Resources
September 23, 2010
Updated: September 27, 2010 Posted: September 27, 2010
The Affordable Care Act will eventually bring about many changes, but it’s important to remember that those changes will not occur all at once. They will be phased in over the next decade.
This issue outlines healthcare reform changes effective for new health plans (both group and individual) and for existing health plans as they renew after September 23, 2010.
Dependent Age Limit Extension
Dependents will be able to stay on their parents’ health plan to age 26. There will be a special enrollment opportunity for children under 26 who previously lost their coverage or were not eligible for coverage because of the age limit.
Preventive Care Coverage
Certain preventive services will not be subject to copayments, coinsurance, or deductibles. The services include those with a rating of A or B from the US Preventive Services Task Force; immunizations recommended by the CDC; and specific services for infants, children, adolescents, and women. You’ll find a list of all recommended preventive care services at Healthcare.gov.
Lifetime Maximum Limits
Lifetime maximum dollar limits are eliminated on “essential benefits.” Clarification is still needed for the definition of “essential benefits.” However, some carriers have decided to remove the overall lifetime maximum benefit limit from all group and individual policies as they renew on or after September 23, 2010.
Annual Maximum Limits
Annual maximum dollar limits for “essential benefits” may not be unreasonable. Carriers are awaiting clarification of the term “essential benefits.”
Pre-existing Condition Exclusions
Exclusions for pre-existing conditions are eliminated for those under 19. Prior to now, we based pre-existing credit on whether the person had prior coverage, what kind of coverage they had, how many months they had coverage, and whether or not there was more than a 63-day gap in coverage. Claims for conditions that qualified as pre-existing were not paid during the pre-existing condition qualification period.
The plan must immediately cover treatment for pre-existing conditions otherwise covered by the plan. With the new legislation, group plans can no longer require children to wait up to six months before the plans cover pre-existing conditions.
Obstetrical and Gynecological Care
Obstetrical and gynecological care is available without authorization or referrals. Members can seek care from in-network OB/GYNs without any preauthorization or referral from their health plan. The law states that preauthorization may be required for treatment of a particular condition as long as the requirement does not restrict access to a participating provider specializing in obstetrics or gynecology.
Prohibition on Recissions
Health plans may not rescind policies unless there was fraud or intentional misrepresentation of a material fact.
Advance Notice of Cancellation
Health plans must provide advance notice to enrollees before canceling coverage.*
Internal Claims & Appeal Process*
Health plans must have an internal claims appeal process and an external review process.
More Information
You’ll find more information, FAQs, and links to online resource on our Healthcare Reform Resource Center. Please note that some of the provisions listed above are grouped together under the heading “Patient’s Bill of Rights.”
*Please see Featured Article above.
Visual timeline of the implementation of Health Care Reform:
PDF: Health Care Reform Bill Insurance Market Provisions Timeline
