Original content from United Benefit Advisors (UBA)
On January 9, 2014, the Department of Health and Human Services (HHS), the Department of Labor (DOL) and the Department of the Treasury (IRS) issued Frequently Asked Questions – Part XVIII that provides additional information about requirements in several areas.
- Must include deductibles, coinsurance and copayments for essential health benefits (EHBs). A plan may exclude benefits that are not EHBs from the out-of-pocket maximum if it wishes.
- Need not include premiums, costs for non-covered services, or costs for out-of-network services, although it may if it wishes.
- May be separated into different out-of-pocket maximums for different categories of services, but the total of all the separate out-of-pocket maximums cannot exceed the out-of-pocket maximum allowed by the Patient Protection and Affordable Care Act (PPACA), which is $6,350 for self-only coverage or $12,700 for family coverage for 2014.
- This option may be helpful for plans with multiple vendors.
- This technique may not be used to create a separate out-of-pocket maximum for mental health services because that would violate the Mental Health Parity Act (MHPA).
- It is sold only to individuals who have other health coverage that is minimum essential coverage,
- There is no coordination between the benefits under the fixed indemnity policy and an exclusion of benefits under any other health coverage,
- The benefits are paid in a fixed dollar amount regardless of the amount of expenses incurred and without regard to the benefits provided under any other health coverage, and
- A notice is displayed prominently in the plan materials informing policyholders that the coverage does not meet the definition of minimum essential coverage and will not satisfy the individual responsibility requirements of PPACA.