American Benefits Council
Benefits Byte

2015-059

May 26, 2015

The Benefits Byte is the American Benefits Council’s regular e-mail and online newsletter for members only, providing timely reports on legislative, regulatory and judicial developments, along with updates on the Council’s activities in support of employer-sponsored benefit plans.

The Benefits Byte is published by the American Benefits Council, based on staff reports and edited by Jason Hammersla, Council director of communications. Contact information for Council staff related to specific topics can be found at the end of each story.

Click here to read past issues on the Benefits Byte Archive page.

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New Guidance Further Clarifies Application of PPACA Maximum Out-of-Pocket Rules, Provider Nondiscrimination

In the latest set of Frequently Asked Questions (FAQs) about Affordable Care Act Implementation (Part XXVII),the U.S. departments of Labor (DOL), Health and Human Services (HHS) and the Treasury provided additional guidance on the application of the Patient Protection and Affordable Care Act’s (PPACA) annual cost-sharing limits for other than self-only coverage. The FAQ also addressed issues related to provider nondiscrimination.

As we have previously reported, the 2016 maximum annual limitation on cost-sharing under PPACA for self-only coverage is $6,850, and for other than self-only coverage, the limit is $13,700. The preamble to the 2016 Notice of Benefit and Payment Parameters, published on February 27, stated that HHS is finalizing language clarifying (under Section 1302 of PPACA) that “the annual limitation on cost sharing for self-only coverage applies to all individuals regardless of whether the individual is covered by a self-only plan or is covered by a plan that is other than self-only.”

In question-and-answer guidance released on May 8, HHS did not provide for any delay in the new requirement to offer an embedded MOOP limit for the 2016 policy year with respect to individual and small group insurance, as many had hoped for, and HHS did not clarify the applicability of the new requirement to large group and self-funded group health plans.

The latest FAQ, however, provided that:

  • The Public Health Service (PHS) Act Section 2707(b) applies the new requirement regarding the maximum annual limitation on cost sharing to all non-grandfathered group health plans.
  • The clarification under PPACA Section 1302(c)(1)  applies only for plan or policy years that begin in or after 2016.
  • The clarification under PPACA Section 1302(c)(1) also applies to non-grandfathered HDHPs.

Employers will need to move quickly to implement this new requirement for the 2016 plan year.

The FAQs also address provider nondiscrimination under Section 2706(a) of the PHS Act, as added by PPACA. According to the statute, “a group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider’s license or certification under applicable State law.” The PHS Act does not require “that a group health plan or health insurance issuer contract with any health care provider willing to abide by the terms and conditions for participation established by the plan or issuer,” and nothing in the PHS Act prevents “a group health plan, a health insurance issuer, or the Secretary [of Health and Human Services] from establishing varying reimbursement rates based on quality or performance measures.”

In response to inquiries from lawmakers in Congress and public comments received in response to a March 2014 request for information (including comments from the Council), the departments are restating their “current enforcement approach.” According to the FAQs,

  • Until further guidance is issued, the Departments will not take any enforcement action against a group health plan, or health insurance issuer offering group or individual coverage, with respect to implementing the requirements of PHS Act Section 2706(a) as long as the plan or issuer is using a good faith, reasonable interpretation of the statutory provision.

This guidance is helpful in clarifying the Departments’ current implementation of PHS Act Section 2706(a).

For more information, contact Kathryn Wilber, senior counsel, health policy, or Katy Spangler, senior vice president, health policy, at (202) 289-6700.



A Bit About Your Benefits: Associate Membership

The Council is honored to have nearly 400 corporate member organizations who, collectively, have extended “associate membership” to 6,800 benefits professionals within their organizations.

This Benefits Byte is just one example of the services we provide. All Council benefits for associate members are included, without additional cost, under a corporate member’s annual dues investment.

If you have a colleague at your company who is not currently receiving Council materials and would like to be included under your company’s membership, they can sign up here. Our staff will reply back with a welcome e-mail confirming their associate membership.

Should you depart your employer for another organization, your associate membership does not transfer. However, we encourage you to join through your new employer. A full list of Council members is available and information about corporate memberships can be obtained by clicking here.

For more information, contact Deanna Johnson, director, membership; Sondra Williams, manager, member & staff engagement; or Mary Lindsay, receptionist, at (202) 289-6700. 



The American Benefits Council is the national trade association for companies concerned about federal legislation and regulations affecting all aspects of the employee benefits system. The Council's members represent the entire spectrum of the private employee benefits community and either sponsor directly or administer retirement and health plans covering more than 100 million Americans.

Notice: the information contained herein is general in nature. It is not, and should not be construed as, accounting, consulting, legal or tax advice or opinion provided by the American Benefits Council or any of its employees. As required by the IRS, we inform you that any information contained herein was not intended or written to be used or referred to, and cannot be used or referred to (i) for the purpose of avoiding penalties under the Internal Revenue Code, or (ii) in promoting, marketing or recommending to another party any transaction or matter addressed herein (and any attachment).