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Guidance allows separate out of-pocket health care expense limits

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Guidance allows separate out of-pocket health care expense limits

New regulatory guidance will give employers more flexibility in complying with a health care reform law rule that caps employees' annual out-of-pocket expenses.

That rule imposes a flat dollar limit for employer plans on how much in deductibles, coinsurance and copayments employees can be required to pay annually for all essential health care services.

In 2014, the maximum out of pocket limit is $6,350 for single coverage and $12,700 for family coverage.

Under an earlier special transition rule, which is applicable only this year, those overall dollar limits can be applied separately for expenses incurred in plans, such as prescription drug plans, that may be carved out from other health benefit plans.

Starting in 2015, though, the guidance — issued Wednesday by the departments of Health and Human Services, Labor and Treasury — allows employers to impose separate limits on categories of essential benefits, such as one for prescription drugs and another for other health care services, so long as the combined dollar limit for those categories does not exceed the statutory set total amount for that year.

“Administratively, an employer could have fewer complications through a separate limit approach,” said Rich Stover a principal with Buck Consultants L.L.C. in Secaucus, N.J.

In addition, the guidance says employers that impose a premium surcharge on employees who are tobacco users but waive the surcharge for employees who agree to participate in smoking cessation programs can place limits on eligibility for the waivers.

The guidance provides an example of an employer who offers a premium surcharge waiver to employees who agree at the time of annual enrollment to participate in a tobacco cessation program.

In the example, an employee declines, at the time of open enrollment, to participate in the tobacco cessation program. Later in the plan year, though, the employee joins the tobacco cessation program. While the employer can remove the premium surcharge for employees who join the tobacco cessation program in mid-year, nothing requires the employer to do so, according to the guidance.

Benefit experts welcomed the flexibility provided by regulators.

“This allows group health plans and employers to have a snapshot for the rewards and not have to offer continual or retroactive adjustments to the reward program,” said Amy Bergner, managing director of human resource solutions at PricewaterhouseCoopers L.L.P. in Washington.