FAQs About ACA Implementation and Mental Health Parity

The Departments of Labor (“DOL”), Health and Human Services (“HHS”), and the Treasury Set have published more Frequently Asked Questions (“FAQs”) regarding implementation of the Affordable Care Act (“ACA”), as well as FAQs regarding implementation of the Mental Health Parity and Addiction Equity Act of 2008 (“MHPAEA”), as amended by the Affordable Care Act.

New information includes:

  • Subject to reasonable medical management techniques, lactation counseling must be covered without cost sharing by the plan when it is performed by any provider acting within the scope of his or her license or certification under applicable State law, even if a State does not license lactation counselors. Lactation counseling could be provided by another provider type acting within the scope of his or her license or certification (for example, a registered nurse), and the plan would be required to provide coverage for the services without cost sharing.
  • It is not a reasonable medical management technique to limit coverage for lactation counseling to services provided on an in-patient basis. Moreover, coverage for lactation support services without cost sharing must extend for the duration of the breastfeeding.
  • The requirement to cover the rental or purchase of breastfeeding equipment without cost sharing extends for the duration of breastfeeding, provided the individual remains continuously enrolled in the plan or coverage.
  • The plan may not impose cost sharing with respect to a required consultation prior to a screening colonoscopy if the attending provider determines that the pre-procedure consultation would be medically appropriate for the individual, because the pre-procedure consultation is an integral part of the colonoscopy.
  • A pathology exam is essential for the provider and the patient to obtain the full benefit of the preventive screening since the pathology exam determines whether the polyp is malignant. Since the primary focus of the colonoscopy is to screen for malignancies, the pathology exam is critical for achieving the primary purpose of the colonoscopy screening, which means no cost sharing can be imposed.
  • Because the Departments’ prior guidance on these colonoscopy issues may reasonably have been interpreted in good faith as not requiring coverage without cost sharing of consultation prior to a colonoscopy screening procedure, the Departments will apply this clarifying guidance for plan years beginning on or after the date that is 60 days after publication of these FAQs, which means calendar year plans must comply in 2016.
  • There are two methods for a qualifying non-profit or closely held for-profit employer who sponsors a self-funded plan to effectuate the religious accommodation to relieve itself of any obligation to pay for contraceptive services:
  • Women found to be at increased risk using a screening tool designed to identify a family history that may be associated with an increased risk of having a potentially harmful gene mutation must receive coverage without cost sharing for genetic counseling, and, if indicated, testing for harmful BRCA mutations. This is true regardless of whether the woman has previously been diagnosed with cancer, as long as she is not currently symptomatic of or receiving active treatment for breast, ovarian, tubal, or peritoneal cancer.
  • Although not required to do so, group health plans can provide a document that provides a description of the medical necessity criteria in layperson’s terms. However, providing such a summary document is not a substitute for providing the actual underlying medical necessity criteria, if such documents are requested.

About John Garner

John Garner has over thirty five years of experience in employee benefits. He specializes in compliance, health care reform, the Health Insurance Portability and Accountability Act (HIPAA), the Consolidated Omnibus Budget Reconciliation Act (COBRA), and the Employee Retirement Income Security Act (ERISA). He helps clients with life, health, and disability benefits, cost containment, flexible benefits, and claim consulting.

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