Monday, July 26, 2010

Guidance on ACA market reforms: where do we stand?

So, the deadline for compliance with several of the market reforms contained in the Affordable Care Act--plan years beginning on or after September 23, 2010--is fast approaching. What help have employers and TPAs received from the tri-agency team (IRS, HHS, and DOL) charged with implementing the Act?

Well, you can't argue that our friendly federal regulators haven't been busy this summer. They've issued guidance--mostly in the form of interim final regulations--on the following market reforms, all contained in new sections in the Public Health Service Act (incorporated by reference into ERISA and IRC):

--PHSA Sec. 2704: prohibition of preexisting condition exclusions--rules relating to enrollees under age 19 (remember, for adults this rule won't kick in until plan years beginning on or after January 1, 2014);
--PHSA Sec. 2711: prohibits group health plans from establishing lifetime and annual limits on the dollar value of benefits (with restricted annual limits permitted until 2014);
--PHSA Sec. 2712: prohibits plans from retroactive rescission of coverage (except in cases of fraud or intentional misrepresentation);
--PHSA Sec. 2713: Requires plans to cover certain preventive services, without any cost sharing;
--PHSA Sec. 2714: Requires plans offering coverage of dependents to make that coverage available to adult children until age 26;
--PHSA Sec. 2719: Requires plans to provide an "effective" internal appeals process for coverage determinations and claims;
--PHSA Sec. 2719A: Requires plans to meet certain "patient protection" standards with respect to the selection of a participating primary care provider and for the use of out-of-network emergency services.

Go here for one-stop access to all these regulations.

No guidance has yet been issued on the following new PHSA provisions, also effective for plan years on or after September 23:

--PHSA Sec. 2715: Requires federal government to develop uniform standards for plans' benefit summaries and explanations of coverage;
--PHSA Sec. 2716: Prohibits fully-insured plans from discriminating in favor of highly-compensated individuals;
--PHSA Sec. 2717: Requires federal government to develop guidelines for health insurance issuers to report on quality of care initiatives and programs; and
--PHSA Sec. 2718: Sets minimum annual standards for medical loss ratio percentages of health insurers (note that the agencies requested comments on this provision in April).


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