New Guidance on Reference Based Pricing and Health Plan IDs 

A raft of guidance issued last week addresses several ACA topics: the interplay of reference-based pricing and the out-of-pocket (OOP) cost-sharing limits, the health plan identifier mandate administered by the Department of Health and Human Services (HHS), and the IRS forms employers will use for the law’s play-or-play and minimum essential coverage reporting.

Updating prior guidance on cost-sharing limits, a new set of “frequently asked questions” (FAQs) outlines the specific issues regulators will consider when evaluating whether a plan that uses reference-based pricing (or a similar network design) is using a “reasonable method” to ensure that it provides adequate access to quality providers at the reference price. Some plan sponsors and insurers use, or are considering incorporating, reference-based prices into their plan designs to curb rising costs. This approach may require some covered individuals to pay higher out-of-pocket costs for in-network charges exceeding the specified reference price.

Another set of FAQs from HHS about health plan identifiers generally confirm information contained in the rules and on website materials, but make it clear that health savings accounts and health flexible spending arrangements – regardless of size – are exempt from the mandate. Additionally, according to the FAQs, health reimbursement arrangements (HRAs) that cover only other plans' deductibles or out-of-pocket costs do not require HPIDs. The FAQs also clarify that sponsors now may authorize TPAs and similar entities to seek plans' HPIDs. Insurers and self-insured plan sponsors must obtain the HPIDs by Nov. 5.

Finally, IRS has posted revised draft forms for ACA's play-or-pay and minimum essential coverage reporting. The Oct. 1 and Oct. 2 versions replace four draft forms in the 1094 and 1095 series issued in July and August. The Aug. 28 draft instructions for these forms have not changed. Employers, insurers, and others will use the finalized forms to report on individuals' plan eligibility and coverage, as well as employees' full-time status.