Federal Health Insurance Rules
The U.S. Department of Health and Human Services (HHS) has begun to release the long-awaited federal rules for health insurance plans.
As the 2010 health reform law requires, insurers will no longer be able to dump patients who are starting to cost too much, they won’t be able to charge women more than men, they have to cover anyone who can pay and they’ll have to pay for maternity care, eye exams for kids and for mental health services.
The new rules from the HHS cover the new state exchanges, where people will be able to buy health insurance starting in 2014. The rules lay out how much extra insurers can charge to cover certain groups of people, like smokers and people who are older. They also say when states outline so-called essential health benefits — the minimums of what health insurers should cover — they should use the best existing plans as a guideline. HHS also issued some guidelines for employers and insurers who want to offer wellness programs, which encourage people to keep themselves healthy.
The Congressional Budget Office predicts that 23 million people who don’t have health insurance now will get it on one of the exchanges. More than 18 million of them will qualify for a federal subsidy averaging $6,000 a year per person. People earning up to four times the federal poverty level can get a subsidy: that’s an income of $92,000 a year for a family of four.
The rules on so-called essential health benefits — specific services that insurers have to offer and conditions they must cover — include 10 areas: Ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, including behavioral health treatment, prescription drugs, rehabilitative services and devices, laboratory services, preventive and wellness services and chronic disease management and pediatric services, including oral and vision care.
HHS also set how much each level of plan — platinum, gold, silver and bronze — may require patients to pay out of pocket. Beginning in 2014, so-called bronze plans can ask patients to pay 40 percent of costs; 30% for a silver, 20% for a gold; the top-level platinum plans must pay 90% of patient costs. The platinum level plans may charge higher premiums, while the bronze plans will be the cheapest in terms of monthly premiums.
Finally, the rules encourage wellness plans. “Programs must be reasonably designed to promote health or prevent disease,” HHS said. “Programs must have a reasonable chance of improving health or preventing disease and not be overly burdensome for individuals.” The plans can reward patients who lower their cholesterol, for instance, by cutting premiums.