What ACA Protections Apply to Emergency Services?

What ACA Protections Apply to Emergency Services?

QUESTION: We’ve heard that the rules governing the emergency services covered by our group health plan changed in 2022. What are the revised requirements?

ANSWER: The Affordable Care Act (ACA) patient protections applicable to group health plans that provide benefits for emergency services were revised and expanded for plan years beginning on or after January 1, 2022. The revised requirements are as follows—

  • No Prior Authorization. The services must be covered without the need for any prior authorization, even if provided out-of-network.
  • No Participating Provider Requirement. The services must be covered without regard to whether the provider is a “participating provider” or “participating emergency facility” (i.e., without regard to whether the provider or facility is in-network or otherwise has a contractual relationship with the plan).
  • Limited Out-of-Network Provider Restrictions. If the services are provided by a nonparticipating provider or nonparticipating emergency facility, the restrictions that may be applied are limited. For example, the plan may not impose any administrative requirement or coverage limitation that is more restrictive than the requirements or limitations that apply to emergency services received from participating providers and facilities. And cost-sharing may not be greater than the cost-sharing that would apply if the services were provided by a participating provider or facility. A host of rules regulate the process for plan payments to nonparticipating providers—and the amount that must be paid—including intricate rules for how cost-sharing is calculate.
  • Restricted Use of Diagnosis Codes. The plan must not use diagnosis codes as the sole basis for limiting required coverage of an emergency medical condition.
  • Limited Application of Other Terms or Conditions. The services must be covered without regard to any other coverage term or condition of the plan, other than the exclusion or coordination of benefits, a permissible waiting period, and applicable cost-sharing.

Source: Thomson Reuters

Can Self-Insured State and Local Governmental Plans Still Opt Out of Complying With Certain Group Health Plan Mandates?

Can Self-Insured State and Local Governmental Plans Still Opt Out of Complying With Certain Group Health Plan Mandates?

QUESTION: Is an opt-out election still available to exempt self-insured state and local governmental plans from compliance obligations under certain group health plan mandates?

ANSWER: Originally, self-insured group health plans of state and local governments could opt out of a wide range of group health plan mandates, including certain HIPAA portability requirements (e.g., special enrollment periods and health status nondiscrimination), the mental health parity rules, standards related to newborns and mothers, reconstructive surgery following mastectomies, and coverage for dependent students on medically necessary leaves of absence (Michelle’s Law). The opt-out right has since been eliminated for certain group health plan mandates, but it is still available for others.

The Affordable Care Act (ACA) eliminated the ability of self-insured plans of state and local governments to opt out of the HIPAA portability requirements for plan years beginning on or after September 23, 2010. And the Consolidated Appropriations Act, 2023 eliminated the election to opt out of compliance with the mental health parity requirements as of December 29, 2022. (No new mental health parity opt-out elections may be made on or after that date, and elections expiring on or after June 27, 2023, may not be renewed. Limited extensions are available for plans subject to multiple collective bargaining agreements.) Still, the opt-out election remains available with respect to three other group health plan mandates: standards related to newborns and mothers, reconstructive surgery following mastectomies, and Michelle’s Law (now obsolete for most plans due to the ACA’s requirement to cover dependent children to age 26). Detailed election and notification requirements apply for plans wishing to rely on the opt-out.

Source: Thomson Reuters

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