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You are here: Home / Blog / Finalized Rules of Section 1557 of the ACA – What People with Disabilities Need to Know About Discriminatory Benefit Design

Finalized Rules of Section 1557 of the ACA – What People with Disabilities Need to Know About Discriminatory Benefit Design

May 16, 2024 by Nuria Piracha

The NDNRC continues to cover landmark changes through a blog series on the finalized rules of Section 1557 of the Affordable Care Act as it relates to people with disabilities. These changes, as mentioned in our previous blog post, have been finalized for the third time since the ACA’s inception in 2010. This rule reinstates and further strengthens the original text that prohibited discrimination based off many intersectional identities, including disability.

This week, we will cover the prohibitions against discriminatory benefit design. The 2024 final rule prohibits discriminatory benefit design and marketing, and health insurers must not “deny or limit coverage of a claim or impose additional cost sharing or other limitations or restrictions on coverage,” “coverage denial or limitation must not be based on unlawful animus or bias or constitute a pretext for discrimination,” or “reasonable medical management” from § 92.207 of the final rule. Health insurers must also evaluate all claims through this section on a case-by-case basis and have a legitimate, nondiscriminatory reason for burden shifting.

Some examples of discriminatory benefit design include excluding certain services from coverage, limiting the number of visits for certain types of providers, establishing narrow networks for providers which does not provide adequate coverage for the insured, strictly defining medical necessity and setting up drug formularies in a discriminatory manner. For instance, with drug formularies insurers have used adverse tiering where all drugs for a specific condition are on a specialty tier with higher cost-sharing. The new final rules would prohibit these types of plan designs.

More information can be found through the National Health Law Program in their Section 1557 section.

Next week, we will cover covered entities and how they relate to people with disabilities, so be sure to continuously check our blog!

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