Plans may not impose cost-sharing on out-of-network services unless in-network providers are available and the plan member goes out of network in spite of that, federal agencies noted in FAQs on the ACA Part XXIX. But if network provider directories fail to list providers as offering the service in question, then plan members do not have to pay cost-sharing when they go out of network, because the in-network provider for that service was too difficult to find.
Applying this principle to breastfeeding counseling and equipment, the agencies said providers offering breastfeeding-related services must be listed separately in network provider directories. The agencies explained this and similar issues in new FAQs listed Oct. 23.
The FAQs also said appointments and services bundled with colonoscopies — including pre-op consultations, the removal of polyps detected during the colonoscopy and the biopsy to examine the removed polyp after the colonoscopy — must be paid for without cost sharing in the same way as the colonoscopy itself.
Lactation Counselors Must Be Listed
Lactation support, counseling and equipment rental are required services under the ACA’s preventive care mandate, one FAQ stated. Plan sponsors and insurers are required to list in-network lactation counselors in provider directories if they are available under the plan or coverage.
In general if a plan does not have in-network providers for a service that is required under the ACA’s preventive services mandate, then the plan will have to provide coverage without cost-sharing when the patient goes to an out-of-network provider for that service.
Also, if in-network lactation experts are not properly identified in provider network handbooks, plans may not impose cost-sharing when a plan member goes out of network for those services.
In other words, cost-sharing can be imposed on an out-of-network preventive service, but only after the employer ensures: (1) that there are in-network providers to provide the preventive service in question; and (2) the provider network handbook has specifically identified the service provider as in-network. This requirement will take effect for plan/policy years beginning on or after Dec. 26, 2015.
Colonoscopies Include Pre- and Post- Services
Pre-exam consultations with specialists and follow-up exams on colon polyp biopsy tissue must covered without cost sharing, under health care reform’s preventive care mandate.
The colonoscopy itself is covered under reform’s mandate to cover preventive services without cost-sharing, but so are associated services.
The consultation, polyp removal and testing are included because they are essential to achieving the purpose of the colonoscopy, an FAQ stated. The colonoscopy bundle must be covered without cost sharing; and no breaking up the bundle and applying cost-sharing to any of the components will be accepted. This requirement will take effect for plan/policy years beginning on or after Dec. 26, 2015.
In both the breastfeeding services and colonoscopy examples, plans will not retrospectively have to pay back cost-sharing amounts, because the narrower reading of both kinds of coverage was reasonable and assumed to have been made in good faith, the agencies said.
Medical Necessity Criteria Shouldn’t Be Concealed
The FAQs also addressed a mental health coverage issue: Plans may not issue a denial of a mental health inpatient stay based on medical necessity, then invoke proprietary restrictions in order to avoid sharing information about the “processes, strategies, evidentiary standards, or other factors” used in its medical necessity decision.
ERISA guarantees participants access to “the instruments by which the plan is operated,” and plans cannot block that access by asserting the proprietary nature of coverage criteria, even if a third-party administrator owns them, DOL said.