for weight management services for adult obesity. Non-grandfathered health plans must cover without cost-sharing, screening for obesity in adults, in addition to behavioral interventions for weight management for certain populations.
- Question 7 – If a colonoscopy is scheduled and performed as a screening procedure based on USPSTF recommendation, a plan or issuer may not impose cost-sharing with respect to a required consultation prior to the colonoscopy, if the provider determines that the pre-procedure consultation would be medically appropriate.
- Question 8 – After colonoscopy is performed as a screening procedure based on USPSTF recommendation, the plan or issuer must cover any pathology exam on a polyp biopsy without cost-sharing.