New ACA Guidance | Chicago Benefits Broker

Abridged from

ACAOn April 20, 2016, the Departments of Labor, Health and Human Services, and the Treasury released the 31st set of Frequently Asked Questions (FAQs) on the implementation of the Affordable Care Act (ACA) and other health plan-related laws.

The FAQs address questions on preventive services, coverage rescissions, mental health parity, and more. This article summarizes the key provisions affecting the typical employer-sponsored group health plan.

Out-of-Network Emergency Services

Nongrandfathered plans are prohibited from imposing greater cost-sharing on emergency services provided out-of-network than on those provided in-network. Out-of-network providers often bill patients for the difference between the plan’s allowed amount and the provider’s billed charges. Although the ACA’s cost-sharing rule cannot protect patients entirely from this type of balance billing, plans are required to make at least a minimum payment for out-of-network emergency care. The minimum required payment is equal to the greatest of the following:

  • The median amount negotiated with in-network providers;
  • The amount calculated using the plan’s usual method for out-of-network providers, such as the usual, customary, and reasonable (UCR) amount; or
  • The amount that would be paid under Medicare.

The FAQs also clarify that plans subject to ERISA must disclose information about how the minimum payment standard amount is calculated within 30 days of a request. Disclosure also is required under ERISA’s claim procedure rules.

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