ACA Now

Implementation Status

This provision is part of what HHS terms the “Patient’s Bill of Rights” (see a July 1, 2010 fact sheet). The implementation of annual limits is described in more detail here on the CCIIO website. General information on annual and lifetime limits also is available on this section of www.healthcare.gov.

See here on the CCIIO website for an inventory of related regulations and guidance documents.

2010

An HHS, Labor and Treasury interim final rule published on June 28, 2010, addresses annual and lifetime limits; it adopted a three-year phased approach for restricted annual limits on essential health benefits before the prohibition on annual limits begins for plan or policy years beginning on or after January 1, 2014 (except for grandfathered individual policies). Additional guidance on this provision – including regarding waivers – is available on a dedicated section of the CCIIO website; CCIIO also posted an FAQ regarding annual limit waivers.

2012

In March 2012, HHS’s ASPE published a report on the ACA’s prohibition on lifetime limits.

A March 21, 2012, final rule on student health insurance coverage addresses annual limit-related requirements in that context.

2013

On April 4, 2013, CMS published a Paperwork Reduction Act Notice relative to the requirement for health plans to provide advance notices of the potential for coverage rescission, as well as patient protection notifications that inform enrollees of their right to select a primary care provider or pediatrician or use OG/GYN services without obtaining prior approval. The Notice also indicates the discontinuation of the requirement for plans and issuers to provide an enrollment opportunity notice to individuals whose coverage ended because they reached a lifetime limit, saying this was a “one-time” requirement.

On April 29, 2013, DOL, Treasury and HHS issued FAQs clarifying that waivers from the annual limit requirements will expire on the approved expiration date, notwithstanding any modifications that plans may make to their plan or policy years. The FAQs also clarify that the ACA’s provider non-discrimination and clinical trial coverage provisions are self-implementing and that no regulations are expected “in the near future.” The Departments note that the Qualified Health Plan transparency reporting requirements under section 1311(e)(3) will take effect “only after QHPs have been certified as QHPs for one benefit year,” adding that outside-the-Exchange reporting requirements under PHSA 2715A will not take effect sooner than this.

On June 28, CMS published a Federal Register Notice pursuant to Paperwork Reduction Act procedures including a reinstatement with change of a previously approved information collection, “Enrollment Opportunity Notice Relating to Lifetime Limits; Required Notice of Rescission of Coverage; and Disclosure Requirements for Patient Protection under the Affordable Care Act.”

As part of a “continuing effort to reduce paperwork and respondent burden,” Treasury published a Notice – indicating a proposed extension of a currently approved information collection – that solicits comments on the ACA’s Enrollment Opportunity Notice Relating to Lifetime Limits. The burden estimate is 29,000 annual respondents and 1,300 annual hours. Comments are due by October 28.

On September 13, the DOL issued a Technical Release providing guidance on the application of certain ACA market reforms – specifically, limitations on annual dollar limits and preventive services requirements – to health reimbursement arrangements, employer payment plans, health FSAs and employee assistance programs. Concurrently, the IRS released Notice 2013-54 largely tracking DOL’s Technical Release. On September 16, CCIIO posted a bulletin concurring with DOL and IRS guidance insofar as it pertains to HHS oversight.

2014

On May 13, 2014 the IRS said in a Q&A that employers cannot give employees tax-free payments for inside or outside of Marketplace plans because such arrangements (employer payment plans) are considered group plans and must comply with certain Affordable Care Act (ACA) reforms, including the ban on annual limits for essential health benefits, as well as preventive services coverage requirements. The IRS says such arrangements “cannot be integrated with individual policies to satisfy the market reforms” and that employers would be subject to excise taxes of $100/day per employee ($36,500/year). Further details are available in a September 2013 notice.

On Nov. 6, DOL, HHS and Treasury issued FAQs specifying certain employer reimbursement arrangement that do not comply with ACA market reforms and reiterates that, pursuant to other guidance, can trigger penalties under the employer mandate.

2016

On June 10, CMS, DOL, and Treasury issued a proposed rule addressing the definition of the ACA prohibition on annual and lifetime limits on essential health benefits (EHBs). The proposed rule would require that, “for plan years (in the individual market, policy years) beginning on or after Jan. 1, 2017, a plan or issuer that is not required to provide EHB may select from among any of the 51 base benchmark plans selected by a State or applied by default.” The rule also addresses short-duration plans, expatriate plans, excepted benefits, and other topics. Comments are due by Aug. 9, 2016.