Employers, plans ask for added clarity in preventive-service rules

November 1, 2010

The federal government is out to change the nature of healthcare from reactive to proactive

Key Points

THE FEDERAL government is out to change the nature of healthcare from reactive to proactive. Provisions in the Patient Protection and Affordable Care Act (PPACA) now require that new or revised insurance policies (those that are not grandfathered) provide members an array of preventive care services without charging a copay, coinsurance or deductible.

"The devil is always in the details," says Gretchen Young, senior vice president of health policy with the ERISA Industry Committee, a Washington, D.C.-based trade association representing America's major employers.

But absorbing the change will be difficult for some sponsors.

Insurers and large employers, who have long been at the forefront of the preventive care movement, are concerned about ambiguities in the Interim Final Rule, and a number of groups have filed letters with the federal government requesting clarification. During this year's open enrollment period, many are moving forward without complete information from the government.

Employers are definitely onboard with the idea that proven, evidence-based preventive services are good measures all around, says Steve Wojcik, vice president of public policy for the National Business Group on Health. But many of his group's members feel the requirements add a layer of complexity and bureaucracy to their business.

"They're wondering, 'Why are we spending all this energy trying to comply with something we're already doing?'" he says.

Young, whose group represents self-insured employer plans, says gray areas in the legislation represent "a huge problem" for such companies.

"I think most of our members had assumed they'd be fine under these mandates," she says, "and we were unpleasantly surprised when the mandates came out. The Task Force recommendations were written for providers, not plans. They just don't translate well to plan guidance. They'll say things like, 'behavioral health intervention.' What does that mean?"

The ERISA Industry Committee has filed two letters with the federal agencies charged with enforcing the mandates, seeking clarification.

Insurers have voiced similar concerns. America's Health Insurance Plans stated in a September 17 letter to the federal agencies requesting guidance on the interim final recommendations that "translating evidence-based preventive services recommendations for clinical practice into sound public and private health benefit designs and coverage policies requires practical application of clinical options and appropriate medical management." In some situations "interpreting, and applying the regulatory requirements and recommendations will present challenges."

Despite their wariness, most large employers intend to move forward with benefit changes that will bring them under the purview of the new mandates. In a survey conducted in May and June by the National Business Group on Health, more than half of large employers said they expected to lose their grandfather status this fall due to planned changes to benefit packages. Of the 72 major employers surveyed, 53% said they would move forward with changes to their benefit plans, while 19% said they would scale back planned changes, and 19% said they would not make any changes.