Last week, the administration issued three proposed rules that address some of the key components in the law, including protections for individuals with pre-existing conditions, standards for state insurance exchange programs, and incentive programs for promoting individual wellness. Protection for individuals with pre-existing conditions According to the Centers for Medicare & Medicaid Services (CMS), 129 million non-elderly Americans have some type of pre-existing health condition, such as cancer, diabetes, asthma, and heart disease. In most states, these individuals can be denied health insurance coverage or have benefits for medical conditions excluded by insurance companies. A proposed rule released November 20 would prohibit issuers from denying coverage to people based on any pre-existing condition. Insurers would also be prohibited from refusing to renew coverage should an individual become sick or have a pre-existing condition. Health insurance companies would still be allowed to vary premiums based on age, tobacco use, family size, and geography. However they would not be able to increase premiums based on an individual’s pre-existing conditions, health status, claims history, duration of coverage, gender, occupation, and small employer size and industry. Framework for insurance exchanges In order to ensure Americans have access to quality, affordable health insurance, the ACA requires each state to maintain an insurance exchange through which individuals can compare and purchase private healthcare coverage. A proposed rule issued on November 20 established the minimum requirements for participation in the insurance exchange program. Specifically, insurers must provide the following essential health benefits:
- Ambulatory patient services
- Emergency services
- Hospitalization
- Maternity and newborn care
- Mental health and substance use disorder services, including behavioral health treatment
- Prescription drugs
- Rehabilitative and habilitative (?) services and devices
- Laboratory services
- Preventive and wellness services and chronic disease management
- Pediatric services, including oral and vision care
The plans available in the exchanges must also provide benefits that are equivalent to a “typical employer plan” in each state. There are four options for determining the typical employer plan:
- The largest plan by enrollment in the state’s small group market
- Any of the largest three state employee health benefit plan options by enrollment
- Any of the largest three national Federal Employees Health Benefits Program plan options
- The largest insured commercial HMO in the state.
Expansion of wellness incentives Finally, the HHS issued a proposed rule that creates new incentives to promote employer wellness programs and encourage healthier workplaces. The proposed rule includes two options. The first option would provide reimbursement to members who enroll in a qualified fitness center, weight management program, or health education seminar. The other option is a “health-contingent wellness program”, which would reward enrollees who meet a specific standard in order to receive a reward. For example, programs can provide a reward to members who achieve a target cholesterol or blood pressure level. According to a CMS press release, the programs “must have a reasonable chance of improving health or preventing disease and not be overly burdensome for individuals.” Providers have 30 days to comment on each of the proposed rules via the Regualtions.gov website. CMS will take provider comments into account before issuing its final rules.
