New rules are proposed for benefits that must be covered under health reform

BMJ 2012; 345 doi: (Published 27 November 2012) Cite this as: BMJ 2012;345:e8112
  1. Janice Hopkins Tanne
  1. 1New York

The Obama administration’s proposed rules for health insurance prohibit discrimination by health insurance companies, require coverage of 10 essential health benefits, and emphasize wellness programs to prevent disease and lower health costs.

The public, consumer groups, and health insurance companies have until December 26 to comment on two of the proposed rules and until January 25 to comment on the third rule, which deals with employee wellness programs. When finalized, the rules will go into effect for health insurance policies after 1 January 2014.

Kathleen Sebelius, the Health and Human Services secretary, said, “The Affordable Care Act is building a health insurance market that works for consumers. Thanks to the healthcare law, no one will be discriminated against because of a pre-existing condition.”

Karen Ignagni, head of the trade group America’s Health Insurance Plans, said she was concerned that the rules might make health insurance more costly for consumers.

The Obama administration issued three proposed rules on 20 November for the benefits offered and the health insurance policies sold in new marketplaces, called health exchanges, where consumers can compare plans:

  • From 2014, health insurance companies cannot discriminate against the approximately 129 million people with pre-existing conditions. The companies cannot charge higher premiums to people because of current or past health problems, their gender, their occupation, or because they work for a small employer or in a particular industry. Companies cannot refuse to renew coverage because someone becomes ill. However, companies can set different premiums based on age, tobacco use, family size, and geography. Premiums for people near retirement cannot be more than three times the premiums of young adults aged 21.

  • A set of standard benefits will allow consumers to compare health plans offered in the individual and small-group insurance markets.

  • Job based wellness programs (to encourage employees to follow healthy behaviors such as stopping smoking, keeping blood pressure under control, and lowering cholesterol) will be expanded. People who engage in wellness programs will be exempt from the higher premiums that can be charged to smokers, for example.

The Health Reform Act sets 10 “essential health benefits” that all health plans in the individual and small-group markets must offer: 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 (therapies for those with intellectual and developmental disabilities such as autism and cerebral palsy) and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services including oral and vision care. States may be allowed flexibility to identify benefits within these 10 categories.

The prescription drug benefit includes contraceptives. Religious institutions and private companies that object on religious or moral grounds have already filed lawsuits. The matter may end up in the Supreme Court.

The proposed rules build on the wellness programs that many employers offer to reduce health costs. Under the proposed rules, employees who have health risks will pay higher insurance premiums unless they try to reduce these risks.


Cite this as: BMJ 2012;345:e8112