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Text of Agency FAQs on ACA Implementation, Set 21: Reference Pricing and Maximum Out-of-Pocket Limitations (PDF)
U.S. Department of Health and Human Services [HHS]; U.S. Department of Labor [DOL] and U.S. Treasury Department Link to more items from this source
[Official Guidance]
Oct. 10, 2014
"Based on comments received, set forth [in this document] is an additional FAQ regarding the [maximum out-of-pocket (MOOP)] requirements. This FAQ addresses only group health plans' and group health insurance issuers' obligations under section 2707(b) of the PHS Act. For non-grandfathered health plans in the individual and small group markets that must provide coverage of the essential health benefit package under section 1302(a) of the Affordable Care Act, additional requirements apply.... Pending issuance of future guidance, for purposes of enforcing the requirements in PHS Act section 2707(b), the Departments will consider all the facts and circumstances when evaluating whether a plan's reference-based pricing design (or similar network design) that treats providers that accept the reference-based price as the only in-network providers and excludes or limits cost-sharing for services rendered by other providers is using a reasonable method to ensure adequate access to quality providers at the reference price, including: [1] Type of service .... [2] Reasonable access .... [3] Quality standards .... [4] Exceptions process .... [5] Disclosure .... The Departments will continue to monitor the use of reference-based pricing and may provide additional guidance in the future[.]"

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