PPACA Requirements and MOOP As They Relate To Health Coverage

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Beginning with the plan year that starts on or after January 1, 2015, the Affordable Care Act (ACA) states that all non-grandfathered group plans are required to accumulate out-of-pocket expenses for Essential Health Benefits (EHB) across several benefit providers. For 2015, the Maximum-Out-of-Pocket (MOOP) is expected to be as follows:

$13,200 for families

$6,600 for individuals

The Affordable Care Act, or Patient Protection and Affordable Care Act (PPACA), also mandates that certain preventive items and services must be covered at 100% within a patient's health plan. This means that such preventive items and services are to be excluded from deductibles or other cost-sharing limitations and covered with no member cost. Coverage is required one year after the U.S Preventive Services Task Force (USPSTF) has issued the new recommendation on the first plan year that starts after such one year date. The plan may use reasonable limits on the frequency, but not the dollar amount of preventive care that it will cover.

Recently, Breast Cancer preventives and Preeclampsia prevention have been added to the list of services that are required to be available without falling subject to cost-sharing limitations. Please see below for some insight into each of these two preventive services:

Breast Cancer Prevention:
For those candidates who are at increased risk for breast cancer and at low risk for adverse medication effects, the USPSTF suggests that clinicians should prescribe risk reducing medications such as tamoxifen or raloxifen. Coverage is required on the first plan year effective date after September 24, 2014.

Preeclampsia Prevention:
By definition, preeclampsia is a complication that occurs during pregnancy that is characterized by high blood pressure and signs of damage to other organ system such as the kidneys. To prevent preeclampsia in high risk women, the USPSTF recommends the use of low-dose aspirin (81 mg/d) after 12 weeks of gestation. Coverage is required on the first plan year effective date after 2015.

For a more comprehensive list of preventive services that are covered without cost-sharing or to learn more about the PPACA requirements that will affect non-grandfathered health plans starting next year, contact us at (888) 797-2479 today! At PBIRx, our consultants can provide you with a more detailed analysis about the items and services that are included under the Affordable Care Act and can educate you further on how to effectively manage your maximum-out-of-pocket costs through different plan options.