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Proposed Rules Address Affordable Care Act Implementation

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The federal government rolled out a number of proposed rules on November 20 dealing with the implementation of the Affordable Care Act (ACA). Below are two of those requirements.

Wellness Program Requirements
The proposed wellness rules, which would be effective for plan years starting on or after January 1, 2014, create new incentives and build on existing wellness program policies.

The proposed rules implement changes in the ACA that increase the maximum permissible reward under a health-contingent wellness program from 20 percent to 30 percent of the cost of health coverage. They also further increase the maximum reward to as much as 50 percent for programs designed to prevent or reduce tobacco use.

Health-contingent wellness programs require an individual to satisfy a standard related to a health factor to obtain a reward. For example, a program may impose a premium surcharge based on tobacco use, or may give employees a reward for having cholesterol within a healthy range.

With the exception of the modification of the size of the reward, the proposed wellness regulations relating to health-contingent wellness programs generally maintain the five requirements of the 2006 regulations.

Consistent with current regulations, the proposed rules also divide wellness programs into two categories: participatory programs and health-contingent wellness programs.

Essential Health Benefits
Under the ACA, health plans offered in the individual and small group markets offer a core package of items and services, known as “essential health benefits.” These benefits must include items and services within at least the following 10 categories:

  • 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.

The benefits also must be equal in scope to benefits offered by a “typical employer plan.”

For more information, please contact Stacey Bruce at 814/833-3200 or 800/815-2660.