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HHS hands down rules for key ACA provisions

Tuesday November 20, 2012
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Two-weeks after President Obama’s re-election, his administration moved forward to implement one of the core provisions of the Affordable Care Act: prohibiting insurance companies from discriminating against people with pre-existing conditions starting in 2014.

Other proposed rules issued Tuesday provide guidance on essential health benefits and make promoting and encouraging employee wellness easier for employers.

Under the rule about pre-existing conditions, insurance companies would be allowed to vary premiums only within limits, and only based on age, tobacco use, family size and geography. Insurance companies would be prohibited from denying coverage to any American because of a pre-existing condition or from charging higher premiums to certain enrollees because of their current or past health problems, gender, occupation and small employer size or industry.

The rule also ensures that young adults and people for whom coverage would otherwise be unaffordable have access to a catastrophic coverage plan in the individual market. For more information about the rule, visit www.healthcare.gov/news/factsheets/2012/11/market-reforms11202012a.html.

The rule regarding essential health benefits applies to health plans offered in the individual and small group markets, most of which will take the form of Affordable Insurance Exchanges.

Essential health benefits must be equal in scope to benefits in a typical employer plan using criteria that varies by state. Items and services must be included in at least the following 10 categories: ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental/behavioral health and substance use disorder services, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management, and pediatric services including oral and vision care.

For more information on the rule regarding essential health benefits, visit www.healthcare.gov/news/factsheets/2012/11/ehb11202012a.html.

Another proposed rule implements employment-based wellness programs to promote health and help control healthcare spending, while ensuring that individuals are protected from unfair underwriting practices that could otherwise reduce benefits based on health status. For more information regarding this rule, visit www.healthcare.gov/news/factsheets/2012/11/wellness11202012a.html.

The ACA is projected to extend coverage to 14 million uninsured people in 2014 and a total of 30 million by 2022, according to the Congressional Budget Office.


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