Tag Archive: Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2016

Workplace wellness flash point of large employer frustration with rising medical costs

Frustration among large employers over the continued high and rising cost of providing medical coverage for their workforces nearly five years since the Affordable Care Act’s 2010 enactment is reaching a flash point. The flash point is workplace wellness programs amid questions over their ability to reduce medical utilization costs by improving the health status of their employees. And specifically whether large employers who require biometric testing of employees are running afoul of rules promulgated to implement Patient Protection and Affordable Care Act provisions governing the programs.

The Affordable Care Act sanctions two types of wellness programs employers can offer as part of employer-sponsored health plans. In addition to the traditional participatory wellness programs such as discounts on fitness club memberships, health assessments and seminars, employers can also offer — on a voluntary basis — contingent wellness programs that require participating employees to take part in health improvement plans designed to help them reach health status goals such reducing weight, body mass index (BMI), blood pressure, or cholesterol levels. Employers can provide those achieving their goals economic incentives in the form of reduced health plan premiums.

However, the U.S. Equal Employment Opportunity Commission (EEOC) has sued some large employers, charging they are requiring all employees and not just those participating in voluntary, contingent wellness programs to undergo biometric testing. That goes beyond contingent wellness program rules and violates Americans with Disabilities Act (ADA) and the Genetic Information Nondiscrimination Act (GINA) since the testing is not job-related or consistent with business necessity, the EEOC claims.

Reuters (via Yahoo News) reports the federal government litigation has ticked off large employers to the extent that they are now politically turning against the Affordable Care Act and may work to undermine it in Congress and the courts.

The application of the workplace wellness rules isn’t the real issue. Large employers have known the how the rules governing voluntary and contingent wellness programs work for two years. Their real beef is over the fact that they’re not seeing their health costs being meaningfully reduced by the Affordable Care Act. Nor are they likely to without reforming their organizations to support a culture that truly respects the health and wellness of their members and affords them ample opportunity to engage in health promoting behaviors.


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email fpilot@pilothealthstrategies.com or call 530-295-1473. 

Proposed rules for 2016 and post individual, small group and exchange marketplace issued

The U.S. Department of Health and Human Services last week issued a proposed rulemaking governing the individual and small group health insurance markets and the state health benefit exchange marketplace for plan year 2016 and later years. Happy holiday reading: comment on the proposed rules (Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2016, CMS-9944-P) is due December 26, 2014.

There’s a lot to digest in the rulemaking with some of the key proposed rules summarized below. As usual, Timothy Jost has taken his customary deep dive into the rulemaking with posts on the Health Affairs blog that can be viewed here and here.

  • Plan issuers must publish up-to-date, (updated at least monthly) accurate, and complete provider directories including information on which providers are accepting new patients, the provider’s location, contact information, specialty, medical group, and any institutional affiliations in a manner that is easily accessible to plan enrollees, prospective enrollees, the State, the Exchange, HHS and OPM. Directories will be considered easily accessible when the general public is able to view all of the current providers for a plan on the plan’s public website through a clearly identifiable link or tab without having to create or access an account or enter a policy number. The general public should be able to easily discern which providers participate in which plan(s) and provider network(s) if the health plan issuer maintains multiple provider networks and the plan(s) and provider network(s) associated with each provider should be clearly identified on the website.
  • For the purposes of the employer shared responsibility mandate, large employer-sponsored plans must meet both minimum actuarial value and minimum standard of benefits. Plans must provide substantial coverage of both inpatient hospital services and physician services.
  • Health plan issuers must establish pharmacy and therapeutics (P&T) committees to ensure plan formularies cover a sufficient number and type of prescription drugs. P&T committee standards that must be met for prescription drug coverage meet prescription drug essential health benefits requirement for individual and small group plans.
  • New special exchange enrollment period for individuals in non-Medicaid expansion states when their household income increases to meet exchange minimum income eligibility standard, i.e. 100 percent of federal poverty.
  • Individual market open enrollment period for plan years 2016 and later: October 1 to December 15.
  • Expansion of special enrollment period to individuals enrolled in non-calendar year individual health insurance coverage when their policy year ends in 2014 to all years.
  • Small employers participating in state exchange Small Business Health Options Programs (SHOP) can elect to offer SHOP coverage to former employees, retirees and also provide required continuation coverage via the SHOP.
  • Exchanges, QHP issuers, and web brokers must provide oral interpretation services to include telephonic interpreters in at least 150 languages.
  • Health plan issuers may optionally count cost sharing for out-of-network services toward annual cost sharing limits.



Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email fpilot@pilothealthstrategies.com or call 530-295-1473. 

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