Is Your EAP Exempt from ACA Mandates?

If you offer an employee assistance program (EAP) as one of your employee benefits, are you aware that it might be considered a group plan by the Affordable Care Act (ACA) and therefore subject to health care reform requirements? Read on to find out whether your EAP must comply as a group plan and what conditions can exempt it from ACA mandates.     

EAPs Subject to ACA Mandate
Does your EAP offer direct counseling by trained professionals for depression, stress or substance abuse or any disease management service? If so, according to the Department of Labor (DOL) and the Treasury Department, it most likely will be considered a group health plan and must meet the following requirements for group health plans:

  • Meet HIPAA (Health Insurance Portability and Accountability Act) privacy and data security requirements
  • Meet requirements of health coverage reporting
  • Provide a summary plan description

EAPs Exempt from ACA Mandates
However, if your EAP is a referral-only service and does not employ trained social workers or mental health providers, it will not be considered a group plan. More clarity was provided by the DOL and Treasury Departments in final regulations issued for the Mental Health and Substance Abuse Parity rules. The government stated that if the following conditions are met, an EAP would be classified exempt from ACA mandates:

 1. No gatekeeper function for benefits under another group health plan. This means an employee cannot be required to go through their EAP to access their mental health benefits through their group health plan.

 2. No significant medical benefits meaning no medical care or treatment. The final regulations do not define “significant medical benefits” but rather state that the “amount, scope and duration of covered services” should be taken into account. The regulators did however provide examples:

  • An EAP that provides limited, short-term outpatient counseling for substance use disorders (and does not cover inpatient, residential, partial residential or intensive outpatient care), without requiring prior authorization or medical necessity review, is not considered to provide significant medical benefits.
  • An EAP that provides disease-management services (such as laboratory testing, counseling, and prescription drugs) for individuals with chronic conditions, such as diabetes, is considered to provide significant medical benefits.

 3. An employee’s eligibility for the EAP cannot be dependent on their eligibility for benefits under the group plan.

 4. Not sure whether your EAP is considered exempt from the ACA mandates? Contact your account manager today for more information.