Health Care Reform

Health Care Reform and Federal Regulations

In response to the passage of the ACA, federal agencies are actively interpreting the law by issuing proposed rules, final rules and guidance. Delta Dental closely monitors these regulations as they are issued. Here is a listing of the various agencies' ACA-related activity in 2012 impacting dental benefits, links to those regulations and Delta Dental's comments where applicable. The application of many of these rules to stand-alone dental plans hinges on their status as "excepted benefits," which are distinct from comprehensive major medical benefits and are regulated in a different way. For more information on excepted benefits and stand-alone dental plans, go here.

Still to come...
Unreleased Proposed and Final Federal Regulations

HITECH Breach
HHS will release a final rule for the HITECH breach notification rules and genetic nondiscrimination privacy standards. Includes "excepted benefits" coverage providing "medical care."

Exchanges and Essential Health Benefits
We expect to see additional informal guidance in the form of "bulletins" and "FAQs" regarding the implementation of Exchanges by states, the federal Exchange and essential health benefits.

2012 Highlights of ACA Federal Regulatory Activities

December

On December 5, 2012, the Office of Personnel Management proposed rules for certification of at least two national multi-state health plans to be offered as qualified health plans (QHPs) in all Exchanges. The proposed rules do not apply to "excepted benefits" coverage. You can read DDPA comments here.

On December 7, 2012, HHS proposed a benefit and payment parameters rule for implementing risk adjustment, reinsurance, and risk corridors; advance payment of tax credit subsidies; and cost-sharing reductions. Tax credit provisions apply to stand-alone dental plans that offer the pediatric dental benefit. The rule does not apply to "excepted benefits" coverage. You can read DDPA comments here.

November

On November 26, 2012, the Department of Health and Human Services (HHS) issued a proposed rule defining the essential health benefits (EHB) requirements which codifies prior agency bulletins. The EHB standards do not apply to "excepted benefits" coverage. The rule clarifies pediatric dental issues including defining pediatric to mean at least age 19, reasonable cost-sharing limit, and special rule for "metal levels" for dental. You can read DDPA comments on the rule here.

On November 26, 2012, HHS proposed rules on insurance market reforms to implement guaranteed availability, guaranteed renewability, and community rating. Proposed rules do not apply to "excepted benefits" coverage. You can read DDPA comments on the rule here.

June

Essential Health Benefits Data
On June 5, 2012, HHS issued a Notice of Proposed Rule (NPRM) to require QHP issuers to report information describing benefits, treatment limitations, drug coverage and enrollment; and for stand-alone dental plans to voluntarily report their intent to participate in an Exchange for purposes of the QHP pediatric dental benefit "waiver." Delta Dental submitted comments on the EHB Data Collection rule in July.

May

Stop Loss Coverage
On May 1, 2012, the Tri-Agencies issued a request for information regarding the use of stop loss insurance by group health plans and employer plan sponsors. The agencies are interested in the prevalence and consequences of stop loss insurance and its use in the small group market.

Medical Loss Ratios
On May 16, 2012, HHS issued a final rule implementing the medical loss ratio rebate requirements by adopting the interim final rules and making amendments regarding notices. Requirements do not apply to "excepted benefits" coverage.

Federally-facilitated Exchanges
On May 16, 2012, CCIIO issued guidance on Federally-facilitated Exchanges describing key functions, plan management and eligibility. Delta Dental submitted comments on Federally-facilitated Exchanges in August.

Exchange Tax Credit
On May 23, 2012, the IRS issued final rules for the health insurance premium tax credit available for qualified coverage purchased through an Exchange. The rule provides that the tax credit for pediatric dental coverage is based on the portion of the premium allocable to pediatric dental benefits. The credit is applicable for tax years after December 31, 2013. Delta Dental provided feedback to the IRS on the Exchange Tax Credit prior to the issuance of this rule.

Medical Loss Ratios
On May 24, 2012, CCIIO issued a "technical guidance" bulletin in the form of frequently asked questions that includes an FAQ specifically stating that the medical loss ratio requirements do not apply to "excepted benefits" coverage because it is explicitly exempt in the statute.

April

Transaction Standards
On April 17, 2012, HHS issued a proposed rule to establish a national unique health plan identifier to be used on or after October 1, 2014, and also to delay the implementation of the requirement to use the ICD-10 standards. These administrative simplification requirements apply to "excepted benefits" coverage to pay the cost of medical care.

Effectiveness Fees
On April 17, 2012, the IRS issued a proposed rule implementing the clinical effectiveness research fee imposed on health insurance policies and self-insured group health plans. The fee is $2 per average number of lives covered but does not apply to "excepted benefits" coverage.

March

Preventive Benefits
On March 21, 2012, the Tri-Agencies issued an advanced notice of proposed rulemaking inviting comments on ways to address requirements for group health plans to provide preventive benefits that include contraceptive services and plan sponsor objections on a religious basis.

Risk Adjustment
On March 23, 2012, HHS issued a final rule for the standards related to reinsurance, risk corridors and risk adjustment for health insurance issuers participating in Exchanges. Preamble and regulatory language expressly excludes "excepted benefits" coverage. Delta Dental commented on the standards related to reinsurance, risk corridors and risk adjustment prior to its finalization.

Exchanges and QHPs
On March 27, 2012, HHS issued final rules for establishment of Exchanges and Qualified Health Plans (QHPs). Certain provisions apply to stand-alone dental plans that offer pediatric essential health benefits; for example, lifetime and annual limits apply to pediatric essential dental benefits. QHP certification standards apply unless they cannot be met by dental plans offering pediatric dental benefits. Exchanges must allow dental plans as both stand-alone and in conjunction with QHPs. States may choose to require separate offer and price of pediatric dental benefits on Exchanges if they determine it to be in the interest of consumers. Delta Dental provided input to HHS on rules for Exchanges and Qualified Health Plans prior to finalization.

February

Coverage Summary
On February 14, 2012, the Department of the Treasury, Department of Labor and HHS (collectively, the Tri-Agencies) issued a final rule implementing required Summary of Benefits and Coverage standards applicable to group and individual health plans. Preamble and template instructions state that the requirements do not apply to "excepted benefits" coverage. Delta Dental submitted comments on the Coverage Summary rule prior to it being finalized.

Preventive Services
On February 15, 2012, the Tri-Agencies issued a final rule adopting the interim final rules providing exemptions for group health plans sponsored by religious employers from the contraceptive benefits requirements. This rule does not apply to "excepted benefits" coverage.

Essential Health Benefits FAQs
On February 17, 2012, the Center for Consumer Information and Insurance Oversight (CCIIO) issued a follow up to the Essential Health Benefits Bulletin issued in December 2011. This frequently asked questions document further explains "benchmark" plans and supplementing "benchmark" plans that do not include specific EHB categories like "pediatric dental" benefit. Delta Dental submitted feedback on the Essential Health Benefits Bulletin..

Information Reporting
On February 24, 2012, the Internal Revenue Service (IRS) issued Notice 2012-9 providing guidance to employers on W-2 information reporting for the cost of employer-sponsored group health plan coverage. This guidance provides that "excepted benefits" coverage is not included in aggregate reportable cost.

Actuarial Value Guidance
On February 24, 2012, CCIIO issued technical guidance on "Determining Actuarial Value and Cost-Sharing Assistance." This applies to qualified health plan offers of "metal levels" of coverage and implementation of reduced cost-sharing assistance to eligible low-income persons. Delta Dental submitted comments on Actuarial Value guidance in May.

State Waivers
On February 27, 2012, HHS and the Treasury issued a final rule, effective 2017, establishing a procedural framework for states to submit applications for "innovation waivers" for requirements relating to qualified health plans and employee health benefits, Exchanges, and individual and employer mandates.

January

Transaction Standards
On January 10, 2012, the Department of Health and Human Services (HHS) issued an interim final rule for administrative simplification standards for electronic funds transfers and remittance advice. This rule applies to group and individual health plans and includes "excepted benefits" coverage that pays the cost of medical care.