different categories of benefits, provide that the combined amount does not exceed the single combined limit. Exceptions: Plan may, but is not required to, count cost-sharing for non-essential health benefits or services toward the limit. If the plan uses a network of providers, plan may, but is not required to, cost-sharing for 45 CFR § 156.130(c) benefits toward the limit. Maximum Annual limit: Cost-Sharing Generally: limit Protections 2016: $6,850 for self-only and $13,700 for family (Grandfathered (Cont’d) For HSA-HDHPs: and 2016: $6.550 for self-only and $13,100 for family Grandfathered The MOOP for self-only coverage applies to all individuals (regardless of whether the plans) individual is in self-only or family coverage). For example, a family plan with a $13,700 family out-of-pocket cannot have cost sharing exceed $6,850 for any individual (Cont’d) enrollee on the contract. Resources: ; ; ; ; If the plan requires a dependent to be a student for coverage, does the contract contain a 42 USC Coverage notice of coverage of a student on a medically necessary leave of absence, in understandable §300gg–28(c) of students language? on Issuer and plan cannot terminate coverage of dependent child who was enrolled on the basis of 42 USC medically §300gg–28(b) being a student due to a medically necessary leave of absence before the earlier of: necessary The date that is 1 year after the first day of the leave; or leave of The date on which coverage would otherwise terminate under the terms of the absence coverage. (Michelle’s 42 USC Dependent on medically necessary leave of absence is entitled to the same benefits as if the Law) child continued to be a covered student who was not on a medically necessary leave of absence.
Cost-Sharing Protections (Grandfathered and plans) (Cont’d) Maximum limit (Cont’d) 45 CFR § 156.130(c) different categories of benefits, provide that the combined amount does not exceed the single combined limit. Exceptions: Plan may, but is not required to, count cost-sharing for non-essential health benefits or services toward the limit. If the plan uses a network of providers, plan may, but is not required to, cost-sharing for benefits toward the limit. Annual limit: Generally: 2016: $6,850 for self-only and $13,700 for family For HSA-HDHPs: 2016: $6.550 for self-only and $13,100 for family The MOOP for self-only coverage applies to all individuals (regardless of whether the individual is in self-only or family coverage). For example, a family plan with a $13,700 family out-of-pocket cannot have cost sharing exceed $6,850 for any individual enrollee on the contract. Resources: ; ; ; ; Coverage of students on medically necessary leave of absence (Michelle’s Law) 42 USC §300gg–28(c) 42 USC §300gg–28(b) 42 USC If the plan requires a dependent to be a student for coverage, does the contract contain a notice of coverage of a student on a medically necessary leave of absence, in understandable language? Issuer and plan cannot terminate coverage of dependent child who was enrolled on the basis of being a student due to a medically necessary leave of absence before the earlier of: The date that is 1 year after the first day of the leave; or The date on which coverage would otherwise terminate under the terms of the coverage. Dependent on medically necessary leave of absence is entitled to the same benefits as if the child continued to be a covered student who was not on a medically necessary leave of absence. Grandfathered
checklist-forms-hmo-large-group.docx