ACA Rules Begin to Flow

Many people agree that the re-election of President Obama earlier this month ensures that implementation of the Affordable Care Act (ACA or Obamacare, depending on who’s talking) will continue.  The Supreme Court, US voters and even Speaker John Boehner have all agreed in recent weeks that the ACA is the law of the land.  In order to meet the ACA’s deadlines, implementation will accelerate over the next year as states, the federal government, insurers, providers and consumers prepare for Exchange open enrollment to begin on October 1, 2013.

Just before the Thanksgiving holiday, HHS released several long-awaited proposed regulations implementing private insurance market reforms relating to essential health benefits (EHB), actuarial value (AV), fair insurance premiums and employer wellness programs.  Together these new policies will reform what health insurance plans cover and what they can charge enrollees for premiums starting in 2014.

To highlight one major new policy, the Essential Health Benefits consist of 10 broad categories of services that all new individual and small group plans will have to cover in 2014. The EHB proposed rule builds on a Bulletin released by HHS last December and directs states to select a benchmark plan among 10 already existing in the state, whose covered services will define the EHB for plans in the state.  About half of the states have already selected a benchmark plan, and the remainder have until December 26th to select a plan.  States that don’t actively pick a plan will end up with the default plan of the largest small group plan in the state.

There are major changes, however, between the proposed rule and last year’s Bulletin relating to prescription drug coverage.  The Bulletin had proposed that health plans could include only one drug per category or class in their formularies.  Patient advocacy groups and other stakeholders objected to this policy, arguing that such a restricted formulary would be insufficient for patients.  The proposed rule changes this policy and requires that plans cover the greater of the number of drugs covered in each category or class by the benchmark plan or one category or class.  The proposed rule further requires health plans to have a process by which patients can access clinically-appropriate drugs not on the formulary.  Both represent more generous coverage for patients than what was in the Bulletin, though the new policy does not go as far as some advocates had hoped. 

This is just one small example of how ACA implementation is progressing.  Comments on the proposed EHB rule are due by December 26th, so there still an opportunity for advocates to influence the broader EHB policy.  There are also opportunities to influence how EHB is defined on the state level.  All health stakeholders – patient advocacy groups, providers, insurers, employers – must understand what is happening in their state and should be advocating to protect their interests.  It’s not too late to get involved - but the window is closing.

Johanna Gray
Vice President

Lisa Ellington

Big Thinkery, LLC, 1011 Kenilworth Court Northwest, Concord, NC, 28027