Affordable Care Act (ACA) - Oficina del Comisionado de Seguros

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Affordable Care Act (ACA) y el Código de Seguros de Salud en el 2016 Lic. Marilú Cháez-Abreu viernes, 22 de enero de 2016

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Advertencias Legales • Esta presentación se ofrece como parte del Seminario para capacitar sobre la Affordable Care Act (ACA) y el Código de Seguros de Salud de Puerto Rico. • El propósito primordial de esta presentación es fortalecer el conocimiento y las destrezas de todos los representantes y productores autorizados a gestionar seguros de salud y planes médicos en Puerto Rico .

• No podrá invocarse el privilegio abogado-cliente o relación alguna por el hecho de tener acceso a esta presentación. • En la preparación de este documento se tomó en consideración las leyes, los reglamentos, las guías y las cartas normativas federales y locales emitidas hasta el 21 de enero de 2016. 2

Requisito Mandatorio de Capacitación Código de Seguros de Salud y ACA

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Encuesta El Nuevo Día - noviembre 2013 Conoce los Beneficios del ObamaCare 17. La ley federal conocida como “Obamacare” tendrá un efecto para muchas personas en Puerto Rico, tanto para quienes tienen y no tienen seguro médico. A juicio suyo, ¿cuán bien o no diría que conoce de qué se trata el “Obamacare” y sus beneficios para personas como ud.? ¿Diría que lo conoce muy bien, lo conoce algo, lo conoce poco o no lo conoce? – 1. Conoce muy bien (7%) – 2. Conoce algo (26%) – 3. Conoce poco (33%) – 4. No lo conoce (34%) 5

Encuesta El Nuevo Día - noviembre 2013 Conoce los Beneficios del ObamaCare 18. Puerto Rico recibirá un subsidio del “Obamacare” de $925 millones entre 2014 y 2019 para ofrecer un seguro de salud a las personas que no tienen uno, migrar a algunos usuarios del plan de salud del gobierno conocido como Mi Salud y ofrecer nuevas cubiertas de salud. ¿Sabe si ud. sería uno(a) de los(as) beneficiados(as) con la ley federal conocida como “Obamacare”? – 1. Sí sabe ¿será beneficiado(a) o no? (35%): 1. Será beneficiado(a) (27%) 2. No será beneficiado(a) (8%) – 2. No sabe (65%)

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Public Opinion on Health Care Issues Kaiser Family Foundation

Source: http://www.kff.org/kaiserpolls/upload/8425-F.pdf. 7

History of Health Reform in the U.S. Sources: • Timeline: History of Health Reform in the U.S.; Kaiser Family Foundation: http://healthreform.kff.org/flash/health _reform-print.html#1900s; http://healthreform.kff.org/flash/healthreformnew.html?CFID=39099268&CFTOKEN=75 244631&jsessionid=603063eeebca955d8 2b12d382110183c3020. • National Health Insurance — A Brief History Of Reform Efforts In The U.S.; Kaiser Family Foundation; March 2009): http://www.kff.org/healthreform/upload /7871.pdf or http://www.kff.org/healthreform/7871.c fm.

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Obama Signing the Bill At the White House

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Affordable Care Act (ACA) • “Affordable Care Act” is the final amended version of the law. – PPACA - Patient Protection and Affordable Care Act of 2010 (Public Law 111–148, signed on March 23, 2010); amended by – HCERA - Health Care and Education Reconciliation Act of 2010 (Public Law 111–152, signed on March 30, 2010). • Acta del Cuidado de Salud a Bajo Precio – Ley de Protección de Pacientes y Cuidado de Salud a Bajo Precio – Ley de Protección al Paciente y Cuidado de Salud Asequible • ACA, PPACA, Health Care Reform, ObamaCare, or O-Care. Source: http://www.healthcare.gov/glossary/a/affordable_care.html. 10

Federal Laws Amended • Public Health Service Act (PHSA) • Employee Retirement Income Security Act (ERISA) • Internal Revenue Code (Code) NOTE: The Affordable Care Act adds section 715(a)(1) to the Employee Retirement Income Security Act (ERISA) and section 9815(a)(1) to the Internal Revenue Code (Code) to incorporate the provisions of Part A of Title XXVII of the PHS Act into ERISA and the Code, and to make them applicable to group health plans and health insurance issuers providing health insurance coverage in connection with group health plans. The PHS Act sections incorporated by these references are sections 2701 through 2728. Accordingly, PHS Act section 2708 is subject to shared interpretive jurisdiction by the Departments. Source: http://www.dol.gov/ebsa/newsroom/tr12-02.html#2.

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Federal Agencies • Department of Health and Human Services (HHS) – CMS: Centers for Medicare & Medicaid Services • CCIIO: Center for Consumer Information and Insurance Oversight http://cciio.cms.gov/ • http://www.healthcare.gov/ and http://www.hhs.gov/healthcare/index.html • Department of Labor (DOL) – EBSA: Employee Benefits Security Administration http://www.dol.gov/ebsa/healthreform/ • Department of Treasury – IRS: Internal Revenue Service http://www.irs.ustreas.gov/newsroom/article/0,,id=220809,00.html 12

Center for Consumer Information and Insurance Oversight (CCIIO) • Is charged with helping implement many provisions of the Affordable Care Act. • Oversees the implementation of the provisions related to private health insurance. • Works closely with governors and the state insurance commissioners, consumers, and stakeholders to ensure the new law best serves the American people. Source: http://cciio.cms.gov/. 13

CMS Responsibility if a State does not Enforce the ACA • The Centers for Medicare & Medicaid Services (CMS) has the responsibility to enforce provisions of Title XXVII of the Public Health Service Act (PHS Act) with respect to health insurance issuers in the group and individual markets when a State informs CMS that it does not have authority to enforce or is not otherwise substantially enforcing one or more of the provisions. • Health insurance issuers providing health insurance coverage in Alabama, Missouri, Oklahoma, Texas, and Wyoming that are subject to the market reform provisions in the PHS Act will need to submit form filings to the Center for Consumer Information & Insurance Oversight (CCIIO), in addition to filing with their state Department of Insurance, as may be required. Source: http://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Market-Reforms/compliance.html and http://www.cms.gov/CCIIO/Resources/TrainingResources/Downloads/form_filing_issuer_instruction_notice_final.pdf 14

Applicability to the Territories, Puerto Rico, March 23, 2010 to July 16, 2014 • There is no uniform “one-size fits all” approach to the territories in the law, … • Title XXVII of the Public Health Service Act (PHSA), as amended by the Title I of the Affordable Care Act, includes the territories in the definition of “State”. • Making all consumer protection amendments applicable to Puerto Rico. Sources: The Secretary of Health and Human Services (HHS), Kathleen Sebelius, letters dated July 29, 2010 and December 10, 2012, and the Memorandum from the Congressional Research Service dated April 19, 2010.

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Applicability to the Territories, Puerto Rico, since July 17, 2014 Applicability of certain ACA provisions to health insurance issuers in the territories. • HHS has determined that the new provisions of the PHS Act enacted in Title I are appropriately governed by the definition of "state“ (includes only the 50 States and the District of Columbia) set forth in that title, and therefore that these new provisions do not apply to the territories. • Specifically, under this interpretation, the definition of "state" set forth in the PHS Act will apply only to PHS Act requirements in place prior to the enactment of the ACA, or subsequently enacted in legislation that does not include a separate definition of "state" (as the ACA). • HHS analysis applies only to health insurance that is governed by the PHS Act. • This interpretation applies prospectively. Source: Letter to Puerto Rico on the Definition of State, http://www.cms.gov/CCIIO/Resources/Letters/Downloads/letter-to-Weyne.pdf 16

ACA Requirements Not Applicable to Issuers in the U.S. Territories ACA requirements will not apply to individual or group health insurance issuers in the territories: 1. Guaranteed availability (PHS Act section 2702) 2. Community rating (PHS Act section 2701) 3. Single risk pool (ACA section 1312(c)) 4. Rate review (PHS Act section 2794 ) 5. Medical loss ratio (PHS Act section 2718) 6. Essential health benefits (PHS Act section 2707) Source: Letter to Puerto Rico on the Definition of State, http://www.cms.gov/CCIIO/Resources/Letters/Downloads/letter-to-Weyne.pdf 17

ACA Applicability to Group Health Plans • As a practical matter, therefore, PHS Act, ERISA, and Code requirements applicable to group health plans continue to apply to such coverage (whether insured or self-insured). • Issuers selling policies to both private sector and public sector employers in the territories will want to make certain that their products comply with the relevant Affordable Care Act amendments to the PHS Act applicable to group health plans since their customersthe group health plans- are still subject to those provisions. Source: Letter to Puerto Rico on the Definition of State, http://www.cms.gov/CCIIO/Resources/Letters/Downloads/letter-to-Weyne.pdf. 18

ACA Applicability to Group Health Plans Group health plans remain subject to those provisions of the PHS Act that were enacted in the ACA, including, inter alia, the: • Prohibition on lifetime and annual limits (PHS Act section 2711 ), • Prohibition on rescissions (PHS Act section 2712), • Coverage of preventive health services (PHS Act section 2713), and • Revised internal and external appeals process (PHS Act section 2719). Source: Letter to Puerto Rico on the Definition of State, http://www.cms.gov/CCIIO/Resources/Letters/Downloads/letter-to-Weyne.pdf

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Posición de la Oficina del Comisionado de Seguros de Puerto Rico • Puerto Rico contará ahora con mayor flexibilidad a la hora de continuar implantando la reforma de salud federal en la isla, lo que implica que Puerto Rico podrá decidir de qué forma y manera ciertas disposiciones del Affordable Care Act (ACA), mejor conocido como el Obamacare, podrán enmendarse de ser necesario en el futuro. • La Oficina del Comisionado de Seguros, no obstante explica, que aunque el Departamento de Salud Federal exime a Puerto Rico de ciertas disposiciones, todas ellas están y continúan estando en vigor a través del Código de Seguros de Salud y de las cartas normativas aprobadas. • A través del Código de Seguros de Salud de Puerto Rico en la Isla ya la reforma de salud federal, con toda su reglamentación, es ley. Fuente: Comunicado de prensa emitido por la Oficina del Comisionado de Seguros, http://www.ocs.gobierno.pr/ocspr/files/Comunicado_de_Prensa-_Implementacion_ACA-_7-17-14.pdf

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Código de Seguros de Salud y la Affordable Care Act Conformidad con Leyes Federales • Cualquier disposición de este Código que conflija o trate sobre un asunto regulado por alguna ley, reglamento federal o directriz administrativa emitida por una agencia federal que sea aplicable a Puerto Rico en el área de la salud o de los planes médicos, se entenderá enmendada para que armonice con tal ley o reglamento federal. Fuente: Artículo 2.050 del Código de Seguros de Salud de Puerto Rico, según enmendado, especialmente por la Ley Número 55 de 10 de julio de 2013. 21

Código de Seguros de Salud y la Affordable Care Act Conformidad con Leyes Federales • J. Los derechos establecidos en este Artículo tendrán el alcance y se regirán de conformidad con los requisitos y procedimientos dispuestos por la Ley Pública 111-148, conocida como “Patient Protection and Affordable Care Act”, la Ley Pública 111-152, conocida como “Health Care and Education Reconciliation Act” y la reglamentación federal y local adoptada al amparo de ésta. • E. Nada de lo provisto en este Artículo se entenderá como que prohíbe a un asegurador u organización de seguros de salud proveer servicios más amplios que los aquí descritos. Fuente: Inciso E y J del Artículo 2.050 del Código de Seguros de Salud de Puerto Rico, según enmendado. 22

Código de Seguros de Salud y la Affordable Care Act Los derechos bajo ACA que incluye el Código: • No discrimen condiciones preexistentes • Beneficios de salud esenciales • No límites económicos, anuales o de por vida, en los beneficios de salud esenciales • Servicios de cuidado preventivo • Acceso a servicios de emergencia • Acceso a servicios de obstetricia y ginecología

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Código de Seguros de Salud y la Affordable Care Act • Selección del proveedor de cuidado primario • No rescisión del plan médico, excepto por fraude o tergiversar intencional mente datos sustanciales • Razón de perdida (Medical Loss Ratio/MLR) y Reembolso • No discriminar a favor de empleados altamente remunerados • Cubierta para dependientes hasta los 26 años de edad • Sistema de querellas interno y externo • Resumen de beneficios y de cubierta, y el glosario uniforme 24

ACA Market Reforms Consumer Protections 1.

Prohibition of Pre-existing Condition Exclusion

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Prohibition on Rescissions

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Coverage of Preventive Health Services

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Essential Health Benefits (EHBs)

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No lifetime or Annual Limits on EHBs

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Extension of Dependent Coverage

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Patient Protections Provisions

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Rate Reviews

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Medical Loss Ratio (MLR)

10. Appeals and External Review 11. Summary of Benefits and Coverage (SBC) 25

Timeline

Reference: http://www.healthcare.gov/law/timeline/full.html.

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Accessibility

Affordability

Adequacy

(Accesible)

(Asequible)

(Adecuada)

Source: http://www.commonwealthfund.org/~/media/Files/Publications/Issue%20Brief/2013/1662_Keith_implementing_ACA_state_action _2014_reform_brief_v2.pdf. 27

What it is Not Applicable to Puerto Rico? • ¿Es cierto que bajo el OBAMACARE mi patrono viene obligado a proveerme cubierta de plan médico? – No, bajo el OBAMACARE en Puerto Rico su patrono no viene obligado a proveer cubierta de plan médico. Esto se conoce como el “mandato patronal” y las disposiciones de ACA sobre este particular solo aplican a los Estados. • ACA tampoco requiere que los residentes bonafides de Puerto Rico tengan un plan médico. Fuente: http://ocs.gobierno.pr/ocspr/documents/obamacare/CONSUMIDORESPREGUNTAS%20Y%20RESPUESTAS%20OBAMACARE-CON%20HYPERLINK.pdf

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Private Health Insurance Market Marketplace Exchange Inside an Exchange (Not available in Puerto Rico) Outside the Exchange Non Marketplace Off-Marketplace Plans Off the Exchange Non-QHPs (Applicable to Puerto Rico)

• Individual • Small Employer (SHOP or Small Business Health Options Program) • Individual Market or Non-Group • Small Employer • Large Employer 29

Health Insurance Market • Individual Market: not based on employment – Individual Health Insurance Coverage – Very Small Group (1 employee) – Student Health Insurance Coverage (45 CFR §147.145) – Associations Plans not related to employment and sold to individuals. • Group Market: provided by an employer or union – Small Employer Plans (2-50 employees, since 2016 are up to 100 employees) – Large Employer Plans (51 or more employees, since 2016 are 101 or more employees) Source: 45 CFR § 144.102, Final Rule, 78 Federal Register 13436; http://www.healthcare.gov/glossary/j/jobbasedhealthplan.html, http://www.healthcare.gov/glossary/i/individualhealthinsurancepolicy.html), 45 CFR § 147.145. Ver el Artículo 10.030 HH del Capítulo 10 del Código de Seguros de Salud, según enmendado. 30

Individual Market • Individual market means the market for health insurance coverage offered to individuals other than in connection with a group health plan. • Individual health insurance coverage means health insurance coverage offered to individuals in the individual market and can include dependent coverage. • Treatment of very small groups: – Includes coverage offered in connection with a group health plan that has fewer than two participants as current employees on the first day of the plan year. – Shall not apply in the case of a State that elects to regulate it as coverage in the small group market. Source: 42 USC § 300gg–91(e)(1) and 45 CFR § 144.103 (Definitions). Ver el Artículo 10.030 HH del Capítulo 10 del Código de Seguros de Salud, según enmendado.

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Individual Market Student Health Insurance Coverage Is a type of individual health insurance coverage that is provided pursuant to an institution of higher education and a health insurance, and provided to students enrolled in that institution and their dependents, that meets the following conditions: (1) Does not make health insurance coverage available other than in connection with enrollment as a student or as a dependent of a student in the institution of higher education. (2) Does not condition eligibility for the coverage on any health status-related factor relating to a student or a dependent. (3) Meets any requirement that may be imposed under State law. Source: 45 CFR § 147.145. Ver el Artículo 10.030 HH del Capítulo 10 del Código de Seguros de Salud, según enmendado.

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Definition of Association Coverage Question: Can states define coverage sold to individuals and small groups through an association as large group coverage and hence avoid subjecting such coverage to the single risk pool and other requirements of the individual and small group market? Answer: No. For purposes of Title XXVII of the PHS Act, including the market reforms, any state law that defines coverage sold to individuals and small groups through an association as large group coverage would be preempted by federal law. Source: http://www.cms.gov/CCIIO/Resources/Fact-Sheets-andFAQs/qa_hmr.html#_ednrefiv. 33

Definition of Association Coverage • In a “mixed” association where different members have coverage that is subject to the individual market, small group market, and/or large group market rules under the PHS Act, as determined by each member’s circumstances, each association member must receive coverage that complies with the requirements arising out of its status as an individual, small employer, or large employer. • For example, it is not permissible under the PHS Act for mixed association coverage to comply only with the large group market rules, even with respect to its individual and small employer members. 34

Individual or Group Market Coverage to Associations • Coverage that is provided to associations, but not related to employment, and sold to individuals is not considered group coverage. – The coverage is considered individual health insurance coverage if the coverage is offered to an association member other than in connection with a group health plan, or is offered to an association’s employer-member that is maintaining a group health plan that has fewer than two participants who are current employees on the first day of the plan year. – The coverage is considered coverage in the individual market, regardless it is considered group coverage under state law. • If the health insurance coverage is offered in connection with a group health plan, it is considered group health insurance coverage. Source: 45 CFR § 144.102, Final Rule, 78 Federal Register 13436; http://cciio.cms.gov/resources/files/association_coverage_9_1_2011.pdf.pdf; http://www.cms.hhs.gov/HealthInsReformforConsume/downloads/HIPAA-02-02.pdf .

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Código de Seguros de Salud Plan de Asociaciones Bona Fides • Plan médico ofrecido por medio de una asociación bona fide que cubre a los miembros de la asociación y sus dependientes. • No se considerará un plan médico grupal ni un plan médico de patronos PYMES cuando la cubierta no depende de una relación patronal y se vende a los individuos. • No se requerirá que la asociación bona fide ofrezca un plan médico individual básico en cualquiera de sus niveles de cubiertas metálicas. Referencia: Artículo 10.030 AA del Capítulo 10 del Código de Seguros de Salud, según enmendado.

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Group Health Plan A group health plan is an employee welfare benefit plan to the extent that the plan provides medical care (including items and services paid for as medical care) to employees (including both current and former employees) or their dependents (as defined under the terms of the plan) directly or through insurance, reimbursement, or otherwise. Source: 45 CFR §146.145

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How to Determine if It is a Individual or Group Health Plan? Circumstances Under Which Health Insurance Regulated As “Individual” Coverage Under State Law Is Subject To The Group Market Requirements Of The Health Insurance Portability And Accountability Act Of 1996 (HIPAA), (Transmittal No. 00-06, Date November 2000): • Ordinarily, a determination of whether there is an employee welfare benefit plan depends on the facts and circumstances surrounding the extent of the employer's involvement. For example, with respect to whether there is a group health plan, one significant factor would be the extent to which the employer makes contributions to health insurance premiums. • For purposes of Title XXVII, the mere fact that coverage is provided through a contract viewed by State law as an "individual" insurance contract does not necessarily prevent it from being characterized as coverage sold in the small group market for purposes of Title XXVII. Similarly, the policy that provides the coverage does not have to be labeled a "group" policy under State law in order for Title XXVII's group market requirements to apply. Furthermore, the employer need not be a party to the insurance policy, or arrange or pay for it directly, in order for its coverage to be considered group health plan coverage. As mentioned earlier, a determination of whether there is a group health plan depends upon the particular facts and circumstances surrounding the employer's involvement. Source: http://www.cms.gov/CCIIO/Resources/Files/Downloads/hipaa_00_06_508.pdf.

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My employer offers employees cash to reimburse the purchase of an individual market policy. Does this arrangement comply with the market reforms? • No. • If the employer uses an arrangement that provides cash reimbursement for the purchase of an individual market policy, the employer's payment arrangement is part of a plan, fund, or other arrangement established or maintained for the purpose of providing medical care to employees, without regard to whether the employer treats the money as pre-tax or post-tax to the employee. Source: FAQs about Affordable Care Act Implementation (Part XXII), http://www.dol.gov/ebsa/faqs/faq-aca22.html 39

My employer offers employees cash to reimburse the purchase of an individual market policy. Does this arrangement comply with the market reforms? • Therefore, the arrangement is group health plan coverage within the meaning of Code section 9832(a), Employee Retirement Income Security Act (ERISA) section 733(a), and PHS Act section 2791(a), and is subject to the market reform provisions of the Affordable Care Act applicable to group health plans. • Such employer health care arrangements cannot be integrated with individual market policies to satisfy the market reforms and, therefore, will violate PHS Act sections 2711 and 2713, among other provisions, which can trigger penalties such as excise taxes under section 4980D of the Code. • Under the Departments' prior published guidance, the cash arrangement fails to comply with the market reforms because the cash payment cannot be integrated with an individual market policy. 40

Increases in Employee Compensation to Assist with Payments of Individual Market Coverage If an employer increases an employee’s compensation, but does not condition the payment of the additional compensation on the purchase of health coverage (or otherwise endorse a particular policy, form, or issuer of health insurance), is this arrangement an employer payment plan? Answer: No. As described iutn Notice 2013-54, an employer payment plan is a group health plan under which an employer reimburses an employee for some or all of the premium expenses incurred for an individual health insurance policy or directly pays a premium for an individual health insurance policy covering the employee, such as arrangements described in Rev. Rul. 61-146. The arrangement described in this Q&A-4 does not meet that description. In addition, because the arrangement described in this Q&A-4 generally will not constitute a group health plan, it is not subject to the market reforms. Providing employees with information about the Marketplace or the premium tax credit under Code § 36B is not endorsement of a particular policy, form, or issuer of health insurance. Source: IRS Guidance on the Application of Code § 4980D to Certain Types of Health Coverage Reimbursement Arrangements, Notice 2015-17, http://www.irs.gov/pub/irs-drop/n-15-17.pdf 41

Employer Health Care Arrangements Employer Payment Plans • Q1. What are the consequences to the employer if the employer does not establish a health insurance plan for its own employees, but reimburses those employees for premiums they pay for health insurance (either through a qualified health plan in the Marketplace or outside the Marketplace)? • Under IRS Notice 2013-54, such arrangements are described as employer payment plans. An employer payment plan, as the term is used in this notice, generally does not include an arrangement under which an employee may have an after-tax amount applied toward health coverage or take that amount in cash compensation. As explained in Notice 2013-54, these employer payment plans are considered to be group health plans subject to the market reforms, including the prohibition on annual limits for essential health benefits and the requirement to provide certain preventive care without cost sharing. Notice 2013-54 clarifies that such arrangements cannot be integrated with individual policies to satisfy the market reforms. Consequently, such an arrangement fails to satisfy the market reforms and may be subject to a $100/day excise tax per applicable employee (which is $36,500 per year, per employee) under section 4980D of the Internal Revenue Code. Source: http://www.irs.gov/uac/Newsroom/Employer-Health-Care-Arrangements 42

How to Determine if It is a Large or Small Group? • Comment: A few commenters asked for clarification about how to determine whether a group policy should be treated as large group or small group coverage for purposes of applying the PHS Act requirements when employer group size fluctuates between the definition of large employer and small employer. • Response: We intend to issue future guidance on counting employees for determining market size of a group health plan. Source: 78 Fed. Reg. 13406, 13408 (Feb, 27, 2013)

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How do I know if I am a small or large employer? Why does it matter? • An employer’s size is determined by the number of its employees. • Employer benefits, opportunities and requirements are dependent upon the employer’s size and the applicable rules. • Generally, an employer with 50 or more fulltime employees or equivalents will be considered a large employer. Source: http://www.irs.gov/uac/Affordable-Care-Act-Tax-Provisions-for-Employers. 44

Group Size Issues under Title XXVII of the Public Health Service Act (PHSA) [O]nce it has been determined that there is an employer-employee relationship with respect to a particular individual, the question of whether the employee is, for example, full-time or part-time becomes irrelevant for purposes of determining employer size under the PHS Act. Therefore, the individual must be counted because the definition of an employee under the PHS Act includes “any” employee of an employer. Source: September 1999 Program Memorandum (Transmittal No. 99-03): Group Size Issues Under Title XXVII of the Public Health Service Act, http://www.cms.gov/CCIIO/Resources/Files/Downloads/hipaa_99_03_508.pdf

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Counting Employees for the Purpose of Determining Which Market Rules Apply under the PHSA Example 1: • For purposes of the PHS Act, an employer with 10 part-time employees is entitled to guaranteed availability of coverage because it has two or more employees. • If, however, State law provides for counting only “full-time” employees, this employer would be considered to have no employees, and, having fewer than two employees, it would be denied the PHS Act protections. • Under these circumstances, the State law would prevent the application of the PHS Act requirement, and would be preempted. Source: September 1999 Program Memorandum (Transmittal No. 99-03): Group Size Issues Under Title XXVII of the Public Health Service Act, http://www.cms.gov/CCIIO/Resources/Files/Downloads/hipaa_99_03_508.pdf

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Counting Employees for the Purpose of Determining Which Market Rules Apply under the PHSA

Example 2: • If an employer in the same State had 45 full-time employees, and 20 part-time employees, it would meet the definition of a large employer under the PHS Act, but would be a small employer under State law. • Since the employer would still qualify for guaranteed availability in the small group market, the State law would not prevent the application of the guaranteed availability provision. Source: September 1999 Program Memorandum (Transmittal No. 99-03): Group Size Issues Under Title XXVII of the Public Health Service Act, http://www.cms.gov/CCIIO/Resources/Files/Downloads/hipaa_99_03_508.pdf

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Small Group Market Small Employer • The term small group market means the health insurance market under which individuals obtain health insurance coverage (directly or through any arrangement) on behalf of themselves (and their dependents) through a group health plan maintained by a small employer. • The term small employer means, in connection with a group health plan with respect to a calendar year and a plan year, an employer who employed an average of at least 2 but not more than 50 employees (1 but not more than 100 employees) on business days during the preceding calendar year and who employs at least 2 (1) employees on the first day of the plan year, unless otherwise provided under State law. Source: 42 USC § 300gg–91(e)(1) and 45 CFR § 144.103 (Definitions). 48

Protecting Affordable Coverage for Employees Act (PACE Act) • Revise the definition of small employer. • Generally defines a small employer as an employer who employed an average of 1-50 employees on business days during the preceding calendar year. – Amends the definition of small employer in ACA so that it would continue to apply to employers with one to 50 employees, rather than changing to one to 100 employees as of 2016 as provided in the original ACA.

• But provides States the option of extending the definition of small employer to include employers with up to 100 employees.

– However, the new legislation also allows states to opt for the one-to-100 employee definition of small employer if they choose

• The law became effective upon enactment.

Source: Frequently Asked Questions on the Impact of PACE Act on State Small Group Expansion, October 19, 2015: http://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/FAQ-on-the-Impact-of-thePACE-Act-on-State-Small-Group-Expansion.pdf 49

Grupos Pequeños en el 2016 Carta Circular CC-2015-1868-D de 24 de noviembre de 2015: http://ocs.gobierno.pr/ocspr/files/CC-2015-1868-D-.pdf

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Small Employer - Proposed Definition • Small employer means, in connection with a group health plan with respect to a calendar year and a plan year, an employer who employed an average of at least 1 but not more than 50 employees on business days during the preceding calendar year and who employs at least 1 employee on the first day of the plan year. • A State may elect to define small employer by substituting ‘‘100 employees’’ for ‘‘50 employees.’’ • In the case of an employer that was not in existence throughout the preceding calendar year, the determination of whether the employer is a small employer is based on the average number of employees that it is reasonably expected the employer will employ on business days in the current calendar year. Source: 45 CFR §144.103 – Definitions: Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2017; Proposed Rule; 80 Federal Register 75487; Wednesday, December 2, 2015.

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Código de Seguros de Salud PYMES (small employer) • Patrono de pequeña y mediana empresa (PYMES) significa toda persona, firma, corporación, sociedad, asociación, con o sin fines de lucro, que haya empleado durante al menos el 50% de sus días laborables del año natural anterior, al menos 2 , pero no más de 50 empleados elegibles. • Al determinar el número de empleados elegibles, las compañías que sean afiliadas, o que sean elegibles para presentar una planilla de impuestos combinada para propósitos de tributación en Puerto Rico, se considerarán un solo patrono. • Después de emitido el plan médico y para determinar la continuidad de la elegibilidad, el tamaño del PYMES se determinará anualmente. • A partir del 1 de enero de 2016 o sujeto a las disposiciones de ACA, el patrono PYMES cubrirá a empresas que tengan hasta 100 empleados. Referencia: Artículo 8.030 K del Código de Seguros de Salud, según enmendado.

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Código de Seguros de Salud PYMES (small employer) • Empleado elegible significa un empleado que trabaja a tiempo completo (semana regular de trabajo de 30 horas o más) o a tiempo parcial (al menos 17.5 horas por semana regular de trabajo) para un patrono de PYMES, en una relación de buena fe de patrono y empleado que no se establece con el propósito de comprar un plan médico. • En este cómputo se deben incluir aquellos empleados que están ausentes del trabajo por motivo de alguna licencia o derecho reconocido por ley. • El término “empleado elegible” no incluye a un empleado temporero ni a los contratistas independientes. Referencia: Artículo 8.030 F del Código de Seguros de Salud, según enmendado.

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Certificación sobre Elegibilidad de Planes PYMES - Artículo 8.030 CSSPR YO,______________________________ Oficial de Cumplimiento de ___________________ certifico que todo patrono de pequeña y mediana empresa (PYMES) al que se haya emitido un plan médico cumple con lo siguiente: • Ha empleado durante al menos cincuenta (50) por ciento de sus días laborables del año natural anterior, al menos dos (2), pero no más de cincuenta (50) empleados. • Al determinar el número de empleados elegibles, las compañías que sean afiliadas, o que sean elegibles para presentar una planilla de impuestos combinada para propósito de tributación en Puerto Rico, se consideraron como un solo patrono. • Después de emitido el plan médico, el tamaño del grupo dicho patrono de pequeña y mediana empresa (PYMES) se determina anualmente para determinar la continuidad de la elegibilidad. • Todo patrono de pequeña y mediana empresa (PYMES) al que se haya emitido un plan médico paga parte o la totalidad de la prima, de los beneficios, o rembolsa al empleado elegible alguna porción de la prima. Y PARA QUE ASI CONSTE: suscribo la presente Certificación de Cumplimiento en ____________ Puerto Rico, a _____ de __________ de _____ . Firma: _________________________________________ Teléfono: __________________ Correo electrónico: ____________________________ Forma: CSS-AS-08-001 Fuente: Carta Circular Número CC-2013-1832-D de 10 de julio de 2013 sobre Adopción del Nuevo Código de Seguros de Salud de Puerto Rico (CSSPR), Requisitos de Presentación de Información y Modelos Estándares. 54

Large Group Market Large Employer • The term large group market means the health insurance market under which individuals obtain health insurance coverage (directly or through any arrangement) on behalf of themselves (and their dependents) through a group health plan maintained by a large employer, unless otherwise provided under State law. • The term large employer means, in connection with a group health plan with respect to a calendar year and a plan year, an employer who employed an average of at least 51 (101) employees on business days during the preceding calendar year and who employs at least 2 employees on the first day of the plan year, unless otherwise provided under State law. Source: 42 USC § 300gg–91(e)(1) and 45 CFR § 144.103 (Definitions). 55

Large Employer – 2016 Definition • Large employer means, in connection with a group health plan with respect to a calendar year and a plan year, an employer who employed an average of at least 51 employees on business days during the preceding calendar year and who employs at least 1 employee on the first day of the plan year. • A State may elect to define large employer by substituting ‘‘101 employees’’ for ‘‘51 employees.’’ • In the case of an employer that was not in existence throughout the preceding calendar year, the determination of whether the employer is a large employer is based on the average number of employees that it is reasonably expected the employer will employ on business days in the current calendar year. Source: 45 CFR §144.103 – Definitions: Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2017; Proposed Rule; 80 Federal Register 75487; Wednesday, December 2, 2015. 56

Minimum Participation Requirement • In the large group market, a minimum participation requirement cannot be used to deny guaranteed issue. • For small employers, an issuer must guarantee issue coverage to a small employer regardless of whether the small employer satisfies any minimum participation requirement. Source: 79 Fed. Reg. at p. 8,566 (Wednesday, February 12, 2014); Guaranteed Availability Under Title XXVII of the Public Health Service Act – Applicability of Group Participation Rules, November 2000, (http://www.cms.gov/CCIIO/Resources/Files/Downloads/hipaa_00_05_508.pdf); Capítulo 8, Artículo 8.070C(9)(a) y (b) del Código de Seguros de Salud . 57

Exemption for Some Market Reforms • Group Health Plans with Less than Two Current Employees (Very Small Group = 1 employee) • Excepted Benefits 46 CFR §146.145(b) • Employee Assistance Programs (EAPs) 46 CFR §146.145(b)(3)(vi) • Grandfathered Health Plans

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Exemption for Market Reforms In General • ACA contains certain market reforms that apply to group health plans (the market reforms). • In accordance with Code § 9831(a)(2) and ERISA §732(a), the market reforms do not apply to: – A group health plan that has fewer than two participants who are current employees on the first day of the plan year, and, in accordance with Code §9831(b), ERISA § 732(b), and PHS Act §§2722(b) and 2763. – A group health plan in relation to its provision of excepted benefits described in Code §9832(c), ERISA §733(c) and PHS Act §2791(c). Excepted benefits include, among other things, accident-only coverage, disability income, certain limited-scope dental and vision benefits, certain long-term care benefits, and certain health FSAs (Flexible Spending Accounts). Source: http://www.dol.gov/ebsa/newsroom/tr13-03.html 59

Exemption for Group Health Plans with Less than Two Current Employees Question: Do the HIPAA statutory exemptions in effect since 1997 for group health plans with “less than two participants who are current employees” apply to the ACA’s group market reforms? Answer: Yes. The preamble to the interim final regulations on grandfathered plansnoted that statutory provisions in effect since 1997 exempting group health plans with “less than two participants who are current employees” from HIPAA also exempt such plans from the group market reform requirements of the ACA. Accordingly, under the terms of these statutory provisions, group health plans that do not cover at least two employees who are current employees (such as plans in which only retirees participate) are exempt from the ACA's market reform requirements. Source: http://www.dol.gov/ebsa/pdf/faq-aca3.pdf , 75 FR 34539-34540, published on June 17, 2010.

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Excepted Benefits 46 CFR §146.145(b)

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Excepted Benefits: First Category Benefits Excepted in All circumstances • The first category inclCdes benefits that are generally not health coverage (such as automobile insurance, liability insurance, workers compensation, and accidental death and dismemberment coverage). • The benefits in this category are excepted in all circumstances. These benefits are generally not health insurance coverage. • In contrast, the benefits in the second, third, and fourth categories are types of health coverage but are excepted only if certain conditions are met. Source: 78 Federal Register 77632, 77633, Tuesday, December 24, 2013, Proposed Rules (Amendments to Excepted Benefits). 79 Federal Register 59130, Wednesday, October 1, 2014, Final Rules (Amendments to Excepted Benefits).

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Excepted Benefits Second Category - Limited Excepted Benefits • The second category of excepted benefits is limited excepted benefits, which may include limited scope vision or dental benefits, and benefits for long term care, nursing home care, home health care, or community based care. • To be excepted under this second category, the statute provides that limited benefits must either: (1) be provided under a separate policy, certificate, or contract of insurance; or (2) otherwise not be an integral part of a group health plan, whether insured or self-insured. Source: 78 Federal Register 77632, 77633, Tuesday, December 24, 2013, Proposed Rules (Amendments to Excepted Benefits). 63

Not an Integral Part of a Group Health Plan Benefits are not an integral part of a group health plan (whether the benefits are provided through the same plan, a separate plan, or as the only plan offered to participants) if either paragraph (A) or (B) are satisfied. • Participants may decline coverage. For example, a participant may decline coverage if the participant can opt out of the coverage upon request, whether or not there is a participant contribution required for the coverage. • Claims for the benefits are administered under a contract separate from claims administration for any other benefits under the plan. Source: 79 Federal Register 59130, Wednesday, October 1, 2014, Final Rules (Amendments to Excepted Benefits). 64

Excepted Benefits Third Category - Noncoordinated Benefits • The third category of excepted benefits, referred to as ‘‘noncoordinated excepted benefits,’’ includes both coverage for only a specified disease or illness (such as cancer-only policies), and hospital indemnity or other fixed indemnity insurance. • In the group market, these benefits are excepted only if all of the following conditions are met: (1) the benefits are provided under a separate policy, certificate, or contract of insurance; (2) there is no coordination between the provision of such benefits and any exclusion of benefits under any group health plan maintained by the same plan sponsor; and (3) the benefits are paid with respect to any event without regard to whether benefits are provided under any group health plan maintained by the same plan sponsor. Source: 78 Federal Register 77632, 77633, Tuesday, December 24, 2013, Proposed Rules (Amendments to Excepted Benefits). 79 Federal Register 59130, Wednesday, October 1, 2014, Final Rules (Amendments to Excepted

Benefits). 65

Excepted Benefits – Fourth Category Supplemental Benefits • The fourth category of excepted benefits is supplemental excepted benefits. Such benefits must be: – (1) Coverage supplemental to Medicare, coverage supplemental to the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) or to Tricare, or similar coverage that is supplemental to coverage provided under a group health plan; and – (2) provided under a separate policy, certificate, or contract of insurance. Source: 80 Federal Register 13995, Wednesday, March 18, 2015, Final Rules (Amendments to Excepted Benefits. (78 Federal Register 77632, 77633, Tuesday, December 24, 2013, Proposed Rules (Amendments to Excepted Benefits). 79 Federal Register 59130, Wednesday, October 1, 2014, Final Rules (Amendments to Excepted Benefits). 79 Federal Register 76931, Tuesday, December 23, 2014, Proposed Rules (Amendments to Excepted Benefits). See footnote 13: 26 CFR 54.9831–1(c)(5); 29 CFR 2590.732(c)(5); 45 CFR 146.145(c)(5). The Departments issued additional guidance regarding supplemental health insurance coverage as excepted benefits. See EBSA Field Assistance Bulletin No. 2007–04 (available at http://www.dol.gov/ebsa/pdf/fab2007-4.pdf); CMS Insurance Standards Bulletin 08–01 (available at http://www.cms.gov/CCIIO/Resources/Files/ Downloads/hipaa_08_01_508.pdf); and IRS Notice 2008–23 (available at http://www.irs.gov/irb/2008-07_IRB/ar09.html). 66

Excepted Benefits – Fourth Category Supplemental Benefits or Coverage Supplemental coverage qualifies as an excepted benefit if: 1. Must be issued by an entity that does not provide the primary coverage under the plan; 2. Must be specifically designed to fill gaps in primary coverage, such as coinsurance or deductibles; 3. The cost of the supplemental coverage may not exceed 15% of the cost of primary coverage; and 4. Must not differentiate among individuals in eligibility, benefits, or premiums based upon any health factor of the individual (or any dependents of the individual) when it is sold in the group insurance market . Source: http://www.dol.gov/ebsa/pdf/faq-aca23.pdf 67

Excepted Benefits – Fourth Category Supplemental Benefits or Coverage Can health insurance coverage that supplements group health coverage by providing additional categories of benefits, be characterized as supplemental excepted benefits? • It depends. • The Departments intend to propose that coverage of additional categories of coverage would be considered to be designed to “fill in the gaps” of the primary coverage only if the benefits covered by the supplemental insurance product are not an essential health benefit (EHB) in the State where it is being marketed. Source: http://www.dol.gov/ebsa/pdf/faq-aca23.pdf

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Excepted Benefits – Fourth Category Supplemental Benefits or Coverage Compliance and Enforcement Action Pending publication and finalization of the above proposed regulations, the Departments will not initiate an enforcement action if an issuer of group or individual health insurance coverage fails to comply with the provisions if: 1. Provides coverage of additional categories of benefits that are not EHB in the applicable State (as opposed to filling in cost-sharing gaps under the primary plan); 2. Complies with the applicable regulatory requirements and meets all of the criteria in the existing guidance on “similar supplemental coverage”; and 3. Has been filed and approved with the State (as may be required under State law). Source: http://www.dol.gov/ebsa/pdf/faq-aca23.pdf

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Excepted Benefits Employer Payment Plan Question If the terms of an employer payment plan provide that the employer payment plan may only be used to reimburse (or pay directly for) premiums for individual market coverage consisting solely of excepted benefits (such as dental coverage), does the employer payment plan fail to satisfy the market reforms? Source: IRS Notice 2015-87 (December 16, 2015) http://www.irs.gov/pub/irs-drop/n15-87.pdf 70

Excepted Benefits Employer Payment Plan Answer: No • An employer payment plan that, by its terms, reimburses (or pays directly for) premiums for individual market coverage only if that individual market coverage covers only excepted benefits does not fail to comply with the market reforms solely due to the ability to reimburse the employer for that individual market coverage. • The market reforms do not apply to a group health plan that is designed to provide solely excepted benefits. • As a result, an employer payment plan and the excepted benefits individual market coverage for which the arrangement pays are not subject to the annual dollar limit prohibition or the preventive services requirement and therefore do not fail to satisfy those market reforms. Source: IRS Notice 2015-87 (December 16, 2015) http://www.irs.gov/pub/irs-drop/n-1587.pdf 71

Employee Assistance Programs (EAPs) 46 CFR §146.145(b)(3)(vi)

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Guidance on Employee Assistance Programs Question 9: Are benefits under an employee assistance program or EAP considered to be excepted benefits? • Answer 9:The Departments intend to amend 26 C.F.R. §54.9831-1(c), 29 C.F.R. §2590.732(c), and 45 C.F.R. §146.145(c) to provide that benefits under an employee assistance program or EAP are considered to be excepted benefits, but only if the program does not provide significant benefits in the nature of medical care or treatment. Excepted benefits are not subject to the market reforms and are not minimum essential coverage under Code § 5000A. Until rulemaking is finalized, through at least 2014, the Departments will consider an employee assistance program or EAP to constitute excepted benefits only if the employee assistance program or EAP does not provide significant benefits in the nature of medical care or treatment. For this purpose, employers may use a reasonable, good faith interpretation of whether an employee assistance program or EAP provides significant benefits in the nature of medical care or treatment. Source: Technical Release 2013-03 issued by the Department of Labor on September 13, 2013: http://www.dol.gov/ebsa/newsroom/tr13-03.html. 73

Employee Assistance Programs (EAPs) Benefits provided under EAPs are excepted if they satisfy all of the following requirements: • (A) The EAP does not provide significant benefits in the nature of medical care. For this purpose, the amount, scope and duration of covered services are taken into account. • (B) The benefits under the EAP are not coordinated with benefits under another group health plan, as follows: – (1) Participants in the other group health plan must not be required to use and exhaust benefits under the EAP (making the EAP a gatekeeper) before an individual is eligible for benefits under the other group health plan; and – (2) Participant eligibility for benefits under the EAP must not be dependent on participation in another group health plan. • (C) No employee premiums or contributions are required as a condition of participation in the EAP. • (D) There is no cost sharing under the EAP. Source: 78 Federal Register 77632, 77633, Tuesday, December 24, 2013, Proposed Rules (Amendments to Excepted Benefits). 79 Federal Register 59130, Wednesday, October 1, 2014, Final Rules (Amendments to Excepted Benefits). 74

Examples of EAPs that Do Not Provide Significant Benefits in the Nature of Medical Care Examples of EAPs that do not provide significant benefits in the nature of medical care, discussed in IRS Notice 2004–50 Q&A–10 include: 1. An EAP with benefits that consist primarily of free or low-cost confidential short-term counseling (which could address substance abuse, alcoholism, mental health or emotional disorders, financial or legal difficulties, and dependent care needs) to identify an employee’s problem that may affect job performance and, when appropriate, referrals to an outside organization, facility or program to assist the employee in resolving the problem; and 2. A wellness program that provides a wide-range of education and fitness services (also including sports and recreation activities, stress management, and health screenings) designed to improve the overall health of the employees and prevent illness, where any costs charged to the individual for participating in the services are separate from the individual’s coverage under the health plan. Source: 78 Federal Register 77632, 77636-77637, footnote 28, Tuesday, December 24, 2013, Proposed Rules (Amendments to Excepted Benefits). 75

Grandfathered Health Plans Preservation of Right to Maintain Existing Coverage Exempt from Certain Provisions of ACA 45 CFR § 147.140

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Grandfathered Health Plan Coverage Definition • Means coverage provided by a group health plan, or a group or individual health insurance issuer, in which an individual was enrolled on March 23, 2010. • Applies separately to each benefit package made available under a group health plan or health insurance coverage. • Grandfathered health plans are exempt from many but not all ACA market reforms. Source: http://www.dol.gov/ebsa/pdf/cag.pdf 77

Grandfathered Health Plan Coverage Definition Does not cease to be grandfathered merely because: • One or more (or even all) individuals enrolled on March 23, 2010 cease to be covered, provided that the plan has continuously covered someone since March 23, 2010 (not necessarily the same person, but at all times at least one person). • The plan (or its sponsor) enters into a new policy, certificate, or contract of insurance after March 23, 2010 (for example, a plan enters into a contract with a new issuer or a new policy is issued with an existing issuer). 78

Grandfathered Health Plan Disclosure of Status • To maintain status as a grandfathered health plan, a plan or health insurance coverage must include a statement, in any plan materials provided to a participant or beneficiary (in the individual market, primary subscriber) describing the benefits provided under the plan or health insurance coverage, that the plan or coverage believes it is a grandfathered health plan. • Must provide contact information for questions and complaints. and must also advise consumers how to contact the U.S. Department of Labor or the U.S. Department of Health and Human Services with questions. Source: 45 CFR § 147.140 79

Grandfathered Plan Model Language for Notice To maintain status as a grandfathered health plan, a plan or health insurance coverage must: • Include a statement, in any plan materials provided to a participant or beneficiary describing the benefits provided under the plan or health insurance coverage. • Include a statement that the plan or coverage believes it is a grandfathered health plan within the meaning of section 1251 of the PPACA. • Provide contact information for questions and complaints. Source: http://www.dol.gov/ebsa/healthreform/

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Grandfathered Plan Model Language for Notice

• This [group health plan or health insurance issuer] believes this [plan or coverage] is a “grandfathered health plan” under the Patient Protection and Affordable Care Act (the Affordable Care Act). As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that your [plan or policy] may not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing. However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits. Source: http://www.dol.gov/ebsa/healthreform/ 81

Grandfathered Plan Model Language for Notice Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to the plan administrator at [insert contact information]. [For ERISA plans, insert: You may also contact the Employee Benefits Security Administration, U.S. Department of Labor at 1-866-444-3272 or www.dol.gov/ebsa/healthreform. This website has a table summarizing which protections do and do not apply to grandfathered health plans.] [For individual market policies and nonfederal governmental plans, insert: You may also contact the U.S. Department of Health and Human Services at www.healthreform.gov.] Source: http://www.dol.gov/ebsa/healthreform/

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Grandfathered Plans Status Maintain Documentation To maintain status as a grandfathered health plan, it must, for as long as the plan or health insurance coverage takes the position that it is a grandfathered health plan— (A) Maintain records documenting the terms of the plan or health insurance coverage in connection with the coverage in effect on March 23, 2010. (B) Maintain any other documents necessary to verify, explain, or clarify its status as a grandfathered health plan. (C) Make such records available for examination upon request. Source: 45 CFR § 147.140.

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Grandfathered Plans Maintenance of Status The plan or policy may lose their “grandfathered” status if they make certain significant changes that reduce benefits or increase costs to consumers. Therefore, the plan or policy: 1. Cannot Significantly Cut or Reduce Benefits 2. Cannot Raise Co-Insurance Charges 3. Cannot Significantly Raise Co-Payment Charges 4. Cannot Significantly Raise Deductibles 5. Cannot Significantly Lower Employer Contributions 6. Cannot Add or Tighten an Annual Limit on What the Insurer Pays Source: http://www.healthcare.gov/news/factsheets/keeping_the_health_plan_you_have_grandfathered.html

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Grandfathered Plans Maintenance of Status 1. Cannot Significantly Cut or Reduce Benefits • The elimination of all or substantially all benefits to diagnose or treat a particular condition causes a plan to cease to be a grandfathered. • The elimination of benefits for any necessary element to diagnose or treat a condition is considered the elimination of all or substantially all benefits to diagnose or treat a particular condition. • Before March 23, 2010, the terms of plan provide benefits for a particular mental health condition, the treatment for which is a combination of counseling and prescription drugs. Subsequently, the plan eliminates benefits for counseling. The plan ceases to be a grandfathered because counseling is an element that is necessary to treat the condition. Thus the plan is considered to have eliminated substantially all benefits for the treatment of the condition. 85

Grandfathered Plans Maintenance of Status 2. Cannot Raise Co-Insurance Charges • Any increase, measured from March 23, 2010, in a percentage cost-sharing requirement (such as an individual's coinsurance requirement) causes a plan to cease to be a grandfathered health plan. • Co-insurance requires a patient to pay a fixed percentage of a charge (example, 20% of a hospital bill). • On March 23, 2010, a grandfathered has a coinsurance of 20% for inpatient surgery. The plan is subsequently amended to increase the coinsurance to 25%. The increase in the coinsurance requirement from 20% to 25% causes the plan to cease to be a grandfathered. 86

Grandfathered Plans Maintenance of Status 3. Cannot Significantly Raise Co-Payment Charges • Any increase in a fixed-amount copayment, determined as of the effective date of the increase, causes a plan to cease to be a grandfathered plan, if the total increase in the copayment measured from March 23, 2010 exceeds the greater of: (i) An amount equal to $5 increased by medical inflation, that is, $5 times medical inflation, plus $5), or (ii) The maximum percentage increase by expressing the total increase in the copayment as a percentage. • Compared with the copayments in effect on March 23, 2010, grandfathered plans will be able to increase those co-pays by no more than the greater of $5 (adjusted annually for medical inflation) or a percentage equal to medical inflation plus 15 percentage points. • For example, if a plan raises its copayment from $30 to $50 over the next 2 years, it will lose its grandfathered status. 87

Grandfathered Plans Maintenance of Status 4. Cannot Significantly Raise Deductibles • Any increase in a fixed-amount cost-sharing requirement other than a copayment (for example, deductible or out-of-pocket limit), determined as of the effective date of the increase, causes to cease to be a grandfathered, if the total percentage increase in the cost-sharing requirement measured from March 23, 2010 exceeds the maximum percentage increase. • There are plans that require patients to pay the first bills they receive each year (for example, the first $1,000 a year). Compared with the deductible required as of March 23, 2010, grandfathered can only increase this by a percentage equal to medical inflation plus 15 percentage points. • If the medical costs have risen an average of 4-to-5%, this formula would allow deductibles to go up, for example, by 19-20% between 2010 and 2011, or by 23-25% between 2010 and 2012. For a family with a $1,000 annual deductible, this would mean if they had a hike of $190 or $200 from 2010 to 2011, their plan could then increase the deductible again by another $50 the following year. 88

Grandfathered Plans Maintenance of Status 5. Cannot Significantly Lower Employer Contributions • A plan ceases to be a grandfathered if the employer or employee organization decreases its: Contribution rate based on cost of coverage towards the cost of any tier of coverage for any class of similarly situated individuals by more than 5 percentage points below the contribution rate for the coverage period that includes March 23, 2010. Contribution rate based on a formula towards the cost of any tier of coverage for any class of similarly situated individuals by more than 5 percent below the contribution rate for the coverage period that includes March 23, 2010. • Grandfathered plans cannot decrease the percent of premiums the employer pays by more than 5 percentage points. • For example, decrease their own share and increase the workers’ share of premium from 15% to 25%. 89

Grandfathered Plans Maintenance of Status 6. Cannot Add or Tighten an Annual Limit on What the Insurer Pays • Addition of an annual limit. A plan that did not impose an overall annual or lifetime limit on the dollar value of all benefits ceases to be a grandfathered plan if it imposes an overall annual limit on the dollar value of benefits. • Decrease in limit for a plan or coverage with only a lifetime limit. A plan that imposed an overall lifetime limit on the dollar value of all benefits but no overall annual limit on the dollar value of all benefits ceases to be a grandfathered plan if the plan adopts an overall annual limit at a dollar value that is lower than the dollar value of the lifetime limit on March 23, 2010. • Decrease in limit for a plan or coverage with an annual limit. A plan that imposed an overall annual limit on the dollar value of all benefits ceases to be a grandfathered health plan if the plan decreases the dollar value of the annual limit (regardless of whether the plan or health insurance coverage also imposed an overall lifetime limit on March 23, 2010 on the dollar value of all benefits). • Moreover, plans that do not have an annual dollar limit cannot add a new one unless they are replacing a lifetime dollar limit with an annual dollar limit that is at least as high as the lifetime limit (which is more protective of high-cost enrollees). 90

Grandfathered Plans Maintenance of Status May Change Insurance Companies • Allow all group health plans to switch insurance companies and shop for the same coverage at a lower cost while maintaining their grandfathered status, as long as the structure of the coverage doesn’t violate one of the other rules for maintaining grandfathered plan status. • An employer with a group health plan can switch plan administrators as well as buy insurance from a different insurance company without losing grandfathered status-provided the plan does not make any of the above six (6) changes to its cost or benefits structure. 91

Grandfathered Health Plan Individual and Family Members • The enrollment date may not reflect the date the plan was created. • Grandfathered plan includes coverage of family members of the individual who enroll in the grandfathered plan of the individual. • New employees (whether newly hired or newly enrolled) and their family members may be added to grandfathered plans after March 23, 2010. Source: http://www.healthcare.gov/glossary/g/grandfathered_health.html

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Grandfathered Health Plan Status Anti-Abuse Rules To prevent health plans from using the grandfather rule to avoid providing important consumer protections, the regulation indicates: • Mergers and acquisitions. If the principal purpose of a merger, acquisition, or similar business restructuring is to cover new individuals under a grandfathered plan, the plan ceases to be a grandfathered plan. 93

Grandfathered Health Plan Status Anti-Abuse Rules Change in plan eligibility. A plan (including a benefit package under a group health plan) ceases to be a grandfathered plan if: (A) Employees are transferred into the plan or health insurance coverage (the transferee plan) from a plan or health insurance coverage under which the employees were covered on March 23, 2010 (the transferor plan); (B) Comparing the terms of the transferee plan with those of the transferor plan (as in effect on March 23, 2010) and treating the transferee plan as if it were an amendment of the transferor plan would cause a loss of grandfather status; and (C) There was no bona fide employment-based reason to transfer the employees into the transferee plan. For this purpose, changing the terms or cost of coverage is not a bona fide employment-based reason. 94

Which Provisions of the ACA APPLY to a Grandfathered Health Plan? • • • • • •

Prohibition on preexisting condition exclusions Prohibition on excessive waiting periods Prohibition on lifetime/restricted annual limits Prohibition on rescissions Extension of dependent coverage Summary of benefits and coverage and uniform glossary

Source: http://www.dol.gov/ebsa/pdf/cag.pdf

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Which Pprovisions of the ACA DO NOT APPLY to a Grandfathered Health Plan? • • • • • • •

Coverage of preventive services Internal claims and appeals and external review Patient protections Fair health insurance Premiums Guaranteed availability of Coverage Guaranteed renewability of coverage Comprehensive health insurance coverage (essential health benefits)

Source: http://www.dol.gov/ebsa/pdf/cag.pdf 96

Application of the New Health Reform Provisions to Grandfathered Plans

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98

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Source: http://www.dol.gov/ebsa/pdf/grandfatherregtable.pdf

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ACA Market Reforms Consumer Protections 1.

Prohibition of Pre-existing Condition Exclusion

2.

Prohibition on Rescissions

3.

Coverage of Preventive Health Services

4.

Essential Health Benefits (EHBs)

5.

No lifetime or Annual Limits on EHBs

6.

Extension of Dependent Coverage

7.

Patient Protections Provisions

8.

Rate Reviews

9.

Medical Loss Ratio (MLR)

10. Appeals and External Review 11. Summary of Benefits and Coverage (SBC) 101

Consumer Protections Health Insurance Mandates A health insurance “mandate” is a command from a governing body, such as a state legislature, to the insurance industry or health plans to include coverage for or offer coverage for: • Providers. • Benefits. • Populations. Source: Health Insurance Mandates in the States 2012, Executive Summary, by the Council for Affordable Health Insurance: http://www.cahi.org/cahi_contents/resources/pdf/Mandatesinthestates2012Execsumm.pdf (visited on August 14, 2013). 102

1. Prohibition of Preexisting Condition Exclusions 45 CFR § 147.108 and 45 CFR §146.111 A. Waiting Period B. Automatic Enrollment (repeal) C. Non-Discrimination Based on Health Factors D.Wellness Program E. Highly Compensated Individual F. Guaranteed Availability of Coverage G. Guaranteed Renewability of Coverage 103

Pre-Existing Condition Prohibition HIPAA - Job-based Coverage Definition: Any condition (either physical or mental) including a disability for which medical advice, diagnosis, care, or treatment was recommended or received within the 6-month period ending on your enrollment date in a health insurance plan. – Genetic information, without a diagnosis of a disease or a condition, cannot be treated as a pre-existing condition. – Pregnancy cannot be considered a pre-existing condition and newborns, newly adopted children and children placed for adoption who are enrolled within 30 days cannot be subject to pre-existing condition exclusions. Exclusion Period: The time period during which a health plan won't pay for care relating to a pre-existing condition. Under a job-based plan, this cannot exceed 12 months for a regular enrollee or 18 months for a late-enrollee. Source: http://www.healthcare.gov/glossary/p/preexisting_jobbased.html; http://www.healthcare.gov/glossary/p/pec_excl_job.html. 104

Pre-Existing Condition Prohibition • Prohibits insurance plans from denying coverage to individuals based on a pre-existing conditions: – For Individuals Under Age 19 since September 23, 2010. – To all ages since on January 1, 2014. • Apply to all non-grandfathered individual, small, and large health plans. • Apply to grandfathered health plans, except for individual policies that are “grandfathered”. Sources: 45 CFR § 147.108 Prohibition of preexisting condition exclusions; http://www.healthcare.gov/law/provisions/billofright/patient_bill_of_rights.html#BenefitsofConsumerProtections http://www.healthcare.gov/law/provisions/ChildrensPCIP/childrenspcip.html http://www.hhs.gov/ociio/regulations/children19/factsheet.html http://www.healthcare.gov/glossary/W/wait_period_job.html.

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Pre-Existing Condition Prohibition Prohibits a plan to deny coverage based on a pre-existing conditions. • Coverage denials Example: the insurer refuses to offer a policy to the family for the child because of the child’s pre-existing medical condition. • Benefit limitations Examples: (1) a health plan refuse to pay for chemotherapy for a child with cancer because the child had the cancer before getting insurance. (2) Provide coverage for accidental injury only if the injury occurred while covered under the plan. (3) Count benefits received for a specific condition under prior health coverage, against a lifetime or annual limit for that condition under the new coverage. (4) Deny benefits until 12 months after an individual otherwise becomes eligible for benefits under the plan. Source: http://www.healthcare.gov/law/provisions/billofright/patient_bill_of_rights.html#BenefitsofConsumerProtections.

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Código de Seguros de Salud No Discrimen Condiciones Preexistentes • Ningún plan médico individual o grupal establecerá exclusiones para condiciones preexistentes en el caso de menores de diecinueve (19) años. • A partir del año 2014, el derecho a que no se discrimine por condiciones médicas preexistentes aplicará a todas las personas, independientemente de su edad. Fuente: Artículo 2.050 (I) del Código de Seguros de Salud, según enmendado.

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Código de Seguros de Salud Cuestionario Médico • Un asegurador podrá requerir al solicitante del plan médico del mercado grupal o individual que complete un cuestionario médico en que suministre información sobre: – Las condiciones que padece. – Los medicamentos que ingiere. – Los cuidados que recibe para mantener bajo control su condición de salud. – Información sobre el médico primario que atiende su condición.

• La información de este cuestionario será usada única y exclusivamente, por el asegurador con el fin de matricular al asegurado en los programas de manejo de enfermedades que tenga establecidos. 108

Carta de Derechos del Paciente No Discrimen Condiciones Preexistentes • Los pacientes menores de 19 años de edad pueden seleccionar el plan de cuidado de salud y aquellos proveedores que se ajusten a sus necesidades sin que se sean discriminados por cualquier condición médica preexistente o su historial médico. • A partir del año 2014, el derecho a que no se discrimine por su condición médica preexistente o historial médico aplicará a todos los pacientes, independientemente de su edad. Fuente: Artículo 6 (a) de la Carta de Derechos y Responsabilidades del Paciente, según enmendada por la Ley Número 161 de 1 de noviembre de 2010.

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A. Prohibition on Waiting Periods that Exceed 90 Days 45 CFR §147.116

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Waiting Period Job-Based Coverage • The time that must pass before coverage can become effective for an employee or dependent, who is otherwise eligible for coverage under a job-based health plan. • If an employee or dependent enrolls as a late enrollee or special enrollee, any period before is not a waiting period. • Starting in 2014, waiting periods for coverage will be limited to 90 days. • Applicable for plan years beginning on or after January 1, 2014. • Applies to all group health plans and health insurance issuers, including grandfathered plans. Source: http://www.healthcare.gov/glossary/W/wait_period_job.html ; 54 CFR §54.98152708, 29 CFR § 2590.715-2708, and 45 CFR § 147.116, Proposed Rules, 78 Federal Register 17324- 17326, 17329-17331, 17334-17336 (March 21, 2013). 111

Prohibition on Waiting Periods Counting Days • All calendar days are counted beginning on the enrollment date, including weekends and holidays. • If the 91st day is a weekend or holiday, the plan or issuer may choose to permit coverage to become effective earlier than the 91st day. • If the plans and issuers do not want to start coverage in the middle of a month (or pay period) may choose to permit coverage to become effective earlier than the 91st day. • A plan or issuer that extends the effective date of coverage beyond the 91st day fails to comply with the 90-day waiting period limitation. Source: 29 CFR § 2590.715-2708 and 45 CFR § 147.116, Proposed Rules, 78 Federal Register 17329-17331 and 17334-17336 (March 21. 2013). 112

Application to Individuals in a Waiting Period Prior to the Applicability Date If an individual is in a waiting period for coverage before January 1, 2014, the waiting period can no longer apply to the individual if it would exceed 90 days with respect to the individual. Source: 29 CFR § 2590.715-2708 and 45 CFR § 147.116, Proposed Rules, 78 Federal Register 17329-17331 and 17334-17336 (March 21. 2013).

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Waiting Period - General Rule • A group health plan, and a health insurance issuer offering group health insurance coverage, must not apply any waiting period that exceeds 90 days, in accordance with the rules. • If, under the terms of a plan, an individual can elect coverage that would begin on a date that is not later than the end of the 90-day waiting period, this is considered satisfied. • Accordingly, in that case, a plan or issuer will not be considered to have violated this paragraph solely because individuals take, or are permitted to take, additional time (beyond the end of the 90-day waiting period) to elect coverage. Source: Ninety-Day Waiting Period Limitation and Technical Amendments to Certain Health Coverage Requirements Under the Affordable Care Act, Final Rule, 79 Federal Register 10295, 10315-10317, Monday, February 24, 2014 / Rules and Regulations.

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Waiting Period - Examples Example 1. Based solely on the lapse of a time period. (i) Facts. A group health plan provides that full-time employees are eligible for coverage under the plan. Employee A begins employment as a full-time employee on January 19. (ii) Conclusion. In this Example 1, any waiting period for A would begin on January 19 and may not exceed 90 days. Coverage under the plan must become effective no later than April 19 (assuming February lasts 28 days). Source: Ninety-Day Waiting Period Limitation and Technical Amendments to Certain Health Coverage Requirements Under the Affordable Care Act, Final Rule, 79 Federal Register 10295, 10315-10317, Monday, February 24, 2014 / Rules and Regulations. 115

Waiting Period - Examples Example 4. Achieving job related licensure requirements specified in the plan's terms. (i) Facts. A group health plan provides that only employees who have completed specified training and achieved specified certifications are eligible for coverage under the plan. Employee C is hired on May 3 and meets the plan’s eligibility criteria on September 22. (ii) Conclusion. In this Example 4, C becomes eligible for coverage on September 22, but for the waiting period. Any waiting period for C would begin on September 22 and may not exceed 90 days; therefore, coverage under the plan must become effective no later than December 21. Source: Ninety-Day Waiting Period Limitation and Technical Amendments to Certain Health Coverage Requirements Under the Affordable Care Act, Final Rule, 79 Federal Register 10295, 10315-10317, Monday, February 24, 2014 / Rules and Regulations. 116

Waiting Period - Examples Example 11. Limitation on orientation periods. (i) Facts. Employee H begins working full time for Employer Z on October 16. Z sponsors a group health plan, under which full time employees are eligible for coverage after they have successfully completed a bona fide one-month orientation period. H completes the orientation period on November 15. (ii) Conclusion. In this Example 11, the orientation period is not considered a subterfuge for the passage of time and is not considered to be designed to avoid compliance with the 90-day waiting period limitation. Accordingly, plan coverage for H must begin no later than February 14, which is the 91st day after H completes the orientation period. (If the orientation period was longer than one month, it would be considered to be a subterfuge for the passage of time and designed to avoid compliance with the 90-day waiting period limitation. Accordingly it would violate the rules of this section.) Source: Ninety-Day Waiting Period Limitation, Final Rules, 79 Federal Register 35942, Wednesday, June 25, 2014. 117

Waiting Period - Special Rule for Health Insurance Issuers To the extent coverage under a group health plan is insured by a health insurance issuer, the issuer is permitted to rely on the eligibility information reported to it by the employer (or other plan sponsor) and will not be considered to violate the requirements of this section with respect to its administration of any waiting period, if both of the following conditions are satisfied: • (1) The issuer requires the plan sponsor to make a representation regarding the terms of any eligibility conditions or waiting periods imposed by the plan sponsor before an individual is eligible to become covered under the terms of the plan (and requires the plan sponsor to update this representation with any changes), and • (2) The issuer has no specific knowledge of the imposition of a waiting period that would exceed the permitted 90-day period. Source: Ninety-Day Waiting Period Limitation and Technical Amendments to Certain Health Coverage Requirements Under the Affordable Care Act, Final Rule, 79 Federal Register 10295, 10315-10317, Monday, February 24, 2014 / Rules and Regulations. 118

Waiting Period Part-Time and Other Employees • Q6. When PHS Act section 2708 (which imposes a 90-day limitation on waiting periods) becomes effective in 2014, will it require an employer to offer coverage to part-time employees or to any other particular category of employees? • A6. No. Many employers make distinctions in eligibility for coverage based on full-time or part-time status, as defined by the employer’s group health plan (which may differ from the standard under Code section 4980H). PHS Act section 2708 does not require the employer to offer coverage to any particular employee or class of employees, including part-time employees. PHS Act section 2708 merely prohibits requiring an otherwise eligible employee to wait more than 90 days before coverage is effective. Furthermore, nothing in the Affordable Care Act penalizes small employers for choosing not to offer coverage to any employee, or large employers for choosing to limit their offer of coverage to full-time employees, as defined in the employer shared responsibility provisions. Source: Technical Release No. 2012-01, Frequently Asked Questions from Employers Regarding Automatic Enrollment, Employer Shared Responsibility, and Waiting Periods, February 9, 2012, http://www.dol.gov/ebsa/newsroom/tr1201.html. 119

Are waiting periods allowed? • Health plans offered outside the open enrollment period and outside a special enrollment period may contain a waiting period that will not exceed ninety (90) days. This 90-day limitation is applicable to group plans and individual plans. • Health plans offered during open enrollment periods or under special enrollment periods (which include but are not limited to the following events: the birth of a person without regard to the insurance status of the parents, marriage, loss of eligibility for Mi Salud or an employment plan, or a dependent reaching 26 years of age) are prohibited to contain waiting periods. Waiting periods cannot be imposed in a discriminatory manner. Source: Industria, Preguntas y Respuestas,: http://www.ocs.gobierno.pr/ocspr/documents/obamacare/Q%20%20A%20INDUSTRIA%20Final.pdf.

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Mi plan médico tiene un “periodo de espera” (waiting period) de 90 días. ¿Los periodos de espera están permitidos? •

Un periodo de espera es el periodo de tiempo que debe transcurrir antes de que se active la cobertura de un plan médico.



Los planes médicos que se ofrezcan fuera del periodo de suscripción garantizada o fuera de un periodo de suscripción especial pueden contener un periodo de espera.



Los planes médicos adquiridos durante el periodo de suscripción garantizada o durante cualquier periodo de suscripción especial (ejemplos: el nacimiento de una persona independientemente de que sus padres estén asegurados, el matrimonio, la pérdida de elegibilidad para Mi Salud o para un plan médico patronal, o que un dependiente cumpla los 26 años de edad) NO pueden contener un periodo de espera.



Los periodos de espera nunca excederán noventa (90) días y esta limitación de los 90 días es aplicable tanto a los planes médicos grupales como a los planes médicos individuales.



Está prohibido que los periodos de espera se impongan de una manera discriminatoria.

Fuente: Consumidores, Preguntas y Respuestas: http://www.ocs.gobierno.pr/ocspr/documents/obamacare/CONSUMIDORESPREGUNTAS%20Y%20RESPUESTAS%20OBAMACARE-CON%20HYPERLINK.pdf 121

B.

Automatic Enrollment Section 18A Fair Labor Standards Act (FLSA) • Repeal of Automatic Enrollment Requirement by Sec. 604 of the Bipartisan Budget Act of 2015: – The Fair Labor Standards Act of 1938 (29 U.S.C. 201 et seq.) is amended by repealing section 18A (as added by section 1511 of the Patient Protection and Affordable Care Act (Public Law 111–148)). 122

Automatic Enrollment Section 18A - Fair Labor Standards Act (FLSA)

Derogada (Repeal): • An employer, that has more than 200 full-time employees, shall automatically enroll new full-time employees in one of its health benefits plans (subject to any waiting period), and to continue the enrollment of current employees in a health benefits plan offered through the employer. • Source: http://www.dol.gov/ebsa/newsroom/tr12-01.html, http://www.dol.gov/ebsa/faqs/faq-aca5.html.

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C. Nondiscrimination Based on Health Factors or Prohibiting Discrimination Against Individuals, Participants, and Beneficiaries Based on Health Factor or Status 45 CFR §147.110 and 45 CFR §146.121 124

Nondiscrimination Based on Health Factors A group health plan and a health insurance issuer offering group or individual health insurance coverage may not establish rules for eligibility (including continued eligibility) of any individual to enroll under the terms of the plan or coverage based on health status-related factors in relation to the individual or a dependent of the individual. – Health Factor – Similarly Situated Individuals – Eligibility – Contributions Source: 45 CFR § 147.110 Prohibiting discrimination against participants, beneficiaries, and individuals based on a health factor.

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ACA Nondiscrimination Provisions Based on Health Factors • ACA adds new provisions regarding wellness programs.

• ACA extends all the nondiscrimination protections to the individual market. • ACA extensions are not applicable to grandfathered health plans (group and individual health plans). Source: http://www.dol.gov/ebsa/pdf/grandfatherregtable.pdf 126

HIPAA Nondiscrimination Provisions Based on Health Factors • ACA retains the HIPAA nondiscrimination provisions for group health plans and group health insurance issuers. – Specifically, plans and group health insurance issuers may not set eligibility rules based on factors such as health status and evidence of insurability – including acts of domestic violence or disability. Provides limits on the ability of plans and issuers to vary premiums and contributions based on health status. • The HIPAA nondiscrimination provisions are applicable to grandfathered group health plans and group health insurance issuers. Source: http://www.dol.gov/ebsa/pdf/grandfatherregtable.pdf 127

Nondiscrimination Based on Health Factors Job-Based Plans • Prohibits discrimination against individuals in eligibility, benefits and premium or contribution rates based on any health factor. – Coverage not discriminate based on health status. – Coverage under job-based plans cannot be denied or restricted. – Can't be charged more because of your health status. • Prohibits discrimination within groups of similarly situated individuals (SSIs). – Restrictions on benefits must apply uniformly to all SSIs. – Can restrict coverage based on other factors such as part-time employment that aren't related to health status. Source: 45 CFR § 147.110 Prohibiting discrimination against participants, beneficiaries, and individuals based on a health factor; http://www.healthcare.gov/glossary/N/nondiscrimination.html.

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Nondiscrimination Based on Health Factors • Benign Discrimination: Nondiscrimination rules do not prohibit plan from establishing more favorable rules for eligibility or premium rates for individuals with an adverse health factor, like a disability. • Restriction on Benefits: A plan may limit benefits for a specific disease or condition if the restriction is applied uniformly to all SSIs and is not directed at individual participants and beneficiaries. Source: http://mp163422.cdn.mediaplatform.com/163422/wc/mp/4000/15208/15212/28521/Arc hive/default.htm 129

Prohibiting Discrimination Based on a Health Factor 1. Health status; 2. Medical condition (including both physical and mental illnesses); 3. Claims experience; 4. Receipt of health care; 5. Medical history; 6. Genetic information; 7. Evidence of insurability; 8. Disability; or 9. Any other health status related factor. Source: 45 CFR § 146.121(a) Prohibiting discrimination against participants and beneficiaries based on a health factor.

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Nondiscrimination Similarly Situated Individuals • Permitted distinctions plans may make among individuals, such as groups of employees, if based on "bona fide employment-based classifications” consistent with the employer’s usual business practice. – For example, part-time and full-time employees can be treated as different groups of similarly situated individuals. In addition, a plan may draw a distinction between employees and their dependents. • Plans can also make distinctions between dependents themselves if the distinction is not based on a health factor. – For example, a plan can distinguish between spouses and dependent children, or between dependent children based on their age or student status. Source: http://www.dol.gov/ebsa/publications/yhphipaa.html#Similarlysituatedindividuals , 45 CFR § 146.121(d) Prohibiting discrimination against participants and beneficiaries based on a health factor. 131

Prohibited Discrimination in Rules for Eligibility May not establish any rule for eligibility (including continued eligibility) of any individual to enroll for benefits under the terms of the plan or coverage that discriminates based on any health factor. 1. Enrollment; 2. The effective date of coverage; 3. Waiting (or affiliation) periods; 4. Late and special enrollment; 5. Eligibility for benefit packages (rules for individuals to change their selection among benefit packages); 6. Benefits (covered benefits, benefit restrictions, and cost-sharing mechanisms such as coinsurance, copayments, and deductibles); 7. Continued eligibility; and 8. Terminating coverage (or disenrollment) of any individual. Source: 45 CFR § 146.121(b) Prohibiting discrimination against participants and beneficiaries based on a health factor. 132

Prohibited Discrimination in Premiums or Contributions A plan may not require an individual, as a condition of enrollment or continued enrollment to pay a premium or contribution that is greater than the premium or contribution for a similarly situated individual enrolled in the plan based on any health factor. Source: 45 CFR § 146.121(c) Prohibiting discrimination against participants and beneficiaries based on a health factor. 133

D. Nondiscriminatory Wellness Programs 45 CFR §147.110 45 CFR §146.121 134

Wellness Program Group Health Coverage • Under Public Health Service Act (PHS Act) section 2705, Employee Retirement Income Security Act (ERISA) section 702, and Internal Revenue Code (the Code) section 9802 and the Departments’ implementing regulations, group health plans and health insurance issuers in the group and individual market are generally prohibited from discriminating against participants, beneficiaries, and individuals in eligibility, benefits, or premiums based on a health factor. • An exception to this general prohibition allows premium discounts, rebates, or modification of otherwise applicable cost sharing (including copayments, deductibles, or coinsurance) in return for adherence to certain programs of health promotion and disease prevention, commonly referred to as wellness programs. Source: FAQs about Affordable Care Act Implementation (Part XXV) addresses the wellness program requirements, April 16, 2015: http://www.dol.gov/ebsa/faqs/faq-aca26.html. 135

Wellness Program - Individual Market • The ACA regulation did not extend the wellness provisions to the individual health insurance market because the wellness exception does not apply to the individual health insurance market. • HHS’s belief that participatory wellness programs in the individual market do not violate the nondiscrimination provisions provided that such programs are consistent with State law and available to all similarly situated individuals enrolled in the individual health insurance coverage. – This is because participatory wellness programs do not base rewards on achieving a standard related to a health factor, and thus do not discriminate based upon health status. Source: 45 CFR § 147.110; 78 Federal Register 33159, Final Rule, Monday, June 3, 2013; 78 Federal Register 13413, Wednesday, February 27, 2013.

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Wellness Program - Group Health Coverage • Are exempt from nondiscrimination requirement. • Can be participatory wellness programs or health-contingent wellness programs. • Provide reimbursement or reward to employees. • Increase the maximum permissible reward from 20% to 30% of the cost of health coverage, and increase the maximum reward to 50% for programs designed to prevent or reduce tobacco use. • Apply to grandfathered and non-grandfathered plans and to insured and self-insured markets. • Was effective for plan years beginning on January 1, 2014. Source: http://www.dol.gov/ebsa/pdf/grandfatherregtable.pdf; New Proposed Wellness Guidance Under PPACA, 04 December 2012, Article by Amy M. Gordon and Susan M. Nash, McDermott Will & Emery: http://www.mondaq.com/unitedstates/article.asp?articleid=209712&print=1. 137

Wellness Programs - Group Health Coverage • A program intended to improve and promote health and fitness that's usually offered through the work place, although insurance plans can offer them directly to their enrollees. • The program allows your employer or plan to offer you premium discounts, cash rewards, gym memberships, and other incentives to participate. • Some examples of wellness programs include programs to help you stop smoking, diabetes management programs, weight loss programs, and preventative health screenings. Source: http://www.healthcare.gov/glossary/W/wellness.html, 45 CFR 45 CFR § 146.121(f). 138

Are All Employment-Based Wellness Programs Subject to ACA Requirements? • No. • Many employers offer a wide range of programs to promote health and prevent disease. For example, some employers may choose to provide or subsidize healthier food choices in the employee cafeteria, provide pedometers to encourage employee walking and exercise, pay for gym memberships, or ban smoking on employer facilities and campuses. • A wellness program is subject to the ACA and HIPAA nondiscrimination rules only if it is, or is part of, a group health plan. • If an employer operates a wellness program separate from its group health plan(s), the program may be subject to other Federal or State nondiscrimination laws, but it is generally not subject to the HIPAA nondiscrimination regulations. Source: http://www.dol.gov/ebsa/pdf/cag.pdf 139

Limits the Wellness Program to only Certain Employer Question: May an issuer limit its offering of a wellness program in connection with a particular health insurance product to only certain employer groups enrolling in that product, such as employers in certain industry classifications? Answer: • No. • The issuer cannot make a wellness program selectively available only to certain employers. Source: http--www.cms.gov-CCIIO-Resources-Fact-Sheets-and-FAQs-Downloads-HHSwellness-FAQs-4-16-15-pdf-AdobeAcrobatPro.pdf 140

Limits the Wellness Program to only Certain Employer • If an issuer offers a wellness program in connection with a particular product that is approved for sale in a market within a State, and the rewards under the program affect the health insurance coverage for that product, including the premiums, benefits, cost sharing, provider network or service area, then the offering of the wellness program would be considered a part of the plan design, and that plan design must generally be made available to every employer in the State and market that applies for such coverage, in accordance with the requirements of section 2702 of the PHS Act. • For example, if an issuer’s wellness program that offered a premium discount was only made available to employer groups who perform office work and not those who perform physical labor, that would not be permissible and the issuer would be in violation of the guaranteed availability requirements of section 2702 of the PHS Act. 141

Limits the Wellness Program to only Certain Employer • This applies only to issuers offering health insurance coverage that is governed by the guaranteed availability provisions of the ACA. • Issuer marketing of wellness programs should be consistent with applicable nondiscrimination standards, including those set forth at 45 CFR 147.104(e). • It does not affect the ability of an employer to define the terms of the group health plan, including the employer’s decision to offer wellness programs as part of the plan that are independent of those offered by the issuer. • It also does not apply to excepted benefits under section 2791(c) of the PHS Act (e.g., employee assistance programs) or wellness programs with rewards that do not affect the coverage (e.g., gym memberships). 142

Participatory Wellness Program Continue to support workplace wellness programs, including “participatory wellness programs” which generally are available without regard to an individual’s health status. It include programs that: • Reimburse for the cost of membership in a fitness center. • Provide a reward to employees for attending a monthly, nocost health education seminar. • Provide a reward to employees who complete a health risk assessment without requiring them to take further action. Source: http://www.healthcare.gov/news/factsheets/2012/11/wellness11202012a.html and http://www.dol.gov/ebsa/newsroom/fswellnessprogram.html. 143

Health-Contingent Wellness Program Reasonably Designed • A health-contingent wellness program must be reasonably designed to promote health or prevent disease. • A program complies with this requirement if it: 1. Has a reasonable chance of improving the health of, or preventing disease in, participating individuals; 2. Is not overly burdensome for individuals; 3. Is not a subterfuge for discrimination based on a health factor; and 4. Is not highly suspect in the method chosen to promote health or prevent disease. Source: FAQs about Affordable Care Act Implementation (Part XXV) addresses the wellness program requirements, April 16, 2015: http://www.dol.gov/ebsa/faqs/faq-aca26.html.

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Health-Contingent Wellness Program Available to All • Programs must be reasonably designed to be available to all similarly situated individuals. • Individuals must be given notice of the opportunity to qualify for the same reward through other means. • A program would have to offer a different, reasonable means of qualifying for the reward to any individual who does not meet the standard based on the measurement, test, or screening. Source: http://www.healthcare.gov/news/factsheets/2012/11/wellness11202012a.html and http://www.dol.gov/ebsa/newsroom/fswellnessprogram.html.

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Health-Contingent Wellness Program Available to All Reasonable alternative means of qualifying for the reward would have to be offered: – To individuals whose medical conditions make it unreasonably difficult. – For whom it is medically inadvisable, to meet the specified health-related standard. Source: http://www.healthcare.gov/news/factsheets/2012/11/wellness11202012a.html and http://www.dol.gov/ebsa/newsroom/fswellnessprogram.html.

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Health-Contingent Wellness Program Available to All (Example) A plan participant's doctor advises that an outcome-based wellness program's standard for obtaining a reward is medically inappropriate for the plan participant. The doctor suggests a weight reduction program (an activity-only program) instead. Does the plan have a say in which one? • Yes. The plan must provide a reward for individuals who qualify by satisfying a reasonable alternative standard. If an individual's personal physician states that the outcome-based wellness program is not medically appropriate for that individual and recommends a weight reduction program (an activity-only program) instead, the plan must provide a reasonable alternative standard that accommodates the recommendations of the individual's personal physician with regard to medical appropriateness. Many different weight reduction programs may be reasonable for this purpose, and a participant should discuss different options with the plan. Source: FAQs about Affordable Care Act Implementation (Part XVIII) and Mental Health Parity Implementation (January 9, 2014) http://www.dol.gov/ebsa/faqs/faq-aca18.html. 147

Wellness Program - Health-Contingent Rewards Amended standards for nondiscriminatory “health-contingent wellness programs,” which generally require individuals to meet a specific standard related to their health to obtain a reward. Programs that: • Provide a reward to those who do not use, or decrease their use of, tobacco. • Provide a reward to those who achieve a specified cholesterol level or weight as well as to those who fail to meet that biometric target but take certain additional required actions. • Increase the maximum permissible reward from 20% to 30% of the cost of health coverage, and increase the maximum reward to 50% for programs designed to prevent or reduce tobacco use. Source: http://www.healthcare.gov/news/factsheets/2012/11/wellness11202012a.html, http://www.dol.gov/ebsa/newsroom/fswellnessprogram.html. 148

Wellness Program Notice Sample Language (Rewards) • Must be simpler for individuals to understand and to increase the likelihood that those who qualify for a different means of obtaining a reward will contact the plan or issuer to request it. • The following language, or substantially similar language, can be used to satisfy the notice requirement: “Your health plan is committed to helping you achieve your best health. Rewards for participating in a wellness program are available to all employees. If you think you might be unable to meet a standard for a reward under this wellness program, you might qualify for an opportunity to earn the same reward by different means. Contact us at [insert contact information] and we will work with you (and, if you wish, with your doctor) to find a wellness program with the same reward that is right for you in light of your health status.” Source: 46 CFR § 146.121 Prohibiting discrimination against participants and beneficiaries based on a health factor, (f) Nondiscriminatory wellness programs. 149

Wellness Program Applicable Percentage: Example 1 • Facts: An employer sponsors a group health plan. The annual premium for employee-only coverage is $6,000 (of which the employer pays $4,500 per year and the employee pays $1,500 per year). The plan offers employees a health-contingent wellness program that is exclusively a tobacco prevention program. Employees who have used tobacco in the last 12 months and who are not enrolled in the plan's tobacco cessation program are charged a $1,000 premium surcharge (in addition to their employee contribution towards the coverage). Those who participate in the plan's tobacco cessation program are not assessed the $1,000 surcharge. • Conclusion: In this Example 1, the reward for the wellness program (absence of a $1,000 surcharge), does not exceed the applicable percentage of 50 percent of the total annual cost of employee-only coverage, $3,000 ($6,000 x 50% = $3,000.) 150

Wellness Program Applicable Percentage: Example 2 • Facts: An employer sponsors a group health plan. The annual premium for employee-only coverage is $6,000 (of which the employer pays $4,500 per year and the employee pays $1,500 per year). The plan offers employees a health-contingent wellness program with several components, focused on exercise, blood sugar, weight, cholesterol, and blood pressure. The reward for compliance is an annual premium rebate of $600. In addition to the $600 reward for compliance with the health-contingent wellness program, the plan also imposes an additional $2,000 tobacco premium surcharge on employees who have used tobacco in the last 12 months and who are not enrolled in the plan's tobacco cessation program. Those who participate in the plan's tobacco cessation program are not assessed the $2,000 surcharge. 151

Wellness Program Applicable Percentage: Example 2 • Conclusion: In this Example 2, the total of all rewards (including absence of a surcharge for participating in the tobacco program) is $2,600 ($600 + $2,000 = $2,600), which does not exceed the applicable percentage of 50 percent of the total annual cost of employee-only coverage ($3,000); and, tested separately, the $600 reward for the wellness program unrelated to tobacco use does not exceed the applicable percentage of 30 percent of the total annual cost of employee-only coverage ($1,800). 152

Wellness Program – Small Group Market Tobacco Use • A health insurance issuer in the small group market may impose the tobacco rating factor only in connection with a wellness program, allowing a tobacco user the opportunity to avoid paying the full amount of the tobacco rating factor by participating in a wellness program meeting the standards of the wellness program regulations. • Under the final rule, a health insurance issuer in the small group market may implement the tobacco use surcharge only in connection with a wellness program that effectively allows tobacco users to reduce their premiums to the level of nontobacco users by participating in a tobacco cessation program or satisfying another reasonable alternative. Source: 78 Federal Register 13413 and 13434, Wednesday, February 27, 2013. 153

Example 1 - Tobacco Use Surcharge With Smoking Cessation Program Alternative Facts: In conjunction with an annual open enrollment period, a group health plan provides a premium differential based on tobacco use, determined using a health risk assessment. The following statement is included in all plan materials describing the tobacco premium differential: ``Stop smoking today! We can help! If you are a smoker, we offer a smoking cessation program. If you complete the program, you can avoid this surcharge.'' The plan accommodates participants who smoke by facilitating their enrollment in a smoking cessation program that requires participation at a time and place that are not unreasonably burdensome or impractical for participants, and that is otherwise reasonably designed based on all the relevant facts and circumstances, and discloses contact information and the individual's option to involve his or her personal physician. The plan pays for the cost of participation in the smoking cessation program. Any participant can avoid the surcharge for the plan year by participating in the program, regardless of whether the participant stops smoking, but the plan can require a participant who wants to avoid the surcharge in a subsequent year to complete the smoking cessation program again. 154

Example 1 - Tobacco Use Surcharge With Smoking Cessation Program Alternative Conclusion: In this Example, the premium differential satisfies the requirements. The program is an outcome-based wellness program because the initial standard for obtaining a reward is dependent on the results of a health risk assessment (a measurement, test, or screening). The program is reasonably designed because the plan provides a reasonable alternative standard to qualify for the reward to all tobacco users (a smoking cessation program). The plan discloses, in all materials describing the terms of the program, the availability of the reasonable alternative standard (including contact information and the individual's option to involve his or her personal physician). Thus, the program satisfies the legal requirements.

155

Example 2 - Tobacco Use Surcharge With Alternative Program Requiring Actual Cessation • Facts: Same facts as Example 1, except the plan does not provide participant F with the reward in subsequent years unless F actually stops smoking after participating in the tobacco cessation program. • Conclusion: In this Example 2, the program is not reasonably designed under the wellness program regulation and does not provide a reasonable alternative standard as required. The plan cannot cease to provide a reasonable alternative standard merely because the participant did not stop smoking after participating in a smoking cessation program. The plan must continue to offer a reasonable alternative standard whether it is the same or different (such as a new recommendation from F's personal physician or a new nicotine replacement therapy). 156

Example 3 - Tobacco Use Surcharge With Smoking Cessation Program Alternative that is Not Reasonable • Facts: Same facts as Example 1, except the plan does not facilitate participant F's enrollment in a smoking cessation program. Instead the plan advises F to find a program, pay for it, and provide a certificate of completion to the plan. • Conclusion: In this Example 3, the requirement for F to find and pay for F's own smoking cessation program means that the alternative program is not reasonable. Accordingly, the plan has not offered a reasonable alternative standard that complies with the wellness program regulation and the program fails to satisfy the requirements.

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Wellness Programs ACA Implementation FAQs Question: My group health plan gives rewards in the form of non-financial (or in-kind) incentives (for example, gift cards, thermoses, and sports gear) to participants who adhere to a wellness program. Are these non-financial incentives subject to the wellness program regulations issued by the Departments? Source: Part XXIX – This set of FAQs addresses coverage of preventive services, wellness programs, and the Mental Health Parity and Addiction Equity Act of 2008, http://www.dol.gov/ebsa/faqs/faq-aca29.html#cite-19 158

Wellness Programs ACA Implementation FAQs Answer: • Yes. • If a group health plan provides a “reward” based on an individual satisfying a standard that is related to a health factor, the wellness program is subject to the Department’s wellness regulations. • As provided in the regulations, a reward may be financial or nonfinancial (or in-kind). • More specifically, the regulations provide that reference to an individual obtaining a reward includes both “obtaining a reward (such as a discount or rebate of a premium or contribution, a waiver of all or part of a costsharing mechanism (such as a deductible, copayment, or coinsurance), an additional benefit, or any financial or other incentive) and avoiding a penalty (such as the absence of a surcharge or other financial or nonfinancial disincentives).” 159

Wellness Programs Designed To Dissuade Or Discourage Enrollment Will Be Scrutinized And May Be Subject To Enforcement Action By The Departments. Source: FAQs about Affordable Care Act Implementation (Part XXV) addresses the wellness program requirements, April 16, 2015: http://www.dol.gov/ebsa/faqs/faq-aca26.html.

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Wellness Programs Designed to Dissuade or Discourage Enrollment • Wellness programs designed to dissuade or discourage enrollment in the plan or program by individuals who are sick or potentially have high claims experience will not be considered reasonably designed under the Departments’ wellness program regulations. • A program that collects a substantial level of sensitive personal health information without assisting individuals to make behavioral changes such as stopping smoking, managing diabetes, or losing weight, may fail to meet the requirement that the wellness program must have a reasonable chance of improving the health of, or preventing disease in, participating individuals. • Programs that require unreasonable time commitments or travel may be considered overly burdensome. 161

Is Compliance With the Wellness Program Regulations Determinative of Compliance With Other Laws? • No. • The fact that a wellness program that complies with the Departments’ wellness program regulations does not necessarily mean it complies with any other provision of the PHS Act, the Code, ERISA, (including the COBRA continuation provisions), or any other State or Federal law, such as the Americans with Disabilities Act or the privacy and security obligations of the Health Insurance Portability and Accountability Act of 1996, where applicable. Source: FAQs about Affordable Care Act Implementation (Part XXV) addresses the wellness program requirements, April 16, 2015: http://www.dol.gov/ebsa/faqs/faq-aca26.html. 162

Equal Employment Opportunity Commission (EEOC) ADA Americans with Disabilities Act GINA Genetic Information Nondiscrimination Act 163

EEOC and Employer Wellness Programs Proposed Rules The Equal Employment Opportunity Commission (‘‘EEOC’’ or ‘‘Commission’’) is issuing two proposed rules that would amend: • The regulations and interpretive guidance implementing Title I of the Americans with Disabilities Act (ADA) as they relate to employer wellness programs. – 80 Federal Register 21659; Monday, April 20, 2015; Proposed Rules; http://www.gpo.gov/fdsys/pkg/FR-2015-04-20/pdf/2015-08827.pdf

• The regulations implementing Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008 as they relate to employer wellness programs. – 80 Federal Register 66853; Friday, October 30, 2015; Proposed Rules; http://www.gpo.gov/fdsys/pkg/FR-2015-10-30/pdf/2015-27734.pdf 164

EEOC Enforcement Guidance on Disability-Related Inquiries and Medical Examinations of Employees Under the Americans with Disabilities Act (ADA) May an employer make disability-related inquiries or conduct medical examinations that are part of its voluntary wellness program? – Yes. The ADA allows employers to conduct voluntary medical examinations and activities, including voluntary medical histories, which are part of an employee health program without having to show that they are job-related and consistent with business necessity, as long as any medical records acquired as part of the wellness program are kept confidential and separate from personnel records. These programs often include blood pressure screening, cholesterol testing, glaucoma testing, and cancer detection screening. Employees may be asked disability-related questions and may be given medical examinations pursuant to such voluntary wellness programs. – A wellness program is "voluntary" as long as an employer neither requires participation nor penalizes employees who do not participate. Source: Equal Employment Opportunity Commission http://www.eeoc.gov/policy/docs/guidance-inquiries.html#N_77_. 165

EEOC Lawsuit Challenges Wellness Program and Related Firing of Employee • "Employers certainly may have voluntary wellness programs -there's no dispute about that -- and many see such programs as a positive development," said John Hendrickson, regional attorney for the EEOC Chicago district. • "But they have to actually be voluntary. • They can't compel participation by imposing enormous penalties such as shifting 100 percent of the premium cost for health benefits onto the back of the employee or by just firing the employee who chooses not to participate. • Having to choose between responding to medical exams and inquiries -- which are not job-related -- in a wellness program, on the one hand, or being fired, on the other hand, is no choice at all." Source: http://www.eeoc.gov/eeoc/newsroom/release/8-20-14.cfm 166

Application of the ADA to Employer Wellness Programs • EEOC Issues Proposed Rule on Application of the ADA to Employer Wellness Programs: Proposed Rule Would Permit Incentives, Emphasize Confidentiality • The U.S. Equal Employment Opportunity Commission (EEOC) today published a Notice of Proposed Rulemaking (NPRM) describing how Title I of the Americans with Disabilities Act (ADA) applies to employer wellness programs that are part of group health plans. Source: EEOC PRESS RELEASE, April 16, 2015: http://www.eeoc.gov/eeoc/newsroom/release/4-1615.cfm.

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ADA Questions and Answers about EEOC's Notice of Proposed Rulemaking on Employer Wellness Programs 1. What is a wellness program? 2. How does Title I of the ADA affect workplace wellness programs? 3. When is a wellness program considered "an employee health program" within the meaning of the ADA? 4. When is a health program considered "voluntary"? 5. How much of an incentive may employers offer to encourage employees to participate in a wellness program or achieve certain health outcomes? Source: http://www1.eeoc.gov//laws/regulations/qanda_nprm_wellness.cfm?renderforprint=1

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ADA Questions and Answers about EEOC's Notice of Proposed Rulemaking on Employer Wellness Programs 6. Why does the NPRM set the incentive limit at 30 percent of the cost of self-only coverage? 7. What confidentiality requirements apply to the medical information employees provide when they participate in wellness programs? 8. Will an employer that complies with the ADA and HIPAA rules applicable to wellness programs also comply with other federal nondiscrimination laws? 9. What is the purpose of this proposed rule and what happens next? 10. What should employers do until a final rule is published to make sure their wellness programs comply with the ADA? 169

ADA Fact Sheet for Small Business EEOC and Wellness Programs • Wellness programs must be reasonably designed to promote health or prevent disease. • Wellness programs must be voluntary. • Employers may offer limited incentives for employees to participate in wellness programs or to achieve certain health outcomes. • Medical information obtained as part of a wellness program must be kept confidential. • Employers must provide reasonable accommodations that enable employees with disabilities to participate and to earn whatever incentives the employer offers. Source: http://www.eeoc.gov/laws/regulations/facts_nprm_wellness.cfm 170

Proposed Rule to Amend GINA EEOC and Wellness Programs • EEOC's current regulations say that a wellness program cannot require employees to provide their genetic information as a condition of receiving incentives. • Because information about the current or past health status of a spouse or other family member is genetic information about an employee, EEOC's current GINA regulations could be read as prohibiting employers from offering incentives in return for a spouse providing his or her current or past health information. Source: http://www.eeoc.gov/laws/regulations/qanda-gina-wellness.cfm

171

Proposed Rule to Amend GINA EEOC and Wellness Programs • Addresses the extent to which an employer may offer incentives for an employee's spouse to provide information about his or her current or past health status as part of an employer-sponsored wellness program, when he or she participates in the employer's health plan. – There is minimal, if any, chance of determining information about an employee's genetic make-up or predisposition to disease from information about current or past health status of the employee's spouse. 172

Proposed Rule to Amend GINA EEOC and Wellness Programs • The exception applies to information on the current and past health status of spouses, but not of children. – There is a significantly higher likelihood of discovering information about an employee's genetic make-up or predisposition to disease from information about the current or past health status of the employee's children. – The possibility that an employee may be discriminated against based on genetic information is greater when an employer has access to information about the health status of the employee's children. 173

Proposed Rule to Amend GINA EEOC and Wellness Programs • Explains how employers may lawfully offer incentives for such information under GINA. • Includes requirements that the spouse provide prior, knowing, written, and voluntary authorization for the employer to collect genetic information, just as the employee must do. • Adds a new provision stating that employers may not require employees (or employees' spouses or dependents covered by the employee's health plan) to agree to the sale, or waive the confidentiality, of their genetic information as a condition for receiving an incentive or participating in a wellness program.

174

Proposed Rule to Amend GINA EEOC and Wellness Programs • Any health or genetic services an employer offers must be reasonably designed to promote health or prevent disease. • The service must have a reasonable chance of improving the health of, or preventing disease in, participating individuals. • That an employer-sponsored wellness program must not be – Overly burdensome to employees, – A subterfuge for violating Title II of GINA or other laws prohibiting employment discrimination, or – Highly suspect in the method chosen to promote health or prevent disease. 175

Proposed Rule to Amend GINA EEOC and Wellness Programs • Clarifies that an employer may offer, as part of its health plan, a limited incentive (in the form of a reward or penalty) to an employee whose spouse – (1) Is covered under the employee's health plan; – (2) Receives health or genetic services offered by the employer, including as part of a wellness program; and – (3) Provides information about his or her current or past health status. Information about current or past health status usually is provided as part of a health risk assessment (HRA), which may include a questionnaire or medical examination, such as a blood pressure test or blood test to detect high cholesterol or high glucose levels. 176

Proposed Rule to Amend GINA EEOC and Wellness Programs 4. How much of an incentive may an employer offer? • The total incentive for an employee and spouse to participate in a wellness program that is part of a group health plan and collects information about current or past health status may not exceed 30% of the total cost of the plan in which the employee and any dependents are enrolled. – For example, if an employee and his or her spouse are enrolled in self and family coverage that costs $14,000, the maximum incentive the employer may offer the employee and spouse to provide information on their current or past health status as part of a wellness program is $4,200 (30 percent of $14,000). • The incentive may be financial or in-kind (e.g., time-off awards, prizes, and other items of value). 177

Proposed Rule to Amend GINA EEOC and Wellness Programs 4. How much of an incentive may an employer offer? • Says that the maximum portion of an incentive that may be offered to an employee alone may not exceed 30 percent of the total cost of self-only coverage. – So, if the employer in the example above offers self-only coverage at a total cost of $6,000, the maximum portion of the $4,200 incentive that may be offered for the employee's participation is $1,800 (30 percent of $6,000). – The rest of the incentive ($2,400 in the example above) may be received for the spouse's participation or for the employee, spouse, and/or employee's other dependents who are covered by the health plan participating in activities designed to promote health or prevent disease. 178

HIPAA Privacy and Security and Workplace Wellness Programs

Source: http://www.hhs.gov/ocr/privacy/hipaa/understan ding/coveredentities/wellness/index.html

179

Q1: Do the HIPAA Rules Apply to Workplace Wellness Programs? • HIPAA Rules apply only to covered entities and business associates – and not to employers in their capacity as employers -- the application of the HIPAA Rules to workplace wellness programs depends on the way in which those programs are structured. • HIPAA Rules do not directly apply to the employer, a group health plan sponsored by the employer is a covered entity under HIPAA, and HIPAA protects the individually identifiable health information held by the group health plan (or its business associates). • HIPAA also protects PHI that is held by the employer as plan sponsor on the plan’s behalf when the plan sponsor is administering aspects of the plan, including wellness program benefits offered through the plan. 180

Q1: Do the HIPAA Rules Apply to Workplace Wellness Programs? • If a workplace wellness program is offered by an employer directly and not as part of a group health plan, the health information that is collected from employees by the employer is not protected by the HIPAA Rules. • However, other Federal or state laws may apply and regulate the collection and/or use of the information. 181

Q2: Where a workplace wellness program is offered through a group health plan, what protections are in place under HIPAA with respect to access by the employer as plan sponsor to individually identifiable health information about participants in the program? The HIPAA Privacy and Security Rules place restrictions on the circumstances under which a group health plan may allow an employer as plan sponsor access to PHI, including PHI about participants in a wellness program offered through the plan, without the written authorization of the individual. 182

Employer Administering Wellness Program and Access to PHI • Often, the employer as plan sponsor will be involved in administering certain aspects of the group health plan, which may include administering wellness program benefits offered through the plan. • Where this is the case, and absent written authorization from the individual to disclose the information, the group health plan may provide the employer as plan sponsor with access to the PHI necessary to perform its plan administration functions, but only if the employer as plan sponsor amends the plan documents and certifies to the group health plan that it agrees to, among other things: 183

Employer Administering Wellness Program and Access to PHI • Establish adequate separation between employees who perform plan administration functions and those who do not; • Not use or disclose PHI for employment-related actions or other purposes not permitted by the Privacy Rule; • Where electronic PHI is involved, implement reasonable and appropriate administrative, technical, and physical safeguards to protect the information, including by ensuring that there are firewalls or other security measures in place to support the required separation between plan administration and employment functions; and Report to the group health plan any unauthorized use or disclosure, or other security incident, of which it becomes aware. 184

Breach of Unsecured PHI at the Plan Sponsor Further, where a group health plan has knowledge of a breach of unsecured PHI at the plan sponsor (i.e., an unauthorized use or disclosure that compromises the privacy or security of the PHI), the group health plan, as a covered entity under the HIPAA Rules, must notify the affected individuals, HHS, and if applicable, the media, of the breach, in accordance with the requirements of the Breach Notification Rule. 185

Employer As Plan Sponsor Does Not Perform Plan Administration Functions • Where the employer as plan sponsor does not perform plan administration functions on behalf of the group health plan, access to PHI by the plan sponsor without the written authorization of the individual is much more circumscribed. • In these cases, the Privacy Rule generally would permit the group health plan to disclose to the plan sponsor only: 1. Information on which individuals are participating in the group health plan or enrolled in the health insurance issuer or HMO offered by the plan; and/or 2. Summary health information if requested for purposes of modifying the plan or obtaining premium bids for coverage under the plan. 186

E. Highly Compensated Individual or Prohibiting Insured Group Health Plans from Discriminating In Favor of Highly Compensated Individuals (HCIs) or Nondiscrimination Provisions Applicable to Insured Group Health Plans 187

Highly Compensated Individual Prohibition • HCIs means one of the 5 highest paid officers, a shareholder who owns more than 10% in value of the stock of the employer, or among the highest paid 25% of all employees. • All benefits provided to highly compensated individuals are provided for all other participants. • The plan discriminate in favor of highly compensated individuals if the eligibility to participate is different or the benefits provided under the plan discriminate in favor of these participants. Source: 26 USC sec. 105(h)(2), (4) and (5) and http://www.irs.gov/irb/2011-02_IRB/ar10.html. 188

Highly Compensated Individual Eligibility and Benefits Test • Eligibility Test: The plan benefits at least 70% or more of all employees or 70% of all employees are eligible to benefit under the plan and at least 80% or more of those eligible in fact benefit. • Benefits Test: All benefits provided for participants who are highly compensated individuals are provided for all other participants. Source: 26 USC sec. 105(h)(3) and (4). 189

Prohibiting Discrimination in Favor of Highly Compensated Individuals • This rule already apply to self-insured medical expense reimbursement plans since 1981. (26 CFR 1.105-11) • The IRS is considering issuing guidance on the extension to insured group health plans. • The requirement for insured group health plans is effective for plan years beginning on or after September 23, 2010. • Compliance should not be required (any sanctions for failure to comply do not apply) until regulations or guidance of general applicability has been issued. Source: Internal Revenue Bulletin: 2010-41, October 12, 2010, Notice 2010-63, Request for Comments on Requirements Prohibiting Discrimination in Favor of Highly Compensated Individuals in Insured Group Health Plans, http://www.irs.gov/irb/2010-41_IRB/ar07.html . 190

Prohibiting Discrimination in Favor of Highly Compensated Individuals • If a self-insured plan fails to comply: – Highly compensated individuals lose a tax benefit. – The plan is subject to a civil action to compel it to provide nondiscriminatory benefits. – The plan is subject to an excise tax or civil money penalty of $100 per day per individual discriminated against. • Under insured group health plans, the rules do not apply to grandfathered health plans. Source: Internal Revenue Bulletin: 2010-41, October 12, 2010, Notice 2010-63, Request for Comments on Requirements Prohibiting Discrimination in Favor of Highly Compensated Individuals in Insured Group Health Plans, http://www.irs.gov/irb/201041_IRB/ar07.html.

191

Código de Seguros de Salud Empleados Altamente Remunerados Los aseguradores no podrán discriminar a favor de empleados altamente remunerados, según dicho término es definido en el Código de Rentas Internas Federal y la reglamentación pertinente, en planes grupales, ya sea en término de la elegibilidad o de los beneficios que le ofrecen al empleado altamente compensado. Fuente: Artículo 2.050 (L) del Código de Seguros de Salud, según enmendado.

192

Código de Seguros de Salud Empleados Altamente Remunerados 36. Q: Section 2716 of ACA has been delayed (Prohibition on Discrimination in Favor of Highly Compensated Individuals) until the federal regulations to put it in effect are issued. Paragraph (L) of Article 2.050 of the Health Insurance Code (“HIC”) regulates the discrimination in favor of highly compensated individuals. The Office of the Commissioner of Insurance will require compliance with Article 2.050 (L) of the HIC even though its federal counterpart provision was delayed? • A: In light of the fact that Section 2716 of ACA has been delayed until the federal regulations to put it in effect are issued, the Office of the Commissioner of Insurance has determined that compliance with Article 2.050(L) of the HIC will also be delayed until the federal regulations for Section 2716 are issued. Source: http://ocs.gobierno.pr/ocspr/documents/obamacare/Q%20%20A%20INDUSTRIA%20Final.pdf.

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F. Guaranteed Availability of Coverage Individual and Group Market 45 CFR §147.104 45 CFR §146.150 194

ACA Guaranteed Availability • The ACA Guaranteed Availability requirement will not apply to individual or group health (small or large) insurance issuers in the U.S. territories (Puerto Rico). • 45 CFR §147.104 Guaranteed availability of coverage • PR Health Insurance Code applies. Source: Letter to Puerto Rico on the Definition of State, http://www.cms.gov/CCIIO/Resources/Letters/Downloads/letter-to-Weyne.pdf 195

HIPAA Guaranteed Availability of Coverage • Each health insurance issuer that offers health insurance coverage in the Small Group Market in a State must: – (1) Offer, to any small employer in the State, all products that are approved for sale in the small group market and that the issuer is actively marketing, and must accept any employer that applies for any of those products; and – (2) Accept for enrollment under the coverage every eligible individual who applies for enrollment during the period in which the individual first becomes eligible to enroll under the terms of the group health plan, or during a special enrollment period, and may not impose any restriction on an eligible individual's being a participant or beneficiary, which is inconsistent with the nondiscrimination provisions against participants and beneficiaries based on a health factor (45 CFR §146.121). • 45 CFR §146.150 - Guaranteed availability of coverage for employers in the small group market 196

Guaranteed Availability of Coverage Individual and Group Market Since January 1st, 2014, a health insurance issuer: • Must offer to any individual or employer (small and large groups) in the state all products that are approved for sale in the applicable market. • Must accept any individual or employer that applies for any of those products. • May restrict enrollment in health coverage to open or special enrollment periods. • May deny coverage if it does not have the financial reserves necessary to underwrite additional coverage. • Does not apply to grandfathered plans. Source: 45 CFR sec. 147.104, Final Rule, see 78 Federal Register 13437-13438 (February 27, 2013). 197

Mercado Individual Suscripción Garantizada

198

Mercado Individual Suscripción Garantizada • Periodo de suscripción o emisión garantizada garantiza el acceso a los seguros de salud. • La suscripción garantizada a los planes médicos se provee dentro de periodos de suscripción fijos; un periodo de suscripción inicial y posteriormente periodos anuales de suscripción. • Los aseguradores estarán obligados a proveer cubierta a todo individuo que la solicite, sin sujetarlos a evaluación de riesgo ni a periodo de espera por condiciones preexistentes. • El individuo tendrá derecho a suscribirse en los planes médicos que el asegurador tenga disponibles para el mercado de planes médicos individuales. Fuente: Cartas Normativas CN-2013-155-AS de 29 de julio de 2013 y CN-2013-156-AS de 30 de septiembre de 2013. 199

Mercado Individual Suscripción Garantizada Initial Open Enrollment Period • El periodo de suscripción inicial transcurre desde el 1ro de octubre de 2013 hasta el 31 de marzo de 2014. • Si se recibe una solicitud de seguro en o antes del 31 de diciembre de 2013, la misma se procesará y el plan médico será efectivo al 1ro de enero de 2014. • Si la solicitud se recibe entre el 1 y 15 del mes comienza el 1ero del mes siguiente; y entre el día 16 al 31 del mes, la cubierta comienza el primer día del segundo mes en que se recibió la solicitud. Fuente: Artículo 10.150, Suscripción Garantizada de Planes Médicos Individuales, del Capítulo 10 del Código de Seguros de Salud, según enmendado. 200

Mercado Individual Suscripción Garantizada • Annual Open Enrollment Period Posteriormente, el periodo de suscripción anual transcurre desde el 1 de octubre al 31 de diciembre de cada año para que los planes comiencen el 1 de enero del año siguiente. • Renovación Hasta 30 días a partir de la terminación del término de suscripción, del 1 al 30 de enero. • Special Enrollment Periods Suscripción especial ocurre en cualquier momento del año. Fuente: Artículo 10.150, Suscripción Garantizada de Planes Médicos Individuales, del Capítulo 10 del Código de Seguros de Salud, según enmendado. 201

Lista de Planes Médicos Individuales en el 2016 Tobacco

Suscripción Especial

First Medical Health Plan Plata (1) y Oro (1)

No



Humana Health Plans of Puerto Rico, Inc

Oro (1), Platino (1), Platino Plus (1)





MCS Life Insurance Company

Bronce (2) y Plata (2)





Plan de Salud Menonita, Inc.

Oro (3) y Platino (3)





Asegurador

Cubierta Metálicos

Plan Médico Servicios de Salud Bella Vista, Inc.



Ryder Health Plan, Inc.

Plata (1) y Platino (1)

No



Triple S Salud Inc.

Bronce (2), Plata (2) y Oro (2); Catastrófico

No



Fuente: http://ocs.gobierno.pr/ocspr/index.php/seguros-de-salud?id=293 202

Guaranteed Availability of Coverage and Tobacco Use • Under guaranteed availability of coverage rules, an issuer may not deny an enrollee or their covered dependents an enrollment period because an enrollee provided false or incorrect information about their tobacco use. Source: http://www.federalregister.gov/articles/2013/02/27/201304335/patient-protection-and-affordable-care-act-health-insurance-market-rulesrate-review#p-140

203

Lista de Planes Médicos Individuales en el 2016 Suscripción después del 31/dic./2015

Periodo de Espera de 90 días (no aplica a suscripción especial)

First Medical Health Plan

No Cerró. Suscripción abierta.



Humana Health Plans of Puerto Rico, Inc

Cerró suscripción.

MCS Life Insurance Company

No Cerró. Suscripción abierta.



Plan de Salud Menonita, Inc.

No Cerró. Suscripción abierta.

No

Plan Médico Servicios de Salud Bella Vista, Inc.

No Cerró. Suscripción abierta.

No

Ryder Health Plan, Inc.

No Cerró. Suscripción abierta.

No

Triple S Salud Inc.

No Cerró. Suscripción abierta.



Asegurador

N/A

Fuente: http://www.ocs.gobierno.pr/ocspr/index.php/seguros-de-salud?id=293 204

Normas para Pólizas 2016 A los Aseguradores y HMO: • Tienen que obtener la aprobación de sus productos y tarifas para los planes en cumplimiento con ACA en o antes del 1ero de octubre de cada año. • Sólo pueden usar las tarifas radicadas en y aprobadas por la OCS. Una vez se aprueben las tarifas, no se pueden cambiar durante el año. • No podrán radicar un producto nuevo en cumplimiento con ACA para ser efectivo en el año 2016 a no ser que se haya presentado en la OCS en o antes del 1ero de junio de 2015. Fuente: Ruling Letter No. CN-2015-187-AS, dated March 26, 2015: Form and Rate Filings Submissions to be Effective for Calendar Year 2016. 205

Normas para Pólizas 2016 A los aseguradores y HMO: • Todos los productos y la estructura de copagos se tienen que radicarse a la misma vez y no se pueden cambiar durante el año. – Los productos en cumplimiento con ACA que estarán vigentes en el año natural 2016 sólo deben incluir un límite de gastos pagados por el beneficiario (MOOP), lo cual incluye los medicamentos recetados. – El MOOP para el año 2016 establecido es de $6,350 para la cubierta que es solamente del beneficiario y $12,700 para todo otro tipo de cubierta. Fuente: Ruling Letter No. CN-2015-187-AS, dated March 26, 2015: Form and Rate Filings Submissions to be Effective for Calendar Year 2016.

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Normas para Pólizas 2016 A los aseguradores y HMO: • Cuyos productos y tarifas no hayan sido aprobados antes del 1ero de octubre de 2015, tendrán que mercadearse y ofrecerse a toda persona que lo solicite, todos los planes médicos individuales en cumplimiento con ACA que tengan aprobados por la OCS durante todo el año 2016. • Deben mercadear todos sus productos en cumplimiento con ACA que estén aprobados por la OCS. • Que ofrezcan sus productos durante todo el año 2016 también tienen que mercadear los mismos durante todo el año sin limitar dicho mercadeo u ofrecimiento a los casos de suscripción especial o eventos cualificantes. Fuente: Ruling Letter No. CN-2015-187-AS, dated March 26, 2015: Form and Rate Filings Submissions to be Effective for Calendar Year 2016. 207

Mercado Individual Suscripción Especial Garantizada • Si la persona opta por no suscribirse al plan médico dentro del periodo de suscripción fijo dispuesto, no tendrá derecho a la suscripción garantizada al plan médico individual hasta el próximo periodo de suscripción anual. • Un asegurador vendrá obligado a extender cubierta en los periodo de suscripción especiales. – Periodo especial de suscripción es el periodo durante el cual una persona o persona cubierta puede suscribirse o cambiar su suscripción a un plan médico, fuera de los periodos iniciales o de suscripción anual, cuando ocurran determinados eventos que cualifiquen a la persona para dicha suscripción. 208

Un asegurador ofrecerá en cualquier momento del año los planes médicos individuales básicos que tenga disponibles en el mercado individual solamente a aquellos asegurados que: 1. Sufren un evento calificador dispuesto por COBRA. 2. Ejerzan su derecho de conversión al mercado individual con el mismo asegurador que lo cubre en el plan médico anterior. 209

Mercado Individual Suscripción Especial Garantizada 3. Provengan de otro asegurador y cumplan con los siguientes criterios: – Ha estado sin cubierta por 63 días o menos; – Su último plan médico fue grupal; – Ha estado cubierto por un plan médico en los últimos 18 meses. En ese lapso el individuo puede haber estado cubierto por planes del mercado individual o grupal. – La póliza anterior no ha sido cancelada por falta de pago o fraude de parte del asegurado. – Si el individuo era elegible a la cubierta COBRA seleccionó la misma, y la agotó. – Si perdió elegibilidad al plan de Mi Salud. 210

Mercado Individual Suscripción Especial Garantizada 4. Cualquier individuo será elegible a un plan individual si se ha quedado sin cubierta grupal o de mercado individual debido a la quiebra, disolución o revocación de licencia del asegurador con el cual tenía su seguro, siempre y cuando presente su solicitud al nuevo asegurador dentro de 63 días luego de declarada la quiebra, disolución o revocación de la licencia del asegurador. 211

Mercado Individual Suscripción Especial Garantizada 5. La persona elegible o su dependiente pierde la cubierta mínima con los beneficios de salud esenciales. 6. La persona elegible adquiere un dependiente por medio de matrimonio, nacimiento, adopción o colocación para adopción. (Por este evento es elegible toda la familia.) 7. La persona cubierta le demuestra a la organización de seguros de salud o asegurador que el plan médico en el que está inscrita violó sustancialmente los términos del contrato con dicha persona. 212

Mercado Individual Suscripción Especial Garantizada 8. La persona elegible se inscribió o dejó de inscribirse en un plan médico de manera no intencional, inadvertida o errónea y como resultado del error, tergiversación o falta de acción de algún oficial, empleado o agente de los aseguradores de salud o HHS o sus instrumentalidades, según sea evaluado y determinado por la organización de seguros de salud o asegurador. – En dichos casos, la organización de seguros de salud o asegurador podrá tomar las medidas necesarias para corregir o eliminar los efectos de dicho error, tergiversación o falta de acción. 213

Mercado Individual Suscripción Especial Garantizada 9. La persona es elegible por primera vez o adviene elegible nuevamente. En aquellos casos, en que la cubierta existente bajo un plan grupal patronal elegible ya no sea costeable o ni siquiera proveerá un valor mínimo para el próximo año del plan médico patronal, el asegurador permitirá que las personas elegibles tengan acceso a la cubierta en un periodo de suscripción especial antes de que termine la cubierta bajo dicho plan patronal. 10. Una persona elegible o una persona cubierta solicita un plan médico nuevo debido a un cambio de residencia. 214

Mercado Individual Efectividad de la Suscripción Efectividad del plan médico: 1. Si la solicitud se recibe entre los días 1 y 15 del mes, la cubierta será efectiva al 1ero del mes siguiente. 2. Si la solicitud se recibe entre el día 16 al 31 del mes, la cubierta será efectiva el primer día del segundo mes en que se recibió la solicitud. 3. En los casos de excepción aplicarán las mismas reglas sobre la efectividad de la cubierta que se indican, excepto en los siguientes casos: 215

Mercado Individual Efectividad de la Suscripción Casos de Excepción • Nacimiento, el plan es efectivo desde el momento en que nacen. • Adopción, el plan es efectivo partir de la fecha en que (i) se coloca en el hogar con el propósito de ser adoptados; (iii) se emitió la orden otorgando la custodia; o (iii) es vigente la adopción, lo que ocurra primero. • Matrimonio, el plan es efectivo el primer día del mes siguiente. • Persona pierde cubierta de los beneficios esenciales mínimos, el plan es efectivo el primer día del mes siguiente. 216

Mercado Individual Persona Indocumentada Soy indocumentado, ¿tengo derecho a suscribirme a un plan médico privado?. • De acuerdo con el Departamento de Salud Federal (HHS), el derecho de suscripción garantizada también es aplicable a las personas indocumentadas. Por tanto, una persona indocumentada puede acudir a una compañía de seguros y adquirir un plan médico privado durante el periodo de suscripción garantizada. Fuente: http://ocs.gobierno.pr/ocspr/documents/obamacare/CONSUMIDORESPREGUNTAS%20Y%20RESPUESTAS%20OBAMACARE-CON%20HYPERLINK.pdf 217

Código de Seguros de Salud Planes Médicos Individuales y Suscripción Garantizada Artículo 10.070 Disponibilidad de cubierta bajo la cláusula de conversión del plan médico grupal a una póliza de conversión. Artículo 10.080 Disponibilidad de Cubierta en el mercado individual – personas elegibles según las leyes federales (HIPAA). Fuente: Capítulo 10 del Código de Seguros de Salud, según enmendado.

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May an issuer medically underwrite for pre-existing conditions outside of the open enrollment period? • Question #11: May an issuer that has an open enrollment period during which it enrolls children under age 19 with pre-existing conditions, medically underwrite during the rest of the year and decline to enroll children under age 19 with pre-existing conditions outside of the open enrollment period? • A: No. Issuers that have an open enrollment period may not decline to enroll children under age 19 with pre-existing conditions outside of the open enrollment period while enrolling children under age 19 without such conditions. Depending on state policies regarding open enrollment periods, issuers must either (i) enroll all children under age 19, regardless of pre-existing conditions, at all times, including outside the open enrollment period; or (ii) enroll all children under age 19, regardless of pre-existing conditions, during the open enrollment period, but decline to enroll all children under age 19 outside the open enrollment period, with exceptions described in Q10. Even for children who qualify for exceptions to enrollment during open enrollment periods, issuers may not decline enrollment due to a pre-existing condition. States may set one or more open enrollment periods for coverage for children under age 19, but cannot allow insurers to selectively deny enrollment for children with a pre-existing condition while accepting enrollment from other children outside of the open enrollment period(s). Source: http://www.cms.gov/CCIIO/Resources/Files/factsheet.html 219

Mercado Grupal Suscripción Garantizada

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Código de Seguros de Salud PYMES - Disponibilidad del Plan Médico

Aquellos aseguradores que ofrezcan seguros a los patronos de PYMES tendrán que ofrecer todos los planes que mercadeen activamente para este sector, incluyendo como mínimo dos planes médicos básicos en por lo menos un nivel metálico diferente cada uno. Fuente: Capítulo 8, Artículo 8.070 del Código de Seguros de Salud, según enmendado. 221

PYMES / Mercado para Grupos Pequeños Suscripción Garantizada • Mercado de grupos pequeños: para los Pymes es todo el año. • El asegurador tendrán que ofrecer todos los planes que mercadee activamente para este sector, incluyendo como mínimo dos planes médicos básicos en por lo menos un nivel metálico diferente cada uno. • El asegurador hará una divulgación razonable, como parte de sus materiales de solicitación y venta, que incluya lo siguiente: – Las disposiciones que permiten cambiar las tarifas y los factores, que no sea la experiencia en reclamaciones. – Las disposiciones relacionadas con la renovación de la póliza. – Una lista e información descriptiva (beneficios y primas) de todos los planes médicos disponibles para los PYMES. 222

PYMES / Grupos Pequeños Planes Médicos para el 2016 Lista de Planes Médicos en cumplimiento con el Affordable Care Act y el Código de Seguros de Salud para el 2016: • • • • • • •

MCS Life Insurance Company Triple S Salud Inc. First Medical Health Plan Plan de Salud Menonita, Inc. Humana Insurance of Puerto Rico, Inc. Pan American Life Insurance Company of Puerto Rico Mapfre Life Insurance Company

Fuente: http://www.ocs.gobierno.pr/ocspr/index.php/seguros-de-salud?id=293 223

Normas para Pólizas 2016 Grupos Grandes • Las radicaciones para los grupos grandes no se deben presentar para la evaluación y aprobación de la OCS. – Esta norma no es aplicable para los planes médicos de un HMO, los cuales tienen que cumplir con las disposiciones de la Sección 19.080(2)(a) del Código de Seguros. – Los formularios de los grupos grandes que no cumplan con la ley se tienen que actualizar y radicar inmediatamente para la revisión y aprobación. • Todos los formularios de los grupos grandes están sujetos a la revisión y aprobación de la OCS. • Los formularios de los grupos grandes tienen que cumplir con todas las disposiciones de la ley ACA que son aplicables a los grupos grandes y del Código de Seguros de Salud. Fuente: Ruling Letter No. CN-2015-187-AS, dated March 26, 2015: Form and Rate Filings Submissions to be Effective for Calendar Year 2016. 224

G. Guaranteed Renewability of Coverage 45 CFR §147.106 45 CFR §146.152 - Guaranteed renewability of coverage for employers in the group market 225

Guaranteed Renewability of Coverage A health insurance issuer is required to renew or continue in force the coverage at the option of the plan sponsor or the individual, unless: • Nonpayment of premiums. • Fraud. • Violation of participation or contribution rules. • Termination of plan. • Enrollees movement outside service area. • Association membership ceases. Does not apply to grandfathered plans. Source: 45 CFR sec. 147.106, Final Rule, see 78 Federal Register 13438-13439 (February 27, 2013). 226

Standard Notices when Renewing or Discontinuing a Product Individual Market • Attachment 1. Renewal notice for the individual market where coverage is being renewed outside the Marketplace

• Attachment 3. Discontinuation notice for the individual market outside the Marketplace Small Group Market

• Attachment 5. Renewal notice to employers for the small group market • Attachment 6. Discontinuance notice to employers for the small group market Source: http://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/2014-0626-Bulletin-onRenewal-and-Termination-Notices-FINAL.pdf; http://www.cms.gov/CCIIO/Resources/Regulations-andGuidance/Downloads/0626-2014-Notice-instructions.pdf 227

Uniform Modification and Plan/Product Withdrawal FAQ • Q1: An issuer stops offering Product X at the end of 2015, and in 2016 begins offering Product Y. Is Product Y a new product? • Q2: An issuer makes changes within a product but submits it as a new product. The state determines that the product changes are within the standards for uniform modification of coverage. Is the issuer required to revert to the product’s former Health Insurance Oversight System (HIOS) product identifier (ID)? • Q3: If an issuer removes a plan from a product or adds a plan to a product, would such a change be considered a discontinuance of that product? • Q4: If an issuer makes minor changes to a plan’s cost sharing, has it changed the plan’s “cost-sharing structure” such that the change will not be considered a uniform modification, and a product discontinuance is triggered under 45 CFR 147.106(e)(3)(iv)? Source: http://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/uniformmod-and-plan-wd-FAQ-06-15-2015.pdf 228

Notices of Product Discontinuation and Renewal for 2016 Guidance on Federal Standard Notices of Product Discontinuation and Renewal in Connection with the Open Enrollment Period for the 2016 Coverage Year • In connection with the open enrollment period for coverage in benefit year 2016, CMS will not take enforcement action against an issuer that fails to provide a discontinuance notice related to individual market coverage at least 90 days prior to the discontinuation, as long as the issuer provides such notice consistent with the timeframes applicable to renewal notices, which for non-grandfathered, non-transitional plans is before the first day of the next annual open enrollment period, and for grandfathered and transitional plans is at least 60 days before the date of renewal. Source: http://cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/Guidanceon-Notices-of-Product-Discontinuation-and-Renewal-for-the-2016-Coverage-Year.pdf 229

Código de Seguros de Salud Planes Médicos Individuales - Renovación • Todo asegurador de planes médicos individuales renovará el plan médico individual al asegurado o dependiente, a opción del asegurado, y en conformidad con la legislación y reglamentación federal aplicable; excepto en los casos indicados en el Artículo 10.060 del Código. • Un plan individual que se haya suscrito en el periodo de suscripción inicial o durante cualquier periodo de suscripción fijo anual descritos, deberá renovarse durante los periodos fijos anuales subsiguientes, es decir del 1 de octubre al 31 de diciembre de cada año. • De no renovarse dentro de ese periodo, este plan se entenderá renovado retroactivamente al 1 de enero si el asegurado renueva el mismo en o antes del 31 de enero. Fuente: Cartas Normativas CN-2013-155-AS de 29 de julio de 2013 y CN-2013-156-AS de 30 de septiembre de 2013. 230

Código de Seguros de Salud Planes Médicos Individuales - Renovación La suscripción garantizada es una garantía adicional que se le ofrece al asegurado y nada de lo dispuesto, se entenderá como una prohibición o limitación a la capacidad de un asegurador a suscribir un plan médico individual fuera de dicho periodo. • Los planes médicos individuales adquiridos en o después del 1ero de enero, tendrán un periodo de cubierta menor a un año, de manera tal que se cumpla con la reglamentación federal que requiere que todos los planes individuales sean efectivos al 1ero de enero de cada año natural. • Todos los planes que sean renovados serán efectivos del 1ro de enero al 31 de diciembre de cada año. 231

Código de Seguros de Salud PYMES - Renovación del Plan Médico El asegurador renovará el plan médico a todos los empleados elegibles y sus dependientes, excepto por: 1. Por no pagar la prima, considerando el período de gracia. 2. Cuando el asegurado realiza un acto que constituye fraude. 3. Cuando el asegurado hizo una representación falsa intencional de un hecho importante y material bajo los términos del plan. 4. Por incumplimiento con los requisitos de participación mínima establecidos por el asegurador de conformidad este Capítulo. Fuente: Artículo 8.060 del Código de Seguros de Salud, según enmendado.

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Código de Seguros de Salud PYMES - Renovación del Plan Médico 5. Por incumplimiento con los requisitos de aportación patronal. 6. Cuando el asegurador decide descontinuar todos sus planes médicos con patronos PYMES, y por ello no podrá suscribir seguros para estos patronos por un período de 5 años. 7. Cuando el Comisionado de Seguros decide que continuar con el plan médico (i) no responde a los mejores intereses de los titulares de las pólizas o (ii) afecta la capacidad del asegurador de cumplir sus obligaciones. 8. Cuando ya no hay un empleado del PYMES que viva, trabaje o resida en el área geográfica establecida por el asegurador, si el plan es mediante una plan de red preferida. 233

Guaranteed Renewability of Coverage Employers Whose Size Shifts • Question: If a group is larger than the small group threshold and subsequently the size falls below the small group threshold, will the group be allowed to keep its existing products, or will it be required to purchase new products? • Answer: An employer has the right to renew or continue in force coverage originally purchased in the large or small group market, even though the employer may no longer meet the definition of a large or small employer. If the employer voluntarily drops the coverage, however, that employer would only be able to purchase coverage in the relevant market (and the coverage would have to comply with the relevant market requirements). Source: http://www.regtap.info/faq_viewu.php?id=153 ; Insurance Standards Bulletin Series, Group Size Issues under Title XXVII of the Public Health Service Act, Transmittal 99-03, available at http://cciio.cms.gov/resources/files/Files2/10112011/hipaa_99_03_508.pdf.pdf. 234

Employers Whose Size Shifts Between Small to Large Group Markets • We have been asked whether small employers that grow beyond 50 employees can continue to renew the coverage they purchased on a guaranteed available basis in the small group market. – The general rule set forth makes clear that a health insurance issuer “offering coverage in the small or large group market is required to renew or continue in force the coverage at the option of the plan sponsor.” (Emphasis added.) Source: September 1999 Program Memorandum (Transmittal No. 99-03): Group Size Issues Under Title XXVII of the Public Health Service Act, http://www.cms.gov/CCIIO/Resources/Files/Downloads/hipaa_99_03_508.pdf 235

Employers Whose Size Shifts Between Large to Small Group Markets Similarly, for a large employer that shrinks below 50 employees, the law guarantees the right to continue to renew the coverage purchased in the large group market. – We understand that some policies state that the policy cannot be renewed if the employer drops below a specified size. These clauses are no longer valid if the issuer is subject to HIPAA’s guaranteed renewability requirements. – However, if an employer whose size has dropped below 50 employees voluntarily drops the coverage issued in the large group market, the employer may not be able to get that policy back. – The employer will only be guaranteed a right to purchase new coverage that is offered in the small group market.

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Small Employers Shrinking to Less Than Two Employees • Employer size is assessed on the first day of the plan year, coverage cannot be terminated until the first renewal date following the beginning of a new plan year, even if the issuer knows as of the beginning of the plan year that the employer no longer has at least two participants who are current employees. • HIPAA’s minimum group market requirements would not supplant contract terms that are more generous. If coverage that was originally issued in the small group market contains a renewal provision that requires guaranteed renewability at the option of the plan sponsor, regardless of whether the group shrinks below two current employees at the start of the plan year, HIPAA would not invalidate the contract provision. • HIPAA does not require an issuer to terminate the coverage of an employer that due to its size fails to qualify for group market protections. If the issuer voluntarily permits the employer’s coverage to renew or otherwise continue in force, State law rather than HIPAA will govern when and under what conditions the employer may terminate the coverage. 237

Proceso de Transición Aplicable a Ciertas ACA Compliance Policy o Grandmother Plan Tercera Extensión Primera Extensión Segunda Extensión • Normas para el • Extensión del Proceso • Extensión del Proceso Proceso de Transición de Transición Aplicable de Transición Aplicable Aplicable a Ciertas a Ciertas Renovaciones a Ciertas Renovaciones de Planes Médicos Renovaciones de de Planes Médicos hasta el 31 de Planes Médicos hasta el 30 de diciembre de 2016 Durante el Año 2014 septiembre de 2015. • Carta Normativa: CN- • Carta Normativa: CN- • Carta Normativa: CN2014-185-D de 26 de 2013-161-D de 18 de 2014-178-D de 12 de noviembre de 2014 noviembre de 2013, junio de 2014 según enmendada por la Carta Normativa: CN-2014-177-D de 19 de mayo de 2014 238

Proceso de Transición de Ciertas Pólizas Tercera Extensión Sólo Aplica a: • Planes médicos individuales y de grupos pequeños. • Cuyo año póliza o cubierta comenzó antes del 1ro de enero de 2014 (la fecha de efectividad de la póliza fue el 31 de diciembre de 2013 o antes). • Se mantuvo en vigor y será renovada antes del 1 de enero de 2017. • Plan médico renovado tendrá una duración máxima de 1 año y no tendrán que emitirse por un periodo de póliza corto. • Emitir notificaciones compulsorias que se incluyen en la CN de la OCS. • Cumplir con las disposiciones de ACA, no indicadas en la CN de la OCS. • Tener la misma cubierta del plan médico anterior. • La renovación se hace de manera voluntaria e informada. • El asegurador tiene que notificar a la OCS en o antes del 31 de enero de 2015 el nombre del producto y número del formulario aprobado. 239

Proceso de Transición de Ciertas Pólizas Tercera Extensión No Aplica a: • Planes médicos de grupos grandes y a los grandfathered plans. • Suscripciones nuevas, (pólizas cuya efectividad es en o después del 1 de enero de 2014). • Planes médicos cuya fecha de renovación fuese posterior al 31 de diciembre de 2016. • Si el asegurador no renueva el plan de conformidad con esta 3ra extensión, enviará una notificación por escrito con por lo menos 30 días de anticipación a la fecha en que venza el plan. • De no renovarse, el asegurado tendrá un período especial de suscripción garantizada de 60 días para suscribirse al plan médico de su preferencia que sea ofrecido por el asegurador de su preferencia. 240

¿Qué ocurre si un asegurador NO desea renovar un plan médico que podría estar sujeto a la Política de Transición? • Las organizaciones de seguros de salud o aseguradores que no tengan la intención de renovar un plan médico durante el año 2014, deberán enviar una notificación por escrito al asegurado con un mínimo de treinta (30) días de anticipación a la fecha de vencimiento del plan médico. • Un asegurado cuyo plan médico no sea renovado por la compañía de seguros, tendrá un periodo especial de “suscripción garantizada” de sesenta (60) días para suscribirse en el plan médico de su preferencia que cumpla con todos los requisitos legales de ACA. Fuente: CONSUMIDORES-Preguntas y Respuestas Sobre los Seguros de Salud y la Implementación del Affordable Care Act (ACA) También Conocida como OBAMACARE, http://ocs.gobierno.pr/ocspr/documents/obamacare/CONSUMIDORESPREGUNTAS%20Y%20RESPUESTAS%20OBAMACARE-CON%20HYPERLINK.pdf 241

Notificaciones Compulsorias para el Proceso de Transición Aplicable a Ciertas Renovaciones de Planes Médicos Fuente: Carta Normativa: CN-2013-163-AS de 26 de noviembre de 2013

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Disposiciones Efectivas al 1/enero/2014 que se posponen para las Pólizas de Transición • Sección 2701 - Fair Health Insurance • Premiums • Sección 2702 - Guaranteed Availability of Coverage • Sección 2703 - Guaranteed Renewability of Coverage • Sección 2704 - Prohibition on Preexisting • Condition Exclusions or Other Discrimination Based on Health Status • – Esta sección se deja sin efecto exclusivamente para los adultos • suscritos en los planes médicos individuales. – Estará en pleno vigor y efecto para los planes médicos grupales y en el caso de menores de edad en los planes médicos individuales.

Sección 2705 - Prohibiting Discrimination Against Individual Participants and Beneficiaries Based on Health Status – Esta sección se deja sin efecto únicamente en los planes médicos individuales. Sección 2706 - Non-Discrimination in Health Care Sección 2707 - Comprehensive Health Insurance Coverage Sección 2709 - Coverage for Individuals Participating in Approved Clinical Trials, (42 U.S.C. § 300gg-8)

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Carta de Derechos del Paciente Selección de Planes y Proveedores • “Profesional de la salud”: significará cualquier practicante debidamente admitido en Puerto Rico, de conformidad con las leyes y reglamentos aplicables, cualquiera de las profesiones del campo de la salud y el cuidado médico tales como, pero sin limitarse a, Médicos, Cirujanos, Podíatras, Doctores en Natutropatía, Quiroprácticos, Optómetras y Sicólogos Clínicos, Dentistas, Farmacéuticos, Enfermeras, Audiólogos y Tecnólogos Médicos, según autorización de las correspondientes Leyes de Puerto Rico. 246

Carta de Derechos del Paciente Selección de Planes y Proveedores • Escoger y tener acceso a los servicios de salud y tratamientos de un Médico, Podíatra u Optómetra, Audiólogo y Psicólogo Clínico si la cubierta provista por su plan de salud ofrece cualquier servicio que se encuentre incluido en el espectro de su práctica. • Si la cubierta o plan del paciente provee para una compensación o reembolso, el beneficiario y el médico podiatra, optómetra y sicólogo clínico que ofrecen los servicios tendrán los derechos a dicha compensación o reembolso bajo condiciones iguales a las de otros profesionales de la salud que ofrezcan los mismos servicios. 247

Carta de Derechos del Paciente Estudio de Tratamiento Clínico Autorizado (g) Todo plan de cuidado de salud deberá contener una disposición que establezca que en el caso de pacientes que padezcan de una condición que amenace su vida, para la cual no exista un tratamiento efectivo, cuando dicho paciente sea elegible para participar en un estudio de tratamiento clínico autorizado, de acuerdo con las disposiciones del protocolo del estudio en cuanto a dicho tratamiento, siempre que la participación del paciente le ofrezca a éste un beneficio potencial y se cumpla con la condición de que el médico que refiera al paciente a participar en el estudio entienda que es apropiada su participación, o que el paciente presente evidencia de que es apropiada su participación en el estudio, la entidad aseguradora costeará los gastos médicos rutinarios del paciente, entendiéndose que no son “gastos médicos rutinarios del paciente” los gastos relacionados con el estudio, o los exámenes administrados para ser utilizados como parte del estudio, ni los gastos que razonablemente deben ser pagados por la entidad que lleve a cabo el estudio. Fuente: Artículo 9.- Derechos en cuanto a la participación en la toma de decisiones sobre tratamiento, de la Carta de Derechos y Responsabilidades del Paciente, Ley Número 194 de 25 de agosto de 2000, según enmendada.

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2. Prohibition on Rescissions 45 CFR §147.128 Rules Regarding Rescissions

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Rescissions A rescission is a cancellation or discontinuance of coverage that has retroactive effect. (1) A cancellation that treats a policy as void from the time of the individual's or group's enrollment is a rescission. (2) A cancellation that voids benefits paid up to a year before the cancellation is also a rescission for this purpose.

250

Prohibition on Rescissions • Must not rescind coverage under the plan, or under the policy, certificate, or contract of insurance, with respect to an individual once the individual is covered under the plan. • Effective for plan or policy years beginning on or after September 23, 2010.

251

Rescissions Written Notice • Must provide at least 30 days advance written notice to each participant (in the individual market, primary subscriber) who would be affected before coverage may be rescinded, regardless if the coverage is insured or selfinsured, or the rescission applies to an entire group or only to an individual within the group. • During that time you may be able to appeal the decision or find new coverage. 252

Rescission When is not Prohibited? • A plan can rescind if the individual performs an act, practice, or omission that constitutes fraud, or makes an intentional misrepresentation of material fact, as prohibited by the plan. • A cancellation or discontinuance of coverage is not a rescission if: (1) Has only a prospective effect. (2) Is effective retroactively to the extent it is attributable to a failure to timely pay required premiums or contributions towards the cost of coverage. 253

Tobacco Use False or Incorrect Information • If an enrollee is found to have reported false or incorrect information about their tobacco use: – The issuer may retroactively apply the appropriate tobacco use rating factor to the enrollee’s premium as if the correct information had been accurately reported from the beginning of the plan year. – The issuer must not rescind the coverage on this basis. • Tobacco use is not a material fact for which an issuer may rescind coverage if there is a misrepresentation because the regulations already provide the remedy of recouping the tobacco premium surcharge that should have been paid since the beginning of the plan or policy year. Source: http://www.federalregister.gov/articles/2013/02/27/2013-04335/patient-protection-andaffordable-care-act-health-insurance-market-rules-rate-review#p-143 254

Rescissions Question and Answer • Question: The Affordable Care Act generally provides that plans and issuers must not rescind coverage unless there is fraud or an individual makes an intentional misrepresentation of material fact. A rescission is defined as it is commonly understood under the law – a cancellation or discontinuance of coverage that has a retroactive effect, except to the extent attributable to a failure to pay timely premiums towards coverage. Is the exception to the statutory ban on rescission limited to fraudulent or intentional misrepresentations about prior medical history? What about retroactive terminations of coverage in the "normal course of business"? Source: http://www.dol.gov/ebsa/faqs/faq-aca.html.

255

Rescissions Question and Answer Answer: • The statutory prohibition related to rescissions is not limited to rescissions based on fraudulent or intentional misrepresentations about prior medical history. An example in the Departments' interim final regulations on rescissions clarifies that some plan errors (such as mistakenly covering a part-time employee and providing coverage upon which the employee relies for some time) may be cancelled prospectively once identified, but not retroactively rescinded unless there was some fraud or intentional misrepresentation by the employee. Source: http://www.dol.gov/ebsa/faqs/faq-aca.html. 256

Rescissions Question and Answer • On the other hand, some plans and issuers have commented that some employers' human resource departments may reconcile lists of eligible individuals with their plan or issuer via data feed only once per month. If a plan covers only active employees (subject to the COBRA continuation coverage provisions) and an employee pays no premiums for coverage after termination of employment, the Departments do not consider the retroactive elimination of coverage back to the date of termination of employment, due to delay in administrative record-keeping, to be a rescission. Source: http://www.dol.gov/ebsa/faqs/faq-aca.html. 257

Rescissions Question and Answer • Similarly, if a plan does not cover ex-spouses (subject to the COBRA continuation coverage provisions) and the plan is not notified of a divorce and the full COBRA premium is not paid by the employee or ex-spouse for coverage, the Departments do not consider a plan's termination of coverage retroactive to the divorce to be a rescission of coverage. (Of course, in such situations COBRA may require coverage to be offered for up to 36 months if the COBRA applicable premium is paid by the qualified beneficiary.) Source: http://www.dol.gov/ebsa/faqs/faq-aca.html.

258

Código de Seguros de Salud Rescisión o Cancelación • Las organizaciones de seguros de salud o aseguradores no podrán rescindir o cancelar un plan médico, tanto para personas individuales como para grupos de personas, luego de que la persona asegurada esté cubierta bajo el plan médico, excepto en casos que involucren fraude o una tergiversación intencional de datos sustanciales de parte de la persona asegurada o de la persona solicitando un plan médico a nombre de otra persona. • La organización de seguros de salud o asegurador que desee rescindir o cancelar una cobertura de un plan médico deberá proporcionar un aviso, con por lo menos treinta (30) días de anticipación, a cada suscriptor del plan médico o, el suscriptor primario en el caso de planes médicos individuales, que se pueda ver afectado por la propuesta rescisión o cancelación de la cubierta. Fuente: Artículo 2.050 (J) del Código de Seguros de Salud, Ley Número 194 del 29 de agosto de 2011. Esta inciso se añadió por virtud de la Ley Número 55 de 10 de julio de 2013. 259

Carta de Derechos del Paciente Continuación de Servicios de Cuidado de Salud Todo plan de cuidado de salud incluya en el contrato o póliza una disposición a los efectos de que el plan de cuidado de salud no puede ser revocado o enmendado, una vez el beneficiario esté cubierto bajo el plan o incluido en la cubierta, a menos que: • No realice el pago de la prima y no cumpla con los períodos de gracia que concede el Código de Seguros; • Haya realizado un acto constitutivo de fraude; o • Haya realizado, intencionalmente una falsa representación que esté prohibida por el plan, sobre un asunto importante y material para la aceptación del riesgo, o para el riesgo asumido por el asegurador. Fuente: Artículo 7 (a) de la Carta de Derechos y Responsabilidades del Paciente, según enmendada por la Ley Número 161 de 1 de noviembre de 2010. 260

3. Coverage of Preventive Health Services 45 CFR §147.130

261

Coverage of Preventive Health Services • Requires new plans and issuers to cover certain preventive services without any cost-sharing (copayment, coinsurance or deductible) for the enrollee when delivered by in-network providers.

• Do not apply to grandfathered plans. • Applies to non-grandfathered individual and group health plans (small and large). • Effective since September 23, 2010. Source: http://www.healthcare.gov/glossary/p/prevention.html, ttp://www.healthcare.gov/glossary/p/preventive_services.html, http://www.hhs.gov/ociio/regulations/prevention/index.html).

262

Coverage of Preventive Health Services Definitions • Prevention: Activities to prevent illness such as routine check-ups, immunizations, patient counseling, and screenings. • Preventive Services: Routine health care that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems. Source: http://www.healthcare.gov/glossary/p/prevention.html, ttp://www.healthcare.gov/glossary/p/preventive_services.html, http://www.hhs.gov/ociio/regulations/prevention/index.html). 263

Coverage of Preventive Health Services Guidelines and Recommendations • Evidence-based items or services that have a rating of A or B in the current recommendations of the United States Preventive Services Task Force (USPSTF): http://www.uspreventiveservicestaskforce.org/uspstf/topicsprog.htm. • Immunizations for routine use that have a recommendation from the Advisory Committee on Immunization Practices (ACIP) and it is listed on the Immunization Schedules of the Centers for Disease Control (CDC) and Prevention: http://www.cdc.gov/vaccines/schedules/hcp/adult.html. • Comprehensive Guidelines (developed by the Institute of Medicine (IOM)) supported by the Health Resources and Services Administration (HRSA) with respect to infants, children, and adolescents, and to women: http://www.hrsa.gov/womensguidelines/. Source: 45 CFR § 147.130, http://www.healthcare.gov/law/provisions/preventive/index.html. 264

Evidence-Based Screenings and Counseling • Insurers now must cover evidence-based services for adults that have a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force (USPSTF), an independent panel of clinicians and scientists commissioned by the Agency for Healthcare Research and Quality. • An “A” or “B” letter grade indicates that the panel finds there is high certainty that the services have a substantial or moderate net benefit. • The services required to be covered without cost-sharing include screening for depression, diabetes, cholesterol, obesity, various cancers, HIV and sexually transmitted infections (STIs), as well as counseling for drug and tobacco use, healthy eating, and other common health concerns. Source: http://kff.org/health-reform/fact-sheet/preventive-services-covered-by-privatehealth-plans/ 265

Routine Immunizations • Health plans must also provide coverage without costsharing for immunizations that are recommended and determined to be for routine use by the Advisory Committee on Immunization Practices, a federal committee comprised of immunization experts that is convened by the Centers for Disease Control and Prevention. • These guidelines require coverage for adults and children and include immunizations such as influenza, meningitis, tetanus, HPV, hepatitis A and B, measles, mumps, rubella, and varicella. Source: http://kff.org/health-reform/fact-sheet/preventive-services-covered-by-privatehealth-plans/ 266

Preventive Services for Children and Youth • The ACA requires that private plans cover without cost-sharing the preventive services recommended by the Health Resources and Services Administration’s (HRSA’s) Bright Futures Project, which provides evidence-informed recommendations to improve the health and wellbeing of infants, children, and adolescents. • The preventive services to be covered for children and adolescents include some of the immunization and screening services described in the previous two categories, behavioral and developmental assessments, iron and fluoride supplements, and screening for autism, vision impairment, lipid disorders, tuberculosis, and certain genetic diseases. Source: http://kff.org/health-reform/fact-sheet/preventive-services-covered-by-privatehealth-plans/ 267

Preventive Services for Women • The recommendations issued by USPSTF, ACIP, and Bright Futures predate the ACA. • In addition to these services, the ACA authorized the federal Health Resources and Services Administration (HRSA) to make additional coverage requirements for women. • Based on recommendations by a committee of the Institute of Medicine (IOM), federal regulations require new private plans to cover additional preventive services without costsharing for women, including well-woman visits, all FDAapproved contraceptives and related services, broader screening and counseling for STIs and HIV, breastfeeding support and supplies, and domestic violence screening. Source: http://kff.org/health-reform/fact-sheet/preventive-services-covered-by-privatehealth-plans/ 268

Coverage of Preventive Health Services 15 For Adults 1. Abdominal Aortic Aneurysm one-time screening for men of specified ages who have ever smoked 2. Alcohol Misuse screening and counseling 3. Aspirin use for men and women of certain ages 4. Blood Pressure screening for all adults 5. Cholesterol screening for adults of certain ages or at higher risk 6. Colorectal Cancer screening for adults over 50 7. Depression screening for adults 269

Coverage of Preventive Health Services 15 For Adults 8. Type 2 Diabetes screening for adults with high blood pressure 9. Diet counseling for adults at higher risk for chronic disease 10. HIV screening for all adults at higher risk 11. Obesity screening and counseling for all adults 12. Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk 13. Tobacco Use screening for all adults and cessation interventions for tobacco users 14. Syphilis screening for all adults at higher risk 270

Coverage of Preventive Health Services 15 For Adults 15. Immunization vaccines for adults--doses, recommended ages, and recommended populations vary: – Hepatitis A – Hepatitis B – Herpes Zoster – Human Papillomavirus – Influenza (Flu Shot) – Measles, Mumps, Rubella – Meningococcal – Pneumococcal – Tetanus, Diphtheria, Pertussis – Varicella Source: http://www.healthcare.gov/news/factsheets/2010/07/preventiveservices-list.html#CoveredPreventiveServicesforAdults. 271

Coverage of Preventive Health Services 26 For Children 1. Alcohol and Drug Use assessments for adolescents 2. Autism screening for children at 18 and 24 months 3. Behavioral assessments for children of all ages Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years. 4. Blood Pressure screening for children Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years. 5. Cervical Dysplasia screening for sexually active females 272

Coverage of Preventive Health Services 26 For Children 6. Congenital Hypothyroidism screening for newborns 7. Depression screening for adolescents 8. Developmental screening for children under age 3, and surveillance throughout childhood 9. Dyslipidemia screening for children at higher risk of lipid disorders Ages: 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years. 10.Fluoride Chemoprevention supplements for children without fluoride in their water source 273

Coverage of Preventive Health Services 26 For Children 11.Gonorrhea preventive medication for the eyes of all newborns 12.Hearing screening for all newborns 13.Height, Weight and Body Mass Index measurements for children: Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years. 14.Hematocrit or Hemoglobin screening for children 15.Hemoglobinopathies or sickle cell screening for newborns 274

Coverage of Preventive Health Services 26 For Children 16. HIV screening for adolescents at higher risk 17. Iron supplements for children ages 6 to 12 months at risk for anemia 18. Lead screening for children at risk of exposure 19. Medical History for all children throughout development: Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years. 20. Obesity screening and counseling

275

Coverage of Preventive Health Services 26 For Children 21. Oral Health risk assessment for young children Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years. 22. Phenylketonuria (PKU) screening for this genetic disorder in newborns 23. Sexually Transmitted Infection (STI) prevention counseling and screening for adolescents at higher risk 24. Tuberculin testing for children at higher risk of tuberculosis Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years. 25. Vision screening for all children 276

Coverage of Preventive Health Services 26 For Children 26. Immunization vaccines for children from birth to age 18 —doses, recommended ages, and recommended populations vary: – Diphtheria, Tetanus, Pertussis – Haemophilus influenza type b – Hepatitis A – Hepatitis B – Human Papillomavirus – Inactivated Poliovirus – Influenza (Flu Shot) – Measles, Mumps, Rubella – Meningococcal – Pneumococcal – Rotavirus – Varicella Source: http://www.healthcare.gov/news/factsheets/2010/07/preventive-serviceslist.html#CoveredPreventiveServicesforChildren. 277

Tobacco Use Interventions: Children and Adolescents Topic

Description

Tobacco use interventions: children and adolescents

The USPSTF recommends that clinicians provide interventions, including education or brief counseling, to prevent initiation of tobacco use in school-aged children and adolescents.

Grade B

Release Date August 2013

Grade B: The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net .benefit is moderate to substantial. Moderate: The available evidence is sufficient to determine the effects of the preventive service on health outcomes, but confidence in the estimate is constrained by such factors as: (i) The number, size, or quality of individual studies. (ii) Inconsistency of findings across individual studies. (iii) Limited generalizability of findings to routine primary care practice. (iv) Lack of coherence in the chain of evidence. As more information becomes available, the magnitude or direction of the observed effect could change, and this change may be large enough to alter the conclusion. 278

Coverage of Preventive Health Services 22 For Women, Including Pregnant Women 1. Anemia screening on a routine basis for pregnant women 2. Bacteriuria urinary tract or other infection screening for pregnant women 3. BRCA counseling about genetic testing for women at higher risk 4. Breast Cancer Mammography screenings every 1 to 2 years for women over 40 5. Breast Cancer Chemoprevention counseling for women at higher risk 6. Cervical Cancer screening for sexually active women 7. Chlamydia Infection screening for younger women and other women at higher risk 279

Coverage of Preventive Health Services 22 For Women, Including Pregnant Women 8. Folic Acid supplements for women who may become pregnant 9. Gonorrhea screening for all women at higher risk 10. Hepatitis B screening for pregnant women at their first prenatal visit 11. Osteoporosis screening for women over age 60 depending on risk factors 12. Rh Incompatibility screening for all pregnant women and follow-up testing for women at higher risk 13. Tobacco Use screening and interventions for all women, and expanded counseling for pregnant tobacco users 14. Syphilis screening for all pregnant women or other women at increased risk 280

Coverage of Preventive Health Services 22 For Women, Including Pregnant Women Must be covered in plan starting on or after August 1, 2012. 1. Breastfeeding comprehensive support and counseling from trained providers, as well as access to breastfeeding supplies, for pregnant and nursing women* 2. Contraception: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, not including abortifacient drugs* 3. Domestic and interpersonal violence screening and counseling for all women* 4. Gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk of developing gestational diabetes* 281

Coverage of Preventive Health Services 22 For Women, Including Pregnant Women 5. Human Immunodeficiency Virus (HIV) screening and counseling for sexually active women* 6. Human Papillomavirus (HPV) DNA Test: high risk HPV DNA testing every three years for women with normal cytology results who are 30 or older* 7. Sexually Transmitted Infections (STI) counseling for sexually active women* 8. Well-woman visits to obtain recommended preventive services* Source: http://www.healthcare.gov/news/factsheets/2010/07/preventive-serviceslist.html#CoveredPreventiveServicesforWomenIncludingPregnantWomen. 282

Revised Recommendation Regarding Medications for Breast Cancer in Women On September 24, 2013, the USPSTF issued new recommendations with respect to breast cancer. What changes must plans make to comply with the new recommendations? • The USPSTF recently revised its "B" recommendation regarding medications for risk reduction of primary breast cancer in women. The September 2013 recommendation now says: Source: FAQs about Affordable Care Act Implementation (Part XVIII) and Mental Health Parity Implementation (January 9, 2014) http://www.dol.gov/ebsa/faqs/faq-aca18.html. 283

Revised Recommendation Regarding Medications for Breast Cancer in Women • The USPSTF recommends that clinicians engage in shared, informed decision making with women who are at increased risk for breast cancer about medications to reduce their risk. For women who are at increased risk for breast cancer and at low risk for adverse medication effects, clinicians should offer to prescribe risk-reducing medications, such as tamoxifen or raloxifene. • Accordingly, for plan or policy years beginning one year after the date the recommendation or guideline is issued (in this case, plan or policy years beginning on or after September 24, 2014), nongrandfathered group health plans and non-grandfathered health insurance coverage offered in the individual or group market will be required to cover such medications for applicable women without cost sharing subject to reasonable medical management. 284

New Preventive Health Services Release Date of Topic Current Recommendation October 2015* Diabetes screening

Description

Grade

The USPSTF recommends screening for abnormal blood glucose as part of cardiovascular risk assessment in adults aged 40 to 70 years who are overweight or obese. Clinicians should offer or refer patients with abnormal blood glucose to intensive behavioral counseling interventions to promote a healthful diet and physical activity.

B

285

New Preventive Health Services Release Date of Topic Description Current Recommendation October 2015* High blood The USPSTF pressure in adults: recommends screening screening for high blood pressure in adults aged 18 years or older. The USPSTF recommends obtaining measurements outside of the clinical setting for diagnostic confirmation before starting treatment.

Grade

A

286

New Preventive Health Services Release Date of Topic Current Recommendation September 2015* Tobacco use counseling and interventions: nonpregnant adults

Description

Grade

The USPSTF recommends that clinicians ask all adults about tobacco use, advise them to stop using tobacco, and provide behavioral interventions and U.S. Food and Drug Administration (FDA)– approved pharmacotherapy for cessation to adults who use tobacco.

A

287

New Preventive Health Services Release Date of Topic Current Recommendation September 2015* Tobacco use counseling: pregnant women

Description

Grade

The USPSTF recommends that clinicians ask all pregnant women about tobacco use, advise them to stop using tobacco, and provide behavioral interventions for cessation to pregnant women who use tobacco.

A

288

New Preventive Health Services Release Date of Topic Description Current Recommendation September 2014* Chlamydia screening: Screening for chlamydia in women sexually active women age 24 years or younger and in older women who are at increased risk for infection.

September 2014*

Gonorrhea screening: women

Screening for gonorrhea in sexually active women age 24 years or younger and in older women who are at increased risk for infection.

Grade

B

B

289

New Preventive Health Services Release Date of Current Recommendation September 2014*

September 2014

Topic

Description

Grade

Sexually transmitted Intensive behavioral infections counseling counseling for all sexually active adolescents and for adults who are at increased risk for sexually transmitted infections.

B

Preeclampsia prevention: aspirin

B

Use of low-dose aspirin (81 mg/d) as preventive medication after 12 weeks of gestation in women who are at high risk for preeclampsia.

NEW

290

New Preventive Health Services Release Date of Current Recommendation August 2014*

June 2014*

Topic

Description

Grade

Healthy diet and physical activity counseling to prevent cardiovascular disease: adults with cardiovascular risk factors

Offering or referring adults who are overweight or obese and have additional cardiovascular disease (CVD) risk factors to intensive behavioral counseling interventions to promote a healthful diet and physical activity for CVD prevention. One-time screening for abdominal aortic aneurysm by ultrasonography in men ages 65 to 75 years who have ever smoked.

B

Abdominal aortic aneurysm screening: men

B

291

New Preventive Health Services Release Date of Current Recommendation May 2014*

May 2014

Topic

Dental caries prevention: infants and children up to age 5 years

Description

Application of fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption in primary care practices. The USPSTF recommends primary care clinicians prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is fluoride deficient. Hepatitis B screening: The USPSTF recommends nonpregnant screening for hepatitis B virus adolescents and infection in persons at high risk for adults infection.

Grade

B

B

NEW 292

New Preventive Health Services Release Date of Current Recommendation January 2014

Topic

Description

Gestational diabetes The USPSTF recommends mellitus screening screening for gestational diabetes mellitus in asymptomatic pregnant women after 24 weeks of gestation.

Grade

B

NEW

*Previous recommendation was an “A” or “B. Source: http://www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-brecommendations-by-date/

293

Coverage of Preventive Health Services • Has to cover recommended preventive services without any cost-sharing (copayment, coinsurance or deductible) if delivered by in-network providers. • May allow you to receive these services from an outof-network provider, but may charge you a fee. • Can require to pay the office visit, if the preventive service is not the primary purpose of the visit, or if the preventive services is billed separately from the office visit. Source: http://www.healthcare.gov/law/provisions/preventive/index.html.

294

Reasonable Medical Management Techniques: In-Network Cost-Sharing Question: My group health plan does not impose a copayment for colorectal cancer preventive services when performed in an in-network ambulatory surgery center. In contrast, the same preventive service provided at an in-network outpatient hospital setting would generally require a $250 copayment. Is this permissible under PHS Act section 2713? Source: http://www.dol.gov/ebsa/faqs/faq-aca.html.

295

Reasonable Medical Management Techniques: In-Network Cost-Sharing Answer: Yes, this plan design is permissible. • PHS Act section 2713 and its implementing regulations allow plans to use reasonable medical management techniques to control costs. • The regulations the Departments issued to implement the preventive health benefits in the ACA recognized the important role that VBID (value-based insurance designs) can play in promoting the use of appropriate, high value preventive services and providers. • Plans may use reasonable medical management techniques to steer patients towards a particular high-value setting such as an ambulatory care setting for providing preventive care services, provided the plan accommodates any individuals for whom it would be medically inappropriate to have the preventive service provided in the ambulatory setting (as determined by the attending provider) by having a mechanism for waiving the otherwise applicable copayment for the preventive services provided in a hospital. 296

Coverage of Preventive Health Services Out-of-Network Services Question: My plan does not have any in-network providers to provide a particular preventive service required under PHS Act section 2713. If I obtain this service out-of-network, can the plan impose cost-sharing? Source: http://www.dol.gov/ebsa/faqs/faq-aca12.html#7.

297

Coverage of Preventive Health Services Out-of-Network Services Answer: No. • While nothing in the interim final regulations generally requires a plan or issuer that has a network of providers to provide benefits for preventive services provided out-ofnetwork, this provision is premised on enrollees being able to access the required preventive services from in-network providers. • Thus, if a plan or issuer does not have in its network a provider who can provide the particular service, then the plan or issuer must cover the item or service when performed by an out-of-network provider and not impose cost-sharing with respect to the item or service. 298

No Frequency, Method, Treatment, or Setting for the Provision of Preventive Service Question: Some of the Services Task Force , the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention and the Health Resources and Services Administration (HRSA) do not definitively state the scope, setting, or frequency of the items or services to be covered. What should my plan do if an individual requests, for example, daily counseling for diet? Source: http://www.dol.gov/ebsa/faqs/faq-aca2.html; http://www.dol.gov/ebsa/faqs/faq-aca12.html#7. 299

No Frequency, Method, Treatment, or Setting for the Provision of Preventive Service Answer: • The interim final regulations regarding preventive health services provide that if a recommendation or guideline for a recommended preventive health service does not specify the frequency, method, treatment, or setting for the provision of that service, the plan or issuer can use reasonable medical management techniques (which generally limit or exclude benefits based on medical necessity or medical appropriateness using prior authorization requirements, concurrent review, or similar practices) to determine any coverage limitations under the plan. • Thus, to the extent not specified in a recommendation or guideline, a plan or issuer may rely on the relevant evidence base and these established techniques to determine the frequency, method, treatment, or setting for the provision of a recommended preventive health service. • If a recommendation or guideline does not specify the frequency, method, treatment, or setting for the provision of that service, the plan or issuer can use reasonable medical management techniques to determine any coverage limitations. 300

Coverage of Sex-specific Recommended Preventive Services Question: Can plans or issuers limit sex-specific recommended preventive services based on an individual’s sex assigned at birth, gender identity or recorded gender? Source: FAQs about Affordable Care Act Implementation (Part XXVI) addresses coverage of preventive services, May 11, 2015: http://www.dol.gov/ebsa/faqs/faq-aca26.html.

301

Coverage of Sex-specific Recommended Preventive Services Answer: No. • Whether a sex-specific recommended preventive service that is required to be covered without cost sharing under PHS Act section 2713 and its implementing regulations is medically appropriate for a particular individual is determined by the individual’s attending provider. • Where an attending provider determines that a recommended preventive service is medically appropriate for the individual – such as, for example, providing a mammogram or pap smear for a transgender man who has residual breast tissue or an intact cervix – and the individual otherwise satisfies the criteria in the relevant recommendation or guideline as well as all other applicable coverage requirements, the plan or issuer must provide coverage for the recommended preventive service, without cost sharing, regardless of sex assigned at birth, gender identity, or gender of the individual otherwise recorded by the plan or issuer. 302

Tobacco Cessation Interventions Question: The USPSTF recommends that clinicians ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products. What are plans and issuers expected to provide as preventive coverage for tobacco cessation interventions? This guidance is based on the Public Health Service-sponsored Clinical Practice Guideline, Treating Tobacco Use and Dependence: 2008 Update, available at: http://www.ahrq.gov/professionals/clinicians-providers/guidelinesrecommendations/tobacco/index.html#Clinic. Source: FAQs about Affordable Care Act Implementation (Part XIX): http://www.dol.gov/ebsa/faqs/faq-aca19.html 303

Tobacco Cessation Interventions Answer: As stated earlier, plans may use reasonable medical management techniques to determine the frequency, method, treatment, or setting for a recommended preventive service, to the extent not specified in the recommendation or guideline regarding that preventive service. Evidence-based clinical practice guidelines can provide useful guidance for plans and issuers. The Departments will consider a group health plan or health insurance issuer to be in compliance with the requirement to cover tobacco use counseling and interventions, if, for example, the plan or issuer covers without cost-sharing: 304

Tobacco Cessation Interventions • Screening for tobacco use; and, • For those who use tobacco products, at least two tobacco cessation attempts per year. For this purpose, covering a cessation attempt includes coverage for: – Four tobacco cessation counseling sessions of at least 10 minutes each (including telephone counseling, group counseling and individual counseling) without prior authorization; and – All Food and Drug Administration (FDA)-approved tobacco cessation medications (including both prescription and over-the-counter medications) for a 90-day treatment regimen when prescribed by a health care provider without prior authorization. 305

Coverage of Colonoscopies Pursuant to USPSTF Recommendations Question: If a colonoscopy is scheduled and performed as a preventive screening procedure for colorectal cancer pursuant to the USPSTF recommendation, is it permissible for a plan or issuer to impose cost sharing with respect to anesthesia services performed in connection with the preventive colonoscopy? Answer: No. The plan or issuer may not impose cost sharing with respect to anesthesia services performed in connection with the preventive colonoscopy if the attending provider determines that anesthesia would be medically appropriate for the individual. Source: FAQs about Affordable Care Act Implementation (Part XXVI) addresses coverage of preventive services, May 11, 2015: http://www.dol.gov/ebsa/faqs/faq-aca26.html. 306

Coverage of Well-woman Preventive Care for Dependents Question: If a plan or issuer covers dependent children, is the plan or issuer required to cover without cost sharing recommended women’s preventive care services for dependent children, including recommended preventive services related to pregnancy, such as preconception and prenatal care? Source: FAQs about Affordable Care Act Implementation (Part XXVI) addresses coverage of preventive services, May 11, 2015: http://www.dol.gov/ebsa/faqs/faq-aca26.html.

307

Coverage of Well-woman Preventive Care for Dependents Answer: Yes. • Non-grandfathered group health plans and health insurance issuers offering non-grandfathered group or individual health insurance coverage must cover specified recommended preventive care services without cost sharing, consistent with PHS Act section 2713 and its implementing regulations, for all participants and beneficiaries under a group health plan (and all individuals enrolled in individual market coverage). • If the plan or issuer covers dependent children, such dependent children must be provided the full range of recommended preventive services applicable to them (e.g., for their age group) without cost sharing and subject to reasonable medical management techniques, in accordance with the requirements of PHS Act section 2713 and its implementing regulations. 308

Coverage of Well-woman Preventive Care for Dependents Answer: Yes. • For example, the HRSA Guidelines recommend well-woman visits for adult women to obtain the recommended preventive services that are age- and developmentally-appropriate, including preconception care and many services necessary for prenatal care. • Therefore, consistent with PHS Act section 2713 and its implementing regulations, plans and issuers must cover without cost sharing these recommended preventive services for dependent children where an attending provider determines that well-woman preventive services are age- and developmentally-appropriate for the dependent. 309

Coverage of Preventive Health Services For Women - Questions and Answers Breastfeeding Question: The USPSTF already recommends breastfeeding counseling. Why is this part of the HRSA Guidelines?

Source: http://www.dol.gov/ebsa/faqs/faq-aca12.html#7.

310

Coverage of Preventive Health Services For Women - Questions and Answers Answer: • Under the topic of "Breastfeeding Counseling" the USPSTF recommends interventions during pregnancy and after birth to promote and support breastfeeding. • The HRSA Guidelines specifically incorporate comprehensive prenatal and postnatal lactation support, counseling, and equipment rental. • Accordingly, the items and services described in the HRSA Guidelines are required to be covered in accordance with the requirements of the interim final regulations (that is, without cost-sharing, subject to reasonable medical management, which may include purchase instead of rental of equipment). 311

Coverage of Preventive Health Services For Women - Questions and Answer

Coverage of BRCA Testing

312

Coverage of BRCA Testing • PHS Act section 2713 addresses coverage for evidence-based items or services with a rating of "A" or "B" in the current recommendations of the USPSTF, as well as, with respect to women, coverage for preventive care and screenings as provided for in comprehensive guidelines supported by HRSA. • The USPSTF recommends with a "B" rating to "screen women who have family members with breast, ovarian, tubal or peritoneal cancer with 1 of several screening tools designed to identify a family history that may be associated with an increased risk for potentially harmful mutations in breast cancer susceptibility genes (BRCA 1 or BRCA 2). • Women with positive screening results should receive genetic counseling and, if indicated after counseling, BRCA testing.“ Source: FAQs about Affordable Care Act Implementation (Part XXIX), October 23, 2015, http://www.dol.gov/ebsa/faqs/faq-aca29.html#cite-13 or http://www.cms.gov/CCIIO/Resources/FactSheets-and-FAQs/Downloads/FAQs-Part-XXIX.pdf 313

Coverage of BRCA Testing • The Departments have answered two previous FAQs on this topic. • In the first, the Departments clarified that HHS believes that the scope of this recommendation includes both genetic counseling and BRCA testing, if appropriate, for a woman as determined by her health care provider. • In the second, the Departments addressed services for women who “previously had breast cancer, ovarian cancer, or other cancer.” • To address remaining questions, the Departments are issuing this additional FAQ. Source: FAQs about Affordable Care Act Implementation (Part XXIX), October 23, 2015, http://www.dol.gov/ebsa/faqs/faq-aca29.html#cite-13 or http://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/FAQs-PartXXIX.pdf 314

Coverage of BRCA Testing Question: Which women must receive coverage without cost sharing for genetic counseling, and if indicated, testing for harmful BRCA mutations? Answer: • Women found to be at increased risk using a screening tool designed to identify a family history that may be associated with an increased risk of having a potentially harmful gene mutation must receive coverage without cost sharing for genetic counseling, and, if indicated, testing for harmful BRCA mutations. • This is true regardless of whether the woman has previously been diagnosed with cancer, as long as she is not currently symptomatic of or receiving active treatment for breast, ovarian, tubal, or peritoneal cancer. Source: FAQs about Affordable Care Act Implementation (Part XXIX), October 23, 2015, http://www.dol.gov/ebsa/faqs/faq-aca29.html#cite-13 or http://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/FAQs-PartXXIX.pdf 315

Coverage of BRCA Testing Question: Must a plan or issuer cover without cost sharing recommended genetic counseling and BRCA genetic testing for a woman who has not been diagnosed with BRCA-related cancer but who previously had breast cancer, ovarian cancer, or other cancer? Source: FAQs about Affordable Care Act Implementation (Part XXVI) addresses coverage of preventive services, May 11, 2015: http://www.dol.gov/ebsa/faqs/faq-aca26.html.

316

Coverage of BRCA Testing Answer: Yes. • The USPSTF recommends that “primary care providers screen women who have family members with breast, ovarian, tubal, or peritoneal cancer with 1 of several screening tools designed to identify a family history that may be associated with an increased risk for potentially harmful mutations in breast cancer susceptibility genes (BRCA1 or BRCA2). • Women with positive screening results should receive genetic counseling and, if indicated after counseling, BRCA testing.” 317

Coverage of BRCA Testing Answer: Yes. • The USPSTF’s Final Recommendation Statement related to BRCA testing indicates that the recommendation “applies to asymptomatic women who have not been diagnosed with BRCA-related cancer.” • Therefore, as set out in the recommendations described above, as long as the woman has not been diagnosed with BRCA-related cancer, a plan or issuer must cover preventive screening, genetic counseling, and genetic testing without cost sharing, if appropriate, for a woman as determined by her attending provider, consistent with PHS Act section 2713 and its implementing regulations. 318

Coverage of Food and Drug Administration (FDA)-approved Contraceptives Guidance on the Scope of Coverage Required for Contraception and the Extent to which Plans and Issuers May Utilize Reasonable Medical Management Source: FAQs about Affordable Care Act Implementation (Part XXVI) addresses coverage of preventive services, May 11, 2015: http://www.dol.gov/ebsa/faqs/faq-aca26.html. 319

Coverage of Preventive Health Services For Women • Contraception and contraceptive counseling: Women with reproductive capacity have access to all Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider. Abortifacient drugs are not included. Contraception has additional health benefits like reduced risk of cancer and improving the health of mothers-to-be. Source: http://www.hhs.gov/healthcare/facts/factsheets/2011/08/womensprevention08 012011a.html. 320

Contraceptives - HRSA Guidelines • The HRSA Guidelines include a recommendation for (1) all FDA-approved contraceptive methods, (2) sterilization procedures, and (3) patient education and counseling for all women with reproductive capacity, as prescribed by a health care provider. • On February 20, 2013, the Departments issued an FAQ stating that the HRSA Guidelines ensure women’s access to the full range of FDA-approved contraceptive methods including, but not limited to, barrier methods, hormonal methods, and implanted devices, as well as patient education and counseling, as prescribed by a health care provider. 321

Contraceptives Coverage FDA-Approved Contraceptive Methods •Plans and issuers must cover without cost sharing at least one form of contraception in each of the methods (currently 18) that the FDA has identified for women in its current Birth Control Guide. •This coverage must also include the clinical services, including patient education and counseling, needed for provision of the contraceptive method. 322

Contraceptives Coverage FDA-Approved Contraceptive Methods The contraceptive methods for women currently identified by the FDA include: (1) Sterilization surgery for women; (2) Surgical sterilization implant for women; (3) Implantable rod; (4) IUD copper; (5) IUD with progestin; (6) Shot/injection; (7) Oral contraceptives (combined pill); (8) Oral contraceptives (progestin only);

(9) Oral contraceptives extended/continuous use; (10) Patch; (11) Vaginal contraceptive ring; (12) Diaphragm; (13) Sponge; (14) Cervical cap; (15) Female condom; (16) Spermicide; (17) Emergency contraception (Plan B/Plan B One Step/Next Choice); and (18) Emergency contraception (Ella) 323

Contraceptives - Reasonable Medical Management Techniques • Within each method, plans and issuers may utilize reasonable medical management techniques to control costs and promote efficient delivery of care, such as covering a generic drug without cost sharing and imposing cost sharing for equivalent branded drugs. –“Methods” refers to the 18 birth control methods for women currently referenced in the FDA Birth Control Guide that must be covered.

324

Contraceptives - Reasonable Medical Management Techniques • A plan or issuer generally may impose cost sharing (including full cost sharing) on some items and services to encourage an individual to use other specific items and services within the chosen contraceptive method. For example, a plan may discourage use of brand name pharmacy items over generic pharmacy items through the imposition of cost sharing. Similarly, a plan may use cost sharing to encourage use of one of several FDA-approved intrauterine devices (IUDs) with progestin. –“FDA-approved items” refers to specific products currently approved or cleared by the FDA within a method. 325

Contraceptives - Exceptions Process • A plan or issuer must accommodate any individual for whom a particular drug (generic or brand name) would be medically inappropriate, as determined by the individual's health care provider, by having a mechanism for waiving the otherwise applicable cost sharing for the brand or non-preferred brand version. • If utilizing reasonable medical management techniques within a specified method of contraception, plans and issuers must have (1) an easily accessible, (2) transparent, and (3) sufficiently expedient exceptions process that is not unduly burdensome on the individual or a provider (or other individual acting as a patient's authorized representative). 326

Contraceptives - Exceptions Process • If an individual’s attending provider recommends a particular service or FDA-approved item based on a determination of medical necessity with respect to that individual, the plan or issuer must cover that service or item without cost sharing. • The plan or issuer must defer to the determination of the attending provider. • Medical necessity may include considerations such as severity of side effects, differences in permanence and reversibility of contraceptives, and ability to adhere to the appropriate use of the item or service, as determined by the attending provider. 327

Contraceptives - Exceptions Process An attending provider means • An individual who is licensed under applicable state law, who is acting within the scope of the provider’s license, and • Who is directly responsible for providing care to the patient relating to the recommended preventive services. Therefore, a plan, issuer, hospital, or managed care organization is not an attending provider. 328

Contraceptives - Exceptions Process The exceptions process must make a determination of the claim according to a timeframe and in a manner that takes into account: • The nature of the claim (e.g., pre-service or postservice) and • The medical exigencies involved for a claim involving urgent care. 329

Contraceptives – Q&As (2) Question: If a plan or issuer covers some forms of oral contraceptives, some types of IUDs, and some types of diaphragms without cost sharing, but excludes completely other forms of contraception, will the plan or issuer comply with PHS Act section 2713 and its implementing regulations? 330

Contraceptives – Q&As (2) Answer: No. • Plans and issuers must cover without cost sharing the full range of FDA-identified methods. • Thus, plans and issuers must cover without cost sharing at least one form of contraception in each method that is identified by the FDA. The FDA currently has identified 18 distinct methods of contraception for women. • A plan or issuer generally may use reasonable medical management techniques and impose cost sharing (including full cost sharing) to encourage an individual patient to use specific services or FDA-approved items within the chosen contraceptive method. 331

Contraceptives – Q&As (2) • If utilizing reasonable medical management techniques, plans and issuers must have an easily accessible, transparent, and sufficiently expedient exceptions process that is not unduly burdensome on the individual (or a provider or other individual acting as a patient's authorized representative) to ensure coverage without cost sharing of any service or FDA-approved item within the specified method of contraception as described in Q&A-3 below. • In this example, even though the plan provides coverage in multiple methods, the plan’s exclusion of some of the methods for women currently identified by the FDA means the plan fails to comply with PHS Act section 2713 and its implementing regulations. 332

Contraceptives – Q&As (3) Question: If multiple services and FDA-approved items within a contraceptive method are medically appropriate for an individual patient, what is a plan or issuer required to cover without cost sharing?

333

Contraceptives – Q&As (3) Answer: • If multiple services and FDA-approved items within a contraceptive method are medically appropriate for an individual, the plan or issuer may use reasonable medical management techniques to determine which specific products to cover without cost sharing with respect to that individual. • However, if the individual’s attending provider recommends a particular service or FDA-approved item based on a determination of medical necessity with respect to that individual, the plan or issuer must cover that service or item without cost sharing. • The plan or issuer must defer to the determination of the attending provider with respect to the individual involved. • As previously stated, the plan or issuer must cover at least one service or item within each of the methods (currently 18) identified by the FDA for women. 334

Contraceptives – Q&As (4) Question: If a plan or issuer covers oral contraceptives (such as the extended/continuous use contraceptive pill), can it impose cost sharing on all items and services within other FDA-identified hormonal contraceptive methods (such as the vaginal contraceptive ring or the contraceptive patch)?

335

Contraceptives – Q&As (4) Answer: No. • The FDA currently identifies 18 distinct methods of contraception for women, and the HRSA Guidelines are designed to provide women’s access to the full range of these contraceptive methods identified by the FDA, as prescribed by a health care provider. • Thus, plans and issuers must cover without cost sharing at least one form of contraception within each method the FDA has identified. • For the hormonal contraceptive methods, coverage therefore must include (but is not limited to) all 3 oral contraceptive methods (combined, progestin-only, and extended/continuous use), injectables, implants, the vaginal contraceptive ring, the contraceptive patch, emergency contraception (Plan B/Plan B One Step/Next Choice), emergency contraception (Ella), and IUDs with progestin. • Accordingly, a plan or issuer may not impose cost sharing on the ring or the patch. 336

Coverage of Preventive Health Services For Women - Questions and Answers Contraception Question: The HRSA Guidelines include a recommendation for all Food and Drug Administration (FDA) approved contraceptive methods, sterilization procedures, and patient education and counseling for all women with reproductive capacity, as prescribed by a health care provider. May a plan or issuer cover only oral contraceptives? Source: http://www.dol.gov/ebsa/faqs/faq-aca12.html#7. 337

Coverage of Preventive Health Services For Women - Questions and Answers Answer: No. • The HRSA Guidelines ensure women's access to the full range of FDA-approved contraceptive methods including, but not limited to, barrier methods, hormonal methods, and implanted devices, as well as patient education and counseling, as prescribed by a health care provider. • Consistent with PHS Act section 2713 and its implementing regulations, plans and issuers may use reasonable medical management techniques to control costs and promote efficient delivery of care. • For example, plans may cover a generic drug without cost-sharing and impose cost-sharing for equivalent branded drugs. 338

Coverage of Preventive Health Services For Women - Questions and Answers • However, in these instances, a plan or issuer must accommodate any individual for whom the generic drug (or a brand name drug) would be medically inappropriate, as determined by the individual's health care provider, by having a mechanism for waiving the otherwise applicable cost-sharing for the branded or non-preferred brand version. • This generic substitution approach is permissible for other pharmacy products, as long as the accommodation described above exists. • If, however, a generic version is not available, or would not be medically appropriate for the patient as a prescribed brand name contraceptive method (as determined by the attending provider, in consultation with the patient), then a plan or issuer must provide coverage for the brand name drug in accordance with the requirements of the interim final regulations (that is, without cost-sharing, subject to reasonable medical management). 339

Coverage of Preventive Health Services For Women - Questions and Answers Contraception Question: Do the HRSA Guidelines include contraceptive methods that are generally available over-the-counter (OTC), such as contraceptive sponges and spermicides? • Answer: Contraceptive methods that are generally available OTC are only included if the method is both FDA-approved and prescribed for a woman by her health care provider. The HRSA Guidelines do not include contraception for men. Source: http://www.dol.gov/ebsa/faqs/faq-aca12.html#7.

340

Coverage of Preventive Health Services For Women - Questions and Answers Contraception Question: Do the HRSA Guidelines include services related to follow-up and management of side effects, counseling for continued adherence, and for device removal? • Answer: Yes. Services related to follow-up and management of side effects, counseling for continued adherence, and device removal are included under the HRSA Guidelines and required to be covered in accordance with the requirements of the interim final regulations (that is, without cost-sharing, subject to reasonable medical management). Source: http://www.dol.gov/ebsa/faqs/faq-aca12.html#7. 341

Coverage of Preventive Health Services For Women - Questions and Answers Contraception Question: Are intrauterine devices and implants contraceptive methods under the HRSA Guidelines and therefore required to be covered without cost-sharing? • Answer: Yes, if approved by the FDA and prescribed for a woman by her health care provider, subject to reasonable medical management. The HRSA guidelines "exclude services relating to a man's reproductive capacity, such as vasectomies and condoms.“ Source: http://www.dol.gov/ebsa/faqs/faq-aca12.html#7. 342

Contraceptives Exemption and Accommodations in Connection with Coverage of Preventive Health Services 45 CFR § 147.131 80 Federal Register pages 41317-41347, Final Rule, Tuesday, July 14, 2015 343

Preventive Health Services For Women Exemption for Religious Employers • The Health Resources and Services Administration (HRSA) may establish an exemption from such guidelines with respect to a health plan established or maintained by a religious employer with respect to any requirement to cover contraceptive services under such guidelines. • A “religious employer” is an organization that is organized and operates as a nonprofit entity and is referred to in section 6033(a)(3)(A)(i) or (iii) of the Internal Revenue Code of 1986, as amended.

344

Preventive Health Services For Women Accommodation for Eligible Organizations An organization that satisfies all of the following requirements: 1. Opposes providing coverage for some or all of any contraceptive services required to be covered on account of religious objections. 2. Is organized and operates as a nonprofit entity. 3. Holds itself out as a religious organization. 4. Self-certifies, in a form and manner specified by the Secretary, that it satisfies the criteria (1) through (3), and makes such self-certification available for examination upon request by the first day of the first plan year to which the accommodation applies. The self-certification must be executed by a person authorized to make the certification on behalf of the organization, and must be maintained in a manner consistent with the record retention requirements under section 107 of the ERISA. 345

Preventive Health Services For Women Contraceptive Coverage Compliance • A group health plan established or maintained by an eligible organization that provides benefits through one or more group health insurance issuers complies for one or more plan years with any requirement to provide contraceptive coverage if the eligible organization or group health plan furnishes a copy of the self-certification described to each issuer that would otherwise provide such coverage in connection with the group health plan. • An issuer may not require any documentation other than the copy of the self-certification from the eligible organization regarding its status as such. 346

Contraceptive Services Payments by the Issuer A group health insurance issuer that receives a copy of the self-certification must: (A)Expressly exclude contraceptive coverage from the group health insurance coverage provided in connection with the group health plan; and (B) Provide separate payments for any contraceptive services required to be covered for plan participants and beneficiaries for so long as they remain enrolled in the plan. 347

Contraceptive Services Payments by the Issuer • The issuer may not impose any cost-sharing requirements (such as a copayment, coinsurance, or a deductible), or impose any premium, fee, or other charge, or any portion thereof, directly or indirectly, on the eligible organization, the group health plan, or plan participants or beneficiaries. • The issuer must segregate premium revenue collected from the eligible organization from the monies used to provide payments for contraceptive services. • If the group health plan of the eligible organization provides coverage for some but not all of any contraceptive services required to be covered, the issuer is required to provide payments only for those contraceptive services for which the group health plan does not provide coverage. However, the issuer may provide payments for all contraceptive services, at the issuer's option. 348

Contraceptive Services Notice of Availability of Separate Payments Insured group health plans and student health insurance coverage. • For each plan year to which the accommodation is to apply, an issuer required to provide payments for contraceptive services must provide to plan participants and beneficiaries written notice of the availability of separate payments for contraceptive services contemporaneous with (to the extent possible), but separate from, any application materials distributed in connection with enrollment (or re-enrollment) in group health coverage that is effective beginning on the first day of each applicable plan year. • The notice must specify that the eligible organization does not administer or fund contraceptive benefits, but that the issuer provides separate payments for contraceptive services, and must provide contact information for questions and complaints. 349

Contraceptive Services Notice of Availability of Separate Payments The following model language, or substantially similar language, may be used to satisfy the notice requirement : “Your [employer/institution of higher education] has certified that your [group health plan/student health insurance coverage] qualifies for an accommodation with respect to the federal requirement to cover all Food and Drug Administration-approved contraceptive services for women, as prescribed by a health care provider, without cost sharing. This means that your [employer/institution of higher education] will not contract, arrange, pay, or refer for contraceptive coverage. Instead, [name of health insurance issuer] will provide separate payments for contraceptive services that you use, without cost sharing and at no other cost, for so long as you are enrolled in your [group health plan/student health insurance coverage]. Your [employer/institution of higher education] will not administer or fund these payments. If you have any questions about this notice, contact [contact information for health insurance issuer].” 350

Contraceptive Services Reliance on the Representation • If an issuer relies reasonably and in good faith on a representation by the eligible organization as to its eligibility for the accommodation and the representation is later determined to be incorrect, the issuer is considered to comply with any requirement to provide contraceptive coverage if the issuer complies with the obligations under this section applicable to such issuer. • A group health plan is considered to comply with any requirement to provide contraceptive coverage if the plan complies with its obligations, without regard to whether the issuer complies with the obligations under this section applicable to such issuer. 351

Contraceptive Services Application to Student Health Plan • The provisions apply to student health insurance coverage arranged by an eligible organization that is an institution of higher education in a manner comparable to that in which they apply to group health insurance coverage provided in connection with a group health plan established or maintained by an eligible organization that is an employer. 352

Final Rule Exemption Religious Non-Profits and Closely Held For-Profit Entities Source: • Coverage of Certain Preventive Services Under the Affordable Care Act, 80 Federal Register 41317, Tuesday, July 14, 2015, Final Rule, http://webapps.dol.gov/FederalRegister/PdfDisplay.aspx?DocId=28364 • HHS Fact Sheet: Women’s Preventive Services Coverage, Non-Profit Religious Organizations, and Closely-Held For-Profit Entities, http://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/womens-preven02012013.html • HHS New Release: Administration issues final rules on coverage of certain recommended preventive services without cost sharing: Final rules secure women’s access to contraceptive services while respecting religious beliefs, http://www.hhs.gov/news/press/2015pres/07/20150710a.html. 353

Final Rule for Religious Non-Profits and Closely Held For-Profit Entities • Maintains the existing accommodation for eligible religious nonprofits, but also finalizes an alternative pathway for those organizations to provide notice of their objection to covering contraceptive services. • Provides certain closely held for-profit entities the same accommodations. • Finalize standards concerning documentation and disclosure of a closely held for-profit entity’s decision not to provide coverage for contraceptive services. To be eligible for the accommodation, the for-profit entity’s highest governing body must adopt a resolution or similar action establishing that it objects to covering some or all of the contraceptive services on account of the owners’ sincerely held religious beliefs. Source: http://www.hhs.gov/news/press/2015pres/07/20150710a.html. Coverage of Certain Preventive Services Under the Affordable Care Act, 80 Federal Register 41317, Tuesday, July 14, 2015, Final Rule, http://webapps.dol.gov/FederalRegister/PdfDisplay.aspx?DocId=28364. 354

Final Rule for Religious Non-Profits and Closely Held For-Profit Entities • Relying on a definition used in federal tax law, the final rules define a “closely held for-profit entity” as an entity that is not publicly traded and that has an ownership structure under which more than 50 percent of the organization’s ownership interest is owned by five or fewer individuals, or an entity with a substantially similar ownership structure, 45 CFR § 147.131 (4). • For purposes of this definition, all of the ownership interests held by members of a family are treated as being owned by a single individual. • The Departments believe that this definition includes all of the forprofit companies that have challenged the contraceptive-coverage requirement on religious grounds. 355

Final Rule for Religious Non-Profits and Closely Held For-Profit Entities • Establish an alternative way for eligible organizations that have a religious objection to covering contraceptive services to seek an accommodation from contracting, providing, paying, or referring for such services. • HHS and the Department of Labor will then notify insurers and third party administrators of the organization’s objection so that enrollees in plans of such organizations receive separate payments for contraceptive services, with no additional cost to the enrollee or organization, and no involvement by the organization. • Provide this accommodations to closely held for-profit entities. 356

Notice to the Secretary of Health and Human Services (HHS) that the eligible organization has a religious objection to coverage of all or a subset of contraceptive services

Source: http://www.dol.gov/ebsa/pdf/modelnoticetosecretaryofhhs.pdf 357

Self-Certification

For (1) Non-Profit

(2) Closely Held For-Profit

Source: http://www.dol.gov/ebsa/pdf/preventiveserviceseligibleorganizationcertificationform.pdf 358

Disclosure with Respect to Preventive Services Facts: My closely held for-profit corporation's health plan will cease providing coverage for some or all contraceptive services mid-plan year. Question: Does this reduction in coverage trigger any notice requirements to plan participants and beneficiaries? Answer: Yes. Source: FAQs about Affordable Care Act Implementation (Part XX), http://www.dol.gov/ebsa/faqs/faq-aca20.html 359

Disclosure with Respect to Preventive Services • ERISA law requires disclosure of information relevant to coverage of preventive services, including contraceptive coverage. • The Department of Labor's regulations at 29 CFR 2520.1023(j)(3) provide that, the summary plan description (SPD) shall include a description of the extent to which preventive services (which includes contraceptive services) are covered under the plan. • If an ERISA plan excludes all or a subset of contraceptive services from coverage under its group health plan, the plan's SPD must describe the extent of the limitation or exclusion of coverage. Source: FAQs about Affordable Care Act Implementation (Part XX), http://www.dol.gov/ebsa/faqs/faq-aca20.html 360

Disclosure with Respect to Preventive Services • For plans that reduce or eliminate coverage of contraceptive services after having provided such coverage, expedited disclosure requirements for material reductions in covered services or benefits apply. • ERISA section 104(b)(1) and 29 CFR 2520.104b-3(d)(1), require disclosure not later than 60 days after the date of adoption of a modification or change to the plan that is a material reduction in covered services or benefits. • Other disclosure requirements may apply, for example, under State insurance law applicable to health insurance issuers. Source: FAQs about Affordable Care Act Implementation (Part XX), http://www.dol.gov/ebsa/faqs/faq-aca20.html 361

Código de Seguros de Salud Servicios de Cuidado Preventivo Todo asegurador u organización de seguros de salud que provea planes médicos individuales o grupales deberá, por lo menos, proveer cubierta y no impondrá requisitos de compartir costos (“cost-sharing”) con respecto a los siguientes servicios de cuidado preventivo, siempre y cuando la persona cubierta los reciba de un proveedor participante. Fuente: Artículo 2.050 (C) del Código de Seguros de Salud, según enmendado por la Ley Número 55 de 10 de julio de 2013. 362

Código de Seguros de Salud Servicios de Cuidado Preventivo 1. Servicios incluidos en las recomendaciones más recientes del United States Preventive Services Task Force. 2. Inmunizaciones para las cuales hay en efecto una recomendación del Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention y del Comité Asesor en Prácticas de Inmunización del Departamento de Salud de Puerto Rico. 3. Con respecto a infantes, niños y adolescentes hasta los 21 años, servicios de cuidado preventivo y cernimiento de los contemplados en las directrices del Health Resources and Services Administration . 4. Con respecto a mujeres, todo servicio preventivo y de cernimiento, según las directrices del Health Resources and Services Administration (HRSA), incluyendo los servicios relacionados con cernimiento de cáncer del seno. 363

Carta de Derechos del Paciente Servicios de Cuidado Preventivo • Que los planes de cuidado de salud incluyan, como parte de su cubierta básica, sin costo adicional ni copago alguno, los siguientes servicios de cuidado preventivo: el cuidado preventivo recomendado por el “United States Preventive Services Task Force”; las inmunizaciones que sean recomendadas por el “Advisory Committe Immunization Practices of the Centers for Disease Control and Prevention”; en cuanto a los infantes, niños y adolecentes hasta los 21 años, cuido preventivo que incluya las vacunas recomendadas según su edad y, en cuanto a las mujeres, el cuidado preventivo contra el cáncer de mama según recomendado por el “Health Resources and Services Administration”. • Estos son los requisitos mínimos, sin que los mismos limiten a los aseguradores a ofrecer una mayor cobertura. Fuente: Artículo 6 (g) de la Carta de Derechos y Responsabilidades del Paciente, según enmendada por la Ley Número 161 de 1 de noviembre de 2010. 364

Acciones Administrativas Tomadas por la Oficina del Comisionado de Seguros • Caso: CM-2014-121 – First Medical Health Plan, Inc. • Orden de 1 de agosto de 2014 • La Organización violentó lo dispuesto en el Artículo 2.050(c)(2) del Código de Seguros de Salud de Puerto Rico al emitir a varios suscriptores certificaciones sobre cubiertas de inmunización con limitaciones que no estaban indicadas en las recomendaciones del “Advisory Committee on Immunization Practices of the CDC and Prevention” y el Comité Asesor en Prácticas de Inmunización del Departamento de Salud de Puerto Rico, y no cubrir los servicios de inmunización que debió haber cubierto. • Sanción: $10,000 multa. Fuente: http://ocs.gobierno.pr/ocspr/files/ACCIONES%20ADMINISTRATIVAS%20FINALES%20Y%20FIRMES%20TODAS201 4.pdf 365

Acciones Administrativas Tomadas por la Oficina del Comisionado de Seguros • Caso: CM-2014-123 – Humana Insurance of Puerto Rico, Inc. • Orden de 5 de agosto de 2014 • El Asegurador violentó lo dispuesto en el Artículo 2.050(c)(2) del Código de Seguros de Salud de Puerto Rico y el Artículo 27.050(1) del Código de Seguros de Puerto Rico al emitir a varios asegurados certificaciones sobre cubiertas de inmunización con limitaciones que no estaban indicadas en las recomendaciones del “Advisory Committee on Immunization Practices of the CDC and Prevention” y el Comité Asesor en Prácticas de Inmunización del Departamento de Salud de Puerto Rico, por lo que no proveyeron cubierta para todas las inmunizaciones recomendadas por dichos comités, y las mismas ser contrarias a las disposiciones de los correspondientes formularios de póliza. • Sanción: $10,000 multa. Fuente: http://ocs.gobierno.pr/ocspr/files/ACCIONES%20ADMINISTRATIVAS%20FINALES%20Y%20FIRMES%20TODAS2014.pdf 366

4. Coverage of Essential Health Benefits (EHBs) or Comprehensive Health Insurance Coverage 45 CFR §147.150 and 45 CFR §156.110 367

The ACA Essential Health Benefits (EHBs) requirement will not apply to individual or group health insurance issuers in the U.S. territories (Puerto Rico). PR Health Insurance Code applies.

Source: Letter to Puerto Rico on the Definition of State, http://www.cms.gov/CCIIO/Resources/Letters/Downloads/letter-to-Weyne.pdf

368

Essential Health Benefits

Must be offered in the individual and small group markets, both inside and outside of the Exchanges.

No lifetime or annual dollar limit on Essential Health Benefits. 369

A. Comprehensive Health Insurance Coverage

370

Essential Health Benefits (EHBs) • ACA ensures health plans offered in the individual and small group markets, both inside and outside of the Exchanges, must offer a comprehensive package of items and services, known as Essential Health Benefits starting on January 1, 2014. • A set of health care service categories that QHPs must be covered starting on January 1, 2014. • Insurance policies must cover these benefits in order to be certified and offered in Exchanges. • Medicaid must cover these services by 2014. Sources: http://www.healthcare.gov/glossary/e/essential.html, http://www.healthcare.gov/glossary/e/essential.html, http://www.healthcare.gov/law/provisions/limits/limits.html. 371

Essential Health Benefits (EHBs) Self-insured group health plans, health insurance coverage offered in the large group market, and grandfathered health plans are not required to cover the EHBs. Minimum Essential Coverage (MEC): • It is not the same EHBs. • It is the type of coverage an individual needs to have to meet the individual responsibility requirement under ACA. • This includes individual market policies, job-based coverage, Medicare, Medicaid, CHIP, TRICARE and certain other coverage. Sources: http://www.healthcare.gov/glossary/M/minimumessentialcoverage.html.

372

Essential Health Benefits General Categories

1.

Ambulatory patient services

2.

Emergency services

3.

Hospitalization

4.

Maternity and newborn care

5.

Mental health and substance use disorder services, including behavioral health treatment

6.

Prescription drugs

7.

Rehabilitative and habilitative services and devices

8.

Laboratory services

9.

Preventive and wellness services, and chronic disease management

10.

Pediatric services, include oral and vision care

Source: 45 CFR sec. 156.110 (a), see 78 Federal Register 12866 (February 25, 2013). 373

State EHB-Benchmark Plan Selection • Small group market health plan: The largest health plan by enrollment in any of the three largest small group insurance products by enrollment. • State employee health benefit plan: Any of the largest three employee health benefit plan options by enrollment offered and generally available to state employees in the state involved. • FEHBP plan: Any of the largest three national Federal Employees Health Benefits Program (FEHBP) plan options by aggregate enrollment that is offered to all health-benefits-eligible federal employees. • HMO: The coverage plan with the largest insured commercial non-Medicaid enrollment offered by a HMO operating in the state. Source: 45 CFR sec. 156.100 (a), see 78 Federal Register 12869 (February 25, 2013), 78 Federal Register 12866 (February 25, 2013). 374

Source: Essential Health Benefits _ 50-State Variations on a Theme: http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2014/rwjf416179 375

State EHB-Benchmark Plan Selection • Default Base-Benchmark Plan: If a state (Puerto Rico) does not make a selection, the default base-benchmark plan will be the largest plan by enrollment in the largest product in the state's small group market. The benchmark options was based on enrollment as of March 31, 2012. • General supplementation methodology: A base-benchmark plan that does not include items or services within one or more of the categories must be supplemented by the addition of the entire category of such benefits offered under any other benchmark plan option. Source: 45 CFR sec. 156.100 (c) and 156.110 (b) (1), see 78 Federal Register 12866 (February 25, 2013).

376

Puerto Rico EHB Benchmark Plan Summary Information Plan Type

Plan from largest small group product, Preferred Provider Organization

Issuer Name

Triple-S Salud, Inc.

Product Name

Óptimo Plus PPO

Plan Name

Óptimo Plus (Plan de Salud PG-OP 2008)

Supplemented Categories (Supplementary Plan Type)

Pediatric Vision (FEDVIP)

Habilitative Services Included Benchmark (Yes/No)

Yes Puerto Rico additional required or mandated benefits to cover specific care, treatment, or services.

Fuente: http://www.ocs.gobierno.pr/ocspr/documents/asuntoslegales/resoluciones/puerto-rico-ehbbenchmark-plan.pdf. 377

Código de Seguros de Salud Beneficios de Salud Esenciales • Todo asegurador u organización de seguros de salud que provea planes médicos individuales o grupales deberá asegurarse que todas sus cubiertas incluyan el Conjunto de Beneficios de Salud Esenciales o “Essential Health Benefits Package” requerido a tenor con la Affordable Care Act. • El Conjunto de Beneficios de Salud Esenciales constituye un plan médico que incluya: Fuente: Artículo 2.050 (D) del Código de Seguros de Salud, Ley Número 194 del 29 de agosto de 2011, enmendado por la Ley Número 55 de 10 de julio de 2013.

378

Código de Seguros de Salud Beneficios de Salud Esenciales 1. Servicios ambulatorios, médico-quirúrgicos. 2. Servicios de emergencia. 3. Hospitalización. 4. Servicios de maternidad y cuidado de recién nacidos. 5. Servicios de salud mental y de desórdenes por el uso de sustancias controladas. 6. Servicios de laboratorios, rayos x y pruebas diagnósticas. 7. Servicios pediátricos, incluyendo la vacuna contra el virus sincitial respiratorio y la

vacuna contra el cáncer cervical, servicios de salud de visión y dental. 8. Cubierta de medicamentos. 9. Servicios de habilitación y rehabilitación 10.Servicios preventivos y de bienestar, así como de manejo de enfermedades crónicas 11.Cualquier otro servicio o beneficio mandatorio que se requiera por ley o reglamento, estatal o federal. 379

Essential Health Benefits Plan Benefits Coverage EHB means that a health plan provides benefits that are substantially equal to the EHB-benchmark plan including: (i) covered benefits; (ii) limitations on coverage including coverage of benefit amount, duration, and scope; and (iii) prescription drug benefits that meet the requirements. Source: 45 CFR sec. 156.115 (a), 78 Federal Register 12869 (February 25, 2013).

380

Essential Health Benefits Coverage in an Entire EHB Category • With the exception of the EHB category of coverage for pediatric servicies, a plan may not exclude an enrollee from coverage in an entire EHB category, regardless of whether such limits exist in the EHB-benchmark plan. –For example, a plan may not exclude dependent children from the category of maternity and newborn coverage. Source: 45 CFR 156.115(a)(2), Guide to Reviewing Essential Health Benefits Benchmark Plans: http://www.cms.gov/CCIIO/Resources/Data-Resources/Downloads/ehb-benchmark-review-guide.pdf.

381

Maternity and Newborn Care Coverage Large Group Health Plans • A large group plan is not required to provide maternity and newborn care coverage because large group plans are not required to provide Essential Health Benefits (EHBs). • However, if the large group plan does provide such maternity and newborn care coverage, and the plan includes dependent coverage, it must make the maternity and newborn care coverage available to all enrollees regardless of age, including dependents. We have provided specific citations below: • Group health plans and issuers are prohibited from varying the terms of the plan based on age (45 CFR § 147.120(d)). Thus, if a large group plan provides dependent coverage, and offers maternity and newborn care benefits, it must make the maternity and newborn care benefits available to dependents in the plan, regardless of age. Source: CCIIO 382

EHB Discrimination - Maternity Benefit

Source: Ruling Letter No. CN-2015-187-AS, dated March 26, 2015: Form and Rate Filings Submissions to be Effective for Calendar Year 2016. 383

Essential Health Benefits Mental Health Parity •The EHB-benchmark plans must comply with respect to the mental health and substance use disorder services, including behavioral health treatment services, as described in 45 CFR § 146.136 (Parity in mental health and substance use disorder benefits). – EHB plans must comply with the standards implemented under the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). Source: 45 CFR 156.115(a)(3). 384

The Mental Health Parity and Addiction Equity Act of 2008 • The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) amended the PHS Act, ERISA, and the Code to provide increased parity between mental health and substance use disorder benefits and medical/surgical benefits. • In general, MHPAEA requires that the financial requirements (such as coinsurance) and treatment limitations (such as visit limits) imposed on mental health and substance use disorder benefits cannot be more restrictive than the predominant financial requirements and treatment limitations that apply to substantially all medical/surgical benefits. Source: FAQs about Affordable Care Act Implementation (Part XVIII) and Mental Health Parity Implementation (January 9, 2014) http://www.dol.gov/ebsa/faqs/faq-aca18.html. 385

MHPAEA Individual Market Coverage • For non-grandfathered individual market coverage: All non-grandfathered individual market coverage that is not otherwise subject to the HHS transitional policy must include coverage for mental health and substance use disorder benefits, and that coverage must comply with the Federal parity requirements. Source: FAQs about Affordable Care Act Implementation (Part XVIII) and Mental Health Parity Implementation (January 9, 2014) http://www.dol.gov/ebsa/faqs/faq-aca18.html. 386

MHPAEA Individual Market Coverage • For grandfathered individual market coverage: Grandfathered individual health insurance coverage is not subject to the EHB requirements and therefore is not required to cover mental health or substance use disorder benefits. However, to the extent mental health or substance use disorder benefits are covered under the policy, coverage must comply with the Federal parity requirements. Source: FAQs about Affordable Care Act Implementation (Part XVIII) and Mental Health Parity Implementation (January 9, 2014) http://www.dol.gov/ebsa/faqs/faq-aca18.html. 387

MHPAEA Small Group Market Coverage • For non-grandfathered small group market coverage: All non-grandfathered small group market coverage that is not otherwise subject to the HHS transitional policy must include coverage for mental health and substance use disorder benefits, and that coverage must comply with the Federal parity requirements. • Grandfathered small group market coverage is not required to comply with either the EHB provisions or MHPAEA. Source: FAQs about Affordable Care Act Implementation (Part XVIII) and Mental Health Parity Implementation (January 9, 2014) http://www.dol.gov/ebsa/faqs/faq-aca18.html. 388

Essential Health Benefits Preventive Services • Must include preventive health services, as described in 45 CFR § 147.130 (Coverage of preventive health services) for adult, children, and women, including pregnant women • Has to cover recommended preventive services without any costsharing (copayment, coinsurance or deductible) if delivered by in-network providers. • May allow you to receive these services from an out-of-network provider, but may charge you a fee. • Can require to pay the office visit, if the preventive service is not the primary purpose of the visit, or if the it is billed separately from the office visit. Source: 45 CFR 156.115(a)(4); http://www.cms.gov/CCIIO/Resources/Data-Resources/Downloads/ehb-benchmark-reviewguide.pdf. 389

Código de Seguros de Salud Servicios de Cuidado Preventivo (EHBs) • Limitaciones a la imposición, en dichas cubiertas, de requisitos de compartir costos (“cost-sharing”) según dispuesto en ACA y en Código sobre servicios de cuidado preventivo.

390

Essential Health Benefits Rehabilitative and Habilitative Services and Devices Rehabilitation Services: • Health care services that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled. • These services may include physical and occupational therapy, speech-language pathology and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings. Source: http://www.healthcare.gov/glossary/r/rehabilitationservices_.html.

Habilitation Services: • Health care services that help a person keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn’t walking or talking at the expected age. • These services may include physical and occupational therapy, speechlanguage pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings. • An example of habilitative services is speech therapy for a child who is not talking at the expected age. Source: http://www.healthcare.gov/glossary/h/habilitation-services.html; http://cciio.cms.gov/resources/files/Files2/12162011/essential_health_be nefits_bulletin.pdf.

391

Essential Health Benefits Habilitative Services and Devices If the EHB-benchmark plan does not include coverage for habilitative services, the issuer must include habilitative services in a manner that meets one of the following:

(i) Provides parity by covering habilitative services benefits that are similar in scope, amount, and duration to benefits covered for rehabilitative services; or (ii) Is determined by the issuer and reported to HHS.

392

Essential Health Benefits Prescription Drug Benefits • Covers at least the greater of: – One drug in every United States Pharmacopeia (USP) category and class; or – The same number of prescription drugs in each category and class as the EHB-benchmark plan; and – Submits its drug list to the Exchange, the state, or OPM. • Does not fail to provide EHB prescription drug benefits solely because it does not offer drugs for abortion services. • Must have procedures in place that allow an enrollee to request clinically appropriate drugs not covered by the health plan. Source: 45 CFR sec. 156.122, see 78 Federal Register 12867 (February 25, 2013). 393

Prescription Drug Benefits Expedited Review Request Such procedures must include a process for an enrollee, the enrollee’s designee, or the enrollee’s prescribing physician (or other prescriber) to request an expedited review based on exigent circumstances. • Exigent circumstances exist when an enrollee is suffering from a health condition that may seriously jeopardize the enrollee’s life, health, or ability to regain maximum function or when an enrollee is undergoing a current course of treatment using a non-formulary drug. • A health plan must make its coverage determination on an expedited review request based on exigent circumstances and notify the enrollee or the enrollee’s designee and the prescribing physician (or other prescriber, as appropriate) of its coverage determination no later than 24 hours after it receives the request. • A health plan that grants an exception based on exigent circumstances must provide coverage of the non-formulary drug for the duration of the exigency. Source: 45 CFR sec. 156.122(c) 394

Código de Seguros de Salud Solicitud de Excepción Médica - Medicinas El asegurador establecerá y mantendrá un procedimiento para solicitar excepciones para que el asegurado solicite el que se: • Cubra un medicamento que no está en el formulario. • Continúe cubriendo una medicina que se eliminará del formulario por motivos no relacionados con la seguridad del mismo o por que el fabricante no continuará supliéndolo o lo ha retirado del mercado. • Conceda una excepción al requisito de terapia escalonada o de la restricción de dosis. Fuente: Artículo 4.070 (Requisitos y Procedimientos para la Aprobación de Excepciones Médicas) del Código de Seguros de Salud, según enmendado.

395

Código de Seguros de Salud Razones para Solicitar la Excepción Cuando el proveedor que prescribe determina que el medicamento es médicamente necesario para el tratamiento ya que: • No hay un medicamento en el formulario que sea una alternativa clínicamente aceptable para tratar la condición. • El medicamento alterno ha sido ineficaz en el tratamiento o ha causado reacción adversa. • Se estaba en un nivel más avanzado en la terapia escalonada de otro plan médico, por lo que no es razonable que comience de nuevo en un nivel menor de terapia. • La dosis disponible según la limitación ha sido ineficaz en el tratamiento de la condición médica del asegurado. Fuente: Artículo 4.070 (Requisitos y Procedimientos para la Aprobación de Excepciones Médicas) del Código de Seguros de Salud, según enmendado. 396

Código de Seguros de Salud Término para Considerar la Excepción La decisión hay que tomarla y notificarla con la premura que requiera la condición médica del asegurado, pero no más tarde de 72 horas, o de 36 en caso de los controlados, contados a partir desde la fecha del recibo de la solicitud. • Si la decisión no se toma ni se notifica en dicho término, el asegurado recibirá la medicina por 30 días; y el asegurador tomará la decisión antes de que se termine la medicina. • Si el asegurador no decide en el termino adicional (30 días), la cubrirá si es recetada al asegurado y sigue siendo segura, excepto que se agote el límites de los beneficios. Fuente: Artículo 4.070 (Requisitos y Procedimientos para la Aprobación de Excepciones Médicas) del Código de Seguros de Salud, según enmendado. 397

Solicitud de Excepción Médica Medicamento Nombre del Paciente y Representante Personal (si aplica): ________________________________ Núm. Contrato _________________________ Núm. de Grupo: ________________________ Se solicita la aprobación de: Medicamento no está incluido en el formulario Cubierta continuada para medicamento que se descontinuará del formulario Excepción a un procedimiento de manejo de medicamento (ei, terapia escalonada) Excepción a un procedimiento de limitación de dosis. Razones para la solicitud de excepción médica: En el formulario no figura un medicamento clínicamente aceptable para tratar la condición del paciente. El medicamento que procede conforme a la terapia escalonada es ineficaz para la condición o el paciente, es probable que cause daño al paciente o y ya el paciente se encontraba en un nivel más avanzado bajo otro plan médico. La dosis disponible para el medicamento probablemente sea ineficaz para la condición o para el paciente. Historial breve del paciente: Diagnóstico primario relacionado con el medicamento de receta objeto de la solicitud (incluya código y descripción): Descripción de la necesidad médica de medicamento para el cual se solicita la excepción: _______________________________________ ______________________ Nombre de la Persona que expide la receta # de Proveedor (NPI) _______________________________________ ______________________ Firma Fecha Forma: CSS-AS-04-002 Fuente: Carta Circular Número CC-2013-1832-D de 10 de julio de 2013 sobre Adopción del Nuevo Código de Seguros de Salud de Puerto Rico, Requisitos de Presentación de Información y Modelos Estándares.

398

Solicitud de Excepción Médica Informe Anual • El Código de Seguros de Salud requiere a los aseguradores mantener registros con respecto a las solicitudes de excepción médica recibidas durante el año natural anterior. • Con el fin de verificar el cumplimiento, los aseguradores deberán haber completado al 31 de marzo de cada año, el Informe sobre Solicitudes de Excepciones Médicas y tener el mismo disponible para ser examinado e inspeccionado por el Comisionado cuando éste lo solicite. • En caso de solicitudes de excepción médica denegadas se deberá especificar, en un documento aparte, las razones para la denegación y las disposiciones del contrato en las que se apoyó tal denegación. Fuente: Carta Circular Número CC-2013-1832-D de 10 de julio de 2013 sobre Adopción del Nuevo Código de Seguros de Salud de Puerto Rico, Requisitos de Presentación de Información y Modelos Estándares.

399

Off Label Prescription Drugs Uso No Indicado en la Etiqueta • Los planes con cubierta de medicinas proveerán para el despacho de un medicamento, independientemente de la condición para la cual son prescritos, cuando: – Tiene la aprobación de la FDA para al menos una indicación. – Es reconocido para el tratamiento de la condición, según la literatura médica. • La cubierta de un medicamento deberá incluir los servicios que estén asociados con su administración. • No hay que cubrir un medicamento cuando la FDA ha determinado que su uso es contraindicado para el tratamiento de la indicación para la cual se prescribe. Fuente: Capítulo 52 - Uso No Indicado en la Etiqueta del Código de Seguros de Salud, según enmendado.

400

Cubierta Dental Pediátrica Código de Seguros de Salud • Cuando el asegurador tenga la certeza razonable que la persona ha obtenido cubierta dental pediátrica en otra póliza mediante un plan dental autorizado por el Comisionado, no se entenderá que ha dejado de proveer los beneficios de salud esenciales si éstos ofrecen un plan médico individual que al combinarse con un plan dental autorizado asegure una cubierta plena de los beneficios de salud esenciales. • Para dejar de proveer la cubierta dental pediátrica será necesario emitir un endoso a esos efectos. Fuente: Cartas Normativas Número CN-2013-155-AS de 29 de julio de 2013 y CN-2013-156-AS de 30 de septiembre de 2013. 401

Código de Seguros de Salud Beneficios de Salud Esenciales - Emergencia • Cuando el proveedor está fuera de la red, no se podrá imponer requisito alguno para la autorización previa de los servicios de emergencia. En estos casos tampoco se podrá imponer limitación alguna de la cubierta que resulte más restrictiva que las aplicables a los servicios de emergencia recibidos por un proveedor de la red. • Si se proveen los servicios fuera de la red, los costos compartidos se limitarán según se dispone en el Artículo 24.110 del Capítulo sobre “Revisión de Utilización y Determinación de Beneficios” del Código de Seguros de Salud de Puerto Rico. Fuente: Cartas Normativas Número CN-2013-155-AS de 29 de julio de 2013 y CN2013-156-AS de 30 de septiembre de 2013. 402

Código de Seguros de Salud Beneficios de Salud Esenciales - Emergencia • Los aseguradores cubrirán los servicios de emergencia necesarios para el cernimiento y estabilización del asegurado. – No se requiere autorización previa para los servicios de emergencia provistos por un no participante. – No se impondrán requisitos administrativos ni limitaciones de cubierta que sean más restrictivos que los aplicables a los proveedores participantes. • Los servicios de emergencia estarán sujetos a los copagos, coaseguros y deducibles aplicables, sean provistos por un participante o no. • Los aseguradores proveerán acceso a un representante designado las 24 horas al día, los 7 días de la semana. 403

Código de Seguros de Salud Beneficios de Salud Esenciales - Emergencia El asegurador pagará por los servicios de emergencia provistos por un proveedor no participante, una tarifa no menor que la que resulte mayor de las siguientes cantidades: • La tarifa negociada con los proveedores participantes para tales servicios de emergencia, excluyendo los copagos o coaseguros. • La tarifa por el servicio de emergencia provisto, calculada según el método que el asegurador utilice para determinar los pagos a los participantes, pero utilizando los copagos, coaseguros y deducibles aplicables a los participantes y no los de los no participantes; • La tarifa que se pagaría bajo Medicare por el servicio de emergencia provisto, excluyendo cualquier requisito de copago o coaseguro aplicable a los participantes.

404

Essential Health Benefits State Additional Required Benefits • A state may require to offer benefits in addition to the EHBs. • A state-required benefit enacted on or before December 31, 2011 is not considered in addition to the EHBs package, thus allowing states to include such benefit mandates in their EHB packages. • State-mandated benefits enacted after December 31, 2011 could not be part of EHB for 2014 or 2015, unless already included within the benchmark plan regardless of the mandate. • If a benefit, including a State-mandated benefit, included within a State-selected EHB benchmark plan was to have a dollar limit, that benefit would be incorporated into the EHB definition without the dollar limit. Source: 45 CFR sec. 155.170, see 78 Federal Register 12865 (February 25, 2013); http://cciio.cms.gov/resources/files/Files2/02172012/ehb-faq-508.pdf.

405

Essential Health Benefits State Additional Required Benefits • For purposes of determining EHB, we consider state-required benefits (or mandates) to include only requirements that a health plan cover specific care, treatment, or services. • We do not consider: – Provider mandates, which require a health plan to reimburse specific health care professionals who render a covered service within their scope of practice, to be state-required benefits for purposes of EHB coverage. – State-required benefits to include dependent mandates, which require a health plan to define dependents in a specific manner or to cover dependents under certain circumstances (e.g., newborn coverage, adopted children, domestic partners, and disabled children). – State anti-discrimination requirements relating to service delivery method (e.g., telemedicine) as state-required benefits. Source: Guide to Reviewing Essential Health Benefits Benchmark Plans: http://www.cms.gov/CCIIO/Resources/Data-Resources/Downloads/ehb-benchmark-review-guide.pdf 406

Puerto Rico Additional Required Benefits

407

Puerto Rico Additional Required Benefits

408

Puerto Rico Additional Required Benefits

409

Essential Health Benefits Benefit Substitution Unless prohibited by applicable State requirements, an issuer of a plan offering EHB may substitute benefits if the issuer meets the following conditions: • Substitutes a benefit that: (i) Is actuarially equivalent to the benefit that is being replaced; (ii) Is made only within the same essential health benefit category; and (iii) Is not a prescription drug benefit. Source: 45 CFR sec. 156.115 (b), see 78 Federal Register 12867 (February 25, 2013). 410

Essential Health Benefits Benefit Substitution Submits evidence of actuarial equivalence that is: (i) Certified by a member of the American Academy of Actuaries; (ii) Based on an analysis performed in accordance with generally accepted actuarial principles and methodologies; (iii) Based on a standardized plan population; and (iv) Determined regardless of cost sharing. Source: 45 CFR sec. 156.115 (b), see 78 Federal Register 12867 (February 25, 2013).

411

Waiting Period Before an Enrollee can Access a Covered Benefit 1. For plans that must provide coverage of the essential health benefit package under section 1302(a) of the Affordable Care Act, if an issuer imposes a waiting period before an enrollee can access a covered benefit, is that a violation of 45 CFR 156.125? Source: CCIIO - Frequently Asked Questions on Health Insurance Market Reforms and Marketplace Standards (http://www.cms.gov/CCIIO/Resources/Fact-Sheets-andFAQs/Downloads/Final-Master-FAQs-5-16-14.pdf)

412

Waiting Period Before an Enrollee can Access a Covered Benefit • 45 CFR 156.125 states that an issuer does not provide EHB if its benefit design, or the implementation of its benefit design, discriminates based on an individual’s age, expected length of life, present or predicted disability, degree of medical dependency, quality of life, or other health condition. • We are concerned that waiting periods for specific benefits discourage enrollment of or discriminate against individuals with significant health needs or present or predicted disability. • For example, a plan that includes a waiting period for any type of transplant would discriminate against those whose conditions make it likely that they would need a transplant: those with kidney disease, heart conditions, or similarly critical and life-threatening ailments. 413

Waiting Period Before an Enrollee can Access a Covered Benefit • In addition, imposing a waiting period on an EHB could mean the issuer is not offering coverage that provides EHB as required by 45 CFR 156.115, which would be a violation of Section 2707(a) of the Public Health Service Act (PHS Act) and its implementing regulations. • Therefore, with respect to plans that must provide coverage of the essential health benefit package, issuers may not impose benefit-specific waiting periods, except in covering pediatric orthodontia, in which case any waiting periods must be reasonable pursuant to §156.125 and providing EHB. • Any issuer that currently has a waiting period in its plan policy for an EHB needs to amend the policies to remove the waiting period within a reasonable timeframe of the release of this document. • This clarification refers to a waiting period that is applied uniformly to a specific benefit within the plan design and not reasonable medical management. 414

Essential Health Benefits Prohibition on Discrimination • An issuer providing EHBs must not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity or sexual orientation, 45 CFR § 156.200(e). • An issuer does not provide EHBs if its benefit design, or the implementation of its benefit design, discriminates based on an individual's age, expected length of life, present or predicted disability, degree of medical dependency, quality of life, or other health conditions. • Nothing in this section shall be construed to prevent an issuer from appropriately utilizing reasonable medical management techniques. Source: 45 CFR sec. 156.125, see 78 Federal Register 12867 (February 25, 2013). http://www.cms.gov/CCIIO/Resources/Regulations-andGuidance/Downloads/2016DraftLettertoIssuers12-19-2014.pdf 415

Essential Health Benefits Prohibition on Discrimination Question: Can scope and duration limitations be included in the EHB? • Answer: Yes. Under the intended approach, a plan must be substantially equal to the benchmark plan, in both the scope of benefits offered and any limitations on those benefits such as visit limits. However, any scope and duration limitations in a plan would be subject to review pursuant to statutory prohibitions on discrimination in benefit design. Source: http://cciio.cms.gov/resources/files/Files2/02172012/ehb-faq-508.pdf.

416

Nondiscrimination in Health Programs and Activities (Section 1557 of the ACA) Proposed Rule • Prohibitions on gender identity discrimination as a form of sex discrimination. For example, a provider may not deny an individual treatment for ovarian cancer, based on the individual’s identification as a transgender man, where the treatment is medically indicated. • Enhances language assistance for people with limited English proficiency. • Requires effective communication for individuals with disabilities. • Ensures consumers have the equal access to health care and health coverage provided by the Affordable Care Act. • Requires that women have equal access to the health care they receive and the insurance they obtain. Source: http://www.hhs.gov/ocr/civilrights/understanding/section1557/nprmsummary.html 417

Código de Seguros de Salud No Discrimen • No se provee beneficios de salud esenciales si el diseño o la implantación de éstos discrimina por motivo de: edad, expectativa de vida, impedimento presente o previsible, grado de dependencia médica, calidad de vida u otras condiciones de salud de la persona. • Tampoco se puede discriminar por razón de raza, color, origen nacional, impedimento, edad, sexo, identidad de genero u orientación sexual. • Se pueden implantar procedimientos para la administración de los servicios de cuidado de salud. Referencia: Carta Normativa CN-2013-155-AS, emitida el 29 de julio de 2013. 418

Essential Health Benefits Update and Review EHB Over Time • ACA directs the HHS Secretary to periodically review the definition of EHB, report the findings of such review to the Congress and the public, and update the EHB definition as needed to address gaps in access to care or advances in the relevant evidence base. • HHS proposed that the state’s benchmark plan selection in 2012 would be applicable for the 2014 and 2015 benefit years, and be based on plan benefits offered by the selected benchmark at the time of selection, including any applicable state required benefits enacted prior to December 31, 2011. • HHS chose this approach for establishing a consistent set of benefits for 2 years in order to reflect current market offerings and limit market disruption in the first years of the Exchanges. Source: Proposed Rule, 77 Federal Register at 70649 (November 26, 2012). 419

Proposed 2017 Essential Health Benefits (EHB) Benchmark Plans • August 28, 2015 List of Proposed 2017 EHB Benchmark Plans and Related Information • For plan year 2017 and beyond, the EHB benchmark plan is a plan that was sold in 2014. • When designing plans that are substantially equal to the EHB benchmark plan issuers may need to conform plan benefits, including coverage and limitations, to comply with current federal requirements. Source: http://www.cms.gov/CCIIO/Resources/Data-Resources/ehb.html

420

Essential Health Benefits Employer in More than One State Question: In the case of a non-grandfathered insured small group market plan that offers coverage to employees residing in more than one State, which State-selected EHB benchmark plan would apply? • Answer: Generally, the current practice in the group health insurance market is for the health insurance policy to be issued where the employer's primary place of business is located. As such, the employer’s health insurance policy must conform to the benefits required in the employer’s State, given that the employer is the policyholder. Nothing in the Bulletin or our proposed approach seeks to change this current practice. Therefore, the applicable EHB benchmark for the State in which the insurance policy is issued would determine the EHB for all participants, regardless of the employee’s State of residence. Source: http://cciio.cms.gov/resources/files/Files2/02172012/ehb-faq-508.pdf. 421

Puerto Rico EHB Benchmark Plan Questions and Answers • 21. Q: Is it necessary to detail the Rx and Pediatric Dental in the benchmark? A: Yes • 22. Q: What is your decision about the age to which Pediatric Dental and Vision has to be covered, age 19 or 21? A: Age 21 • 23. Q: Can we offer Pediatric benefits (vision, dental) through a medical endorsement or rider or do they need to be included in the basic medical plan? A: The Pediatric benefits are to be part of the basic medical plan. Source: http://ocs.gobierno.pr/ocspr/documents/obamacare/Q%20%20A%20I NDUSTRIA%20Final.pdf 422

Puerto Rico EHB Benchmark Plan Questions and Answers • 24. Q: Is transplant coverage offered under the basic medical plan or can it be offered in a major medical plan? A: The benchmark plan does not specify. • 25. Q: The Dental Medical Equipment Benefit has a annual limt of $5,000, is this acceptable under the Essential Health Benefit requirements? A: No, the Essential Health Benefit cannot have dollar limits. 423

Essential Health Benefits Non EHBs Services A health plan does not fail to provide EHB solely because it does not offer or include: • The abortion services, (45 CFR §156.280(d). • Non-pediatric routine dental services. • Non-pediatric routine eye exam services. • Long-term or custodial nursing home care benefits. • Non-medically necessary orthodontia. Source: 45 CFR sec. 156.115 (c) and (d), see 78 Federal Register 12867 (February 25, 2013).

424

Which Plans Must Offer the Essential Health Benefits Package?

Source: http://www.acscan.org/pdf/healthcare/implementation/background/EssentialHealthBenefits.pdf 425

B. Niveles de Cubierta Metálicos Levels of Coverage 45 CFR §156.140

426

Niveles de Cubierta Metálicos Todo asegurador u organización de seguros de salud que provea planes médicos individuales o grupales deberá asegurarse que el Conjunto de Beneficios de Salud Esenciales se provea en los niveles de cubierta metálicos, según descritos en la Sección 1302(d) del Affordable Care Act. Fuente: Inciso D (3) del Artículo Artículo 2.050 del Código de Seguros de Salud, según enmendado.

427

Código de Seguros de Salud Niveles de Cubierta Metálicos • Nivel Bronce –La cubierta provee beneficios que son actuarialmente equivalentes a un 60% del valor actuarial total de los beneficios incluidos en la cubierta. • Nivel Plata – La cubierta provee beneficios que son actuarialmente equivalentes a un 70% del valor actuarial total de los beneficios incluidos en la cubierta. • Nivel Oro – La cubierta provee beneficios que son actuarialmente equivalentes a un 80% del valor actuarial total de los beneficios incluidos en la cubierta. • Nivel Platino – La cubierta provee beneficios que son actuarialmente equivalentes a un 90% del valor actuarial total de los beneficios incluidos en la cubierta. 428

Código de Seguros de Salud Niveles de Cubierta Metálicos Cubierta

Plan

Asegurado

Bronce

60%

40%

Plata

70%

30%

Oro

80%

20%

Platino

90%

10%

La cubierta provee beneficios que son actuarialmente equivalentes a un % del valor actuarial total de los beneficios incluidos en la cubierta. 429

Essential Health Benefits Niveles de Cubierta Metálicos

A health insurance plan’s actuarial value is the average share of medical spending that is paid by the plan and not by the member. As a general rule: the higher the actuarial value, the less cost-sharing responsibilities (deductibles, copays and coinsurance) for the member, but the higher the premium. (http://www.choosehap.org/plan-levels) 430

431

Código de Seguros de Salud Niveles de Cubierta Metálicos • Si un asegurador u organización de seguros de salud ofrece un plan médico con alguno de los niveles de cubierta metálicos descritos en ACA y en el Código tendrá que ofrecer el plan médico en el mismo nivel de cubierta metálica a todo aquel asegurado que a principio del año póliza no haya cumplido 21 años.

432

Código de Seguros de Salud Niveles de Cubierta Metálicos 32. Q: Would it be discriminatory, pursuant to ACA, if the insurer offers only the EHB plans in all of the metallic coverage, or if it has to offer also, all the riders and endorsements available for any insured? • A: If a plan includes benefits in addition to EHB, those benefits must be made available to everyone who wants to purchase that plan. Sometimes riders and endorsements are optional, in which case a consumer must be allowed to purchase them (unless they are excepted benefits). If they are built into the plan, then they of course would need to be made available to anyone who wants to purchase the plan. Source:

http://ocs.gobierno.pr/ocspr/documents/obamacare/Q%20%20A%20INDUSTRIA%20Final.pdf .

433

Planes Médicos Individuales y de Patronos de PYMES • Normas y procedimientos para la presentación de los planes médicos individuales, grupos pequeños y de patronos de PYMES ante el Comisionado de Seguros para su aprobación. – Presentación de las Tarifas y Formularios de los Planes Médicos Individuales grupos pequeños y de Patronos PYMES y de los cambios en las tarifas. – Modificación de Formularios de Pólizas o Evidencias de Cubierta para incluir las disposiciones relacionadas a Beneficios de Salud Esenciales. Fuente: Cartas Normativas CN-2013-155-AS de 29 de julio de 2013 y CN-2013-156-AS de 30 de septiembre de 2013. 434

Carta de Derechos del Paciente Selección de Planes y Proveedores Que los planes de cuidado de salud les ofrezcan una cubierta sin límite económico o “dollar limits”, según estos términos son definidos en la legislación federal y su reglamentación federal correspondiente, ya sea de por vida; por contrato anual, en los beneficios esenciales cubiertos, definidos como “essential health benefits” en ACA, y por sus reglamentos, y por las normas establecidas por el Comisionado. Fuente: Artículo 6 (f) de la Carta de Derechos y Responsabilidades del Paciente, según enmendada por la Ley Número 161 de 1 de noviembre de 2010.

435

C. Cost-Sharing Requirements on Essential Health Benefits (EHBs) (Límites Máximos de los Costos Compartidos que Asume el Asegurado Aplicable a los Servicios de Salud Esenciales) • Annual Deductible Limitations. • Annual Limitation on Out-of-Pocket Maximums. 45 CFR § 156.130 436

Annual Deductible Limitations

437

Limitation on Deductibles in the Small Group Market • Protecting Access to Medicare Act of 2014, Public Law No. 113-93, was enacted on April 1, 2014. • Section 213 of that law repeals the limitation on deductibles ($2,000 for self-only coverage and $4,000 for other than self-only coverage) in the small group market that was previously required in this market under section 2707(b) of the PHS Act and section 1302(c)(2) of the Affordable Care Act. Source: FAQs about Affordable Care Act Implementation (Part XIX): http://www.dol.gov/ebsa/faqs/faq-aca19.html 438

Cost-Sharing Requirements on EHBs Annual Deductible Limitations • El término deducible es la cantidad que el asegurado debe pagar por los servicios cubiertos antes de que el plan médico comience a pagar. Por ejemplo, si el deducible es $1000, el plan no pagará hasta que el asegurado haya gastado $1000 en los servicios cubiertos a los que se aplica el deducible. • Las pólizas a venderse en el mercado individual pueden establecer un tope anual de $2,000 en un contrato individual (self-only coverage) y de $4,000 (other than self-only coverage) cuando no es un contrato individual (ejemplo es familiar). • Esta disposición no aplica a los granfathered health plans, a las pólizas que se venden en el mercado de grupos pequeños (small group health plans), grupos grandes (large group health plans) y a los self-insured.

439

Cost-Sharing Requirements on EHBs Annual Deductible Limitations • El deducible es con relación a los beneficios esenciales. – No se aplica a los deducibles por los beneficios no esenciales. – Se aplica a los servicios que provee un proveedor participante. – No aplica a los servicios prestados por un proveedor no participante. – Se consideran los servicios de un proveedor no participante en caso de servicios prestados en una emergencia o cuando no hay un participante que pueda proveer los mismos. • El asegurado no paga deducible alguno por los servicios de cuidado preventivo. – Por ejemplo, si el asegurado recibe un servicio preventivo no paga cantidad alguna aunque no se haya pagado el deducible correspondiente. 440

Cost-Sharing Requirements on EHBs Annual Deductible Limitations • No puede imponerse un deducible separado para condiciones de salud física y otro para condiciones de salud mental. • Se establece un solo deducible anual, que aplica tanto a la cubierta de salud física y mental y a la cubierta de farmacia. • El deducible anual a que se refiere ACA no es un copago o coaseguro por servicio. – En Puerto Rico el concepto de deducible se utiliza para referirse al pago (copago o coaseguro) que se hace al momento de recibir un servicio de salud. – Ahora el concepto deducible tiene la misma definición que se utiliza en Medicare y en los planes médicos privados de los EUA.

441

Annual Limitation on Out-of-Pocket Maximums

442

Cost-Sharing Requirements on EHBs Maximum Out-of-Pocket (MOOP) • ACA también dispone un tope en los out-of-pocket (MOOP) que debe pagar un asegurado por los beneficios esenciales. – Límite de gastos del bolsillo: El monto máximo que usted pagará mientras tenga el plan (generalmente un año) antes de que su seguro médico o su plan comiencen a pagar el 100% de la cantidad aprobada. – Este límite nunca incluye la prima, el saldo de facturación o los servicios que su plan no cubre. • Luego que el asegurado llega al tope no tienen que hacer ningún otro desembolso por estos conceptos. El asegurador pagará al proveedor el total de la cantidad por los servicios esenciales prestados. 443

Cost-Sharing Requirements on EHBs Maximum Out-of-Pocket (MOOP) • Se dispone que las pólizas a venderse en Puerto Rico en el 2016 solo pueden establecer un tope anual de $6,350 en un contrato individual (self-only coverage) y de $12,700 en un contrato familiar (other than self-only coverage). – En el 2016 un self-insured group health plan puede imponer el tope de $6,850 en la cubierta individual y $13,700 cubierta familiar. • El plan médico puede disponer un MOOP menor al tope de la cantidad indicada en la reglamentación aplicable. • Esta disposición aplica a los, a las pólizas que se venden en el mercado individual, de grupos pequeños y de grupos grandes, así como self-insured group health plans. 444

Cost-Sharing Requirements on EHBs Maximum Out-of-Pocket (MOOP) • El MOOP es con relación a los beneficios esenciales. – No se aplica a los deducibles, copagos y coaseguros que se pagan por los beneficios no esenciales. – Aplican los deducibles, copagos y coaseguros por los servicios que provee un proveedor participante. – No se aplican los deducibles, copagos y coaseguros por los servicios prestados por un proveedor no participante. – Se consideran los deducibles, copagos y coaseguros por los servicios de un proveedor no participante en caso de servicios de emergencia o si no hay un participante que proveer los mismos. 445

Cost-Sharing Requirements on EHBs Maximum Out-of-Pocket (MOOP) • No puede imponerse un MOOP para condiciones de salud física y otro para condiciones de salud mental. – Under Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) plans and issuers are prohibited from imposing an annual out-of-pocket maximum on all medical/surgical benefits and a separate annual out-of-pocket maximum on all mental health and substance use disorder benefits. • Se establece un solo MOOP anual, que aplicara tanto para la cubierta de salud física y mental, como para la cubierta de farmacia.

446

Limitations on Cost Sharing under the Affordable Care Act • The self-only maximum annual limitation on cost sharing applies to each individual, regardless of whether the individual is enrolled in self-only coverage or in coverage other than self-only (family coverage or other coverage that is not self-only coverage). Source: http://www.dol.gov/ebsa/faqs/faq-aca27.html

447

Self-only Maximum Annual Limitation Example

• Assume that a family of four individuals is enrolled in family coverage under a group health plan in 2016 with an aggregate annual limitation on cost sharing for all four enrollees of $13,000 (note that a plan is permitted to set an annual limitation below the maximum established under section 1302(c)(1), which is an aggregate $13,700 limitation for coverage other than self-only for 2016). • Assume that individual #1 incurs claims associated with $10,000 in cost sharing, and that individuals #2, #3, and #4 each incur claims associated with $3,000 in cost sharing (in each case, absent the application of any annual limitation on cost sharing). • Assume that individual #1 incurs claims associated with $10,000 in cost sharing, and that individuals #2, #3, and #4 each incur claims associated with $3,000 in cost sharing (in each case, absent the application of any annual limitation on cost sharing). 448

Self-only Maximum Annual Limitation Example In this case, because, under the clarification discussed above, the self-only maximum annual limitation on cost sharing ($6,850 in 2016) applies to each individual, cost sharing for individual #1 for 2016 is limited to $6,850, and the plan is required to bear the difference between the $10,000 in cost sharing for individual #1 and the maximum annual limitation for that individual, or $3,150. With respect to cost sharing incurred by all four individuals under the policy, the aggregate $15,850 ($6,850 + $3,000 + $3,000 + $3,000) in cost sharing that would otherwise be incurred by the four individuals together is limited to $13,000, the annual aggregate limitation under the plan, under the assumptions in this example, and the plan must bear the difference between the $15,850 and the $13,000 annual limitation, or $2,850. 449

How Does the New OOP Max Rule Work?

Example • An employee enrolls in his nonprofit organization's group health plan for the calendar year. He selects the employee-plus-children option so he can cover himself, his son, and his daughter. The coverage period is the calendar year. In January, before any other health expenses have been incurred, the employee has a surgical medical operation. Between his deductible and his coinsurance, and before the application of any OOP Max, the employee's share of the medical expenses is $10,000. • If this were January 2015, the plan would say that because the amount owed ($10,000) is less than the overall OOP Max ($13,200), the employee must pay $10,000. • If this were January 2016, the plan would say that because the amount owed ($10,000) is more than the individual OOP Max ($6,850), the employee must pay $6,850; the plan must pay the $3,150 difference. Source: United States: New Out-Of-Pocket Maximum Rule Affects Most Group Health Plans Sponsored By Nonprofit Organizations; Last Updated: June 3 2015; Article by Thora A. Johnson and Juliana RenoVenable LLP; http://www.mondaq.com/article.asp?articleid=402104&email_access=on 450

Who must comply with the annual limitation on out-of-pocket maximums? • As stated in the preamble to the HHS final regulation on standards related to essential health benefits, the Departments read PHS Act section 2707(b) as requiring all non-grandfathered group health plans to comply with the annual limitation on out-of-pocket maximums described in section 1302(c)(1) of the Affordable Care Act.[3] – Large group market and self-insured group health plans must comply with the annual limitation on out-of-pocket maximums. Source: http://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/aca_implementation_faqs12.html#Limitations on Cost-Sharing under the Affordable Care Act; Source: 78 Federal Register 12837 and 12847, Monday, February 25, 2013 (http://www.gpo.gov/fdsys/pkg/FR-2013-02-25/pdf/2013-04084.pdf)

451

Who must comply with the annual limitation on out-of-pocket maximums? • The Departments recognize that plans may utilize multiple service providers to help administer benefits (such as one third-party administrator for major medical coverage, a separate pharmacy benefit manager, and a separate managed behavioral health organization). – Separate plan service providers may impose different levels of outof-pocket limitations and may utilize different methods for crediting participants’ expenses against any out-of-pocket maximums. – These processes will need to be coordinated under section 1302(c)(1), which may require new regular communications between service providers. Source: http://www.cms.gov/CCIIO/Resources/Fact-Sheets-andFAQs/aca_implementation_faqs12.html#Limitations on Cost-Sharing under the Affordable Care Act; Source: 78 Federal Register 12837 and 12847, Monday, February 25, 2013 (http://www.gpo.gov/fdsys/pkg/FR-2013-02-25/pdf/2013-04084.pdf)

452

Can a Self-Insured Plans be Exempt from the Cost Sharing Limits? Comment: • Some commenters requested that self-insured plans be exempt from the cost sharing limits described in §156.130(a). • Several of these comments indicated operational concerns with applying a single annual limitation on cost sharing to EHB that are administered by separate contractors; in particular, commenters noted the practice of using a pharmacy benefit manager to administer prescription benefits separately from other medical benefits. • Other commenters agreed with the legal read that cost sharing limits described in §156.130(a) apply to all group health plans. Source: 78 Federal Register 12837, Final Rule (Monday, February 25, 2013). 453

Can a Self-Insured Plans be Exempt from the Cost Sharing Limits? Response: • We note that DOL also received correspondence on this issue seeking clarification of how the three Departments would interpret section 2707(b) of the PHS Act and the corresponding provisions in ERISA and the Code. • As discussed in more detail above, the three Departments interpret these provisions to mean that large group market and self-insured group health plans must comply with the annual limitation on out-of-pocket maximums described in section 1302(c)(1). • Nevertheless, the Departments are concerned about the operational and timing issues raised by commenters, and find that some transitional relief is appropriate. Accordingly, the three Departments are issuing concurrent sub-regulatory guidance identifying an enforcement safe harbor for large and self-insured group health plans to address those operational concerns. Source: 78 Federal Register 12837, Final Rule (Monday, February 25, 2013). 454

Count an Individual's Out-of-Pocket Costs • The term "cost-sharing" does not include premiums, balance billing amounts for nonnetwork providers, or spending for non-covered services. • Nothing, however, prohibits a plan or issuer from counting such expenses toward the plan's annual maximum out-of-pocket limit, particularly in the circumstances described in Q4 above with respect to QHP issuers. – HHS strongly encourages QHP issuers to allow enrollees to receive in-network benefits with respect to any provider listed in the version of the provider directory as of the date of that enrollee's enrollment for the beginning months of coverage, in cases where issuers are unable to maintain provider directories in a current status. – HHS also urges QHP issuers to temporarily cover non-formulary drugs, as well as drugs that are on a QHP issuer's formulary but typically require prior authorization or step therapy prior to being covered, during the first 30 days of coverage, starting on January 1, 2014. – Accordingly, under these limited circumstances, HHS strongly encourages QHP issuers to count enrollees' out-of-pocket expenses on these services and items toward the QHPs' annual maximum out-of-pocket limits. Source: FAQs about Affordable Care Act Implementation (Part XVIII) and Mental Health Parity Implementation (January 9, 2014) http://www.dol.gov/ebsa/faqs/faq-aca18.html. 455

Out-of-Network Provider Charges Q2: If an out-of-network provider charges an amount greater than the plan's or issuer's allowed amount, does individual spending for the amount in excess of the allowed amount (also known as balance billing) count toward the out-ofpocket maximum? • The Departments previously stated if a plan includes a network of providers, the plan may, but is not required to, count out-of-pocket spending for out-ofnetwork items and services towards the plan's annual out-of-pocket maximum. • A plan that counts such spending towards the out-of-pocket maximum may use any reasonable method for doing so. For example, if the plan covers 75% of the usual, customary, and reasonable amount (UCR) charged for services provided out-of-network and the participant pays the remaining 25% of UCR plus any amount charged by the out-of-network provider in excess of UCR, the 25% of UCR paid by the participant may reasonably be counted, in full or in part, toward the out-of-pocket maximum without including any amount charged above UCR paid by the participant. Source: FAQs about Affordable Care Act Implementation (Part XIX): http://www.dol.gov/ebsa/faqs/faq-aca19.html 456

Costs for a Brand Name Drug, When a Generic is Available and Medically Appropriate Q3: With respect to the annual out-of-pocket maximum, how should large group market coverage and self-insured group health plans treat an individual's out-of-pocket costs for a brand name prescription drug, in circumstances in which a generic was available and medically appropriate? • As the Departments previously stated in guidance on how to apply annual and lifetime dollar limits under section 2711 of the Public Health Service Act, large group market coverage and self-insured group health plans have discretion to define "essential health benefits." For example, a plan may include only generic drugs, if medically appropriate (as determined by the individual's personal physician) and available, while providing a separate option (not as part of essential health benefits) of electing a brand name drug at a higher cost sharing amount. If, under this type of plan design, a participant or beneficiary selects a brand name prescription drug in circumstances in which a generic was available and medically appropriate (as determined by the individual's personal physician), the plan may provide that all or some of the amount paid by the participant or beneficiary (e.g., the difference between the cost of the brand name drug and the cost of the generic drug) is not required to be counted towards the annual out-of-pocket maximum. For ERISA plans, the SPD must explain which covered benefits will not count towards an individual's out-ofpocket maximum. • In determining whether a generic is medically appropriate, a plan may use a reasonable exception process. For example, the plan may defer to the recommendation of an individual's personal physician, or it may offer an exceptions process meeting the requirements of 45 CFR 156.122(c). • For non-grandfathered health plans in the individual and small group markets that must provide coverage of the essential health benefit package under section 1302(a) of the Affordable Care Act, additional requirements apply. Source: FAQs about Affordable Care Act Implementation (Part XIX): http://www.dol.gov/ebsa/faqs/faq-aca19.html 457

Costs for a Brand Name Drug, When a Generic is Available and Medically Appropriate Q4: If large group market coverage or self-insured group health plan has a reference-based pricing structure, under which the plan pays a fixed amount for a particular procedure (for example, a knee replacement), which certain providers will accept as payment in full, how does the out-of-pocket limitation apply when an individual uses a provider that does not accept that amount as payment in full? •

Reference pricing aims to encourage plans to negotiate cost effective treatments with high quality providers at reduced costs. At the same time, the Departments are concerned that such a pricing structure may be a subterfuge for the imposition of otherwise prohibited limitations on coverage, without ensuring access to quality care and an adequate network of providers.



Accordingly, the Departments invite comment on the application of the out-of-pocket limitation to the use of reference based pricing. The Departments are particularly interested in standards that plans using referencebased pricing structures should be required to meet to ensure that individuals have meaningful access to medically appropriate, quality care. Please send comments by August 1, 2014 to [email protected]



Until guidance is issued and effective, with respect to a large group market plan or self-insured group health plan that utilizes a reference-based pricing program, the Departments will not consider a plan or issuer as failing to comply with the out-of-pocket maximum requirements of PHS Act section 2707(b) because it treats providers that accept the reference amount as the only in-network providers, provided the plan uses a reasonable method to ensure that it provides adequate access to quality providers.



For non-grandfathered health plans in the individual and small group markets that must provide coverage of the essential health benefit package under section 1302(a) of the Affordable Care Act, additional requirements apply.

Source: FAQs about Affordable Care Act Implementation (Part XIX): http://www.dol.gov/ebsa/faqs/faq-aca19.html 458

459

Normas para Pólizas 2016 • Todos los productos y la estructura de copagos se tienen que radicarse a la misma vez y no se pueden cambiar durante el año. – Los productos en cumplimiento con ACA que estarán vigentes en el año natural 2016 sólo deben incluir un límite de gastos pagados por el beneficiario (MOOP), lo cual incluye los medicamentos recetados. – El MOOP para el año 2016 establecido es de $6,350 para la cubierta que es solamente del beneficiario y $12,700 para todo otro tipo de cubierta. Fuente: Ruling Letter No. CN-2015-187-AS, dated March 26, 2015: Form and Rate Filings Submissions to be Effective for Calendar Year 2016. 460

5. No Lifetime or Annual Dollar Limits on Essential Health Benefits (EHBs) 45 CFR § 147.126

461

A. No Lifetime Dollar Limits Definition Lifetime Limit: • A cap on the total lifetime benefits you may get from your insurance company during the entire time you were enrolled in that plan. • An insurance company may impose a total lifetime dollar limit on benefits (like a $1 million lifetime cap) or limits on specific benefits (like a $200,000 lifetime cap on organ transplants or one gastric bypass per lifetime) or a combination of the two. • After a lifetime limit is reached, the insurance plan will no longer pay for covered services. Source: http://www.healthcare.gov/glossary/L/lifetimelimit.html. 462

No Lifetime Dollar Limits on Essential Health Benefits • No lifetime dollar limit on essential health benefits since September 23, 2010. • No lifetime limit on what the plan would spend for covered benefits during the entire time you were enrolled in that plan. • Lifetime dollar limit on spending for health care services that are not essential. • Applies to individual or group health plan. Sources: http://www.healthcare.gov/law/provisions/limits/limits.html http://www.healthcare.gov/glossary/e/essential.html.

463

Model Language Notice Lifetime Limit No Longer Applies and Enrollment Opportunity • Written notice that the lifetime limit on the dollar value of all benefits no longer applies and that an individual, if covered, is once again eligible for benefits under the plan. • If the individual is not enrolled in the plan or if an enrolled individual is eligible for but not enrolled in any benefit package under the plan or health insurance coverage, then the plan or issuer must also give such an individual an opportunity to enroll that continues for at least 30 days (including written notice of the opportunity to enroll). Source: http://www.dol.gov/ebsa/healthreform/.

464

Model Language Notice Lifetime Limit No Longer Applies and Enrollment Opportunity • Must be provided beginning not later than the first day of the first plan year beginning on or after Sept. 23, 2010. • For individuals who enroll under this opportunity, the coverage must take effect not later than the first day of the first plan year beginning on or after Sept. 23, 2010. • May be provided to an employee on behalf of the employee’s dependent. • May be included with other enrollment materials that a plan distributes to employees, provided the statement is prominent. Source: http://www.dol.gov/ebsa/healthreform/. 465

Model Language Notice Lifetime Limit No Longer Applies and Enrollment Opportunity The lifetime limit on the dollar value of benefits under [Insert name of group health plan or health insurance issuer] no longer applies. Individuals whose coverage ended by reason of reaching a lifetime limit under the plan are eligible to enroll in the plan. Individuals have 30 days from the date of this notice to request enrollment. For more information contact the [insert plan administrator or issuer] at [insert contact information]. Source: http://www.dol.gov/ebsa/healthreform/.

466

B. No Annual Dollar Limits on Definition Annual Limit: • A cap on the benefits paid in a year while you're enrolled in a particular health insurance plan. • These caps are sometimes placed on particular services such as prescriptions or hospitalizations. • Annual limits may be placed on the dollar amount of covered services or on the number of visits that will be covered for a particular service. Source: http://www.healthcare.gov/glossary/a/annuallimit.html.

467

No Annual Dollar Limits on Essential Health Benefits • Since January 1, 2014, it is be prohibited ($0) on coverage of essential health benefits for plans issued or renewed. • Can put limits for services that are not essential. • Applies to individual or group health plan, except for grandfathered individual plans. Sources: http://www.hhs.gov/ociio/regulations/annual_limits_waiver_guidance.pdf http://www.healthcare.gov/law/provisions/limits/limits.html http://www.healthreform.gov/newsroom/new_patients_bill_of_rights.html

468

Annual and Lifetime Dollar Limits EHB-Benchmark Plans • The EHB-benchmark plans displayed may include annual and/or lifetime dollar limits. • In accordance with 45 CFR 147.126, these limits cannot be applied to the essential health benefits. • Annual and lifetime dollar limits can be converted to actuarially equivalent treatment or service limits. Source: Guide to Reviewing Essential Health Benefits Benchmark Plans: http://www.cms.gov/CCIIO/Resources/Data-Resources/Downloads/ehb-benchmark-review-guide.pdf.

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Código de Seguros de Salud Límites Anuales y de Por Vida • Ningún plan médico establecerá límites anuales irrazonables o de por vida en los beneficios esenciales cubiertos, según dispone ACA. • Un plan médico puede establecer dicho límites en aquellos beneficios que no son esenciales y si están permitidos por otras leyes federales o estatales. Fuente: Fuente: Artículo 2.050 (A) y (B) del Código de Seguros de Salud, Ley

Número 194 del 29 de agosto de 2011.

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Carta de Derechos del Paciente Selección de Planes y Proveedores Que los planes de cuidado de salud les ofrezcan una cubierta sin límite económico o “dollar limits”, según estos términos son definidos en la legislación federal y su reglamentación federal correspondiente, ya sea de por vida; por contrato anual, en los beneficios esenciales cubiertos, definidos como “essential health benefits” en la Affordable Care Act, y por sus reglamentos, y por las normas establecidas por el Comisionado. Fuente: Artículo 6 (f) de la Carta de Derechos y Responsabilidades del Paciente, según enmendada por la Ley Número 161 de 1 de noviembre de 2010.

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6. Extension of Dependent Coverage 45 CFR § 147.120 Eligibility of Children Until At Least Age 26 Dependent Coverage: • Insurance coverage for family members of the policyholder, such as spouses, children, or partners. • http://www.healthcare.gov/glossary/d/dependent.html 472

Extension of Dependent Coverage Eligibility of Children Until Age 26 • Young Adults have access to dependent coverage up to the age of 26 since September 23, 2010. • If the plan offers dependent coverage has to make it available until the adult child reaches 26 years. • Same Benefits: the plan must offer all of the benefit packages available to dependants. • Same Price: the young adult cannot be required to pay more for the coverage. • Married and unmarried children qualify. Sources: http://cciio.cms.gov/programs/marketreforms/youngadults/index.html http://www.hhs.gov/ociio/regulations/adult_child_fact_sheet.html. 473

Extension of Dependent Coverage Eligibility of Children Until Age 26 • Applies to employer plans unless the adult child has a plan with his/her employer. • Since January 1, 2014, children up to age 26 can stay on their parent’s plan even if they have another offer of coverage through an employer. • Applies to all plans in the individual market and in the group market (small and large), as well as to grandfathered plans. • All eligible young adults will have a special enrollment opportunity. Sources: http://cciio.cms.gov/programs/marketreforms/youngadults/index.html http://www.hhs.gov/ociio/regulations/adult_child_fact_sheet.html. 474

Model Language for Notice of Opportunity to Enroll Extension of Dependent Coverage to Age 26 • To give such a child an opportunity to enroll that continues for at least 30 days (including written notice of the opportunity to enroll), regardless of whether the plan or coverage offers an open enrollment period and regardless of when any open enrollment period might otherwise occur. • The enrollment opportunity (including the written notice) must be provided not later than the first day of the first plan year beginning on or after September 23, 2010. • The notice may be included with other enrollment materials that a plan distributes, provided the statement is prominent. • Enrollment must be effective as of the first day of the first plan year beginning on or after September 23, 2010. Source: http://www.dol.gov/ebsa/healthreform/. 475

Model Language for Notice of Opportunity to Enroll Extension of Dependent Coverage to Age 26 Individuals whose coverage ended, or who were denied coverage (or were not eligible for coverage), because the availability of dependent coverage of children ended before attainment of age 26 are eligible to enroll in [Insert name of group health plan or health insurance coverage]. Individuals may request enrollment for such children for 30 days from the date of notice. Enrollment will be effective retroactively to [insert date that is the first day of the first plan year beginning on or after September 23, 2010.] For more information contact the [insert plan administrator or issuer] at [insert contact information]. Source: http://www.dol.gov/ebsa/healthreform/.

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Dependent Coverage of Children Question and Answer Question: Will a group health plan or issuer fail to satisfy section 2714 of the Public Health Service Act (PHS Act) and its implementing interim final regulations merely because it conditions health coverage on support, residency, or other dependency factors for individuals under age 26 who are not described in section 152(f)(1) of the Internal Revenue Code (Code)? (That section of the Code defines children to include only sons, daughters, stepchildren, adopted children (including children place for adoption), and foster children.) • Answer: No. A plan or issuer does not fail to satisfy the requirements of PHS Act section 2714 or its implementing regulations because the plan limits health coverage for children until the child turns 26 to only those children who are described in section 152(f)(1) of the Code. For an individual not described in Code section 152(f)(1), such as a grandchild or niece, a plan may impose additional conditions on eligibility for health coverage, such as a condition that the individual be a dependent for income tax purposes. Source: http://www.dol.gov/ebsa/faqs/faq-aca.html. 477

Código de Seguros de Salud Dependientes - Definición • Cualquier persona que es o pudiese ser elegible a un plan médico por motivo de la relación que tiene con el asegurado principal y a tenor con las condiciones dispuestas en el plan médico. • Un hijo biológico, un hijo adoptivo o colocado para adopción que, independientemente de la edad, no pueda sostenerse así mismo por razón de incapacidad mental o física existente antes de cumplir los 26 años, a tenor con ACA, podrá considerarse dependiente del asegurado principal. Fuente: Artículo 2.030 (G) del Código de Seguros de Salud, Ley Número 194 del 29 de agosto de 2011, enmendado por la Ley Número 55 de 10 de julio de 2013. 478

Código de Seguros de Salud Parejas Cohabitantes • De acuerdo con el Capítulo 10, las parejas cohabitantes son elegibles para obtener un plan médico individual. – Cohabitante significa personas solteras, adultas, con plena capacidad legal, sujetas a una convivencia sostenida y a un vínculo afectivo, que cohabitan voluntariamente, de manera estable y continua. • Los aseguradores que suscriban planes médicos individuales deberán utilizar la Forma CSS-AS-10-002 para notificar la existencia de una pareja cohabitante e incluir los dependientes de la pareja en un plan médico individual. • Los aseguradores utilizarán la Forma CSS-AS-10-003 para notificar la terminación de la pareja cohabitante. Fuente: Artículo 10.030 H (6) del Código de Seguros de Salud, según enmendado, y la Carta Normativa Número CN-2013_156_AS de 30 de septiembre de 2013. 479

Código de Seguros de Salud Criterios para una Pareja Cohabitante • Ambos cuentan con veintiún años de edad o más; • No están casados; • Tienen plena capacidad legal para administrar nuestras personas y bienes; • No están relacionados por lazos familiares dentro del cuarto grado de consanguinidad ni segundo de afinidad; • Han asumido obligaciones mutuas para el bienestar y manutención de cada uno; • Han estado compartiendo una residencia en común y viviendo como pareja bajo el mismo techo voluntariamente, de manera estable y continua durante un plazo no menor de un (1) año; y • Tienen la intención de continuar con la cohabitación indefinidamente. Fuente: Forma: CSS-AS-10-002 480

Carta de Derechos del Paciente Dependientes hasta los 26 Años Que los planes de cuidado de salud ofrecen parte de su cubierta incluyan a los dependientes, hagan la misma extensiva a los dependientes que no estén casados, hasta los 26 años de edad. El Comisionado reglamentará estos casos y su aplicación. Fuente: Artículo 6 (h) de la Carta de Derechos y Responsabilidades del Paciente, según enmendada por la Ley Número 161 de 1 de noviembre de 2010.

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Coverage of a Same-sex Spouse Q: If a health insurance issuer in the group or individual market offers coverage of an opposite-sex spouse, may the issuer refuse to offer coverage of a same-sex spouse? •

No. Federal regulations at 45 CFR 147.104(e) provide that a health insurance issuer offering non-grandfathered group or individual health insurance coverage cannot employ marketing practices or benefit designs that discriminate on the basis of certain specified factors. One such factor is an individual’s sexual orientation.

• This section prohibits an issuer from choosing to decline to offer to a plan sponsor (or individual in the individual market) the option to cover same-sex spouses under the coverage on the same terms and conditions as opposite sex-spouses. • While issuers are encouraged to implement this clarification for the 2014 coverage year, we expect issuers to come into full compliance with the regulations as clarified in this guidance no later than for plan or policy years beginning on or after January 1, 2015. Source: Frequently Asked Question on Coverage of Same-Sex Spouses (http://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/frequentlyasked-questions-on-coverage-of-same-sex-spouses.pdf)

482

7. Patient Protections Provisions 45 CFR § 147.138

483

Patient Protections Provisions A. Choice of any available primary care doctor or pediatrician in a plan’s network. B. Access to an OB/GYN services without a referral. C. Access to out-of-network emergency care without prior authorization or higher cost sharing than would otherwise be charged.

484

Patient Protections Provisions A. Choice of Primary Care Providers • You select the primary care doctor: You choose any participating primary care provider as your doctor and any available participating pediatrician as your child’s primary care doctor.

• Applies to all individual and group plans, except to grandfathered plans. Source: http://www.healthcare.gov/law/features/rights/doctorchoice/index.html. 485

Patient Protection Model Disclosure • ACA requires plans and issuers to provide notice to participants of these rights when applicable. • It must be provided whenever the plan or issuer provides a participant with a SPD or other similar description of benefits under the plan or health insurance coverage. • The notice must be provided no later than the first day of the first plan year beginning on or after September 23, 2010. Source: http://www.dol.gov/ebsa/healthreform/.

486

Patient Protection Model Disclosure Primary Care Doctor • For the designation of primary care providers by participants or beneficiaries, insert: [Name of group health plan or health insurance issuer] generally [requires/allows] the designation of a primary care provider. You have the right to designate any primary care provider who participates in our network and who is available to accept you or your family members. [If the plan or health insurance coverage designates a primary care provider automatically, insert: Until you make this designation, [name of group health plan or health insurance issuer] designates one for you.] For information on how to select a primary care provider, and for a list of the participating primary care providers, contact the [plan administrator or issuer] at [insert contact information]. • For the designation of a primary care provider for a child, add: For children, you may designate a pediatrician as the primary care provider. Source: http://www.dol.gov/ebsa/healthreform/. 487

Código de Seguros de Salud Proveedor de Cuidado Primario • Significa el proveedor participante, seleccionado por la persona cubierta o asegurada; o en su defecto designado por la organización de seguros de salud o asegurador, que tenga a su cargo, la supervisión, coordinación y suministro de cuidado inicial o de seguimiento de la persona cubierta o asegurados. Fuente: Artículo 2.030 del Código de Seguros de Salud, según enmendado por la Ley Número 55 de 10 de julio de 2013. 488

Código de Seguros de Salud Proveedor de Cuidado Primario • Todo plan médico individual o grupal que requiera la designación de un proveedor de cuidado primario, cuando el asegurado tiene 18 años o menos, deberá permitir que se designe un médico especializado en pediatría en calidad de proveedor de cuidado primario, siempre que ese médico pediatra sea parte de la red del plan médico. • La organización de seguros de salud o asegurador puede requerir que el proveedor de cuidado primario inicie los trámites de referido para cuidado especializado y continúe supervisando los servicios de cuidado de la salud ofrecidos a la persona cubierta o asegurado. Fuente: Artículo 2.050 (G) del Código de Seguros de Salud, según enmendado por la Ley Número 55 de 10 de julio de 2013.

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Carta de Derechos del Paciente Proveedor de Cuidado Primario Que los planes de cuidado de salud individuales o grupales que tengan en la cubierta a un menor de edad como participante o beneficiario, permitan que el padre o tutor del menor dependiente pueda seleccionar a un pediatra como su proveedor de cuidado primario, siempre que ese médico pediatra sea parte de la red de proveedores del plan de cuidado de salud. Fuente: Artículo 6 (j) de la Carta de Derechos y Responsabilidades del Paciente, según enmendada por la Ley Número 161 de 1 de noviembre de 2010. 490

Patient Protections Provisions B. Access OB-GYN Services • No health plan barriers to obstetrical or gynecological (OB-GYN) services: Prohibit plans from requiring a referral from a primary care provider before you can seek OB-GYN care from a participating OB-GYN. • Applies to all individual and group plans, except to grandfathered plans. Source: http://www.healthcare.gov/law/features/rights/doctorchoice/index.html. 491

Patient Protection Model Disclosure • ACA requires plans and issuers to provide notice to participants of these rights when applicable. • It must be provided whenever the plan or issuer provides a participant with a SPD or other similar description of benefits under the plan or health insurance coverage. • The notice must be provided no later than the first day of the first plan year beginning on or after September 23, 2010. Source: http://www.dol.gov/ebsa/healthreform/.

492

Patient Protection Model Disclosure Obstetrics or Gynecology Professionals For plans and issuers that provide coverage for obstetric or gynecological care and require the designation by a participant or beneficiary of a primary care provider, add: You do not need prior authorization from [name of group health plan or issuer] or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, contact the [plan administrator or issuer] at [insert contact information]. Source: http://www.dol.gov/ebsa/healthreform/. 493

Código de Seguros de Salud Servicios de OB-GYN • Ningún plan médico individual o grupal establecerá requisitos de referido o de autorización previa para obtener servicios de obstetricia y ginecología provistos por proveedores participantes especialistas en obstetricia y ginecología. • Todo plan médico individual o grupal que provee la cubierta para servicios de obstetricia y ginecología y a su vez requiera la designación de un proveedor de cuidado primario, considerará como proveedor o servicios de cuidado primarios los servicios provistos por el ginecólogo u obstetra, así como cualquiera de los servicios de cuidado de salud por éstos ordenados. Fuente: Artículo 2.050 (H) del Código de Seguros de Salud, según enmendado por la Ley Número 55 de 10 de julio de 2013. 494

Carta de Derechos del Paciente Servicios de OB-GYN Que los planes de cuidado de salud individuales o grupales cubran los servicios de ginecología y obstetricia con acceso directo, sin requerir referido o autorización previa del plan, siempre que ese médico sea parte de la red de proveedores del plan de cuidado de salud. Fuente: Artículo 6 (i) de la Carta de Derechos y Responsabilidades del Paciente, según enmendada por la Ley Número 161 de 1 de noviembre de 2010.

495

Patient Protections Provisions C. Access to Emergency Services • Access to out-of-network emergency room services. • Prevent plans from requiring higher copayments or coinsurance for out-of-network emergency services. • Prohibit plans from requiring to get prior approval before seeking emergency room services from a provider outside the plan’s network. • Applies to individual and group plans, except to grandfathered. Source: http://www.healthcare.gov/law/features/rights/doctor-choice/index.html.

496

Código de Seguros de Salud Servicios de Emergencia Ningún plan médico que incluya servicios de emergencia requerirá aprobación previa para tales servicios, independientemente de que el proveedor sea un proveedor participante o no. Fuente: Artículoss2.050 (F) 2.030 (BB) del Código de Seguros de Salud, según enmendados por la Ley Número 55 de 10 de julio de 2013.

497

Código de Seguros de Salud Definiciones Condición médica de emergencia condición médica que se manifiesta por síntomas agudos de suficiente severidad, incluyendo dolor severo, ante la cual una persona lega, razonablemente prudente y con un conocimiento promedio de salud y medicina, puede esperar que, en ausencia de atención médica inmediata, la salud de la persona se colocaría en serio peligro, o resultaría en una seria disfunción de cualquier miembro u órgano del cuerpo o, con respecto a una mujer embarazada que esté sufriendo contracciones, que no haya suficiente tiempo para trasladarla a otras instalaciones antes del parto, o que trasladarla representaría una amenaza a su salud o a la de la criatura por nacer. Fuente: Artículo 2.030 del Código de Seguros de Salud. 498

Código de Seguros de Salud Definiciones • Servicios de emergencia los servicios de cuidado de la salud prestados o que se requieren para tratar una condición médica de emergencia. • Urgencia condición médica suscitada, que no expone a riesgo de muerte inminente o la integridad de la persona, y que puede ser tratada en oficinas médicas u oficinas de horario extendido, no necesariamente en salas de emergencia, pero la cual, de no ser tratada en el momento adecuado y de la manera correcta, se podría convertir en una emergencia. Fuente: Artículo 2.030 del Código de Seguros de Salud. 499

Código de Seguros Fundamento para Desaprobar Modelos El Comisionado desaprobara un formulario de póliza, solicitud, aditamento o endoso, o retirara su aprobación si es uno de seguro de incapacidad física (salud) y el mismo no provee beneficios para cuando un asegurado, por motivo de emergencia o de accidente reciba atención hospitalaria. Fuente: Artículo 11.120 (8) del Código de Seguros, según enmendado, 26 LPRA sec. 1112 (8).

500

Carta de Derechos del Paciente Emergencia Médica - Definición Se refiere a una condición médica que se manifiesta por síntomas agudos de suficiente severidad, incluyendo dolor severo, donde una persona lega razonablemente prudente, que tenga un conocimiento promedio de salud y medicina, pueda esperar que en la ausencia de acción médica inmediata colocaría la salud de la persona en serio peligro, o resultaría en una seria disfunción de cualquier miembro u órgano del cuerpo o con respecto a una mujer embarazada que esté sufriendo contracciones, que no haya suficiente tiempo para transferirla a otras instalaciones antes del parto, o que transferirla representaría una amenaza a la salud de la mujer o de la criatura por nacer. Fuente: Ley Número 194 de 25 de agosto de 2000. 501

Carta de Derechos del Paciente Acceso a Servicios de Emergencia 1. Tener acceso libre, directo e irrestricto a servicios y facilidades de emergencia cuando y donde surja la necesidad de tales servicios y facilidades, independientemente de la condición socioeconómica y capacidad de pago de dicho usuario o consumidor, y ningún plan de cuidado de salud podrá negar a sus asegurados o beneficiarios el pago o cubierta por servicios de salud médico-hospitalarios de emergencia. Fuente: Artículo 8 de la Carta de Derechos y Responsabilidades del Paciente, según enmendada. 502

Carta de Derechos del Paciente Acceso a Servicios de Emergencia 2. Recibir información confiable y detallada sobre la disponibilidad, localización y uso apropiado de facilidades y servicios de emergencia en sus respectivas localidades, así como las disposiciones relativas al pago de primas y recobro de costos con relación a tales servicios y la disponibilidad de cuidado médico comparable fuera de dichas facilidades y servicios de emergencia. 503

Carta de Derechos del Paciente Acceso a Servicios de Emergencia 3. Tener acceso a servicios de emergencia sin período de espera, sin la necesidad de autorización previa por parte de la entidad aseguradora; serán provistos independientemente de que el proveedor sea un proveedor participante. Si los servicios son provistos por un proveedor no contratado, el paciente no será responsable de un pago por los servicios que exceda la cantidad aplicable, si hubiese recibido dichos servicios de un proveedor contratado. La entidad aseguradora compensará al proveedor que ofrezca los servicios, y éste vendrá obligado a aceptar dicha compensación, por una cantidad que no será menor a la contratada con los proveedores a su vez contratados por la entidad aseguradora para ofrecer los mismos servicios. Además, los servicios de emergencia serán provistos independientemente de las condiciones del plan de cuidado de salud correspondiente. 504

Carta de Derechos del Paciente Acceso a Servicios de Emergencia 4. En el caso de que el paciente reciba servicios de cuidado de salud posteriores a los servicios de emergencia, o de post-estabilización, que estarían cubiertos bajo el plan de cuidado de salud, excepto por el hecho de que se trata de un proveedor no participante, la entidad aseguradora compensará al paciente por aquella parte de los costos con respecto a dichos servicios recibidos que se hubiese pagado con arreglo al plan, siempre que exista una razón médica de peso por la cual el paciente no pueda ser transferido a un proveedor participante. 505

8. Fair Health Insurance Premiums Rate Reviews 45 CFR § 147.102 45 CFR § 147.103 - State Reporting 45 CFR Part 154 - Health Insurance Issuer Rate Increases: Disclosure and Review Requirements 506

The ACA Community Rating, Single Risk Pool, and Rate Review requirements will not apply to individual or group health insurance issuers in the U.S. territories (Puerto Rico). PR Health Insurance Code applies. Source: Letter to Puerto Rico on the Definition of State, http://www.cms.gov/CCIIO/Resources/Letters/Downloads/letter-to-Weyne.pdf

507

Rate Reviews Review of Insurance Rates • Review of Insurance Rate Increases. • Ensures that large proposed increases (10% or more) will be evaluated by experts to make sure they are based on reasonable cost assumptions and solid evidence. • Must provide easy to understand information to their customers about their reasons for significant rate increases, as well as publicly justify and post on their website any unreasonable rate increases. • Applies to individual or small group health plans. • Does not apply to large group market and grandfathered plans. Source: http://cciio.cms.gov/programs/marketreforms/rates/index.html, http://www.healthcare.gov/law/features/costs/rate-review/index.html. 508

Rate Reviews and Restrictions Minimum premium rating rules for individuals and small groups and can only adjust premiums: • Individual vs. family enrollment: – Allow to vary rates based on who is enrolled in the plan. Rates can be charged based on whether the plan covers only an individual or a family (i.e., individual + spouse, individual + dependents). – Per-member rating. The total premium for family coverage must be determined by summing the premiums for each individual family member. – With respect to family members under the age of 21, the premiums for no more than the three oldest covered children must be taken into account in determining the total family premium. 509

Rate Reviews Rate Restrictions • Geographic area: Can charge more for people who live in areas where medical costs are high. (State Specific Geographic Rating Areas: http://cciio.cms.gov/programs/marketreforms/pr-gra.html). • Age: Allow rates based on age, but cannot charge an older adult more than 3 times the rate of a younger person. – Child age bands. A single age band for individuals age 0 through 20. – Adult age bands. One-year age bands for individuals age 21 through 63. – Older adult age bands. A single age band for individuals age 64 and older. • Tobacco use: May charge more for people that use tobacco products but cannot charge more than 1.5 times the non-tobacco user’s rate. Source: http://www.kff.org/healthreform/upload/8328.pdf. 510

Tobacco Use and Age • The tobacco rating should be limited to legal use of tobacco products under federal and state law, which generally is limited to those 18 years and older. • Consistent with these rules and subject to applicable state law, issuers will have the flexibility to vary tobacco rating by age, provided the tobacco use factor does not exceed 1.5:1 for any age band. Source: http://www.federalregister.gov/articles/2013/02/27/2013-04335/patientprotection-and-affordable-care-act-health-insurance-market-rules-rate-review#p-140

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o

512

Tobacco Use Definition • Specifically, HHS defines ‘‘tobacco use’’ as use of tobacco on average of four or more times per week within no longer than the past six months. Further, the tobacco use must be defined in terms of when a tobacco product was last used. – ‘‘Tobacco use’’ is based on the National Health Interview Survey, administered by the Centers for Disease Control and Prevention, asks survey respondents if they use tobacco products ‘‘every day, some days, or not at all?’’ • Tobacco includes all tobacco products. • Religious or ceremonial uses of tobacco (for example, by American Indians and Alaska Natives) are specifically exempt. Source: http://www.federalregister.gov/articles/2013/02/27/2013-04335/patientprotection-and-affordable-care-act-health-insurance-market-rules-rate-review#p-140 513

Tobacco Use Definition • The definition establishes a minimum standard to assure consistency in the individual and small group health insurance markets and simplifies administration of the tobacco rating factor. • For example, an individual could be asked the following two questions about tobacco use: – (1) Within the past six months, have you used tobacco regularly (four or more times per week on average excluding religious or ceremonial uses)? – (2) If yes, when was the last time you used tobacco regularly? Source: http://www.federalregister.gov/articles/2013/02/27/2013-04335/patient-protection-andaffordable-care-act-health-insurance-market-rules-rate-review#p-140

514

Tobacco Rating - Small Group Market Wellness Program • A health insurance issuer in the small group market would be required to offer a tobacco user the opportunity to avoid paying the full amount of the tobacco rating factor permitted under ACA if he or she participates in a wellness program. • An employee’s or dependent’s premium will be established for a period of one year upon enrollment, renewal or re-enrollment. At that time, the enrollee or dependent can agree to participate in a wellness program meeting the ACA standards, such as tobacco cessation program in order to avoid the tobacco premium surcharge. If the employee or dependent does not agree at that time to participate in such wellness program, the employee or dependent will have an opportunity to avoid the tobacco premium surcharge upon renewal or reenrollment for subsequent coverage. Source: http://www.federalregister.gov/articles/2013/02/27/2013-04335/patientprotection-and-affordable-care-act-health-insurance-market-rules-rate-review#p-140 515

Opportunity to Avoid the Surcharge or Provide Another Reward for the Plan Year? A group health plan charges participants a tobacco premium surcharge but also provides an opportunity to avoid the surcharge if, at the time of enrollment or annual re-enrollment, the participant agrees to participate in (and subsequently completes within the plan year) a tobacco cessation educational program. A participant who is a tobacco user initially declines the opportunity to participate in the tobacco cessation program, but joins in the middle of the plan year. Is the plan required to provide the opportunity to avoid the surcharge or provide another reward to the individual for that plan year? •

No. If a participant is provided a reasonable opportunity to enroll in the tobacco cessation program at the beginning of the plan year and qualify for the reward (i.e., avoiding the tobacco premium surcharge) under the program, the plan is not required (but is permitted) to provide another opportunity to avoid the tobacco premium surcharge until renewal or reenrollment for coverage for the next plan year.



Nothing, however, prevents a plan or issuer from allowing rewards (including pro-rated rewards) for mid-year enrollment in a wellness program for that plan year.

Source: FAQs about Affordable Care Act Implementation (Part XVIII) and Mental Health Parity Implementation (January 9, 2014) http://www.dol.gov/ebsa/faqs/faq-aca18.html. 516

HHS Next Considerations • This definition is transitional. • HHS intends to consult with experts, use experience with the above definition, and study the interaction effects with the permanent risk adjustment program to develop a more evidenced-based definition of tobacco use through future rulemaking or guidance. • HHS also intends to conduct consumer testing of language and questions about tobacco use. Source: http://www.federalregister.gov/articles/2013/02/27/201304335/patient-protection-and-affordable-care-act-health-insurance-marketrules-rate-review#p-140 517

Cambios Trimestrales de Tarifas Grupos Pequeños en el 2016 • Todo asegurador que se proponga hacer cambios trimestrales de tarifas en los planes médicos de grupos pequeños en el 2016, tenía que haber radicado las tarifas para todos los trimestres a más tardar el 1 de junio de 2015. • Si las tarifas se aumentan trimestralmente, se deben radicar por adelantado a la misma vez. No se aceptará ningún otro aumento trimestral. • Se harán auditorías para verificar que sólo se estén usando las tarifas aprobadas. Fuente: Carta Normativa Número CN-2015-187-AS sobre Radicaciones de Formularios y Tarifas para el Año Natural 2016 518

Restricción a las Tarifas Mercado Individual y de Grupos Pequeños • Son a base de un cálculo comunitario ajustado. • Sólo podrán variar por: – Área geográfica: todo Puerto Rico es un área; – Edad: un solo rango de 0-20, rangos de un año cada uno de 21 hasta los 63 y un solo rango de 64 en adelante; – Composición familiar: individual o familiar; y – Uso del tabaco: fumar en promedio 4 o más veces a la semana dentro de un periodo de 6 meses.

• All other factors prohibited (e.g., health status, claims experience, gender, industry classification, small group size). Fuente: Cartas Normativas CN-2013-155-AS de 29 de julio de 2013 y CN-2013-156-AS de 30 de septiembre de 2013. http://www.cms.gov/CCIIO/Resources/Files/Downloads/market-rules-2-27-2013.pdf

519

State Effective Rate Review Programs Puerto Rico • Following issuance of July, 2011 Ruling Letter from the Puerto Rico Department of Insurance, Puerto Rico now has effective rate review in both the individual and small group markets. • HHS has determined that “In addition, with respect to rate review grants, they would no longer be considered to have an "effective rate review program" since they would not be subject to PHS Act requirements enacted in the ACA.” Source: http://www.cms.gov/CCIIO/Resources/Fact-Sheets-andFAQs/rate_review_fact_sheet.html#ttt. Letter to Puerto Rico on the Definition of State, http://www.cms.gov/CCIIO/Resources/Letters/Downloads/letter-to-Weyne.pdf 520

521

Código de Seguros de Salud PYMES - Tarifas • El asegurador de patronos de PYMES deberá desarrollar sus tarifas a base de un cálculo comunitario ajustado y sólo podrá variar el cálculo comunitario ajustado por área geográfica, composición familiar, edad y uso del tabaco. Fuente: Artículo 8.050, Restricciones Relacionadas con las Tarifas, del Código de Seguros de Salud, según enmendado por la Ley Número 55 de 10 de julio de 2013. Véase la Carta Normativa de 12 de julio de 2011 sobre la divulgación de los aumentos (10% o más) en las tarifas de los planes médicos en el mercado individual y de grupos pequeños para cumplir con ACA.

522

Código de Seguros de Salud Planes Médicos Individuales • Las tarifas relacionadas a las primas de los planes médicos individuales estarán sujetas a las disposiciones de ACA y la reglamentación interpretativa, adoptada al amparo de ésta. • Los aseguradores mantendrán en su sede principal e incluyendo de forma digital en su página electrónica en la Internet para ser accedida por cualquier persona, una descripción completa y detallada de las prácticas de suscripción y tarifaje, la cual incluirá información y documentación que acredite que sus métodos y prácticas de tarifas se basan en supuestos actuariales comúnmente aceptados y que son cónsonos con los principios actuariales reconocidos. Fuente: Artículo 10.050, Restricciones a las tarifas, del Capítulo 10 del Código de Seguros de Salud, según enmendado por la Ley Número 69 de 22 de julio de 2013.

523

Acciones Administrativas Tomadas por la Oficina del Comisionado de Seguros • Caso: CM-2014-38 – Triple-S Salud, Inc., CGF Insurance LLC • Orden de 12 de marzo de 2014 • El Asegurador violentó lo dispuesto en el Artículo 10.050 del Código de Seguros de Salud, lo dispuesto en la Carta Normativa CN-2013-156-AS y en el Artículo 27.100 del Código de Seguros de Puerto Rico al ofrecer, a través de la página de internet que mantiene el Agente General, planes médicos individuales a primas menores que las archivadas y aprobadas por la OCS. • Sanción: $5,000 multa al Asegurador y Cese y Desista al Asegurador y al Agente General. Fuente: http://ocs.gobierno.pr/ocspr/files/ACCIONES%20ADMINISTRATIVAS%20FINALES%20Y%20FI RMES%20TODAS2014.pdf 524

525

Large Group Rates and Form Filings

Source: Ruling Letter No. CN-2015-187-AS, dated March 26, 2015: Form and Rate Filings Submissions to be Effective for Calendar Year 2016. 526

ACA Health Insurance Provider Fee • It is annual fee on certain health insurance providers engaged in the business of providing health insurance, which begin in 2014. • The Consolidated Appropriations Act of 2016, (Title II, § 201, Moratorium on Annual Fee on Health Insurance Providers), suspends collection of the health insurance provider fee for the 2017 calendar year. –Health insurance issuers are not required to pay these fees for 2017. –This moratorium does NOT affect the filing requirement and payment of these fees for 2016. –Form 8963 must be filed by April 18, 2016. Source: http://www.irs.gov/Affordable-Care-Act/Affordable-Care-Act-Tax-Provisions

527

9. Medical Loss Ratio 45 CFR Part 158 — Issuer Use of Premium Revenue: Reporting and Rebate Requirements 528

The ACA Medical Loss Ratio (MLR) requirement will not apply to individual or group health insurance issuers in the U.S. territories (Puerto Rico). PR Health Insurance Code applies. Source: Letter to Puerto Rico on the Definition of State, http://www.cms.gov/CCIIO/Resources/Letters/Downloads/letter-to-Weyne.pdf

529

Medical Loss Ratio - MLR

530

Medical Loss Ratio MLR • Value for Your Premium Dollar. • Requires to submit data on the proportion of premium revenues spent on health services and quality improvement. • Requires to issue rebates to enrollees if does not meet the MLR minimum standards (80% or 85% of premium dollars on medical care). • If they fail, it will be required to provide a rebate to their customers starting in 2012. Source: (http://www.healthcare.gov/law/resources/reports/mlr-rebates06212012a.html, http://www.healthcare.gov/blog/2012/07/rebatetool071312.html.

531

MLR Value for Your Premium Dollar • 85% in the large group market (now 51 or more employees, but in 2016 will be 101 employees or more). • 80% in the small group market (now 2-50, but in 2016 will be 1100 employees). • 80% in the individual market (very small plans with 1 employee and to individuals, but in 2016 will be individuals). Source: http://www.healthcare.gov/law/resources/reports/mlrrebates06212012a.html, http://www.healthcare.gov/blog/2012/07/rebatetool071312.html. 532

Activities To Improve Health Quality 1. Activities to increase health outcomes. 2. Case management, care coordination, chronic disease management, and medication and care compliance initiatives. 3. Quality reporting and documentation of care in nonelectronic format. 4. Accreditation fees directly related to quality of care activities. 5. Implementing ICD-10 code sets for each of the 2012 and 2013 MLR reporting years. Source: 45 CFR § 158.150 (b) Activities that improve health care quality. 533

Activities To Improve Health Quality 6. Prevent hospital readmissions through a comprehensive program for hospital discharge. 7. Improve patient safety, reduce medical errors, and lower infection and mortality rates. 8. Implement, promote, and increase wellness and health activities. 9. Enhance the use of health care data to improve quality, transparency, and outcomes and support meaningful use of health information technology. 10. Health information technology to support these activities. Source: 45 CFR § 158.150 (b) Activities that improve health care quality. 534

Excluded Expenditures and Activities • Designed to control or contain costs. • Activities paid separate from premium revenue. • Establishing or maintaining a claims adjudication system and maintenance of ICD-10 code sets. • Retrospective and concurrent utilization review. • Fraud prevention activities. • Develop and execute provider contracts and fees. • Provider credentialing. • Marketing expenses. Source: 45 CFR § 158.150 (c) Activities that improve health care quality.

535

Components of the ACA-MLR Equation • Premiums: All premiums earned from policyholders. • Claims: Payments for medical care and drugs. • Quality Improvement: Health improvement activities must lead to measurable improvements in patient outcomes or patient safety, prevent hospital readmissions, promote wellness, or enhance health information technology in a way that improves quality, transparency, or outcomes. • Taxes, Licensing and Regulatory Fees: Includes federal taxes and assessments, state and local taxes, and regulatory licenses and fees. Source: http://kff.org/health-reform/factsheet/explaining-health-care-reform-medicalloss-ratio-mlr/ 536

MLR Rebates Must be paid by August 1 of each year and it can be paid as: • A rebate check in the mail, • A lump-sum reimbursement to the same account that was used to pay the premium if it was paid by credit card or debit card, • A direct reduction in their future premiums, or • Their employer providing one of the above rebate methods, or applying the rebate in a manner that benefits its employees. Sources: http://cciio.cms.gov/programs/marketreforms/mlr/index.html http://www.healthcare.gov/law/features/costs/value-for-premium/index.html http://www.healthcare.gov/law/resources/reports/mlr-rebates06212012a.html .

537

CCIIO Technical Guidance (CCIIO 2015—0001): Questions and Answers Regarding the Medical Loss Ratio (MLR) Reporting and Rebate Requirements Source: http://www.cms.gov/CCIIO/Resources/Regulations-andGuidance/Downloads/MLR-Guidance-Earned-Premium-and-APTCRebates-20150527.pdf

538

Agent and Broker Fees or Commissions Paid • Question #64: May an issuer, for MLR reporting purposes, exclude from earned premium agent and broker fees or commissions paid in connection with a health insurance policy?

• Answer #64: No, unless all of the conditions stated in this guidance exist. CMS is issuing this guidance to clarify when it may be acceptable for an issuer to exclude agent or broker fees and commissions from premium for MLR reporting purposes. Accordingly, if all of the following seven conditions are met, an issuer may exclude these agent or broker fees and commissions from premium in the applicable state/market for MLR reporting purposes: 539

Agent and Broker Fees or Commissions Paid 1. The law of the state in which the policy is sitused does not deem the agent or broker to be a representative of the issuer; 2. The policyholder is not required to utilize an agent or broker to purchase insurance and may purchase a policy directly from the issuer; 3. The policyholder selects, retains, and contracts with the agent or broker on his or her own accord; 4. The policyholder negotiates and is responsible for the fee or commission separate and apart from premium; 5. The issuer does not include these agent or broker commissions and fees in rate filings submitted to the applicable regulatory agency; 6. The policyholder voluntarily chooses to pass the fee or commission through the issuer and is not required to do so, or the policyholder pays the fees or commission directly to the agent or broker; and, 7. The policyholder issues the 1099 to the agent or broker, if a 1099 is required. If any condition in the above list is not met, then the issuer must include the agent or broker fees and commissions in earned premium for MLR reporting purposes. 540

MLR - Summary • Value for Your Premium Dollar: 85% in the large group market, 80% in the small group, and 80% in the individual market. • Plans can spent premium on administrative or excluded activities: 15% - large group market, 20% - small group, and 20% - individual market. • Requires to submit data on the proportion of premium revenues spent on health care services and quality improvement. • Requires to issue rebates to enrollees if does not meet the MLR minimum standards starting in 2012. • Puerto Rico Total Rebates paid: $5,508,831 (2011 paid 2012), $3,955,123 (2012 paid 2013), and $3,545,675 (2013 pay 2014). Source: http://www.cms.gov/CCIIO/Resources/Data-Resources/mlr.html; http://www.healthcare.gov/law/resources/reports/mlr-rebates06212012a.html; http://www.healthcare.gov/blog/2012/07/rebatetool071312.html. 541

Puerto Rico MLR Rebates (Year 2011) Insurance Market

Individual Market (1 individual or 1 employee)

Total Rebates

Total Consumers Benefiting from Rebates

Average Rebate per Family

$0

0

$0

Small Group Market (Insurance Provided Through Small Employers between 2 and 50 employees)

$1,283,046

17,966

$191

Large Group Market (Insurance Provided Through Large Employers - 51 or more employees)

$4,225,785

40,682

$238

Summary of All Markets

$5,508,831

58,648

$225

542

Puerto Rico MLR Rebates (Year 2012) Insurance Market

Individual Market (1 individual or 1 employee)

Total Rebates

Total Consumers Benefiting from Rebates

Average Rebate per Family

$43,056

534

$135

Small Group Market (Insurance Provided Through Small Employers between 2 and 50 employees)

$3,912,067

41,007

$199

Large Group Market (Insurance Provided Through Large Employers - 51 or more employees)

$0

0

$0

$3,955,123

41,541

$198

Summary of All Markets

543

Puerto Rico MLR Rebates (Year 2013) Insurance Market

Individual Market (1 individual or 1 employee)

Total Rebates

Total Consumers Benefiting from Rebates

Average Rebate per Family

$10,481

391

$75

Small Group Market (Insurance Provided Through Small Employers between 2 and 50 employees)

$2,093,591

44,821

$98

Large Group Market (Insurance Provided Through Large Employers - 51 or more employees)

$1,441,603

31,018

$101

Summary of All Markets

$3,545,675

76,230

$99

544

Notice of Health Insurance Premium Rebate • Notice to Group Policyholders and Their Subscribers, Rebate Sent to the Policyholder • Notice to Subscribers of Group Policyholders, Rebate Sent to the Subscribers • Notice to Policyholders and Subscribers when MLR Standard is Met Source: http://cciio.cms.gov/resources/files/mlr-notice-2-group-markets-rebate-topolicyholder.pdf, http://cciio.cms.gov/resources/files/mlr-notice-3-group-marketsrebate-to-subscribers.pdf, http://cciio.cms.gov/resources/files/mlr-notice-3-groupmarkets-rebate-to-subscribers.pdf.

545

Notice of Health Insurance Premium Rebate Notice to Group Policyholders and Their Subscribers, Rebate Sent to the Policyholder [August 1, 20XX 1] [Subscriber or Policyholder Name 2a 123 Main Street 2b Anytown, USA 2c] Dear [Subscriber or Policyholder Name 5]: Re: Health Insurance Premium Rebate for Year [20XX 3]; [Policy #XXXXX 4] This letter is to inform you that [Health Insurer 6] will be rebating a portion of your health insurance premiums through your employer or group policy holder. This rebate is required by the Affordable Care Act – the health reform law. The Affordable Care Act requires [Health Insurer 7] to rebate part of the premiums it received if it does not spend at least [80/85 8] percent of the premiums [Health Insurer 9] receives on health care services, such as doctors and hospital bills, and activities to improve health care quality, such as efforts to improve patient safety. No more than [20/15 10] percent of premiums may be spent on administrative costs such as salaries, sales, and advertising. This is referred to as the “Medical Loss Ratio” standard or the [80/20 85/15 11] rule. The [80/20 85/15 12] rule in the Affordable Care Act is intended to ensure that consumers get value for their health care dollars. You can learn more about the [80 /20 85/15 13] rule and other provisions of the health reform law at: http://www.healthcare.gov/law/features/costs/value-for-premium/index.html. [The Affordable Care Act allows States to require health insurers to meet a higher ratio. [Your State 14] sets a higher Medical Loss Ratio standard, so [Health Insurer 15] must meet a [XX% 16] Medical Loss Ratio, meaning that [XX% 17] of premiums must be spent on medical services and activities to improve health care quality, and no more than [XX% 18] of premiums can be spent on administrative costs.] What the Medical Loss Ratio Rule Means to You : The Medical Loss Ratio rule is calculated on a State by State basis. In [your State 19], [Health Insurer 20] did not meet the [80/20 85/15 /target in your state 21] standard. In [20XX 22], [Health Insurer 23] spent only [XX% 24] of a total of [$YYY 25] in premium dollars on health care and activities to improve health care quality. Since it missed the [80 85 percent target / target in your State 26] by [X% 27] of premium it receives, [Health Insurer 28] must rebate [X% 29] of the total health insurance premiums paid by the employer and employees in your group health plan. We are required to send this rebate to your employer or group policyholder by August 1, [20XX 30], or apply this rebate to the health insurance premium that is due on or after August 1, [20XX 31]. Employers or group policyholders must follow certain rules for distributing the rebate to you. Ways in Which an Employer Can Distribute the Rebate: If your group health plan is a non-Federal governmental plan, the employer or group policyholder must distribute the rebate in one of two ways: Reducing premium for the upcoming year; or Providing a cash rebate to employees or subscribers that were covered by the health insurance on which the rebate is based. If your group health plan is a church plan, the employer or group policyholder has agreed to distribute the portion of the rebate that is based on the total amount all of the employees contributed to the health insurance premium in one of the ways discussed in the prior paragraph. If your group health plan is not a governmental plan or a church plan, it likely is subject to the Federal Employee Retirement Income Security Act of 1974 (ERISA). Under ERISA, the employer or the administrator of the group health plan may have fiduciary responsibilities regarding use of the Medical Loss Ratio rebates. Some or all of the rebate may be an asset of the plan, which must be used for the benefit of the employees covered by the policy. Employees or subscribers should contact the employer or group policyholder directly for information on how the rebate will be used. For general information about your rights regarding the rebate, you may contact the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or review the Department’s technical guidance on this issue on its web site at http://www.dol.gov/ ebsa/newsroom /tr11-04.html. Need more information?: If you have any questions about the Medical Loss Ratio and your health insurance coverage, please contact [Health Insurer 32] toll-free at [1-XXX-XXX-XXX 33] or [website or email address 34]. Contact your employer or Administrator directly for information on how the rebate will be distributed. For general information about your rights regarding the rebate if your group health plan is subject to ERISA, you may contact the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or review the Department’s technical guidance on this issue on its web site at http://www.dol.gov/ ebsa/newsroom /tr11-04.html. Sincerely, [John Doe, Authorized Executive 35] [Health Insurer 36] Source: http://cciio.cms.gov/resources/files/mlr-notice-2-group-markets-rebate-to-policyholder.pdf .

546

Notice of Health Insurance Premium Rebate Notice to Subscribers of Group Policyholders, Rebate Sent to the Subscribers [August 1, 20XX 1]

[Subscriber Name 2a 123 Main Street 2b Anytown, USA 2c] Dear [Subscriber Name 5]: Re: Health Insurance Premium Rebate for Year [20XX 3]; [Policy #XXXXX 4] This letter is to inform you that you will receive a rebate of a portion of your health insurance premiums. This rebate is required by the Affordable Care Act – the health reform law. The Affordable Care Act requires [Health Insurer 6] to rebate part of the premiums it received if it does not spend at least [80/85 7] percent of the premiums [Health Insurer 8] receives on health care services, such as doctors and hospital bills, and activities to improve health care quality, such as efforts to improve patient safety. No more than [20/15 9] percent of premiums may be spent on administrative costs such as salaries, sales, and advertising. This is referred to as the “Medical Loss Ratio” standard or the [80/20 85/15 10] rule. The [80/20 85/15 11] rule in the Affordable Care Act is intended to ensure that consumers get value for their health care dollars. You can learn more about the [80/20 85/15 12] rule and other provisions of the health reform law at: http://www.healthcare.gov/law/features/costs/value-for-premium/index.html. [The Affordable Care Act allows States to require health insurers to meet a higher ratio. [Your State 13] sets a higher Medical Loss Ratio standard, so [Health Insurer 14] must meet a [XX% 15] Medical Loss Ratio, meaning that [XX% 16] of premiums must be spent on medical services and activities to improve health care quality, and no more than [XX% 17] of premiums can be spent on administrative costs]. What the Medical Loss Ratio Rule Means to You: The Medical Loss Ratio rule is calculated on a State by State basis. In [your State 18], [Health Insurer 19] did not meet the [80/20 85/15 /target in the state 20] standard. In [20XX 21], [Health Insurer 22] spent only [XX% 23] of a total of [$YYY 24] in premium dollars on health care and activities to improve health care quality. Since it missed the [80 85 percent target / target in your State 25] by [X% 26], [Health Insurer 27] is required to rebate [X% 28] of the total health insurance premiums paid by the employer and employees in your group health plan. We must send this rebate by August 1, [20XX 29]. Rebate Distribution Method: [Health Insurer 30] is distributing the rebate based on the total premium paid by your group health plan directly to the employees or subscribers in the group health plan. The rebate is being distributed evenly among these subscribers. [We are enclosing a check/We are sending you a check separately from this letter 31]. Need more information?: If you have any questions about the Medical Loss Ratio and your health insurance coverage, please contact [Health Insurer 32] tollfree at [1-XXX-XXX-XXX 33] or [website or email address 34]. Sincerely, [John Doe, Authorized Executive 35] [Health Insurer 36] Source: http://cciio.cms.gov/resources/files/mlr-notice-3-group-markets-rebate-to-subscribers.pdf .

547

Notice to Policyholders and Subscribers when MLR Standard is Met • The Affordable Care Act requires health insurers in the individual and small group markets to spend at least 80 percent of the premiums they receive on health care services and activities to improve health care quality (in the large group market, this amount is 85 percent). This is referred to as the Medical Loss Ratio (MLR) rule or the 80/20 rule. If a health insurer does not spend at least 80 percent of the premiums it receives on health care services and activities to improve health care quality, the insurer must rebate the difference. • A health insurer’s Medical Loss Ratio is determined separately for each State’s individual, small group and large group markets in which the health insurer offers health insurance. In some States, health insurers must meet a higher or lower Medical Loss Ratio. No later than August 1, 2012, health insurers must send any rebates due for 2011 and information to employers and individuals regarding any rebates due for 2011. • You are receiving this notice because your health insurer had a Medical Loss Ratio for 2011 that met or exceeded the required Medical Loss Ratio. For more information on Medical Loss Ratio and your health insurer’s Medical Loss Ratio, visit www.HealthCare.gov.” Source: http://cciio.cms.gov/resources/files/mlr-notice-3-group-markets-rebate-to-subscribers.pdf. 548

Medical Loss Ratio Guidance on Rebates for Group Health Plans Source: (1) Technical Release 2011-4 issued by the U.S. Department of Labor on December 2, 2011 (2) Health Care Reform from Employers and Advisors, Chapter XIV – Insurance Mandates, pages 480-481 (1st Qtr. 2013), Thomson Reuters/EBIA Publisher

549

Factors

Rebate as Plan Rebate Hold in Trust? Assets? 1. Specific plan or policy Yes, to extent language addressing ownership provided by plan or division of rebates or refunds or policy language 2. Policy issued to employer; No, to extent plan or policy language can fairly plan or policy be read to give employer language gives ownership in some or all of a employer refund or rebate ownership 3. Policy issued to plan or trust Yes, but policyholder could ask insurer to provide rebate as premium reduction 4. Policy issued to plan or trust; Yes, 100% no specific plan or policy language 550

Factors

Rebate as Plan Assets?

5. Premiums paid entirely from plan assets

6. Premiums paid entirely from Yes, 100% plan assets, no specific plan or policy language 7. Policy issued to employer, premiums paid 100% by employer 8. Policy issued to employer; No no specific plan or policy language, and premiums paid 100% by employer

Rebate Hold in Trust? Yes, but policyholder could ask insurer to provide rebate as premium reduction

No

551

Factors

Rebate as Plan Assets?

9. Policy issued to employer, premiums paid 100% by participants

10. Policy issued to employer; no specific plan or policy language, premiums paid 100% by participants 11. Policy issued to employer, premiums shared by employer and participants by fixed percentage (e.g. employer pays 60%, participant pays 40%) 12. Policy issued to employer; no specific plan or policy language, premiums shared by employer and participants by fixed percentage (e.g. employer pays 60%, participant pays 40%)

Rebate Hold in Trust? No, if Tech Rel. 92-01 satisfied (but must be used to pay premiums or refunds within 3 months)

Yes, 100%

No, if Tech Rel. 92-01 satisfied (but must be used to pay premiums or refunds within 3 months Yes, for percentage equal to percentage of premiums paid by participants 552

Factors

13. Policy issued to employer, employer pays fixed amount of premiums, participants pays balance (e.g. employer pays $5,000/year toward coverage, participant pays any balance) 14. Policy issued to employer; no specific plan or policy language, employer pays fixed amount of premiums, participants pays balance (e.g. employer pays $5,000/year toward coverage, participant pays any balance) 15. Policy issued to employer, participants pay fixed amount of premiums, employer pays balance (e.g. participant pays $5,000/year toward coverage, employer pays any balance) 16. Policy issued to employer; no specific plan or policy language, participants pay fixed amount of premiums, employer pays balance (e.g. participant pays $5,000/year toward coverage, employer pays any balance)

Rebate as Plan Assets?

Rebate Hold in Trust? No, if Tech Rel. 92-01 satisfied (but must be used to pay premiums or refunds within 3 months

Yes, up to total amount paid by participants, balance not plan assets.

No, up to total amount paid by employer, no for balance if Tech Rel. 92-01 satisfied (but must be used to pay premiums or refunds within 3 months No, up to total amount paid by employer, balance is plan assets.

553

Medical Loss Ratio (MLR) FAQs Affordable Care Act Tax Provisions • The IRS frequently questions and answers provide information on the federal tax consequences to: – A health insurance issuer that pays a MLR rebate. – An individual policyholder that receives the MLR rebate. – Employees when a MLR rebate stems from a group health insurance policy. • These FAQs were last revised on April 2, 2012. Source: http://www.irs.gov/uac/Medical-Loss-Ratio-(MLR)-FAQs; http://www.irs.gov/uac/Affordable-Care-Act-Tax-Provisions. 554

Código de Seguros de Salud Razón de Perdida/MLR y Reembolso • Las organizaciones de seguros de salud y aseguradores de planes médicos individuales y de patronos PYMES deberán utilizar directamente al menos un 80% de las primas en proveer cuidado de salud y para el mejoramiento de la calidad del cuidado de salud que recibe el asegurado. En el caso de los grupos grandes esta razón deberá ser 85%. • Los grupos grandes tienen más de 50 empleados o miembros y en el 2016 tendrán más de 100 empleados o miembros. • Si la organización de seguros de salud o el asegurador incumplan con la disposición deberá reembolsarle al suscriptor la diferencia. Fuente: Artículo 2.050 (K) del Código de Seguros de Salud, Ley Número 194 del 29 de agosto de 2011, enmendado por la Ley Número 55 de 10 de julio de 2013. Ver Carta Normativa CN-2013155-AS de 29 de julio de 2013. 555

Código de Seguros de Salud Cumplimiento • Se requiere a todas las organizaciones de seguros de salud y aseguradores que suscriben planes médicos en Puerto Rico, presentar ante la Oficina del Comisionado de Seguros una copia del informe sobre la Razón de Pérdida por Servicios Médicos (“Medical Loss Ratio”) en la misma fecha en que vienen obligados a presentarlo ante el Secretario de Salud Federal, en o antes del 1 de junio de cada año . • Estas entidades deberán informar, en un documento por separado, el monto total, si alguno, que le corresponde reembolsar, el segmento del mercado al que aplicarán los reembolsos, la fecha en que se realizarán los pagos de los reembolsos y el método que se utilizará para desembolsar los mismos. Fuente: Cartas Normativas CN-2013-155-AS de 29 de julio de 2013 y CN-2013-156-AS de 30 de septiembre de 2013. 556

10. Internal Claims and Appeals and External Review Processes 45 CFR § 147.136

557

Improved Appeals Processes • The appeals provision applies to all health plans created or purchased after March 23, 2010 and affects each plan as that plan starts a new “plan year” or “policy year” on or after September 23, 2010. • HHS will not enforce these rules against issuers of stand-alone retiree-only plans in the private health insurance market. Source: http://www.healthcare.gov/law/provisions/appealing/Appealing%20Health%20Plan%20Decisions%202/moreinfo.html.

558

Improved Appeals Processes Give consumers in new health plans the right to appeal decisions, including claims denials and rescissions, made by the health plans. – The right to appeal decisions made by their health plan through the plan’s internal process. – The right to appeal decisions made by their health plan to an outside, independent decision-maker, no matter what State they live in or what type of health coverage they have. – States will work to establish or update their external appeals process to meet new standards, and consumers who are not protected by a State law will have access to a Federal external review program. Source: http://www.healthcare.gov/law/provisions/appealing/Appealing%20Health%20Plan%20Decisions%202/moreinfo.html.

559

What This Means for You? • When an insurance plan denies payment for a treatment or service, you can appeal to the plan to review its own decision. Your plan must explain how to appeal when it informs you of the denial. • When you appeal, your plan must give you its decision within: – 72 hours for denials of urgent care. – 30 days for denials of non-urgent care you have not yet received. – 60 days for denials of service you have already received. Source: http://www.healthcare.gov/law/provisions/appealing/appealinghealthplandecisions.html

560

What This Means for You? • If the plan still denies your request, it must explain why and tell you how to appeal for an independent review of the decision. In some cases involving urgent care, you may be able to have the internal and external review take place at the same time. • If you do not speak English, you may be entitled to receive all appeals-related information in your native language. Source: http://www.healthcare.gov/law/provisions/appealing/appealinghealthplandecisions.html

561

Right to Information About Why a Claim or Coverage has been Denied Health plans and insurance companies have to tell you why they’ve decided to deny a claim or chosen to end your coverage – and how you can appeal that decision. Source: http://cciio.cms.gov/resources/files/working_with_states_to_protect_consumers_06222011.html

562

Right to Appeal to the Insurance Company If you’ve had a claim denied or had your coverage rescinded, you have the right to an internal appeals process, a process in which you ask your insurance company to conduct a full and fair review of its decision. If the case is urgent, your insurance company must speed up this process. Source: http://cciio.cms.gov/resources/files/working_with_states_to_protect_consumers_06222011.html

563

Internal Appeals • The internal appeals process will guarantee a venue where consumers may present information their health plan might not have been aware of, giving families a straightforward way to clear up misunderstandings. • New health plans beginning on or after September 23, 2010 must have an internal appeals process that allows consumers to appeal when a health plan denies a claim for a covered service or rescinds coverage; Source: http://www.dol.gov/ebsa/newsroom/fsaffordablecareact.html

564

Internal Appeals • Gives consumers detailed information about the grounds for the denial of claims or coverage; • Requires plans to notify consumers about their right to appeal and instructs them on how to begin the appeals process; • Ensures a full and fair review of the denial; and • Provides consumers with an expedited appeals process in urgent cases. Source: http://www.dol.gov/ebsa/newsroom/fsaffordablecareact.html

565

Right to an Independent Review External Review • Often, insurers and their policyholders can resolve disputes during the internal appeals process. If you can’t work it out through the internal appeals process, you now have the right to take your appeal to an independent third-party for review of the insurer’s decision. • This way, the insurance company no longer gets the final say regarding your benefits, and patients and doctors get a greater measure of control over health care. Source: http://cciio.cms.gov/resources/files/working_with_states_to_protect_consumers_06222011.html 566

External Appeals: NAIC Standards • External review of plan decisions to deny coverage for care based on medical necessity, appropriateness, health care setting, level of care, or effectiveness of a covered benefit. • Clear information for consumers about their right to both internal and external appeals - both in the standard plan materials, and at the time the company denies a claim. • Expedited access to external review in some cases - including emergency situations, or cases where their health plan did not follow the rules in the internal appeal. Source: http://www.dol.gov/ebsa/newsroom/fsaffordablecareact.html

567

External Appeals: NAIC Standards • Health plans must pay the cost of the external appeal under State law, and States may not require consumers to pay more than a nominal fee. • Review by an independent body assigned by the State. The State must also ensure that the reviewers meet certain standards, keep written records, and are not affected by conflicts of interest. • Emergency processes for urgent claims, and a process for experimental or investigational treatment. Source: http://www.dol.gov/ebsa/newsroom/fsaffordablecareact.html

568

External Appeals: NAIC Standards • Final decisions must be binding so, if the consumer wins, the health plan is expected to pay for the benefit that was previously denied. If State laws don't meet these standards, consumers in those States will be protected by comparable Federal external appeals standards. In addition, people in health plans that are not subject to State law - including new self-insured employer plans - will be protected by the new Federal standards. Source: http://www.dol.gov/ebsa/newsroom/fsaffordablecareact.html

569

Model Notice Revised as June 22, 2011 • Model Notice of Adverse Benefit Determination • Model Notice of Final Internal Adverse Benefit Determination • Model Notice of Final External Review Decision Source: http://www.dol.gov/ebsa/healthreform/

570

State External Review Process Extension of the Transition Period Extension of the Transition Period for the Temporary NAIC-Similar State External Review Process under the Affordable Care Act (March 15, 2013) • Extends the applicability of the temporary NAIC-similar process standards until January 1, 2016. • During this extended transition period, States that CCIIO has already determined to meet the NAIC-similar process standards will continue to be considered compliant with the requirements until January 1, 2016. Source: http://www.dol.gov/ebsa/pdf/tr13-01.pdf; http://www.cms.gov/CCIIO/Resources/Files/Downloads/appeals-technical-release-315-2013.pdf 571

State External Review Process Extension of the Transition Period • This extension of transitional relief will serve as a bridge until additional clarification regarding State standards for external review is issued. The Departments intend to issue additional clarification regarding the State standards for external review that takes into account comments, inquiries, and other feedback received from stakeholders on the July 2010 regulations, the June 2011 amendment, and subsequent guidance. 572

State External Review Process Extension of the Transition Period • Until January 1, 2016 (or earlier if a State enacts an NAIC-parallel process prior to January 1, 2016), issuers (and, if applicable, selfinsured nonfederal governmental plans) will be considered to comply with the requirements of the July 2010 regulations if they comply with an applicable State external review process that meets the temporary NAIC-similar process standards established in T.R. 201102, even if it does not meet all the minimum standards consumer protections for State External review process of the regulations. • Beginning January 1, 2016, a State external review process will need to satisfy the minimum standards for State External review process of the regulations, as amended, or issuers (and, if applicable, selfinsured nonfederal governmental plans) in that State will need to comply with a Federally-administered external review process. 573

Código de Seguros de Salud Procedimiento Internos de Querellas • El Capítulo 22 se conoce como el Capítulo sobre Procedimientos Internos de Querellas de las Organizaciones de Seguros de Salud o Aseguradores. • En el caso de los planes de patronos privados regidos por la Ley Federal de Seguridad en el Ingreso por Retiro (ERISA, por sus siglas en inglés), cualquier disposición de este Capítulo que esté en conflicto con alguna ley o reglamento federal aplicable a Puerto Rico en el área de determinaciones adversas, se entenderá enmendada para que armonice con tal ley o reglamento federal. Fuente: Capítulo 22 del Código de Seguros de Salud, Ley 194 de 29 de agosto de 2011, según enmendado por la Ley Número 55 de 10 de julio de 2013.

574

Código de Seguros de Salud Revisión Externa Independiente • Capítulo 28 provee las normas para establecer y mantener los procedimientos de revisión externa que regirán en Puerto Rico, a fines de garantizar que las personas cubiertas o asegurados tengan la oportunidad de recibir una revisión independiente de las determinaciones adversas o determinaciones adversas finales que hacen las organizaciones de seguros de salud o aseguradores. Fuente: Capítulo 28 del Código de Seguros de Salud, Ley 194 de 29 de agosto de 2011, según enmendado por la Ley Número 203 de 23 de agosto de 2012. 575

PR External Review Process CCIIO Determination (May 9, 2014)

576

Código de Seguros de Salud Revisión Externa Independiente • El asegurador tiene la opción de escoger uno de los siguientes procesos de revisión externa: – El proceso de revisión independiente externa establecido por la Oficina del Comisionado de Seguros. – El proceso de revisión independiente externa establecido por el Departamento de Salud Federal. – La contratación de entidades privadas de revisión independiente. Fuente: Carta Circular Número CC-2013-1832-D de 10 de julio de 2013

577

Código de Seguros de Salud Revisión Externa Independiente

578

Election of a Federally-administered External Review Process TECHNICAL GUIDANCE- JUNE 15, 2015 • Sets instructions for self-insured non-federal governmental health plans and health insurance issuers offering group and individual health coverage on how to elect a federal external review process. • Sets forth instructions regarding the election of a Federally-administered external review process using the Health Insurance Oversight System (HIOS). • Applies to health insurance issuers offering group and individual health coverage that are using a Federally-administered external review process. Applies to self-insured, non-federal governmental health plans. • Do not apply to plans and issuers in connection with grandfathered health plans. Source: http://www.cms.gov/CCIIO/Resources/Regulations-andGuidance/Downloads/20150608-HHS-SRG-on-elections-FINAL-6-8-15-MM508.pdf 579

Carta de Derechos y Responsabilidades del Paciente de Puerto Rico Artículo 6.-Derechos en cuanto a selección de planes y proveedores (k) Que los planes de cuidado de salud individuales o grupales implanten un sistema de querellas interno aprobado por el Comisionado que provea procedimientos adecuados y razonables para la pronta resolución de querellas relacionadas con las determinaciones sobre cubiertas y reclamaciones de asegurados. Los planes le notificarán a sus asegurados que tienen acceso a un proceso de apelaciones; que tienen derecho a ser asistidos por un funcionario del gobierno como el Procurador del Paciente o el Procurador del Ciudadano o un abogado de su preferencia; que tienen acceso a su expediente médico; que pueden presentar evidencia escrita o testifical; y que tienen derecho a recibir los beneficios, según se determine en el proceso. Los asegurados tienen derecho a que los planes de cuidado de salud establezcan un sistema de apelación ante una entidad externa e independiente que cumpla con los requisitos que el Comisionado establezca. Todo asegurado tiene derecho a que se establezca un proceso de evaluación expedita en los casos de emergencia que pongan en riesgo su salud. Fuente: Ley Número 161 de 1 de noviembre de 2010

580

11. Summary of Benefits and Coverage (SBC) and Uniform Glossary Plain Language Benefits Information 45 CFR § 147.200 79 Federal Register 78577, Tuesday, December 30, 2014, Proposed Rules Source: http://cciio.cms.gov/programs/consumer/summaryandglossary/index.html, http://www.healthcare.gov/law/features/rights/sbc/index.html, http://www.dol.gov/ebsa/healthreform/

581

Summary of Benefits and Coverage Group and Individual Insurance • Public Health Service (PHS) Act section 2715, as added by the Affordable Care Act, directs the Departments to develop standards for use by a group health plan and a health insurance issuer offering group or individual health insurance coverage in compiling and providing a summary of benefits and coverage (SBC) that “accurately describes the benefits and coverage under the applicable plan or coverage.” Source: http://www.dol.gov/ebsa/faqs/faq-aca14.html.

582

What This Plan Covers and What it Costs Guide for Group Coverage • What is the overall deductible? doesn’t cover? • Are there other deductibles for • Cost sharing information specific services? • Limitations and exceptions • Is there an out-of-pocket limit on • Specific additional instructions for my expenses? some of the common medical • What is not included in the out-of- events pocket limit? • Excluded services and other • Is there an overall annual limit on covered services what the plan pays? • Rights to continue coverage • Does this plan use a network of • Grievance and appeals rights providers? • Coverage examples Source: Guide for Group Coverage • Do I need a referral to see a http://www.dol.gov/ebsa/pdf/SBCInstruction specialist? sGroup.pdf • Are there services this plan 583

What This Plan Covers and What it Costs Instruction Guide for Individual Health Insurance Coverage • What is the overall deductible? • Cost sharing information • Are there other deductibles for • Limitations and exceptions specific services? • Specific additional instructions for • Is there an out-of-pocket limit on my some of the common medical expenses? events • What is not included in the out-of- • Excluded services and other covered pocket limit? services • Is there an overall annual limit on • Rights to continue coverage what the plan pays? • Grievance and appeals rights • Does this plan use a network of • Coverage examples Source: Guide for Individual Health Insurance providers? Coverage • Do I need a referral to see a http://www.dol.gov/ebsa/pdf/SBCInstruction specialist? sIndividual.pdf • Are there services this plan doesn’t cover? 584

Summary of Benefits and Coverage • A group health plan and a health insurance issuer are required to provide a written SBC for each benefit package without charge to entities and individuals. • SBC must be provided to a participant or beneficiary with respect to each benefit package offered by the plan for which the participant or beneficiary is eligible. Source: 45 CFR sec. § 147.200, Summary of benefits and coverage and uniform glossary.

585

SBC Must Be Provided TO:

Group Health Plan: • Upon application. • By first day of coverage (if there are changes). • Upon renewal • Upon request. Source: Source: 45 CFR sec. § 147.200, Summary of benefits and coverage and uniform glossary.

Participants and Beneficiaries: • Upon application. • By first day of coverage (if there are changes). • Special enrollees. • Upon renewal. • Upon request. 586

Unnecessary SBC Duplication • An entity satisfies the requirement if another party provides the SBC, but if the SBC is timely and complete. • If a single SBC is provided to a participant and any beneficiaries at the participant's last known address then the requirement to provide the SBC is generally satisfied. • If multiple benefit packages are offered, the SBC must be provided automatically upon renewal only with respect to the benefit package in which a participant or beneficiary is enrolled. 587

SBC Content 1. Uniform definitions of standard insurance terms and medical terms so that consumers may compare health coverage and understand the terms of (or exceptions to) their coverage. 2. A description of the coverage, including cost sharing, for each category of benefits. 3. The exceptions, reductions, and limitations of the coverage. 4. The cost-sharing provisions of the coverage, including deductible, coinsurance, and copayment obligations. 588

SBC Content 5. The renewability and continuation of coverage provisions. 6. Coverage examples that illustrate benefits provided under the plan or coverage for common benefits scenarios (pregnancy and serious or chronic medical conditions). 7. A statement that the SBC is only a summary and that the plan document, policy, certificate, or contract of insurance should be consulted to determine the governing contractual provisions of the coverage. 8. Contact information for questions and obtaining a copy of the plan document or the insurance policy, certificate, or contract of insurance (telephone number and an Internet address). 589

SBC Content 9. For plans and issuers that maintain one or more networks of providers, an Internet address (or similar contact information) for obtaining a list of network providers. 10. For plans and issuers that use a formulary in providing prescription drug coverage, an Internet address (or similar contact information) for obtaining information on prescription drug coverage. 11. An Internet address for obtaining the uniform glossary, a contact phone number to obtain a paper copy of the uniform glossary, and a disclosure that paper copies are available. 12. With respect to coverage beginning on or after January 1, 2014, a statement about whether the plan or coverage provides minimum essential coverage. 590

Second Year of Applicability January 1, 2014 On or After January 1, 2014, and Before January 1, 2015

Does this Coverage Provide Minimum Essential Coverage? • The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy [does/does not] provide minimum essential coverage. Does this Coverage Meet the Minimum Value Standard? • The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage [does/does not] meet the minimum value standard for the benefits it provides. Source: http://www.dol.gov/ebsa/pdf/correctedsbctemplate2.pdf; http://www.dol.gov/ebsa/pdf/CorrectedSampleCompletedSBC2.pdf; http://www.dol.gov/ebsa/faqs/faq-aca14.html; 591

SBC Requirements • SBC Appearance: Must be presented in a uniform format, use terminology understandable by the average plan enrollee, not exceed four double-sided pages in length, and not include print smaller than 12-point font. • SBC Form: May be provided in paper form. The SBC may be provided electronically (such as by email or an Internet posting) if the format is readily accessible, the SBC is provided in paper form free of charge upon request, the issuer timely advises that the documents are available on the Internet and provides the Internet address. • SBC Language: Must be provided in a culturally and linguistically appropriate manner. 592

SBC Requirements • Notice of Modification: If case of any material modification in any of the terms of the plan or coverage that would affect the content of the SBC, the plan or issuer must provide notice of the modification to enrollees not later than 60 days prior to the date on which the modification will become effective. • Uniform Glossary: Must make available to participants and beneficiaries the uniform glossary with health-coverage-related terms and medical terms. • Applicability Date: Begins on or after September 23, 2012.

Failure to provide is subject to a fine of not more than $1,000 for each such failure. 593

Enforcement Safe Harbor “Closed Blocks of Business” Relief provided to insurance products that are no longer being offered for purchase and meets three conditions: • The insured product is no longer being actively marketed; • The health insurance issuer stopped actively marketing the product prior to September 23, 2012, when the requirement to provide an SBC was first applicable to health insurance issuers, provided the SBC is provided for that product no later than September 23, 2014; and • The health insurance issuer has never provided an SBC with respect to the insured product. 594

Oficina Comisionda de Seguros Carta Normativa 29/julio/2013

595

Summary of Benefits and Coverage and Uniform Glossary Final Rule Source: Final Rules, 80 Federal Register 34292, Tuesday, June 16, 2015 http://www.federalregister.gov/articles/2015/06/16/2015-14559/summary-of-benefits-andcoverage-and-uniform-glossary; http://www.gpo.gov/fdsys/pkg/FR-2015-06-16/pdf/201514559.pdf http://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/FactSheet_SBCFinalRule-6-11-15-MM-508.pdf http://cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2015-Press-releasesitems/2015-06-12.html 596

Provide a Brief SBC • Health insurance issuers and group health plans must still provide a brief SBC that includes coverage examples and a uniform glossary to consumers. • Revisions to the SBC, coverage examples, and uniform glossary are anticipated to be finalized by January 2016 after the Departments utilize consumer testing and receive additional input from the public, including the National Association of Insurance Commissioners (NAIC). • The revisions will apply to SBCs for coverage beginning on or after January 1, 2017. 597

Require Online Access to Individual Underlying Policy or Group Certificate The final regulations clarify that issuers must include an Internet web address where a copy of the actual individual coverage policy or group certificate of coverage can be reviewed and obtained. The final regulations require these documents to be easily available to individuals, plan sponsors, and participants and beneficiaries shopping for coverage prior to submitting an application for coverage. For the group market only, because the actual “certificate of coverage” is not available until after the plan sponsor has negotiated the terms of coverage with the issuer, an issuer is permitted to satisfy this requirement with respect to plan sponsors that are shopping for coverage by posting a sample group certificate of coverage for each applicable product. After the actual certificate of coverage is executed, it must be easily available to plan sponsors and participants and beneficiaries via an Internet web address. 598

Reduce Unnecessary Duplication The final regulations help prevent unnecessary duplication: • Where a group health plan utilizes a binding contractual arrangement where another party assumes responsibility to provide the SBC; • Where a group health plan uses two or more insurance products provided by separate issuers to insure benefits with respect to a single group health plan; and • Where the SBC for student health insurance coverage is provided by another party (such as an issuer that provides coverage for student enrollees and covered dependents of an institution of higher education). 599

SBC and Uniform Glossary Regulations and Guidance • Final Regulations - June 2015 – HHS Fact Sheet – HHS News Release • Proposed Regulations - December 2014 • Final Regulations - February 2012 • Guidance for Compliance - February 2012 • Proposed Regulations - August 2011 • Solicitation of comments - Templates, Instructions, and Related Materials - August 2011 • Culturally and Linguistically Appropriate Services (CLAS) County Data Source: http://www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html 600

Templates, Instructions, and Related Materials – Currently Applicable (SBCs Before 1/1/2017) • Summary of Benefits and Coverage (SBC) Template | MS Word Format • Sample Completed SBC | MS Word Format • Instructions for Completing the SBC - Group Health Plan Coverage and Consumer Assistance Programs • Instructions for Completing the SBC - Individual Health Insurance Coverage • Why This Matters language for "Yes" Answers • Why This Matters language for "No" Answers • HHS Information For Simulating Coverage Examples • HHS Coverage Example Calculator and Related Information • Uniform Glossary of Coverage and Medical Terms Source: http://www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html 601

Templates, Instructions, and Related Materials – Proposed (SBCs On or After 1/1/2017) • Summary of Benefits and Coverage (SBC) Template | MS Word Format • Sample Completed SBC | MS Word Format • Instructions for Completing the SBC - Group Health Plan Coverage • Instructions for Completing the SBC - Individual Health Insurance Coverage • Why This Matters language for "Yes" Answers • Why This Matters language for "No" Answers • HHS Information For Simulating Coverage Examples • HHS Coverage Example Calculator and Related Information • Uniform Glossary of Coverage and Medical Terms Source: http://www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html 602

Employees are protected from retaliation for reporting alleged violations of the ACA. Source: Section 18 C of the Fair Labor Standards Act of 1938; http://www.osha.gov/Publications/whistleblower/OSHAFS-3641.pdf; 29 CFR Part 1984: Procedures for the Handling of Retaliation Complaints under Section 1558 of the Affordable Care Act, Interim Final Rule, 78 Federal Register 13222, (February 27, 2013); http://www.whistleblowers.gov/.

603

PROTECTIONS FOR EMPLOYEES No employer shall discharge or in any manner discriminate against any employee with respect to his or her compensation, terms, conditions, or other privileges of employment because the employee (or an individual acting at the request of the employee) has: 604

Protected Activity • Provided information relating to any violation of Title I of the ACA, or any act that he or she reasonably believed to be a violation of Title I of the ACA to the: – Employer, – Federal Government, or – Attorney General of a State.

• Testified, assisted, or participated in a proceeding concerning a violation of Title I of the ACA, or is about to do so. 605

Protected Activity • Objected to or refused to participate in any activity that he or she reasonably believed to be in violation of Title I of the ACA. • Received a health insurance tax credit or a cost sharing reduction as a result of participating in a Health Insurance Exchange, or Marketplace.

606

607

608

Código de Seguros de Salud Nuevas Reglas para los Planes Médicos

609

Rol de la Oficina del Comisionado de Seguros para Implantar ACA en Puerto Rico • Preparó legislación, el Código de Seguros de Salud, para viabilizar la implantación de las disposiciones de ACA que aplican a Puerto Rico. • Emite Cartas Normativas y Circulares para requerir a la industria que cumpla con ACA y para proveer orientación sobre los planes médicos y las guías adecuadas para la suscripción de los mismos. • Uniformó el proceso para someter las tarifas de los planes médicos y para revisar y aprobar las mismas. 610

Rol de la Oficina del Comisionado de Seguros para implantar ACA en Puerto Rico • Unió esfuerzos con la Asociación Nacional de Comisionados de Seguros (NAIC) y los otros territorios para informar al Departamento de Salud Federal sobre los retos que para implantar algunas de las disposiciones de ACA y para identificar alternativas viables. • Ofrece seminarios y orientaciones al público y a la industria sobre las disposiciones de ACA que nos aplican. • Desarrolló campaña de servicio público para orientar al consumidor ACA y el Código de Seguros de Salud. 611

Código de Seguros de Salud Aprobación por Fases Debido a la complejidad e importancia de este asunto, se determinó aprobar por fases el nuevo Código de Seguros de Salud, para que los distintos Capítulos que lo componen sean analizados responsablemente. • Fase 1 - Ley 194 de 29 de agosto de 2011 – Ley 290 de 29 de septiembre de 2012 – Ley 55 de 10 de julio de 2013 • Fase 2 - Ley 203 de 23 de agosto de 2012 • Capítulo 10 - Ley 69 de 22 de julio de 2013

Aprobados 18 Capítulos 612

Código de Seguros de Salud Áreas que Atiende el Código Tema Capítulo 2. Capítulo 4.

Disposiciones Generales Manejo de Medicamentos de Receta

Capítulo 6.

Auditoría de Reclamaciones Presentadas a las Organizaciones de Seguros de Salud o Aseguradores

Capítulo 8.

Disponibilidad de Planes Médicos para Los Patronos de Pequeñas y Medianas Empresas Capítulo 10. Planes Médicos Individuales y Suscripción Garantizada Capítulo 12. Prohibición del Uso de Cláusulas Discrecionales 613

Código de Seguros de Salud Áreas que Atiende el Código Tema Capítulo 14.

Protección de la Información de Salud

Capítulo 16.

Organizaciones de Servicios de Salud Limitados

Capítulo 18.

Verificación de Credenciales de los Profesionales o Entidades de la Salud

Capítulo 20.

Evaluación y Mejora de Calidad en las Organizaciones de Seguros de Salud o Aseguradores

Capítulo 22.

Procedimientos Internos de Querellas de las Organizaciones de Seguros de Salud o Aseguradores

Capítulo 24.

Revisión de Utilización y Determinación de Beneficios 614

Código de Seguros de Salud Áreas que Atiende el Código Tema Capítulo 26. Suficiencia de las Redes de Proveedores para Planes de Cuidado Coordinado Capítulo 28. Revisión Externa Independiente Capítulo 52. Uso No Indicado en la Etiqueta Capítulo 54. Cubierta para Niños Recién Nacidos, Niños Recién Adoptados y Niños Colocados para Adopción Capítulo 66. Seguro de Cuidado Prolongado Capítulo 72. Discrimen Indebido Contra Víctimas de Maltrato

615

Exposición de Motivos Legislación Modelo de la NAIC Todo lo anterior, basado en la legislación modelo desarrollada por la Asociación Nacional de Comisionados de Seguros (National Association of Insurance Commissioners o la NAIC). http://www.naic.org/.

616

1. Aplicabilidad del Código de Seguros de Salud Capítulo 2: (1ra. Fase) Disposiciones Generales

617

Declaración de Política Pública • El Gobierno del Estado Libre Asociado de Puerto Rico adopta como política pública el garantizar una regulación y reglamentación más efectiva de la industria de los seguros de salud, incluyendo la regulación de aquellas entidades que ofrecen planes médicos grupales e individuales. Como parte de esa política pública, es vital que se cumplan las normas promovidas por la Reforma de Salud Federal implantada a través del “Patient Protection and Affordable Care Act” y el “Health Care and Education Reconciliation Act.” De igual forma, a nivel estatal es necesario recoger y uniformar, en lo posible, en un nuevo cuerpo legal conocido como el Código de Seguros de Salud de Puerto Rico, las normas legales aplicables a esta importante industria, la cual ha experimentado un crecimiento sin precedentes en los pasados años. Fuente: Artículo 2.020 del Código de Seguros de Salud de Puerto Rico, según enmendado por la Ley Número 5 de 3 de enero de 2014. 618

Declaración de Política Pública • La política pública aquí adoptada tiene como fin primordial lograr que todos los puertorriqueños tengan acceso a más y mejores servicios de salud y promover un mayor crecimiento y desarrollo de esta industria. • En adición, se reconoce como política pública del Estado Libre Asociado de Puerto Rico que la salud es un asunto de naturaleza ética, de justicia social y de derechos humanos sobre el ánimo de lucro. Por tanto, en caso de necesitar interpretar las disposiciones de esta Ley o surgir algún conflicto entre lo establecido en este Código de Seguros de Salud y cualquier otra legislación, la interpretación que prevalecerá será aquella que resulte más favorable para el paciente. Fuente: Artículo 2.020 del Código de Seguros de Salud de Puerto Rico, según enmendado por la Ley Número 5 de 3 de enero de 2014. 619

Aplicabilidad del Código de Seguros y Otras Leyes Especiales Código de Seguros

Código de Seguros de Salud

Leyes Aplicables

El Código de Seguros, el Reglamento de Seguros y las Cartas Normativas y Circulares emitidas al amparo del mismo aplicarán a los planes médicos y a las entidades reguladas por el Código de Salud, en todo aquello que no sea incompatible. 620

Código de Seguros Disposiciones Aplicables Capítulo (25)

Título

Capítulo 1 Capítulo 2 A Capítulo 3

Alcance del Código Comisionado de Seguros Autorización de Aseguradores y Requisitos Generales Clases de Seguros; Reaseguro; Limitaciones de Riesgos

Capítulo 4 Capítulo 5 Capítulo 6 B

Activo y Pasivo Inversiones

Capítulo 7

Arancel e Impuestos 621

Código de Seguros Disposiciones Aplicables Capítulo

Título

Capítulo 8

Administración de Depósitos

Capítulo 9 A Capítulo 11

Productor, Representante Autorizado, Solicitador, Agente General, Ajustador y Consultor de Seguros Contrato de Seguro

Capítulo 16

Seguro de Incapacidad Física

Capítulo 17

Seguro Colectivo y General de Incapacidad

Capítulo 19

Organizaciones de Servicios de Salud

622

Código de Seguros Disposiciones Aplicables Capítulo

Título

Capítulo 26

Fondos No Reclamados en Compañías de Seguros, Productores Generales, Gerentes y Productores Prácticas Desleales y Fraudes

Capítulo 27 Capítulo 28 Capítulo 29

Organización de Aseguradores Poderes Corporativos y Procedimientos de Aseguradores por Acciones y Mutualistas del País

Capítulo 30

Pago de Reclamaciones por Servicios

Capítulo 31

Negociación Colectiva de Proveedores y Organizaciones de Servicios de Salud 623

Código de Seguros Disposiciones Aplicables Capítulo

Título

Capítulo 34

Aseguradores Cooperativos

Capítulo 39

Asociación de Garantía de Seguro de Vida e Incapacidad

Capítulo 40

Rehabilitación y Liquidación de Aseguradores

Capítulo 45

Capital Computado en Función del Riesgo

Capítulo 49

Salud--Sistema de Facturación Uniforme

Capitulo 51

Prohibición del Uso Restringido del Servicio 9-1-1 por Planes de Salud 624

Código de Seguros Definición de Asegurador • Es la persona que se dedica a la contratación de seguros. • Ejemplos de un asegurador: – Una asociación de seguro reciproco. – Una asociación mutualista. – Una organización de servicios de salud. – Un grupo de cualquier clase, organizado con fines pecuniarios o sin ellos, dedicado al negocio de otorgar contratos de seguros. Fuente: Artículo 1.030 del Código de Seguros, 26 L.P.R.A. § 103. 625

Código de Seguros Definición de Seguro • Es el contrato mediante el cual una persona se obliga a indemnizar a otra o a pagarle o a proveerle un beneficio especifico o determinable al producirse un suceso incierto previsto en el mismo. • El termino seguro incluye reaseguro. Fuente: Artículo 1.020 del Código de Seguros, 26 L.P.R.A. § 102

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Código de Seguros Contratar o Tramitar Seguros Incluye los siguientes actos: 1. Solicitación y persuasión. 2. Negociaciones anteriores al otorgamiento. 3. Otorgamiento de un contrato de seguro. 4. Asegurar o reasegurar. 5. Tramitación de asuntos subsiguientes al otorgamiento de un contrato de seguro. Fuente: Artículo 1.050 del Código de Seguros, 26 L.P.R.A. § 105.

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Código de Seguros Organismos y Entidades Excluidos 1. No cubrirá ni determinará la existencia de operaciones, contratos, ni funcionarios, directores, ni representantes de todo organismo hasta donde sus actividades relacionadas con seguros estuvieron prescritas o permitidas por otra ley expresamente votada al efecto, con excepción de la Asociación de Empleados del Estado Libre Asociado. El Comisionado de Seguros promulgará y a ejecutará la reglamentación que sea necesaria para llevar a cabo la supervisión y fiscalización de las actividades de seguros de la Asociación. 2. El Proyecto de Fianzas Aceleradas, creada mediante Orden de 28 de abril de 1988 dictada por el Tribunal de Distrito de los Estados Unidos para el Distrito de Puerto Rico en el caso Carlos Morales Feliciano, et al. v. Pedro Rosselló González, et al., Caso Civil Núm. 79A (PG). Fuente: Artículo 1.070 del Código de Seguros, 26 L.P.R.A. § 107. 628

Código de Seguros Organismos y Entidades Excluidos 3. Toda sociedad o asociación de socorros o auxilios mutuos de fines no pecuniarios fundada en Puerto Rico antes del 11 de abril de 1899, y que al día de hoy tenga, mantenga y opere en Puerto Rico cualquier plan de servicios medico-quirúrgicos y servicios de hospitalización a sus socios. – Estas sociedades y asociaciones excluidas que actualmente tengan, mantengan y operen cualquier plan de servicios de hospitalización tienen que cumplir con las secciones 47, 48 y 50 del Titulo 6 y mantener las reservas requeridas a las entidades organizadas bajo la secciones 41 et seq. del Titulo 6. – Ver Capitulo 3: Asociaciones de Servicio de Hospitalización y/o MedicoQuirúrgicos, 6 L.P.R.A. sección 41 a la 55. (§ 4147: Informes anuales - estado financiero, § 48: Examen de las condiciones de la asociación, § 50: Capital en explotación inicial; reservas). NOTA: Ver Inciso K del Artículo 2.030 (Definiciones) del Código de Seguros de Salud, según enmendado por la Ley Número 90 de 15 de julio de 2014. 629

Aplicabilidad del Código de Seguros y Otras Leyes Especiales • El Código no enmienda o deroga las leyes, los reglamentos o los procedimientos que administran la Oficina del Procurador del Paciente o la Administración de Seguros de Salud (ASES). • Los aseguradores que contratan con ASES para ofrecer el Plan MI Salud cumplirán con los requisitos y las disposiciones establecidas por ASES, excepto que el Código de Seguros y el Código de Salud aplicará en: – Los asuntos relativos a la autorización o licencia requerida para hacer negocios de seguros en Puerto Rico. – Aquellas áreas pertinentes a la solvencia económica.

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Definiciones • • • • • • • • • • • • • • • •

Beneficios cubiertos o beneficios Código de Seguros de Puerto Rico Comisionado Condición médica de emergencia Criterios de revisión clínica Cuidado médico Dependientes Instalación de cuidado de salud o instalación Necesidad Médica NAIC Organización de servicios de salud Organización de seguros de salud o asegurador Persona cubierta o asegurado Persona Plan abierto Plan cerrado

• • • • •

• • • • • • • • •

Plan de cuidado coordinado Plan de indemnización médica Plan médico Profesional de la salud Proveedor de cuidado de salud o proveedor Proveedor de cuidado primario Proveedor partcipante Representante personal Reglamento del Código de Seguros de Salud Servicios de cuidado de la salud o servicios médicos Servicios de emergencia Suscriptor Urgencia Beneficios de Salud Esenciales 631

Definiciones Organización de Servicios de Salud Toda entidad que se compromete mediante contrato a proveer o tramitar servicios de cuidado de la salud a sus suscriptores a base del prepago de los mismos, según se establece en el Capítulo sobre Organizaciones de Servicios de Salud del Código.

632

Definiciones: Organización de Seguros de Salud o Asegurador • Entidad sujeta a las leyes y reglamentos de seguros de Puerto Rico o sujeta a la jurisdicción del Comisionado, que contrata o se ofrece a contratar para proveer, suministrar, tramitar o pagar los costos de servicios de cuidado de salud o reembolsar los mismos, incluyendo cualquier corporación con o sin fines de lucro de servicios hospitalarios y de salud, las organizaciones de servicios de salud u otra entidad que provea planes de beneficios, servicios o cuidado de la salud. • Las entidades excluidas en el Artículo 1.070 del Código de Seguros no serán consideradas como una organización de seguros de salud o asegurador para propósitos del Código de Seguros de Salud. Fuente: Inciso K del Artículo 2.030 (Definiciones) del Código de Seguros de Salud, según enmendado por la Ley Número 90 de 15 de julio de 2014. 633

Definiciones Plan Médico • Es un contrato de seguro, póliza, certificado, o contrato de suscripción con una organización de seguros de salud, organización de servicios de salud o cualquier otro asegurador.

• Se provee en consideración o a cambio del pago de una prima, o sobre una base prepagada. • Provee o paga por la prestación de determinados servicios médicos, de hospital, gastos médicos mayores, servicios dentales, servicios de salud mental, o servicios incidentales a la prestación de éstos. Fuente: Artículo 2.030 del Código de Seguros de Salud.

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Necesidad Médica Significa todo aquello que un médico licenciado prudente y razonable entienda que es medicamente necesario sobre todo aquel servicio o procedimiento de salud que se brinde a un paciente con el propósito de prevenir, diagnosticar o tratar una enfermedad, lesión, padecimiento, dolencia o sus síntomas en una forma que: • Sea conforme con las normas generalmente aceptadas de la práctica médica, a la luz de los medios modernos de comunicación y enseñanza; • Sea clínicamente apropiado en cuanto a tipo, frecuencia, grado, lugar y duración de los servicios o procedimientos de salud; • La determinación de “necesidad médica” no sea hecha meramente para la conveniencia del paciente o del médico o para el beneficio económico de la aseguradora, organización de servicios de salud u otro proveedor de planes de salud, del tratamiento médico en sí mismo o de otro proveedor de atención médica; • Sea dentro del ámbito de la práctica y/o especialidad médica de la o del profesional médico licenciado quien determinó la necesidad médica; y • Que dicha determinación de “necesidad médica” esté basada en evidencia clínica que sostenga la determinación y esté debidamente documentada por el facultativo que trató al paciente. Fuente: Artículo 2.030 del Código de Seguros de Salud de Puerto Rico, según enmendado por la Ley Número 5 de 3 de enero de 2014. 635

Negación de Servicios de Hospitalización y Pagos Facturados • Bajo este Código se establece que ninguna compañía de seguros de salud, organización de servicios de salud u otro proveedor de planes de salud autorizado en Puerto Rico, por sí o por medio de sus agentes, empleados o contratistas, negará la debida autorización para los procesos de hospitalización de un paciente, incluyendo el largo del periodo de dicha hospitalización y los pagos por servicios facturados tanto por el tratamiento, medicamentos y la debida prestación de servicios de salud al mismo, cuando medie una recomendación médica a estos fines, basada en la premisa de necesidad médica definida en este Código, en los casos en que estos servicios sean parte de la cubierta del plan médico del asegurado, el servicio sea prestado mientras la póliza se encuentre vigente y el servicio se encuentre dentro de las categorías de servicios cubiertos por dicha póliza.” Fuente: Artículo 2.090 del Código de Seguros de Salud de Puerto Rico, según enmendado por la Ley Número 5 de 3 de enero de 2014. 636

Discrimen Indebido Contra Victimas de Maltrato (Capítulo 72 del CSSPR) Si se termina la cubierta grupal de una víctima, cuando el plan está a nombre del maltratante y éste se divorció o separó de la víctima o perdió su custodia, o si la cubierta del maltratante terminó: • La víctima tiene derecho a continuar con el plan grupal por 18 meses si paga la prima, pero se puede establecer como condición que la víctima resida o trabaje en el área de servicio del plan médico y que el requisito se aplique por igual a todas los asegurados. • El asegurador podrá terminar la cubierta grupal después de que la cubierta continuada que aquí se requiere haya estado vigente durante 18 meses, si ofrece una conversión equivalente a un plan individual. • La cubierta continuada que aquí se requiere se podrá satisfacer con la cubierta que dispone la ley COBRA y no será adicional a ésta. 637

CAMPAÑA DE ORIENTACION AL CONSUMIDOR SOBRE EL “AFFORDABLE CARE ACT” Y EL CÓDIGO DE SEGUROS DE SALUD

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ANUNCIOS EN LA PRENSA

639

ANUNCIOS EN LA PRENSA

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Pauta de Radio y Video Informativo Seminarios sobre “Affordable Care Act y el Código de Seguros de Salud

Recursos Adicionales ¿Dónde Obtengo más Información? WWW.PLANMEDICOGARANTIZADO.COM 787-304-2500

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SENADO DE PUERTO RICO

P. del S. 1354 13 DE ABRIL DE 2015

Presentado por los señores Bhatia Gautier, Dalmau Santiago, Torres Torres; la señora López León; los señores Fas Alzamora, Nadal Power, Rosa Rodríguez; la señora González López; los señores Nieves Pérez, Pereira Castillo, Rivera Filomeno, Rodríguez González, Rodríguez Otero, Rodríguez Valle, Ruiz Nieves, Suárez Cáceres, Tirado Rivera y Vargas Morales Referido a la Comisión de Salud y Nutrición

LEY

Para enmendar el Artículo 2.030; enmendar el Artículo 2.050; añadir un nuevo Artículo 2.060; añadir un nuevo Artículo 2.070; añadir un nuevo Artículo 2.080; añadir un nuevo Artículo 2.090; añadir un nuevo Artículo 2.100; añadir un nuevo Artículo 2.110; renumerar los Artículos 2.060, 2.070, 2.080 y 2.090 como los Artículos 2.120, 2.130, 2.140 y 2.150; enmendar el Artículo 8.030; enmendar el Artículo 8.050; enmendar el Artículo 8.070; enmendar el Artículo 8.120; enmendar el Artículo 10.020; enmendar Artículo 10.030; enmendar el Artículo 10.040; enmendar el Artículo 10.050; derogar el Artículo 10.070; derogar el Artículo 10.080; enmendar el Artículo 10.090; enmendar el Artículo 10.100; enmendar el Artículo 10.110; derogar el Artículo 10.120; derogar el Artículo 10.130; derogar el Artículo 10.140; derogar el Artículo 10.150 y, en su lugar, crear un nuevo Artículo 10.150 de la Ley 194-2011, según enmendada, conocida como el “Código de Seguros de Salud de Puerto Rico”.

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Senado de Puerto Rico P. del S. 1354 PS 1354

Núm. de Fortaleza: F-195

Equiv: PC 2413

Trámite: • 4/13/2015 Radicado • 4/13/2015 Referido a Comisión(es): Salud y Nutrición (SENADO) • 4/16/2015 Aparece en Primera Lectura del Senado Fuente: http://www.oslpr.org/buscar/

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CÁMARA DE REPRESENTANTES

P. de la C. 2413 13 DE ABRIL DE 2015

Presentado por los representantes Perelló Borrás, Rivera Ruiz de Porras, Hernández López, Bianchi Angleró, Aponte Dalmau, Báez Rivera, Cruz Burgos, De Jesús Rodríguez, Franco González, Gándara Menéndez, Hernández Alfonzo, Hernández Montañez, Jaime Espinosa, López de Arrarás, Matos García, Méndez Silva, Natal Albelo, Ortiz Lugo, Pacheco Irigoyen, Rodríguez Quiles, Santa Rodríguez, Torres Cruz, Torres Ramírez, Torres Yordán, Varela Fernández, Vargas Ferrer, Vassallo Anadón y Vega Ramos Referido a la Comisión de Salud LEY

Para enmendar el Artículo 2.030; enmendar el Artículo 2.050; añadir un nuevo Artículo 2.060; añadir un nuevo Artículo 2.070; añadir un nuevo Artículo 2.080; añadir un nuevo Artículo 2.090; añadir un nuevo Artículo 2.100; añadir un nuevo Artículo 2.110; renumerar los Artículos 2.060, 2.070, 2.080 y 2.090 como los Artículos 2.120, 2.130, 2.140 y 2.150; enmendar el Artículo 8.030; enmendar el Artículo 8.050; enmendar el Artículo 8.070; enmendar el Artículo 8.120; enmendar el Artículo 10.020; enmendar Artículo 10.030; enmendar el Artículo 10.040; enmendar el Artículo 10.050; derogar el Artículo 10.070; derogar el Artículo 10.080; enmendar el Artículo 10.090; enmendar el Artículo 10.100; enmendar el Artículo 10.110; derogar el Artículo 10.120; derogar el Artículo 10.130; derogar el Artículo 10.140; derogar el Artículo 10.150 y, en su lugar, crear un nuevo Artículo 10.150 de la Ley 194-2011, según enmendada, conocida como el “Código de Seguros de Salud de Puerto Rico”. 645

Cámara de Representantes P. de la C. 2413 PC 2413 Núm. de Fortaleza: F-195 Equiv: PS 1354 Trámite: • 4/13/2015: Radicado • 4/13/2015: Referido a Comisión(es): Salud (CAMARA) • 4/13/2015: Aparece en Primera Lectura de la Cámara • 7/8/2015: Vista Pњblica: 10:30 AM, Salón de Audiencias 3, Comisión(es): Salud (CAMARA) • 7/8/2015: Vista Pública: 2:00 PM, Salón de Audiencias 3, Comisión(es): Salud (CAMARA) • 8/4/2015: Vista Pública: 10:30 AM, Aud. #1, Comisión(es): Salud (CAMARA) • 8/4/2015: Vista Pública: 1:30 PM, Aud. #1, Comisión(es): Salud (CAMARA) Fuente: http://www.oslpr.org/buscar/ 646

Puerto Rico

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Carta de Derechos y Responsabilidades del Paciente 1.No discrimen por condición médica preexistente o su historial médico. 2.No límite económico en los beneficios esenciales, ya sea de por vida o contrato anual. 3.Servicios de Cuidado Preventivo en la cubierta básica sin copago y sin costo adicional. 4.Cubierta para dependientes hasta los 26 años de edad. 5.Acceso directo a los Servicios de Ginecología y Obstetricia, sin referido o autorización previa del plan si el proveedor pertenece a la red del plan. 648

Carta de Derechos y Responsabilidades del Paciente 6.Selección de Pediatra como proveedor de cuidado primario, si es de la red. 7.Acceso a servicios y facilidades de emergencia, el plan no negará el pago. 8.Sistema de Querellas interno y externo que provea procedimientos adecuados y razonables para la pronta resolución. 9.No puede ser revocado o enmendado, una vez el beneficiario esté cubierto bajo el plan o incluido en la cubierta. Referencias: Ley Número 194 de 25 de agosto de 2000, enmendada por la Ley Número 161 de 1 de noviembre de 2010 649

Referencias

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Referencias 1.Código de Seguros de Salud de P.R. (Ley Número 194 de 29 de agosto de 2011, según enmendada por la Ley Número 203 de 23 de agosto de 2012, Ley Número 290 de 29 de septiembre de 2012, Ley Número 55 de 10 de julio de 2013, Ley Número 69 de 22 de julio de 2013, Ley Número 5 de 3 de enero de 2014, Ley Número 90 de 15 de julio de 2014.) 2.Carta de Derechos y Responsabilidades del Paciente, según enmendada, especialmente por la Ley Núm. 161 de 1 de noviembre de 2010. 3.45 CFR Parts 144-155 4.29 CFR Part 2590 5.26 CFR Part 54

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Referencias 6. http://www.ocs.gobierno.pr/ocspr/ 7. http://cciio.cms.gov/index.html 8. http://www.healthcare.gov/ 9. http://www.healthcare.gov/law/index.html 10. http://www.hhs.gov/healthcare/index.html 11. http://www.dol.gov/ebsa/healthreform/ 12. http://www.irs.gov/uac/Affordable-Care-Act-TaxProvisions?portlet=6 13. http://www.irs.gov/uac/Affordable-Care-Act-of-2010:News-Releases,-Multimedia-and-Legal-Guidance 652

Referencias 14. http://www.whitehouse.gov/healthreform 15. http://www.naic.org/index_health_reform_section.htm 16. http://www.commonwealthfund.org/HealthReform/Health-Reform-Resource.aspx 17. http://healthreform.kff.org/ 18. http://www.cahi.org/index.asp 19. http://www.heritage.org/issues/health-care/healthcare-reform 20. http://marketplace.cms.gov/index.html

21.http://business.usa.gov/healthcare 653

Federal Register • HHS Notice of Benefit and Payment Parameters for 2016, 80 Federal Register 10749, Friday, February 27, 2015, Final Rule. (http://www.gpo.gov/fdsys/pkg/FR-2015-02-27/pdf/201503751.pdf ) • Summary of Benefits and Coverage and Uniform Glossary; 80 Federal Register 34292, Tuesday, June 16, 2015, Final Rule. (http://www.gpo.gov/fdsys/pkg/FR-2015-06-16/pdf/201514559.pdf) • Coverage of Certain Preventive Services Under the Affordable Care Act, 80 Federal Register 41317, Tuesday, July 14, 2015, Final Rule. (http://webapps.dol.gov/FederalRegister/PdfDisplay.aspx?DocId= 28364) 654

Federal Register • Nondiscrimination in Health Programs and Activities; Proposed Rule; 80 Federal Register 54171, Tuesday, September 8, 2015 (http://www.gpo.gov/fdsys/pkg/FR-201509-08/pdf/2015-22043.pdf) • Final Rules for Grandfathered Plans, Preexisting Condition Exclusions, Lifetime and Annual Limits, Rescissions, Dependent Coverage, Appeals, and Patient Protections under the Affordable Care Act: [FR Doc. 2015-29294 Filed: 11/13/2015 4:15 pm; Publication Date: 11/18/2015] (http://s3.amazonaws.com/publicinspection.federalregister.gov/2015-29294.pdf) 655

Referencias - Implementation Frequently Asked Questions http://www.dol.gov/ebsa/healthreform/regulations/acaimplement ationfaqs.html • Part I - This set of FAQs addresses implementation topics including compliance, grandfathered health plans, claims, internal appeals and external review, dependent coverage of children, out-ofnetwork emergency services, and highly compensated employees. • Part II - This set of FAQs addresses grandfathered health plans, dental and vision benefits, rescissions, preventive health services, and ACA effective date for individual health insurance policies. • Part III - This set of FAQs addresses the exemption for group health plans with less than two current employees. • Part IV - This set of FAQs addresses grandfathered health plans. 656

Referencias - Implementation Frequently Asked Questions • Part V - This set of FAQs addresses a variety of ACA implementation topics, the HIPAA nondiscrimination and wellness program rules, and the Mental Health Parity and Addiction Equity Act of 2008. • Part VI - This set of FAQs addresses grandfathered health plans. • Part VII - This set of FAQs addresses the Summary of Benefits and Coverage and Uniform Glossary requirements of PHS Act §2715 and the Mental Health Parity and Addiction Equity Act of 2008. • Part VIII* - This set of FAQs addresses the Summary of Benefits and Coverage requirements of PHS Act §2715. • Part IX* - This set of FAQs addresses the Summary of Benefits and Coverage requirements of PHS Act §2715. 657

Referencias - Implementation Frequently Asked Questions • Part X* - This FAQ addresses the Summary of Benefits and Coverage requirements of PHS Act §2715. • Part XI - This set of FAQs addresses the employer notice of coverage options, health reimbursement arrangements, disclosure of information related to firearms, employer group waiver plans supplementing Medicare Part D, fixed indemnity insurance and payment of PCORI fees. Related information: CMS Bulletin on NonMedicare Supplemental Drug Benefits. • Part XII - This set of FAQs addresses limitations on cost-sharing under the ACA. • Part XIII - This set of FAQs addresses expatriate health plans.

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Referencias - Implementation Frequently Asked Questions • Part XIV - This set of FAQs addresses the Summary of Benefits and Coverage requirements of PHS Act §2715 (* Note: Some of the guidance in FAQs Parts VIII, IX, and X has been superseded by guidance contained in FAQs Part XIV.) • Part XV - This set of FAQs addresses annual limit waiver expiration date based on a change to a plan or policy year, provider non-discrimination, coverage for individuals participating in approved clinical trials and transparency reporting. • Part XVI - This set of FAQs addresses the employer notice of coverage options and the 90-day waiting period limitation. • Part XVII - This set of FAQs addresses the implementation of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), as amended by the Affordable Care Act. 659

Referencias - Implementation Frequently Asked Questions • Part XVIII — This set of FAQs addresses coverage of preventive services, limitations on cost-sharing, expatriate health plans, wellness programs, fixed indemnity insurance, and the Mental Health Parity and Addiction Equity Act of 2008. • Part XIX — This set of FAQs addresses updated DOL model notices, limitations on cost-sharing, coverage of preventive services, health FSA carryover and excepted benefits, and the Summary of Benefits and Coverage requirements of PHS Act §2715. • Part XX — This set of FAQs addresses coverage of preventive services. • Part XXI — This set of FAQs addresses limitations on cost-sharing under the ACA. 660

Referencias - Implementation Frequently Asked Questions • Part XXII — This set of FAQs addresses compliance of premium reimbursement arrangements. • Part XXIII — This set of FAQs addresses compliance of Excepted Benefits. • Part XXIV – This set of FAQs addresses the Summary of Benefits and Coverage requirements of PHS Act §2715. • Part XXV – This set of FAQs addresses the wellness program requirements. • Part XXVI – This set of FAQs addresses coverage of preventive services. 661

Referencias - Implementation Frequently Asked Questions Part XXVII* – This set of FAQs addresses limitations on cost sharing and provider non-discrimination. Part XXVIII – This set of FAQs addresses transparency reporting for non-QHP issuers and non-grandfathered group health plans. Part XXIX – This set of FAQs addresses coverage of preventive services, wellness programs, and the Mental Health Parity and Addiction Equity Act of 2008.

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Referencias - Implementation Frequently Asked Questions *Notes: • Some of the guidance in FAQs Parts VIII, IX, and X has been superseded by guidance contained in FAQs Part XIV. • Some of the guidance in FAQs Parts VIII, IX, X, and XIV has been superseded by guidance contained in FAQs Part XIX. • Some of the guidance in FAQs Part XV has been superseded by guidance contained in FAQs Part XXVII.

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Compliance Assistance Guide Health Benefits Coverage Under Federal Law... Table of Contents • Introduction • The Affordable Care Act • HIPAA Portability Provisions – Special Enrollment – Nondiscrimination Requirements • HIPAA and the Affordable Care Act Wellness Program Requirements • The Genetic Information Nondiscrimination Act • Mental Health Parity Provisions • The Newborns' and Mothers' Health Protection Act • The Women's Health and Cancer Rights Act • Applying and Enforcing Laws in Part 7 of ERISA • Appendices – Appendix A: Self-Compliance Tools – Appendix B: Chart of Required Notices – Appendix C: Model Notices Source: http://www.dol.gov/ebsa/publications/CAG.html 664

Referencias Health Benefits Laws Self Compliance Tools Part 7 of ERISA: Affordable Care Act Provisions • Under the Affordable Care Act, there are various provisions that apply to group health plans and health insurance issuers and various protections and benefits for consumers that are beginning to take effect or that will become effective very soon. The Departments are working together with employers, issuers, States, providers and other stakeholders to help them come into compliance with the new law and are working with families and individuals to help them understand the new law and benefit from it, as intended. Compliance assistance is a high priority for the Departments. Our approach to implementation is and will continue to be marked by an emphasis on assisting (rather than imposing penalties on) plans, issuers and others that are working diligently and in good faith to understand and come into compliance with the new law. This approach includes, where appropriate, transition provisions, grace periods, safe harbors, and other policies to ensure that the new provisions take effect smoothly, minimizing any disruption to existing plans and practices. See DOL FAQs About the Affordable Care Act Implementation Part I, question 1. Source: Self-Compliance Tool for Part 7 of ERISA: Affordable Care Act Provisions: http://www.dol.gov/ebsa/pdf/part7-2.pdf; http://www.dol.gov/ebsa/healthlawschecksheets.html 665

Referencias Health Benefits Laws Self Compliance Tools Part 7 of ERISA: HIPAA and Other Health Care-Related Provisions • This self-compliance tool is useful for group health plans, plan sponsors, plan administrators, health insurance issuers, and other parties to determine whether a group health plan is in compliance with some of the provisions of Part 7 of ERISA. The requirements described in the Part 7 tool generally apply to group health plans and group health insurance issuers. However, references in this tool are generally limited to "group health plans" or "plans" for convenience. Source: Self-Compliance Tool for Part 7 of ERISA: HIPAA and Other Health Care-Related Provisions: http://www.dol.gov/ebsa/pdf/part7-1.pdf; http://www.dol.gov/ebsa/healthlawschecksheets.html. 666

Referencias HIPAA and ACA Materials • HIPAA Guidance: http://www.cms.gov/CCIIO/Resources/Regulations-andGuidance/index.html • September 21, 2010: Memo on Amendments to the HIPAA Opt-Out Provision made by the Affordable Care Act: http://cciio.cms.gov/resources/files/opt_out_memo.pdf • April 1, 2011: Procedures and Requirements for HIPAA Exemption Election ―Model HIPAA Exemption Election Document: http://cciio.cms.gov/resources/files/model_exemption_election_letter_04 072011.pdf ―Model Notice to Enrollees of HIPAA Exemption: http://cciio.cms.gov/resources/files/model_enrollee_notice_04072011.pdf • May 23, 2012 List of HIPAA Opt-Out Elections for Self-Funded, Non-Federal Government Plans: http://cciio.cms.gov/resources/files/hipaa-nfgp-05-23-2012.pdf 667

Muchas Gracias por su Atención

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Former HHS Secretary Kathleen Sebelius

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Affordable Care Act (ACA) - Oficina del Comisionado de Seguros

Affordable Care Act (ACA) y el Código de Seguros de Salud en el 2016 Lic. Marilú Cháez-Abreu viernes, 22 de enero de 2016 1 Advertencias Legales • ...

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