Proposed Rules Address Pre-existing Conditions, Essential Health Benefits, Wellness Programs

December 03, 2012 05:45 pm James Arvantes
[Doc looking at chart with patient]

The Obama administration has issued a series of proposed rules( to implement key provisions of the Patient Protection and Affordable Care Act going forward, including a provision that will prohibit insurance companies from denying coverage based on pre-existing conditions as of 2014.

"One of the goals of the AAFP is to make health insurance fair for patients and fair for physicians," said AAFP President Jeff Cain, M.D., of Denver, in an interview with AAFP News Now. "These rules help move that agenda forward."

The administration has issued three proposed rules to implement various provisions of the Affordable Care Act that are scheduled to take effect in 2014:

  • A proposed rule( prohibiting insurance companies from denying coverage based on pre-existing or chronic conditions starting in 2014. This means health insurance companies would be prohibited from denying coverage to any patient because of a pre-existing condition or from charging higher premiums to certain patients because of current or past health care problems, gender, occupation, employer size, or industry. It also would give patients access to catastrophic coverage in the individual market.
  • A proposed rule( outlining polices and standards for coverage of essential health benefits to give consumers a way of comparing health plans in the individual and small-group markets. The proposed rule specifically cites ambulatory patient services, or primary care services, as essential health benefits.
  • A proposed rule( implementing and expanding employment-based wellness programs to promote health and control health care costs.

Cain said the proposed rules and provisions will have an immediate impact on primary care when they take effect in 2014. For example, the proposed rule that bars insurance companies from denying coverage based on pre-existing conditions means that patients with pre-existing medical conditions have easier access to health care services. At the same time, patients will be able to change jobs without the risk of losing insurance coverage, Cain noted.

"The general population and AAFP members have strong feelings on both sides about the Affordable Care Act," said Cain. "But several individual parts of the Affordable Care Act enjoy broad support across the population. One of the most important on the list for both doctors and patients is making it illegal for insurance companies to discriminate based on pre-existing conditions."

Cain also applauded the second proposed rule that outlines policies and standards for coverage of essential health benefits, praising, in particular, the rule's emphasis on primary care as an essential benefit.

"Our patients will not lose insurance benefits if they change jobs, and if they change jobs or have new insurance, the new insurance will cover primary care services," Cain said.

The third proposed rule supports and expands workplace wellness programs and outlines standards for nondiscriminatory wellness programs that, for example, reward workers for not smoking or for achieving a certain weight loss goal. With this proposed rule in place, family physicians will have more resources to help patients live a healthier lifestyle, Cain said.