Throughout June and July of this year, federal agencies have been issuing interim final rules to guide the implementation of key points in the healthcare reform laws signed this spring. On June 23 and July 14, the U.S. Departments of Health and Human Services (HHS), Treasury, and Labor jointly published interim final rules regarding pre-existing conditions and caps on the essential health benefits.
No Pre-Existing Conditions
According to healthcare-legislation experts Andy R. Anderson and Kimberly Boggs, writing in a July 23 Lexology post, new interim final rules assert that, beginning immediately, “group health plans (including grandfathered plans) may not impose a preexisting condition exclusion for any individual under age 19…. For plan years that begin on or after January 1, 2014, plans may not apply a preexisting condition exclusion to any individual, regardless of age.” That is, it will be illegal to either decline coverage to an individual who has a pre-existing condition, such as an amputation or cerebral palsy (CP), or to not provide benefits related to such a condition. Anderson and Boggs emphasized that “any preexisting condition exclusion running at the time the prohibition takes effect is cut short and coverage must be offered immediately.”
No Annual or Lifetime Caps
Within the new rules, group health plans (including grandfathered plans) also may not impose an annual or lifetime limit on the dollar amount of the essential health benefits mandated under those plans. “Rehabilitative and habilitative services and devices” are listed as being essential benefits and, according to the National Association for the Advancement of Orthotics and Prosthetics (NAAOP), should include orthotic and prosthetic care.
Loopholes Remain
These new rules do not prohibit payers from excluding all benefits for a specific condition. Payers will also be allowed to place lifetime or annual caps on benefits that are not on the essential benefits list; however, other state and federal laws may mandate coverage of those conditions instead.
