I would like to discuss another portion of the Patient Protection Affordability and Care Act (PPACA) in this post. I will return to my posts about interviews tomorrow. There is some additional guidance that was just released by the Department of Health and Human Services (HHS) with the rules that will govern these areas: Denying Coverage, Essential Health Benefits, Benchmark Plans, Wellness Programs and Unfair Underwriting.
There was some additional clarification about how this would work. As of Jan. 1, 2014, insurers will not be allowed to prevent care based on pre-existing conditions. The insurers will also not be allowed to charge a higher premium based on gender, occupation, or employer. The insurers will be allowed to charge a higher premium based on age, tobacco use, family size, and geography. In the event an individual is denied coverage for some reason, they will be allowed access to the healthcare exchange. Individuals will be required to purchase their coverage during open enrollment periods.
Essential Health Benefits (EHB)
All insurance plans, including those on the Healthcare Exchanges, will be required to provide these 10 items at a minimum:
· Ambulatory patient services
· Emergency services
· 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 new rules require that each state selects a “benchmark” plan that offers these EHB services in quality and affordability. All other insurance plans will then be rated and judged in comparison to that plan. The rules governing the benchmark plans are still up for public comment. Some additional items that may be added or changed including a Drug listing benchmark, preventive care benchmark, and a mental health standards benchmark. If a state fails to; or refuses to select a benchmark plan, the HHS will select one for them.
Wellness Programs and Unfair Underwriting
New guidelines were release regarding employer based wellness programs. Insurance plans will be required to offer coverage of programs designed to reduce disease and promote health. These plans must be reasonably expected to be effective, cannot be overly burdensome for an employee to use, must be fairly and equally offered, with accommodation offered for those who cannot medically participate in the primarily offered wellness program. Any health problems revealed in the course of a wellness program cannot be unfairly used to increase premiums.
Additional rules that were rolled out for the PPACA also include actuarial value rulings with regards to “Medal” levels and rules on Accreditation standards
There really is much more to the PPACA and these rules than I have the time to put down here. There is so much; I certainly do not understand it all. I suggest you do your own research to learn more.
Please note, this information is based on my understanding and is only to be used for informational and educational purposes. Do not take what I am writing as advice. Seek your own legal counsel and/or see a tax accountant before making business or personal decisions.