HHS Releases Proposed ACA Rules On Essential Health Benefits November 21, 2012 Health Care Reform, News ACA, Essential Health Benefits 0 On Tuesday, the Obama administration proposed three rules outlining how provisions under the Affordable Care Act would work. The three rules—listed below—are not yet final and will be open for comment until December 26. Proposed Rule To Prohibit Insurers From Discriminating Against Certain Patients HHS proposed a rule implementing an ACA provision that prevents insurers from discriminating against individuals with pre-existing or chronic conditions. The rule would prevent insurers from denying coverage to patients with pre-existing or chronic conditions. It also would prevent insurers from charging higher premiums to certain beneficiaries because of current or past insurance programs, gender, occupation and industry or employer size. However, the rule would allow insurance companies to vary premiums—within limits—based on age, tobacco use, family size, and geography. According to HHS, the rule targets 50 million to 129 million U.S. residents who have conditions that insurance companies have cited in coverage denials or insurance cost increases. The rule also requires states to establish a single statewide risk pool for individual and small employer markets, unless a state opts to combine the two pools. Premiums and yearly rates would be based on the entire pool. In addition, the rule calls for a catastrophic plan in the individual market for young adults and individuals who cannot find affordable coverage. Proposed Rule To Establish Essential Health Benefits This proposed rule delineates an ACA provision that creates essential health benefits for plans in the individual and small group markets. Specifically, the rule ties essential benefits to a state’s benchmark plan, including the state’s largest small group plan, and must include items and services in at least the following 10 categories: Ambulatory patient services; Emergency services; Hospitalization; Laboratory services; Maternity and newborn care; Mental health and substance use disorder services; Pediatric services; Prescription drugs; Preventive and wellness services and chronic disease managements; and, Rehabilitative services and devices. Most states are using the benefits provided by the largest health plan in the state’s small-group insurance market as a benchmark. However, the rule requires insurers to provide additional benefits, including dental care and vision services for children, mental health and drug misuse treatment, and “habilitative services” for individuals with conditions such as autism or cerebral palsy. The proposed rule also addresses the actuarial value component of the essential health benefits, which is the percentage of the total average costs for benefits that a plan covers. In 2014, a “bronze” plan must cover 60% of all covered benefits, a “silver” plan must cover 70%, a “gold” plan must cover 80% and a “platinum” plan must cover 90%. Proposed Rule To Establish, Expand Wellness Programs The third proposed rule would establish and expand workplace wellness programs that promote health and control health spending. The rule allows employers to award employees as much as 30% of their health coverage costs for participating in wellness programs, an increase from the current 20%. Meanwhile, workers that enroll in smoking cessation programs could earn back as much as 50% of their coverage costs, HHS said. The rule also requires employer-based wellness programs to provide alternative ways to qualify for rewards for individuals with special medical conditions. Source: HHS News Release, November 20, 2012 and California Healthline, November 21, 2012. Comments are closed.
