[Official Guidance]

Text of Agency FAQs on ACA Implementation (Part XXVII): Limitations on Cost-Sharing, and Provider Nondiscrimination

Limitations on Cost Sharing under the Affordable Care Act

"In the final HHS Notice of Benefit and Payment Parameters for 2016 ..., HHS clarified that under section 1302(c)(1) of the [ACA], the self-only maximum annual limitation on cost sharing applies to each individual, regardless of whether the individual is enrolled in self-only coverage or in coverage other than self-only.... [T]he Departments received questions regarding the application of the clarification to self-funded and large group health plans [and] are issuing the following FAQs ...

Q1. Does PHS Act section 2707(b) apply this requirement to all non-grandfathered group health plans? Yes.... Q2. Does the clarification of section 1302(c)(1) of the [ACA] apply for plan or policy years that begin in 2015? No. The Departments will apply this clarification only for plan or policy years that begin in or after 2016. Q3. Does the clarification of section 1302(c)(1) of the [ACA] apply to self-only coverage or other coverage that is not self-only coverage under a high-deductible health plan (HDHP) as defined at section 223(c)(2) of the Internal Revenue Code? Yes....

Provider Nondiscrimination

On April 29, 2013, the Departments issued FAQs which addressed, among other issues, provider nondiscrimination requirements under PHS Act section 2706(a).... The House Committee on Appropriations subsequently [directed CMS] to provide a corrected FAQ or provide an explanation. The Departments are issuing the following FAQs in response ...

Q4. What is the Departments' approach to PHS Act section 2706(a)? ... Until further guidance is issued, the Departments will not take any enforcement action against a group health plan, or health insurance issuer offering group or individual coverage, with respect to implementing the requirements of PHS Act section 2706(a) as long as the plan or issuer is using a good faith, reasonable interpretation of the statutory provision.... Q5. Does Q2 in FAQs About Affordable Care Act Implementation Part XV continue to apply? No. [It] is superceded by this FAQ[.]"

(Employee Benefits Security Administration [EBSA], U.S. Department of Labor [DOL])