• News New Blog Banner

  • HHS Releases Essential Health Benefits Proposed Rule

    The Department of Health and Human Services (HHS) released several proposed rules today dealing with insurance reforms, including the proposed rule "Patient Protection and Affordable Care Act; Standards Related to Essential Health Benefits, Actuarial Value, and Accreditation." The proposed rule provides guidance to states on the essential health benefits (EHBs) that must be offered in most nongrandfathered qualified health plans (QHPs) that are offered in each state's affordable Health Insurance Exchanges ("Exchanges") as directed under the Affordable Care Act (ACA). The Exchanges are expected to create competitive marketplaces making health insurance plans more affordable for individuals. EHB applicability to Medicaid will be defined in a separate regulation. The Exchanges must become operational by January 1, 2014. (See related articles titled "Proposed Rule Protects Patients From Discriminatory Policies" and "HHS Proposes Incentives for Nondiscriminatory Wellness Programs in Group Health Plan.")

    The proposed rule outlines Exchange and issuer standards related to coverage of EHBs and actuarial value. The proposed rule reiterates the 10 mandatory EHB categories of (1) ambulatory patient services; (2) emergency services; (3) hospitalization; (4) maternity and newborn care; (5) mental health and substance use disorder services, including behavioral health treatment; (6) prescription drugs; (7) rehabilitative and habilitative services and devices; (8) laboratory services; (9) preventive and wellness services and chronic disease management; and (10) pediatric services (under age 19), including oral and vision care. States must create EHB benchmark plans from their default benchmark state health plans by adding any mandatory categories that are not in their default plans. These nongrandfathered health plans must offer balanced benefits not unduly weighted toward any one category. 

    The proposed rule includes that:

    • States would determine EHB-benchmark plans that would serve as  reference plans and would reflect both the scope of services and limits offered by a typical employer plans in that state. This would allow states to build on coverage that is already widely available, minimize market disruption, and provide consumers with familiar products. Additionally, it is intended to balance consumers’ needs for  comprehensiveness and affordability, as recommended by the Institute of Medicine in its report on EHBs;
    • The EHB-benchmark plan must not include benefit designs that discriminate on the basis of an individual's medical condition, or against specific populations as described in the statute;
    • A transitional policy for coverage of habilitative services be implemented that would provide states with the opportunity to define these services if not included in the base-benchmark plan; states could determine the services they choose to provide under the habilitative category;
    • Covered benefits must remain substantially equal to those covered by the EHB-benchmark plan;
    • Certain preventive services must be offered without cost-sharing;
    • Health benefit substitution could only occur within benefit categories, not between different benefit categories. States have the option to enforce a stricter standard on benefit substitution or prohibit it completely;
    • An issuer cannot provide an EHB benefit design that discriminates based on an individual’s age, expected length of life, or present or predicted disability, degree of medical dependency, quality of life, or other health conditions;
    • States may require that a [nongrandfathered] QHP cover additional benefits beyond the 10 EHB categories;
    • A (nongrandfathered) health insurance issuer that offers health insurance coverage in the individual or small group market—inside or outside of the Exchange—ensure that such coverage offers the EHB package; and
    • HHS' secretary review the plans after 2 years, then similar policy thereafter, to ensure that gaps in access to care are remediated or advances in the relevant evidence base are included.

    Finally, the Affordable Care Act describes the levels of coverage that of the EHB packages offered in the Exchanges: actuarial values of 60% for a bronze plan, 70% for a silver plan, 80% for a gold plan, and 90% for a platinum plan.

    APTA will be commenting on this proposed rule. Comments are due on or around December 20.

    APTA's Regulatory Affairs department will provide full summaries of the 3 proposed rules shortly.

    Proposed Rule Protects Patients From Discriminatory Policies

    The Department of Health and Human Services (HHS) today released a proposed regulation that would implement the policies in the Affordable Care Act that make it illegal for insurance companies to discriminate against people with preexisting conditions. The provisions in the proposed rule are related to fair health insurance premiums, guaranteed availability, guaranteed renewability, risk pools, and catastrophic plans. Notably, the proposed rule clarifies the approach used to enforce the applicable requirements of the Affordable Care Act with respect to health insurance issuers and group health plans that are nonfederal governmental plans. Additionally, this proposed rule would amend the standards for health insurance issuers and states regarding reporting, utilization, and collection of data under the Public Health Service Act, which established a process for reviewing unreasonable increases in premiums for health insurance coverage. The rule also revises the timeline for states to propose state-specific thresholds for rate review and approval by the Centers for Medicare and Medicaid Services.

    Comments on this proposed rule are due on or around December 26.

    See related articles titled "HHS Releases Essential Health Benefits Proposed Rule" and "HHS Proposes Incentives for Nondiscriminatory Wellness Programs in Group Health Plans."

    APTA's Regulatory Affairs department will provide full summaries of the 3 proposed rules shortly.

    HHS Proposes Incentives for Nondiscriminatory Wellness Programs in Group Health Plans

    A third proposed regulation issued today by the Department of Health and Human Services (HHS) offers amendments to regulations, consistent with the Affordable Care Act, regarding nondiscriminatory wellness programs in group health coverage. Nondiscriminatory wellness programs generally allow premium discounts, rebates, or modification to otherwise applicable cost sharing (including copayments and deductibles) in return for adherence to certain programs of health promotion and disease prevention.

    Specifically, these proposed regulations would increase the maximum permissible reward under a health-contingent wellness program offered in connection with a group health plan (and any related health insurance coverage) from 20% to 30% of the cost of coverage. In addition, the proposed regulations would further increase the maximum permissible reward to 50% for wellness programs designed to prevent or reduce tobacco use. These regulations also include other proposed clarifications regarding the reasonable design of health-contingent wellness programs and the reasonable alternatives they must offer in order to avoid prohibited discrimination.

    Comments on this proposed rule are due on or around January 26, 2013.   

    See related articles titled "HHS Releases Essential Health Benefits Proposed Rule" and "Proposed Rule Protects Patients From Discriminatory Policies."

    APTA's Regulatory Affairs department will provide full summaries of the 3 proposed rules shortly.

    APTA 'Improvement Standard' Statement Featured in AMA Publication

    A November 19 article in American Medical News, a publication of the American Medical Association (AMA), highlights APTA's statement on the recent legal settlement prohibiting Medicare contractors from denying coverage based on a patient's potential for improved health status.

    New Heard on the Hill Podcast Recognizes Veteran-specific Issues

    A new Heard on the Hill podcast provides a comprehensive update on APTA's Veterans Affairs (VA) and Armed Services initiatives, including a traumatic brain injury briefing held on Capitol Hill in September and discussions with the Federal Physical Therapy Section on recent developments in the Joining Forces Initiative. The podcast also addresses recruitment and retention efforts aimed at physical therapists in the VA.     

    NCOA Launches State Policy Toolkit for Advancing Falls Prevention

    The National Council on Aging's (NCOA) new State Policy Toolkit aims to organize and maximize community falls prevention assets and resources, and establish innovative policies and practices within states, communities, and organizations. The toolkit offers a compendium of suggested policy changes to advance falls prevention, categorized under 8 major goals. It outlines the opportunities, strategies, and examples of what is possible through education and engagement of key stakeholders.

    The toolkit can be used as a guide for promoting discussion and potential action on policy changes that are appropriate for the population, geographic location, partnerships, and culture of your community. Users can adapt a limited, manageable set of strategies from the toolkit to put into action; include a set of indicators to measure progress of select recommendations; and review the resource compendium to find materials to promote strategic partnerships with providers.   

    APTA is a member of NCOA's Falls Free Coalition.

    For additional patient care and consumer education resources on this topic, visit APTA's Balance and Falls webpage.

    Aerobic Exercise Beneficial for Patients With Cancer-related Fatigue

    Aerobic exercise can be regarded as beneficial for individuals with cancer-related fatigue during and postcancer therapy, specifically those with solid tumors, say authors of an updated version of an original Cochrane review published in The Cochrane Library in 2008.    

    For this update, the authors searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, British Nursing Index, AMED, SIGLE, Dissertation Abstracts International, and reference lists of all studies identified for inclusion and relevant reviews. In addition, they hand-searched relevant journals and contacted experts in the field of cancer-related fatigue.

    They identified a total of 56 studies (4,068 participants) for inclusion (28 from the original search and 28 from the updated search), with the majority carried out in participants with breast cancer (28 studies). A meta-analysis of all fatigue data, incorporating 38 comparisons, provided data for 1,461 participants who received an exercise intervention and 1,187 control participants. At the end of the intervention period exercise was seen to be statistically more effective than the control intervention. Benefits of exercise on fatigue were observed for interventions delivered during or postadjuvant cancer therapy. In relation to diagnosis, the authors identified benefits of exercise on fatigue for breast and prostate cancer but not for those with hematological malignancies. Aerobic exercise significantly reduced fatigue, but resistance training and alternative forms of exercise failed to reach significance.

    "We're not expecting people to go out and be running a mile the next day," Fiona Cramp, who worked on the analysis at the University of the West of England in Bristol, told Reuters News. "Some people will be well enough that they're able to go for a jog or go for a bike ride, and if they can, that's great. But we would encourage people to start with a low level."

    Online Atlases Illustrate Prevalence of Diabetes, Obesity, and Physical Inactivity

    The Centers for Disease Control and Prevention (CDC) has introduced a new online tool, Diabetes Interactive Atlases, which provides data for diagnosed diabetes, obesity, and leisure-time physical inactivity at the national, state, and county levels. The new tool also includes interactive motion charts showing trends in the growth of diabetes and obesity throughout the United States and within states.

    The tool was launched with the release of CDC's November 15 Morbidity and Mortality Weekly Report, which highlights a study that found that the prevalence of diagnosed diabetes increased in all US states, the District of Columbia, and Puerto Rico between 1995 and 2010. During that time, the prevalence of diagnosed diabetes increased by 50% or more in 42 states, and by 100% or more in 18 states.

    The states with the largest increases are Oklahoma (226%), Kentucky (158%), Georgia (145%), Alabama (140%), and Washington (135%).

    RWFJ/AHA Collaboration Aims to Reverse Childhood Obesity

    The Robert Wood Johnson Foundation (RWJF) and the American Heart Association (AHA) have joined in an ambitious collaboration to reverse the nation's childhood obesity epidemic by 2015. RWJF will provide AHA with $8 million in initial funding to create and manage an advocacy initiative focused on changing local, state, and federal policies to help children and adolescents be more active and eat healthier foods.

    Under the new initiative, RWJF and AHA will focus on policy interventions to advance 6 priorities that research shows are likely to have the greatest impact on childhood obesity. AHA will develop the overarching strategy that connects efforts across all 6 priorities and will fund efforts in underserved communities for the last 3 of them:

    • improving the nutritional quality of snack foods and beverages in schools
    • reducing consumption of sugary beverages
    • protecting children from unhealthy food and beverage marketing
    • helping schools and youth-serving programs increase children's physical activity levels
    • increasing access to parks, playgrounds, walking paths, bike lanes, and other opportunities to be physically active
    • increasing access to affordable healthy foods

    Both RWJF and AHA will focus on reaching communities hardest hit by the epidemic, including communities of color and lower-income communities.