In the weeks since President Obama's re-election assured the future of health benefits exchanges, many stakeholders have demanded details on how the exchanges and essential benefits would actually work.

On Tuesday, Nov. 20, the Health and Human Services agency tipped its hand, releasing three significant documents that will help states make decisions on whether to go forward on exchanges, help insurers better understand how to shape benefits, and give other stakeholders, such as pharma and PBMs, an idea of what's ahead come 2014.

The three sets of proposed rules address how employers can shape cost-sharing for wellness activities such as smoking cessation and obesity management; how insurers can set rates; and how benefits, including prescription drugs, would be offered.

On prescription drugs, the proposed rules may be a victory for pharmaceutical manufacturers and the advocacy groups who had argued against strict limits on the number of drugs per class. On the other hand, the rules are a defeat for PBMs, small employers and insurers who argued that limits were needed in order to make drugs affordable for the small groups and individuals who will enroll in exchanges.

The rules say that each qualified health plan has to cover at least one drug per class unless their state benchmark plan is more generous?then they?d have to follow that.  ?We propose that a plan offering essential benefits have procedures in place to ensure enrollees have access to clinically appropriate drugs that are prescribed by a provider but are not included in the plan's drug list, which is consistent with private practice today,? the HHS said.

Besides the proposed rules on drugs, the Nov. 20 documents also reveal HHS's plans to:

  • Limit the variation insurers can use for pricing plans for smokers. The variation would be 1.5-to-1, meaning a tobacco user could not be charged more than 1.5 times the rate of a nonsmoker;
  • Limit the rating bands that insurers for older adults to 3-to-1;
  • Eliminate any difference in pricing based on gender;
  • Amend current regulations to allow rewards for participation in certain wellness programs to grow to 30 percent (or possibly, later, as much as 50 percent). The wellness programs eligible for certain rewards are those that provide a reward and condition the reward on satisfying a standard that is related to a health factor.

The long-awaited rules go a long way toward helping states, insurers and others lay the groundwork for exchanges. They may also help tamp down calls to delay exchange implementation beyond Jan. 1, 2014. (Since open enrollment begins Oct. 1, 2013, there is less than a year to get the exchanges going). Yet, many people believe some parts of ACA implementation around exchanges and essential benefits could be put on hold, at least for a few months.

By agreeing last week to a delay in submitting blueprints for exchange plans, the Obama administration signaled its willingness to get as many state-run exchanges under way as possible. At least now, they have a clearer idea of what they will have to do to kick the can?or the IT system?down the road.

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