On April 29, 2013, the DOL issued FAQs addressing Affordable Care Act (ACA) provisions regarding:

The FAQs were jointly prepared by the Departments of Labor, Health and Human Services, and Treasury (the Departments).

Under the ACA, group health plans and insurers cannot impose annual limits on the dollar amount of essential health benefits for individuals. However, for plan years beginning before January 1, 2014, plans and insurers may include restricted annual limits on essential health benefits, up to certain limits (see Practice Note, Lifetime Limits, Annual Limits, and Essential Health Benefits Under the ACA). Interim final regulations issued in June 2010 provided that these restricted annual limits may be waived by HHS if compliance with the regulations would result in either:

In an FAQ, the Departments clarify that a group health plan or insurer that was granted a waiver from the annual limit requirement cannot modify the waiver's expiration date by changing its plan year before the waiver expires. A change in plan year will not alter the expiration date because annual limit waivers and waiver extensions are approved by HHS for the plan in effect when the plan or insurer applied for the waiver. This is true regardless of whether the plan or insurer later amends its plan year. However, waiver recipients may terminate the waiver at any time before the approved expiration date.

The Departments cautioned that waiver recipients must retain all records pertaining to their waiver applications to permit HHS to conduct audits. If there is a discrepancy between the plan year in an original application and a subsequent annual update, HHS may review the waiver to determine whether the group health plan or insurer is in compliance with HHS's policy on annual limit waivers.

Under Section 2706(a) of the Public Health Service Act (PHSA), added by the ACA, non-grandfathered group health plans and insurers offering group coverage cannot discriminate against any health care provider who is acting within the scope of that provider's license or certification under applicable state law with respect to the provider's participation under the plan. The requirement is effective for plan years beginning on or after January 1, 2014. Section 2706(a) does not:

In an FAQ, the Departments state that they will not be issuing regulations addressing Section 2706(a) before its effective date. According to the Departments, Section 2706(a) is self-implementing and group health plans and insurers are expected to implement its requirements using a good faith, reasonable interpretation of the law.

Under the FAQ, to the extent an item or service is a covered benefit under the plan, and consistent with reasonable medical management techniques specified under the plan for the item's or service's frequency, method, treatment or setting, a plan or insurer cannot discriminate based on a provider's license or certification to the extent the provider is acting within the scope of its license or certification under applicable state law.

According to the Departments, Section 2706(a) does not:

The FAQ provides contact information for questions and complaints about compliance with Section 2706(a).

Under the ACA, insurers seeking certification of a health plan as a qualified health plan (QHP) must make accurate and timely disclosures of certain information to the appropriate health insurance exchange, HHS, state insurance commissioner and the public (see Article, Health Insurance Exchanges and Related Requirements Under the ACA). The transparency reporting provisions also apply to non-grandfathered group health plans and insurers offering group coverage, though plans not offered through exchanges need not disclose information to an exchange.

In an FAQ, the Departments indicate that QHP insurers:

Under PHSA Section 2709(a), added by the ACA, if a group health plan or insurer provides coverage to certain individuals, the plan or insurer may not:

PHSA Section 2709 applies to non-grandfathered group health plans and insurers for plan years beginning on or after January 1, 2014. In an FAQ, the Departments stated that they will not be issuing regulations addressing Section 2709 before its effective date. Until further guidance is issued, group health plans and insurers are expected to implement these requirements using a good faith, reasonable interpretation of the law. The FAQ provides contact information for questions and complaints about compliance with Section 2709.

Though subregulatory, these latest FAQs offer basic guidance regarding two of the ACA's lesser-known provisions (that is, its rules addressing provider nondiscrimination and clinical trials). As the 2014 effective date for these provisions draws near, plans and insurers subject to the requirements will need to become familiar with them and prepare for implementation.