CurrentHighmark Blue Cross Blue Shield WnyPolicy N/A

Federal rules on account-based group health plans, rescissions, and preventive services (selected 45 CFR provisions)

This document contains regulatory provisions governing account-based group health plans (including HRAs), integration with Medicare, rules on forfeiture and waivers, prohibitions on rescissions of coverage, and coverage of preventive health services; it applies to group health plans and health insurance issuers subject to these CFR sections.

Policy Summary

PayerHighmark Blue Cross Blue Shield Wny

PolicyFederal rules on account-based group health plans, rescissions, and preventive services (selected 45 CFR provisions)

Policy CodePolicy N/A

Change TypeMinor/none

Effective DateN/A

Next Review DateN/A

Key ActionDo not impose cost-sharing for preventive services rated A or B by USPSTF; ensure office visit billing aligns with preventive service rules.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Jan 1, 2020§147.126 applicability

Jan 1, 2017§147.128 rescissions rules

no cost-sharingPreventive services

30 daysRescission notice

Regulatory Coverage Criteria

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Regulatory coverage criteria

Key coverage and compliance criteria from relevant CFR sections.

ALL of the following

The plan sponsor offers a group health plan (other than the HRA or account-based plan and not limited to excepted benefits) to employees who are not eligible for Medicare.
The employee receiving the HRA or account-based plan is actually enrolled in Medicare Part B or D.
The HRA or account-based group health plan is available only to employees who are enrolled in Medicare Part B or D.
The HRA or account-based group health plan complies with the specified integration requirements in the section (paragraphs referenced in the regulatory text).

ALL of the following

Account-based group health plan: an employer-provided group health plan that provides reimbursements of medical care expenses with the reimbursement subject to a maximum fixed dollar amount for a period (an HRA is a type of account-based group health plan).
Medical care expenses: expenses for medical care as defined under section 213(d) of the Code.

ALL of the following

Forfeiture or waiver of amounts in an HRA is irrevocable with respect to amounts that participants and beneficiaries have no access to from the effective date through any reinstatement event; reinstated amounts may not reimburse care incurred during the forfeiture period.

Rescission prohibition and notice requirement: A group health plan or health insurance issuer must not rescind coverage with respect to an individual once the individual is covered, except where the individual (or person seeking coverage) commits fraud or makes an intentional misrepresentation of material fact. Before rescinding coverage for such reasons, the plan or issuer must provide at least 30 days advance written notice to each affected participant (or primary subscriber in the individual market).

Rescission exceptions (not a rescission):

A cancellation or discontinuance that has only a prospective effect.
A retroactive cancellation attributable to failure to timely pay required premiums or contributions (including COBRA premiums).

ALL of the following

Evidence-based items or services rated A or B by the current U.S. Preventive Services Task Force for the individual involved.
Immunizations for routine use in children, adolescents, and adults recommended by the Advisory Committee on Immunization Practices.
Preventive care and screenings supported by HRSA for children and adolescents and additional women’s preventive services as specified by HRSA, subject to the related regulatory sections.

Office visit cost-sharing guidance for preventive services: If a preventive item or service is billed separately from an office visit (or billed separately by the provider), the plan may impose cost-sharing for the office visit. If the preventive item or service is not billed separately and the primary purpose of the visit is delivery of the preventive service, no cost-sharing may be imposed; otherwise cost-sharing may apply.

Codes, Limits, and Account Rules

Preventive services (USPSTF A/B, ACIP, HRSA)mixedCovered

	Evidence-based items or services that have in effect a rating of A or B in the current recommendations of the United States Preventive Services Task Force with respect to the individual involved
	Immunizations for routine use in children, adolescents, and adults that have in effect a recommendation from the Advisory Committee on Immunization Practices
	Preventive care and screenings supported by the Health Resources and Services Administration for infants, children, adolescents, and women, including additional women's preventive services as described in related sections (§§147.131–147.133)

HRA reimbursement cap concept — definition and key points

HRA reimbursement cap conceptMaximum fixed dollar amount for a period — an account-based group health plan provides reimbursements of medical care expenses with the reimbursement subject to a maximum fixed dollar amount for a period (an HRA is a type of account-based group health plan)

Forfeiture and reinstatementForfeited or waived amounts may be reinstated on a fixed date or event, but amounts reinstated may not reimburse care incurred during the forfeiture period

Applicability contextApplies to HRAs and other account-based group health plans when determining integration and reimbursement rules (see integration provisions in §146.123)

Provider Requirements and Notices

Billing Rule

No cost-sharing for USPSTF A/B preventive services and recommended immunizations

Plans must not impose any cost-sharing (copayments, coinsurance, deductibles) for preventive services rated A or B by the USPSTF and for recommended immunizations. Providers should bill these services as preventive; do not collect member cost-sharing when the service matches an A/B USPSTF recommendation or an ACIP-recommended immunization.

Applies to group health plans and health insurance issuers offering group or individual coverage
Includes evidence-based USPSTF A/B services and routine immunizations recommended by ACIP
No cost-sharing: copayment, coinsurance, deductible

Denial Risk

Rescission notice and limitation

Coverage may not be rescinded once an individual is covered, except for fraud or intentional misrepresentation of material fact. If rescission is contemplated under those exceptions, the plan or issuer must provide at least 30 days advance written notice to each affected participant or primary subscriber before coverage is rescinded. Rescission means a retroactive cancellation or discontinuance of coverage; prospective terminations and retroactive terminations solely for nonpayment of premiums are not rescissions.

Rescission prohibited except for fraud or intentional misrepresentation
At least 30 days advance written notice required to affected participant/primary subscriber
Rescission = cancellation with retroactive effect (voiding coverage or benefits retroactively)
Not a rescission: prospective-only cancellations or retroactive cancellations due to failure to timely pay premiums

Key Definitions

Account-based group health plan — definition

Definition — Account-based group health planAn employer‑provided group health plan that provides reimbursements of medical care expenses with the reimbursement subject to a maximum fixed dollar amount for a period; an HRA is a type of account‑based group health plan

ExclusionDoes not include a qualified small employer health reimbursement arrangement as defined in section 9831(d)(2) of the Code

Medicare integrationMay be integrated with Medicare for employees enrolled in Medicare Part B or D when specific offer and enrollment requirements are met (see integration rules)

Medical care expenses — definition

Definition — Medical care expensesExpenses for medical care as defined under section 213(d) of the Code

ScopeUsed as the reimbursable expense standard for HRAs and other account‑based group health plans

ApplicationReimbursed amounts under an account‑based group health plan are applied to medical care expenses as defined by section 213(d)