With the recent Supreme Court decision to uphold the Affordable Care Act, there is much speculation on how this legislation will change clinical practice. While the unknowns are greater than what we currently understand about the ACA, the AASM has been analyzing what is in store for sleep medicine. Over the next several weeks, the AASM website will provide a synopsis of certain provisions in the bill. This week will focus on Changes to Private Insurance.

Some of the provisions below have already been implemented while others will take effect on January 1, 2014.

No Lifetime or Annual Limits:

Prohibits group health plans and health insurance issuers from establishing lifetime limits on the dollar value of benefits for any participant or beneficiary. Will prohibit annual limits beginning January 1, 2014.

Coverage of Preventive Health Services:

Requires group health plans and health insurance issuers to provide, at a minimum, coverage for certain specified healthcare services. Group health plans and health insurance issuers cannot impose any cost-sharing requirements for these healthcare services: (1) evidence-based items or services recommended by the United States Preventive Services Task Force; (2) immunizations recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; (3) evidence-informed preventive care and screenings for infants, children and adolescents; and (4) with respect to women, such additional preventive care and screenings.

Coverage for Preexisting Conditions:

Prohibits excluding children from coverage on the basis of a preexisting medical condition in all group plans and plans in the individual market. This prohibition will be extended to adults beginning 2014.

Extension of Dependent Coverage:

Requires group health plans and health insurance issuers to provide coverage for unmarried children of participants until the age of 26.

Coverage for Essential Health Benefits:

Effective January 1, 2014, health insurance issuers that offer coverage in the individual or small group market must ensure that such coverage includes the “essential health benefits” package. These “essential health benefits” will include ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management, and pediatric services including oral and vision care.

Guaranteed Availability of Coverage:

Effective January 1, 2014, each health insurance issuer that offers health insurance coverage in the individual or group market in a given state must accept every employer and individual in that state that applies for such coverage.

Guaranteed Renewability of Coverage:

Effective January 1, 2014, health insurance issuers that offer health insurance coverage in the individual or group market must renew or continue in force such coverage at the option of the plan sponsor or the individual, as applicable.

Prohibition on Excessive Waiting Periods:

Effective January 1, 2014, group health plans and health insurance issuers offering group or individual health insurance coverage are prohibited from imposing coverage waiting periods that exceed 90 days.

Review of Increases in Premiums:

Directs the Secretary of Health and Human Services to establish a process for the annual review of unreasonable increases in premiums for health insurance coverage.

Quality Reporting Requirements:

Within two years after enactment, the Secretary must develop reporting requirements for use by group health plans and health insurance issuers with respect to plan or coverage benefits and healthcare provider reimbursement structures that (1) improve health outcomes through implementation of activities such as quality reporting and care compliance initiatives, (2) implement activities to prevent hospital readmissions; (3) implement activities to improve patient safety and reduce medical errors; and (4) implement wellness and health promotion activities. For purposes of the reporting requirements, wellness and prevention programs may include personalized wellness and prevention services (e.g. smoking cessation and weight management), which are coordinated by a healthcare provider, a wellness and prevention plan manager, or a health, wellness or prevention services organization.

Reporting of Medical Loss Ratio:

Health plans are required requires insurance companies to spend at least 80% or 85% of premium dollars on medical care, known as the medical loss ratio (“MLR”). If the MLR does not fall within these parameters, the Act requires payment of rebates to enrollees.

Antidiscrimination Provisions:

Prohibits sponsors of group health plans from discriminating against full-time employees based on hourly or annual wages, or favoring of higher-wage employees. Effective January 1, 2014, the Act prohibits discrimination based on health status, medical condition (including mental illnesses), claims experience, receipt of healthcare, medical history, genetic information, evidence of insurability (including conditions arising out of acts of domestic violence), disability, and any other health status-related factor.

Prohibition on Rescissions:

Subject to certain exceptions for fraud and intentional misrepresentations by an enrollee, prohibits a group health plan or a health insurance issuer to rescind a plan or coverage with respect to an enrollee once the enrollee is covered under such plan or coverage.