2014 Health Insurance Reforms: Waiting Period Limitation and Out of Pocket Maximum Requirements

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PHSA Section 2708, generally limits waiting periods for otherwise eligible individuals to 90 calendar days. Regulations clarify that terms of eligibility generally cannot be based solely on the passage of time but that eligibility based on accumulated hours, not to exceed 1200, or a “measurement period” are permissible. Also clarified is that employers may implement a 30 day orientation period for employees who otherwise satisfies the eligibility requirement after which the waiting period can begin.

Per the agencies FAQs XIX and XXI addressing out-of-pocket requirements for “reference-based pricing arrangement” generally such arrangements I didn’t find amount that will be paid or allowed by the plan with respect to a particular service or treatment. According to the FAQs, plans my treat providers who accept the plans reference base pricing as the only network providers provide certain conditions are satisfied. If those conditions are satisfied, then all services or treatment provided by providers who did not accept the plans reference base pricing-including “network providers” can be treated as out of network in the cost-sharing for such services falls outside of the out-of-pocket maximum limitation. This is an important distinction because typically, the out-of-pocket maximum imposed by the ACA applies to all cost sharing with respect to services or treatments provided by in network providers; cost sharing for out of network providers do not have to be applied to the out-of-pocket maximum.

Source: Employers Council on Flexible Compensation: John Hickman, Esq., Ashley Gillihan, Esq., and Merdith Gage, Esq., Alston & Bird, LLP

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