Coordination of Benefits (Cont’d) 42 USC Issuer and plan may not establish any lifetime or annual trial on the dollar amount of essential Cost-Sharing Lifetime and 45 CFR 147.126(a) health benefits for any individual. Protections annual dollar 45 CFR § 147.126(c) The term health benefits” means essential health benefits under section 1302(b) of “essential (Grandfathered limits on the Patient Protection and Affordable Care Act and applicable regulations. and dollar value Per CMS Bulletin: DOL, Treasury, and HHS will consider a large group plan, or a grandfathered Grandfathered of EHB group health plan, to have used a permissible definition of EHB if the definition is one that is plans) authorized by the Secretary of HHS (including any available benchmark option, supplemented as needed to ensure coverage of all ten statutory categories). The definition must be used consistently by the issuer. 42 USC §300gg-11(b) Exception: May place lifetime or annual limits on the dollar amount of specific covered benefits 45 CFR that are not essential health benefits. §147.126 (b)(1) 45 CFR Note: Restriction on lifetime or annual limits does not apply to FSAs, MSAs, or HSAs. In the case of Cost-Sharing §147.126(a)(2)(ii) HRAs that are integrated with other group health plan coverage that complies, the fact that benefits Protections under the HRA itself are limited is not a violation. (Grandfathered Resource: (Q10) and 42 USC §18022(c) Plan must comply with annual limit on cost-sharing (e.g., deductible, copayment, coinsurance) Grandfathered Maximum 45 CFR § with respect to the essential health benefits. plans) 156.130(a)(2) This single MOOP must apply to all essential health benefits under the plan (e.g., medical, prescription drug, and mental health benefits). Plans design may include separate OOP limits (Cont’d) for different categories of benefits, provide that the combined amount does not exceed the single combined limit. Exceptions:
Coordination of Benefits (Cont’d) Cost-Sharing Protections (Grandfathered and plans) Cost-Sharing Protections (Grandfathered and plans) (Cont’d) Lifetime and annual dollar limits on dollar value of EHB 42 USC 45 CFR 147.126(a) 45 CFR § 147.126(c) 42 USC §300gg-11(b) 45 CFR §147.126 (b)(1) 45 CFR §147.126(a)(2)(ii) Issuer and plan may not establish any lifetime or annual on the dollar amount of essential health benefits for any individual. The term “essential health benefits” means essential health benefits under section 1302(b) of the Patient Protection and Affordable Care Act and applicable regulations. Per CMS Bulletin: DOL, Treasury, and HHS will consider a large group plan, or a grandfathered group health plan, to have used a permissible definition of EHB if the definition is one that is authorized by the Secretary of HHS (including any available benchmark option, supplemented as needed to ensure coverage of all ten statutory categories). The definition must be used consistently by the issuer. Exception: May place lifetime or annual limits on the dollar amount of specific covered benefits that are not essential health benefits. Note: Restriction on lifetime or annual limits does not apply to FSAs, MSAs, or HSAs. In the case of HRAs that are integrated with other group health plan coverage that complies, the fact that benefits under the HRA itself are limited is not a violation. Resource: (Q10) Maximum 42 USC §18022(c) 45 CFR § 156.130(a)(2) Plan must comply with annual limit on cost-sharing (e.g., deductible, copayment, coinsurance) with respect to the essential health benefits. This single MOOP must apply to all essential health benefits under the plan (e.g., medical, prescription drug, and mental health benefits). Plans design may include separate OOP limits for different categories of benefits, provide that the combined amount does not exceed the single combined limit. Exceptions: trial Grandfathered Grandfathered
checklist-forms-hcsc-large-group.docx