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November 20, 2012

With health-care law set, now come the new rules

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"The big one that everyone's watching is more definition around the exchanges," said Chas Roades, chief research officer at the Advisory Board, a Washington consultancy.

The government also has to specify how cost-sharing rules for consumers will work and what types of medical services must be covered in health plans sold in the exchanges. Twenty-six states have already chosen an existing health plan as a benchmark identifying what "essential benefits" their state's insurers must provide. In those states that don't establish a benchmark, the administration is empowered to choose one. Until the government does, insurers say they are hampered in devising what kind of insurance policies to offer.

"Unless such guidance is forthcoming, it will be difficult for health plans to complete product development, fulfill network adequacy requirements, obtain necessary state approvals and reviews, and ensure that their operations, materials, training and customer service teams are fully prepared," Daniel Durham, a vice president for America's Health Insurance Plans, testified before a House subcommittee in September.

Debra Ness, president of the National Partnership for Women and Families, said consumer advocates are concerned that the rules may give insurers too much leeway in deciding how skimpy or rich benefits are within the 10 broad categories of coverage the health law requires. "You can end up with places that have fine prescription drug treatment and really lousy maternity care," she said.

Other insurance regulations are also expected. The government has to clarify new standards for companies that insure their own workers, including what level of coverage is sufficient, how a new tax on premiums included in the health law will be assessed and how wellness programs designed to encourage employees to adopt health behaviors will operate.

Several of these insurance rules appear to be far along in the pipeline and are pending before the White House Office of Management and Budget, the final stage before issuance. The office's Web site shows that three rules — on exchanges, the health insurance market and wellness programs_ were submitted by HHS to the OMB days after the election.

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