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PPACA: Commenters Ask for Commonsense Limits

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Affordable Care Act implementation guidelines should let insurers and health plans impose sensible limits on use of medical services.

Commenters representing insurers, insurance producers and health plans have made that argument in comment letters now posted on the website of the Employee Benefits Security Administration (EBSA).

EBSA, an arm of the U.S. Labor Department, has posted a batch of 145 comments that it received after it released Affordable Care Act interim final regulations in June.PPACA Toolkit

The Affordable Care Act is the legislative package that includes the Patient Protection and Affordable Care Act (PPACA).

The June regulations, issued by the U.S. Treasury Department and the U.S. Department of Health and Human Services as well as the Labor Department, covered topics such as the rules governing annual and lifetime benefits limits, rescissions, internal appeals, external appeals, provider access, and a ban on consideration of pre-existing conditions when plans or insurers are looking at applications under age 19.

The annual and lifetime benefits limits rules apply only to “essential benefits”; plans still can set separate benefits limits for “non-essential benefits.”

Many of the commenters representing patients with specific conditions have asked officials to ensure that the official definition of “essential benefits” includes the benefits that the people with those conditions need.

Christine Brown, executive director of the National PKU Alliance, Tomahawk, Wis., has asked that coverage for medical foods designed for people with severe metabolic disorders be treated as an essential benefit.

Peter Bell of Autism Speaks, Washington, says the definition of essential health benefits ought to include applied behavior analysis for people with autism and other disorders that affect behavior.

Other commenters have asked federal agencies to use commonsense when essential benefits rules intersect with new Affordable Care Act preventive services coverage requirements.

“For example,” says Ken Crerar, president of the Council of Insurance Agents & Brokers, Washington, “questions have been raised about annual physical exams, which may be classified under the ‘preventive and wellness services’ category of essential benefits and thus subject to no annual or lifetime limits, but which also fall under the preventive services rule and would be subject to first-dollar coverage by non-grandfathered plans.”

In theory, a combination of the two sets of rules could require plans to provide first-dollar coverage for an unlimited number of routine physical exams each year, Crerar says.

If that is how the agencies interpret the rules, then the Affordable Care Act “will quickly become unmanageable,” Crerar says. “Rather, the rule on annual and lifetime limits should specify that use of reasonable medical management techniques (where permitted), does not trigger an annual or lifetime limit analysis.”

A number of commenters have written to warn the

agencies that the rules governing the interaction between the new benefits limits restrictions and personal health accounts, such as health savings accounts, leave out stand-alone health reimbursement arrangements (HRAs). Unless the agencies do something, they may accidentally eliminate stand-alone HRAs, benefit plan administrators and others warn.

Many commenters wrote to address PPACA Section 1252, which will require carriers to sell coverage to children without taking pre-existing conditions into account.

Lynda Rossi, a vice president at Blue Cross Blue Shield of Michigan, Detroit, says her nonprofit company has a statutory obligation to sell coverage to children on a true continuous open enrollment, guaranteed-issue basis.

“If some states require one or more health insurance issuers to offer continuous open enrollment as a matter of state law, under Section 1252, all insurance issuers in such states should be required to offer continuous open enrollment to achieve the uniform regulation intended by this section,” Rossi says.

Other commenters have written to warn that the only way to make the provision work without causing extreme antiselection is to establish an open-ennrollment season schedule, and to apply the same schedule to all carriers.

“The combination of preexisting and guaranteed-issue rules may encourage a financially prudent family with healthy children to defer purchase of insurance until a child gets sick,” says Karen Bender, chair of the benefit and eligibility changes work group at the American Academy of Actuaries, Washington. “As long as there is at least one carrier with an open-enrollment period available at any time during the year, and no penalty for deferral, then there is an economic incentive to defer purchase of insurance.”


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