Subtitle C is a pretty exciting subtitle, and I don't mind saying so, and the bulk of it is found here in Part 1. Here, Sections 2701 - 2708 are amended. Rather than breaking them down one by one bullet-point style, I'll just give you the gist of it all at once.
First, we eliminate exclusions and discrimination based on preexisting and other health conditions. Apparently, the Public Health Service Act specifically allowed for such discrimination, but it's off the table now. Also changed are the rate and reasons for which premium rates can vary. Now, the only variance allowed is based on: individual vs. family coverage; age (not more than 3 : 1); tobacco use (not more than 1.5 : 1); and rating areas, which will be established by each state. Also of note, here, is that age and tobacco variations have to be proportionate. So if 1 person in your family of 5 would be affected by those variances, your premium can only be affected by that same proportion.
Another major change in these amendments is that health plans cannot discriminate against people based on what they're calling "health status." First, eligibility rules are stated, listing several examples of health status factors such as "health status" (wow, thanks!), medical condition, claims experience, medical history, genetic information and disability. Second, to put those factors into practice, the amendment prohibits "wellness programs" and disease prevention programs with rewards (like premium discounts and rebates) if they require the fulfillment of a health status requirement to achieve. So, a program cannot require that, for example, an individual meet a certain weight requirement, or run a given distance or lift a required amount of weight in order to receive a premium reduction or rebate. Those goals may not be medically feasible (or advisable) for certain people, so they are not valid goals in these programs. There are, of course, exceptions to this rule. In order to be legal, such a program must meet the following requirements:
- The discount must be equal to less than 30% of the total cost of coverage
- The program must be "reasonably designed to promote health or prevent disease" and can't be "subterfuge for discriminating based on a health factor" and, my favorite, can't be "highly suspect" in the method of health promotion or disease prevention. You gotta love legislative language, eh?
- It must have open eligibility at least once a year
- It must be available to all "similarly situated" individuals, and offer alternative standards for cases in which achieving the standard is medically dangerous or inadvisable. And whenever one standard is listed in the program literature, they must both be listed.
Other notable changes in the amendments:
- Insurance issuers have to grant coverage to all who apply
- Renewability of coverage is guaranteed
- Insurance issuers cannot discriminate against health providers (i.e. hospitals/doctors) if they meet plan requirements and, of course, are practicing legally
- All health insurance plans must meet certain "comprehensive" coverage requirements, which will be enumerated later in the legislation, and will be called "essential benefits"
- Excessive waiting periods are prohibited - apparently we'll hear more about this in Section 2704(b)(4)
Two other little tidbits from this subtitle - all standards have to be applied uniformly to all health insurance issuers; and all amendments in Subtitle C are effective for plan years on or after January 1, 2014.
So that's it! That's Subtitle C, in all its glory. Stay tuned for the next installment - Subtitle D, the longest subtitle yet! And let me tell you, it's a real page turner. All 30 or so pages of it!