Administration Lays Down Rules For Future Health Insurance : Shots - Health News Now that the Supreme Court has found the Affordable Care Act constitutional and the president's re-election made clear that big chunks of the law will take effect in 2014, the administration is finally releasing rules of the road that states and insurance companies have been clamoring for.
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Administration Lays Down Rules For Future Health Insurance

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Administration Lays Down Rules For Future Health Insurance

Administration Lays Down Rules For Future Health Insurance

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From NPR News, this is ALL THINGS CONSIDERED. I'm Robert Siegel.


And I'm Audie Cornish.

Federal officials today began addressing several key questions about how the federal health law will work when it takes effect just over a year from now. Among them, how will health plans sell policies to people with pre-existing health conditions? And what kinds of benefits will have to be offered?

Joining us in the studio with some answers is NPR health policy correspondent Julie Rovner.

And, Julie, what exactly did the Department of Health and Human Services release today and why does it matter?

JULIE ROVNER, BYLINE: Well, that's a good question and it's more than 300 pages of regulation. Most of the time we don't pay attention to the reams and reams of stuff that the department issues, even on the big health law. But there are two reasons to pay attention to what's come out today. One is that these are actually some of the most important aspects of the law itself; the parts that ban insurers from discriminating against people with pre-existing conditions, and against charging those people higher premiums.

These new rules also lay out what kinds of benefits have to be offered and the policies that will be sold in these new marketplaces called health exchanges, and how that can vary from state to state. But the other reason is that states and the insurance industry have been complaining that they can't make some key decisions that they need to get ready to roll out the law, until they have more guidance from federal officials. So these rules are that guidance.

CORNISH: So let's get into some of the specifics. What will be the rules for people with pre-existing health conditions?

ROVNER: Well, first I should say these are still proposed rules and they are subject to change; but they're not likely to see major change at this point. So generally, starting January 1st, 2014, health insurers will no longer be allowed to deny coverage because someone has an existing medical condition. Nor will they be allowed to refuse to renew coverage because someone has developed an illness.

There are also rules limiting how much premiums can vary. In general, the only variations that will be allowed will be based on age, on tobacco use, family size and geography. And in the case of age, older people can only be charged three times more than younger people, and tobacco users can only be charged one and a half times more than non-tobacco users.

CORNISH: OK, so that's who they have to cover and what they can charge. What about what they have to cover?

ROVNER: Well, this document dump, if you will, also includes another round of what's called the Essential Health Benefits List. It's a list of 10 categories of benefits - things like hospital, outpatient, prescription drug care - that every plan in these new health exchanges has to offer.

The trick here is to make sure every plan offers comprehensive coverage, but that the plans don't get so loaded down with bells and whistles that they become unaffordably expensive. And also, to make sure they don't get out of line with community standards. So the rules let each state set a benchmark plan that's equal to one of several popular plans available in that state.

CORNISH: And finally, there's something about employer wellness programs?

ROVNER: That's right. This is an increasingly popular way employers are trying to hold down health costs, by giving their workers incentives to quit smoking or lose weight or lower their cholesterol. And the rules say that these programs are OK, but they can't discriminate against people who have medical conditions that make reaching those goals impossible or medically inadvisable. Those people would have to be given other ways of getting lower premiums or whatever incentive is being offered by the employer.

CORNISH: That's NPR health policy correspondent Julie Rovner. Julie, thank you.

ROVNER: Thank you.

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