2 key points tucked away in new Obamacare guidance

When the feds created those new model COBRA notices to account for the Obamacare exchanges, they also included some other key info — info that was easy to miss on first read.

In addition to the COBRA notices, the DOL’s latest FAQ — FAQ XIX — delved into some of the finer points regarding the new Affordable Care Act rules that apply to out-of-pocket limits and the preventive services requirement.

So what do HR pros need to know about these reform requirements?

1. Out-of-pocket limits

Let’s start with the Obamacare out-of-pocket limits.

For 2014, the out-of-pocket limits under the Affordable Care Act are:

• $5,350 (individual), and
• $12,700 (for family coverage).

Then, starting in 2015, those limits jump to:

• $6,600 (individual), and
• $13,200 (for families).

In the FAQ, the DOL clarified how these out-of-pocket maximums will apply to different benefits — e.g., medical, pharmacy, etc.

According to the feds, plans are able to have separate out-of-pocket limits for different benefit categories as long as the combined amount of those limits does not exceed the out-of-pocket maximums outlined above.

And these limits only apply to in-network healthcare expenses. Plans don’t have to limit the amount of out-of-pocket costs spent on out-of-network care — but they do have the option to do so.

Another key clarification — a clarification that is good news for employer plans — centered around non-covered items.

The DOL says plans don’t have to include items or services in the out-of-pocket limit calculation if those things aren’t covered by the plan.

Plus, plans don’t have to count the amount paid by employees for brand-name drugs toward the annual limit, when there’s a generic (and medically appropriate) drug available.

2. Preventive services

The FAQ also touched on preventive services that must be covered without any cost-sharing requirements to employees.

According to the DOL guidance, group health plans beginning on or after September 24, 2014, must cover breast cancer risk-reducing medications — e.g., tamoxifen, raloxifene — at no cost to employees.

On top of breast-cancer medications, Obamacare requires plans or health insurance issuers to cover tobacco-use counseling and interventions. And the FAQ listed a “safe harbor” regarding these services — which must be provided to employees at no-cost as preventive services — that applies if a plan provides:

• a screening for tobacco use, and
• at least two tobacco cessation attempts per year for individuals who use tobacco products.

This post originally ran on our sister site, HR Benefits Alert.