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Proposed Health Insurance Rules Issued
November 27, 2012

Three sets of proposed rules related to health insurance were issued by the Department of Health and Human Services (HHS) and were available for public inspection on the Office of the Federal Register web site (http://www.ofr.gov/inspection.aspx) prior to publication in the November 26 Federal Register. Instructions for submitting comments are included with the proposed regulations.

A proposed rule for Health Insurance Market Reforms (CMS-9972-P) is intended to prevent insurance discrimination against individuals with pre-existing conditions. The proposed rule would prohibit denial of coverage based on a pre-existing condition, establish open enrollment periods for purchase of insurance, and afford special enrollment opportunities in individual markets when certain coverage is lost. Health insurance issuers in individual and small group markets would only be allowed to vary premiums based on age, tobacco use, family size, and geography. States are permitted to establish stronger consumer protections and, in 2017, large employers could purchase coverage through exchanges if states permit. Insurers would be required to have a single, statewide risk pool for each individual and small employer market, unless a state chose to merge the individual and small group market into one pool with premiums and rate changes based on the health risk of the pool. Provisions are also included for enrollment in catastrophic plans. The proposed rule also amends the rate review program to be more streamlined. Comments may be submitted through December 26.

Proposed rules for Standards Related to Essential Health Benefits, Actuarial Value, and Accreditation (CMS -9980-P) describe health insurance issuer standards for coverage of essential health benefits (EHB) and determination of actuarial value, leaving states with discretion on how EHBs are defined. A timeline is established for when issuers offering coverage in a federally-facilitated exchange or a state partnership exchange must be accredited. An application process for accrediting bodies is also addressed. The proposed rule includes a list of state-selected EHB plans and the default benchmark plan. States can make an EHB benchmark selection until December 20. The proposed rule includes information about the actuarial value calculator to be used to determine the actuarial value based on a national, standard population. The rule proposes that National Committee for Quality Assurance and URAQ accreditation is accepted for commercial or Medicaid products until the fourth year of certification of a qualified health plan, then the plan must be accredited based on local performance of the qualified health plan. HHS will consider additional accrediting entities for qualified health plan certification. Guidance for Medicaid programs on meeting EHB provisions is available at http://www.medicaid.gov/Federal-Policy-Guidance/Federal-Policy-Guidance.html.  Comments on this proposed rule may be submitted by December 26.

A third proposed rule (CMS-9979-P) identifies changes to existing workplace wellness programs and encourages development of wellness programs in group health coverage. The rule, Incentives for Nondiscriminatory Wellness Programs in Group Health Plans, addresses both participatory wellness programs that do not consider a participant’s health status and health-contingent wellness programs that require individuals to meet certain criteria in order to obtain a reward. The proposed rule does not specify the types of wellness programs that employers can offer. HHS requests comments on additional consumer protection standards for wellness programs. Comments will be accepted until January 25, 2013.

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