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Health Net Discusses Reform Update and Wellness Programs

Apr 18, 2013

Is all of the legislation activity planned for 2014 related only to benefits? What about other  provisions?  How are administrative standards being developed? 

Administrative simplification
. HHS must adopt and regularly update standards and operating rules for the electronic exchange of information for financial and administrative transactions. HHS must also develop standards for use in providing enrollees with benefit summaries and coverage explanations. 

Wellness programs. This provision codifies and enhances provisions of the HIPAA nondiscrimination regulations that allow rewards to be provided to employees for participation in or for meeting certain health status targets related to a wellness program. If certain conditions are met, it also allows health plans to provide a discount or rebate when an individual satisfies a standard related to a health factor.

Quality reporting. HHS must develop annual reporting requirements with respect to plan benefits and health care provider reimbursement structures to improve quality. These reports will be published on a public website.

The “comparative effectiveness” fee

How does Health Net plan to bill for the “comparative effectiveness” fee? Under the ACA, the comparative effectiveness fee funds clinical effectiveness research projects at the Patient-Centered Outcomes Research Institute (PCORI). The fee is assessed against individual and group health insurance policies and self-funded employer group coverage.

The comparative effectiveness fee is imposed for policy and plan years ending after September 30, 2012, and is assessed for each covered life. The fee sunsets for policy and plan years ending after September 1, 2019. The fee will be treated as a tax for federal income tax purposes.

The following types of coverage are exempted from the fee:

The amount of the fee is as follows:

Health Net is building this fee into administrative expenses.

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