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Government releases new ACA rule proposals

The federal government took another step toward the implementation of the Affordable Care Act Nov. 20 when it released three proposed rules totaling more than 300 pages that outline essential health benefits, the cost structure for plans and market reforms.

The CEO of Connecticut’s Health Insurance Exchange (HIX) said that at first glance, the proposals released by the U.S. Department of Health and Human Services (HHS) and the Centers for Medicare and Medicaid Services (CMS) contained no “huge surprises.”

Kevin Counihan, who is responsible for ensuring the Connecticut HIX is up and running by Jan. 1, 2014, reiterated that the state remains on target in its preparations.

“I think that we at the exchange are feeling quite prepared for next October,” Counihan said, noting that the state will begin marketing plans through the exchange to individuals and small businesses at that point.

“Do I wish we were a little bit ahead? Sure. … But I think the staff is feeling very good about where we are,” he said.

Included among the proposed rules released by HHS and CMS are provisions that would prohibit insurers from denying coverage due to pre-existing conditions or any other factor and that outline 10 items and services that must be included in all coverage plans marketed after Jan. 1, 2014.

HHS also outlined the required cost structure for any plans marketed after Jan. 1, 2014, with the proposal calling for plans to be classified as bronze, silver, gold or platinum based on the percentage of costs a consumer would be expected to pay.

The department has said the classifications will allow consumers to better compare plans that have similar coverage levels.

Plans classified as bronze would come at a higher cost to consumers, with anyone covered by a bronze-level plan expected to pay for about 40 percent of the cost of all covered benefits.

On the other end of the spectrum, plans classified as platinum would come at a lower cost to consumers, with anyone covered under a platinum-level plan expected to pay for about 10 percent of the cost of all covered benefits.

The proposed rule detailing essential health benefits would require all plans – regardless of whether they are marketed through a state health exchange or on the open market – to cover items such as hospitalization, maternity and newborn care, mental health and substance use disorder services, preventative and wellness services and chronic disease management, and pediatric services, among other items.

HHS also released a proposal outlining requirements for wellness programs.

The proposals would increase the maximum permissible reward under a health-contingent wellness program from 20 percent to 30 percent of the cost of health coverage, and to as much as 50 percent for programs designed to prevent or reduce tobacco use.

At a Nov. 15 luncheon hosted by the Bridgeport Regional Business Council, Jewel Mullen, commissioner of the state Department of Public Health, said that it is “critical” for employers to implement wellness programs despite difficulties in determining a return on investment.

Last week, Katherine Sullivan of health and group benefits consultant Towers Watson said at a breakfast hosted by the Business Council of Fairfield County that there is literature that shows wellness programs can deliver as much as a three-to-one return on investment.

“Depending on how you approach it, you could probably spend anything from $100 per employee per year up to $500,” Sullivan said.

She said that, on average, companies can save more than $1,000 in health care costs per employee through the successful implementation of wellness programs.

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Patrick Gallagher

Bio: Fairfield County Bureau Chief Staff Reporter Westchester County Business Journal Covers: Economy, energy, government, infrastructure and public works projects, law, media, technology Phone: (914) 694-3600, ext. 3017

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