Wellness and Prevention Initiatives

A summary of wellness and prevention initiatives as a result of the Patient Protection and Affordable Care Act (PPACA), as amended by the Health Care and Education Reform Act.Elimination of Co-Payments for Screenings and Preventive Care

Starting in September of 2010, employer-sponsored (and other) group health plans and health insurance issuers are prohibited from requiring co-pays for all preventive services recommended by an independent expert panel, the United States Preventive Services Task Force. Co-pays are also eliminated for certain recommended immunizations, breast cancer screenings and other preventive care/screenings for women and children. However, this requirement does not apply to “grandfathered” health plans, which are defined in PPACA as any plan in which at least one individual was enrolled as of March 23, 2010.

Note: Pay careful attention to the cost-sharing requirements for office visits under this rule.

Employee Wellness Discounts
Starting January 1, 2014, PPACA enhances such wellness discounts by permitting group health plans to give reductions of up to 30 percent of the cost of premiums to employees who participate in such wellness programs. This may be expanded to 50 percent subject to the discretion of the Secretary of Health and Human Services (HHS).

Break Time for Nursing Mothers
Effective immediately, the PPACA also provides that employers covered by the Fair Labor Standards Act must provide reasonable break time and a private space – other than a restroom – for nursing mothers for up to one year after the birth of a child. Employers are not required to compensate employees during such break times. Additionally, employers with less than 50 employees may qualify for exceptions if it can be proven that the requirement would impose an undue hardship on the employer.

Posting of Nutritional Requirements
By March of 2011, the Secretary of HHS must publish regulations requiring all chain restaurants (defined as any establishment that has 20 or more locations operating under the same name) to disclose the nutritional content of all menu items. Specifically, the number of calories for each item must be disclosed on menus, menu boards and drive through menu boards, and such menus must also feature “a succinct statement concerning suggested daily caloric intake.”  This requirement also extends to buffet items, and vending machines maintained by companies that operate 20 or more machines.

Government Funding for Wellness Programs
In addition to the specific provisions outlined above, PPACA also creates a “Prevention and Public Health Fund” which will be administered through HHS and will support prevention and public health programs.  Beginning with the fiscal year 2010, $500 million will be appropriated to various programs within HHS, with the amount of appropriations increasing each year to $2 billion in the fiscal year 2015 and each year thereafter. Under PPACA, the funds are to be used for activities such as prevention research and health screenings, the Community Transformation grant program (designed to fund state and municipal wellness programs by creating walking paths, nutrition awareness programs, etc.), Education and Outreach Campaign for Preventive Benefits (a planned public-private partnership to raise awareness on preventive care), and immunization programs.

Additionally, school-based health centers (facilities that provide primary health care to students on school campuses) will receive $50 million per year in grant funding through 2013. These grant monies are to be used only for expenditures on facilities and equipment, not for hiring personnel.

Small Business Grants for Wellness Programs
The PPACA includes a grant program to assist small businesses in providing comprehensive workplace wellness programs. Grants will be awarded to eligible employers to provide their employees with access to new workplace wellness initiatives. The grants will be awarded beginning in 2011 with $200 million appropriated for a five year period.

An eligible employer is an employer that:

• Employs fewer than 100 employees who work 25 hours or more per week; and
• Did NOT have a workplace wellness program in place as of March 23, 2010 (date of PPACA enactment)

The PPACA requires the Secretary of HHS to develop program criteria that are based on research and best practices. A comprehensive workplace wellness program must be made available to all employees and include:

• Health awareness initiatives (including health education, preventive screenings and health risk assessments)
• Efforts to maximize employee engagement (including mechanisms to encourage employee participation)
• Initiatives to change unhealthy behaviors and lifestyle choices (including counseling, seminars, online programs and self-help materials)
• Supportive environment efforts (including workplace policies to encourage healthy lifestyles, healthy eating, increased physical activity and improved mental health)

Note: The money will likely go quickly. Small businesses need to be prepared with a wellness program which meets the criteria and requirements as described in the PPACA and developed by the Secretary of HHS.

While there are still many unanswered questions regarding the implementation of the above mentioned programs, especially the small business wellness grant funding, adding provisions for wellness and prevention under PPACA is one small step for a healthier workforce.

BCBSTX stopped quoting its current child-only policies on July 30, and the last assigned effective dates for those policies will be September 15, 2010. Any application that has not been approved by September 1, 2010, will be withdrawn from consideration. Once the DOI approves this new policy, BCBSTX will provide information on how to apply for the coverage.

BCBSTX will continue to honor all existing individual policies issued for those under age 19. In addition, those under 19 can request coverage through the carrier’s individual and group policies that include dependent coverage.

For October 1, 2010 and later effective dates, Aetna will discontinue new business sales of child-only policies to applicants (under the age of 19) for Aetna Advantage Plans for Individuals, Families and the Self Employed. No existing policyholder is affected by this action.

Effective immediately, any applications received requesting a child-only policy with a October 1, 2010 effective date (or later) will be closed. Aetna Underwriting will notify applicants by mail of their ineligibility, but also provide options for coverage – see below.

Why is Aetna making this change?

This change positions Aetna for the future so the carrier can effectively handle upcoming changes resulting from healthcare reform. New federal rules require guaranteed issue (GI) of coverage for individuals under the age of 19 and no corresponding coverage requirement. These conditions have the potential to significantly increase the cost of premiums and make coverage unaffordable.

No impact to existing child-only policies

Existing policyholders will not be impacted by this action and they may continue their current coverage. These policies are renewable

States affected

Discontinuation of child-only coverage for the following states AK, AR, AZ, CA, CO, DC, DE, FL, GA, IL, IN, KS, KY, LA, MI, MO, MS, NC, NE, NV, PA, SC, TN, TX, VA, WV, and WY will occur on October 1, 2010. The implementation date for the following states CT, MD, OH, and OK is still being established. Aetna will notify you once dates are confirmed for these states.

Other health insurance options available for individuals under age 19

• Be added as a dependent to a parent's plan.
• If the above option is not a viable solution, applicants can check www.healthcare.gov for alternatives

Aetna continues to explore options with states where the carrier is ceasing the sales of new child-only policies, including reviewing other regulatory changes that may allow them to re-enter this market and provide a valuable product between now and 2014.