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.
Denying Coverage
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
·
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
Benchmark Plans
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.
Relevant Links:
http://www.hhs.gov/news/press/2012pres/11/20121120a.html
http://www.healthcare.gov/news/factsheets/2012/11/market-reforms11202012a.html
http://www.healthcare.gov/news/factsheets/2012/11/ehb11202012a.html
http://cciio.cms.gov/resources/data/ehb.html#review
benchmarks
http://www.healthcare.gov/news/factsheets/2012/11/wellness11202012a.html
Disclaimer:
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.
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