Guidance for using reference prices to determine maximum out-of-pocket expenses

Posted November 4, 2014 Company News

 

Guidance for non-grandfathered group health plans using reference prices to determine maximum out-of-pocket expenses for various provider networks has been issued in a FAQ prepared jointly by the Employee Benefits Security Administration, Internal Revenue Service, and Department of Health and Human Services.

The FAQs were released to assist group health plans to comply with their obligations under the Public Health Service Act (PHSA), which provides that a group health plan must ensure that any cost-sharing requirements under the plan not exceed the ACA’s limit on annual out-of-pocket maximums and annual limitations on deductibles.
Plans or issuers that include reference-based pricing as a component in their health plan should ensure individuals have meaningful access to medically appropriate quality care and comply with the PHSA by instituting:

  • Standards safeguarding the network’s ability to enable a plan to offer benefits for reduced-cost services from high-quality providers, and does not cover for prohibited limitations on coverage.
  • Procedures ensuring an adequate number of providers accepting the reference price are available to participants and beneficiaries.
  • Procedures making certain an adequate number of providers accepting the reference price meet reasonable quality standards.
  • Easily accessible exemptions process
  • Disclosures regarding reference-based pricing (or similar network design) provided to plan participants free of charge

 


Please note that the information contained in this document is designed to provide authoritative and accurate information, in regard to the subject matter covered. However, it is not provided as legal or tax advice and no representation is made as to the sufficiency for your specific company’s needs. This document should be reviewed by your legal counsel or tax consultant before use.

Additionally, the messages and content within the Pittsburgh Health Care Reform group do not reflect the advisory services of Henderson Brothers, Inc.