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Tue Nov 20, 2012, 07:17 PM

HHS releases draft rules on key elements of Obamacare, including pre-existing conditions

HHS releases draft rules on key elements of Obamacare, including pre-existing conditions

by Joan McCarter

Yes, President Obama won reelection and the Affordable Care Act is the law of the land. On Tuesday, the Department of Health and Human Services released proposed regulations on some of the key elements of health insurance reform in the law, including how insurers can vary premiums based on age, tobacco use, family size and geography, proposed rules for essential health benefits, and rules governing employer-based wellness programs. These are the draft rules, with comment period open for the next month.

For the majority of the uninsured, the key rules are the market reforms, the rules that prevent insurers from denying coverage because of pre-existing conditions, and that set the limits on how insurers can vary premiums, limiting the variation to age (within a 3:1 ratio for adults), tobacco use (within a 1.5:1 ratio and subject to wellness programs in group insurance), family size and geography. That means that insurers can no longer charge exorbitant premiums as individuals age, or for smokers. Nor can they charge higher premiums because you have lady parts. Also prohibited is charging more based on occupation, past health problems, or employer size or industry. What's more, insurers will be prohibited from refusing to renew coverage because an individual or employee becomes sick or has a pre-existing condition.

The essential health benefits rules establish 10 categories in which services must be included in health plans: 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, and pediatric services, including oral and vision care. Health plans offered in the individual and small group markets, including both those in the exchanges and in the existing market, have to offer a core package of items and services in those categories.

The third set of rules provides the requirements for employer wellness programs. These programs have to be "reasonably designed to promote health or prevent disease," meaning that they can't set unreasonable or unobtainable goals and rewards to employees. They have to establish alternative health standards that can be met by all people, including those "whose medical conditions make it unreasonably difficult, or for whom it is medically inadvisable, to meet the specified health-related standard."

This is the stuff health insurance reform was all about, the core regulations that will make health insurance affordable and accessible. They're also the parts of reform that will be most popular and important to the public. This is the stuff Republicans absolutely did not want to see implemented, and the stuff that will make "Obamacare" be as much an appreciated part of the nation's health care system as Medicare.


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Reply HHS releases draft rules on key elements of Obamacare, including pre-existing conditions (Original post)
ProSense Nov 2012 OP
HockeyMom Nov 2012 #1

Response to ProSense (Original post)

Tue Nov 20, 2012, 07:23 PM

1. I thought they couldn't charge more by geographical area

When we moved from NY to Florida, we were in absolute shock at how much more health insurance costs in the Sunshine state.

I paid less to cover my entire family in NY than I did for just myself in Florida.

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