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Reform Update: Wellness Programs and Reporting Requirements

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

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:

  • Coverage for exempted benefits (HIPAA “excepted benefits”)
  • Medicare, Medicaid and state Children’s Health Insurance programs
  • Programs for medical care (other than through insurance policies) to members of armed forces and their families ( i.e., TRICARE)
  • Programs under the Indian Health Care Improvement Act

The amount of the fee is as follows:

  • For policy or plan years ending during federal fiscal year 2013 (October 1, 2012, through September 30, 2013): $1 for each covered life.
  • For policy or plan years ending during federal fiscal year 2014 (October 1, 2013, through September 30, 2014): $2 for each covered life.
  • For policy or plan years ending in federal fiscal years after September 30, 2014, the fee is equal to the dollar amount for the preceding fiscal year, multiplied by the percentage increase in the projected per capita amount of National Health Expenditures as most recently published before the beginning of the fiscal year.

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