On October 23, 2015, the Departments of Labor, Health and Human Services and Treasury (the “Agencies”) jointly released FAQs about Affordable Care Act (ACA) Implementation (Part XXIX) and Mental Health Parity Implementation. These FAQs clarify several items.
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Clarify that ancillary services to certain preventive services must be covered with no cost-sharing. We will discuss in a few in further detail below.
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Group health plans must provide participants with a list of in-network lactation counseling providers and such information can be included in other in-network provider directories. If there are no providers within the preferred network, the plan must cover lactation counseling services obtained outside of the network without cost-sharing. Furthermore, the FAQs provide that a plan cannot limit the coverage of breastfeeding equipment with no cost-sharing to a specified time period following birth but rather it must be covered with no cost-sharing for the entire duration of breastfeeding.
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Colonoscopy has been designated as a preventive care service for certain individuals. The FAQs provide that a consultation prior to a colonoscopy must be covered without cost-sharing if it has been determined to be medically appropriate. The FAQs also indicate that the Agencies consider a pathology exam of a polyp biopsy to be an integral part of a colonoscopy, and thus, must be covered without cost-sharing.
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The FAQs prohibit plans from imposing general exclusions on weight management services for adult obesity. Screening for adult obesity has been designated as a preventive service. In addition to no cost-sharing screening, plans must cover with no cost-sharing weight management programs for individuals with certain risk factors.
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The FAQs clarify that in-kind incentives such as gift cards, sports gear or other items, must also be considered when determining whether the incentive limitation satisfies the incentive limitations imposed by HIPAA.
As provided in its title, the FAQs also provide some guidance on Mental Health Parity implementation. The FAQs provide that upon a participant’s request, a plan must provide medical necessity guidelines related to mental health and substance abuse benefits to the participant. The FAQs provide that a plan may offer participants a summary document describing the criteria in layperson’s terms; however, the summary must be in addition to the detailed criteria that must be made available upon request.
