Your group health plan imposes 25-percent coinsurance for emergency services, whether they are provided in network or out of network. If a covered individual notifies the plan within two days after the services are provided, the plan reduces the coinsurance to 15 percent. Does the requirement to notify the plan to receive a reduced coinsurance rate violate the Patient Protection and Affordable Care Act (ACA) requirement to cover emergency services without prior authorization?
No, this requirement is not a violation of Public Health Service Act Sec. 2719A, which was added by the ACA. That provision imposes special cost-sharing and other requirements for plans that provide benefits for emergency services. The rules are designed to provide special patient protections for individuals covered by network plans who obtain emergency services from an out-of-network provider.
The Departments of Labor, Health and Human Services, and the Treasury have issued interim final regulations implementing the requirements for emergency services. Under the regulations, if a group health plan or health insurance issuer offering group coverage provides any benefits for services in the emergency department of a hospital, the plan or issuer must provide coverage for emergency services as follows:
- without the need for any prior authorization, even if the emergency services are provided out of network;
- without regard to whether the health care provider furnishing the emergency services is a network provider;
- without imposing any administrative requirement or limitation on coverage for out-of-network services that is more restrictive than the requirements or limitations that apply to in-network services; and
- without regard to any term or condition of coverage other than the exclusion or coordination of benefits, a permitted affiliation or waiting period for coverage, or permitted cost sharing.
Source: IRS Reg. §54.9815–2719AT, ERISA Reg. §2590.715–2719A, HHS Reg. §147.138.