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Important Takeaways From The New ACA Guidance

May 11 2016, by PEOPLE in Sales

The DOL, HHS, and IRS (the federal agencies responsible for the ACA) have put out new guidance that provides a plethora of important information on ACA compliance. Agents will need to take this info and share it with their clients. The new ACA guidance offers a lot of answers to questions that employers have been scratching their heads about. Here are some important takeaways from the newly released FAQs that agents can share with clients to keep them up to speed on the ACA.

Preventative care is one of the first things addressed in the new ACA FAQs. They discuss in particular one of the most routine preventative procedures, a colonoscopy. The feds state that the preparation for the procedure is a crucial element of the procedure itself, so it should be covered without cost-sharing. This includes medications for bowel preparation that are typically given before the procedure. But with the right medical management know-how, employers can make plans with a standard exception form, similar to the Medicare Part D Coverage Determination Request Form. This will allow providers to offer specific services and FDA-approved items. Your clients probably have employees who will need preventative care procedures such as colonoscopies, so it’s important to know where the ACA stands on coverage of preparation for procedures.

Out-of-network ER services were also addressed. This will be important for agents to pass down to their clients so that you can work together to ensure their plan is up to code. The FAQ clarifies that plans should explain how payments for out-of-network ER services were calculated to show that they comply with ERISA’s rules regarding disclosure and the ACA’s external review requirements and appeals process.

The new ACA guidance shed light on cancer and clinical trials as well. According to the feds, cancer treatment coverage can actually apply to clinical trials. If your client provides a plan that covers chemotherapy, the plan can’t actually limit that same coverage when it is tied to an employee’s participation in an approved clinical trial. Agents also need to ensure that their clients are aware that plans cannot deny coverage of services or items that diagnose or treat side effects that result from participation in a clinical trial if the plan already covers those things in regular treatments.

The Mental Health Parity Act has been causing some confusion for employers but the feds have provided three sections in the new ACA FAQs that state how certain tests need to be performed for quantitative limits and financial requirements. These testing requirements have to be applied to any benefits that a plan offers regarding medication-assisted treatment for opioid use disorder.

ACA rules and regulations can be tricky to understand, especially when they are constantly being adjusted. But it’s crucial for employers and business owners to know what they’re dealing with to avoid legal issues or costly fines. Luckily, agents now have even more information from these new FAQs so that they can help their clients stay ACA compliant.