Many people are confused about the recent Health Care Reform changes……what they are and when they take effect. The earliest revisions take place September 23, 2010 and the latest go into effect January 2010. In many cases, current plans in place prior to March 23, 2010 are grandfathered in and are not subject to some of the changes.
There are many details that are still be worked out. We recommend that you work with your current Health Insurance advisor or agent to make sure you are able to take full advantage of any enhancements. Some changes will happen automatically with your carrier, others will take place over time or when you make a plan change.
Whether you have a group or indivdual plan, a good agent or advisor should be reviewing and analyzing the market place each year for the best value or innovative plan designs such as H.S.A., H.R.A., Section 125 plans, etc. that can improve your plan and save you money.
Below is a brief summary of the health care changes being implement.
Health Care Reform Summary:
Extension of dependent coverage (9/23/2010)*
- Health insurance plans must offer coverage to dependents on their parents’ plan until the young adult turns 26.
- Coverage must be the same as for other dependents and can’t cost any more.
Preventive care coverage (9/23/2010)*
All private health plans must cover the costs for preventive care.
There can be no copays, deductibles or out-of-pocket fees for preventive services.
Lifetime and annual limits (phased in by 1/1/2014)*
- Lifetime limits on essential health benefits are no longer allowed.
- Restrictive annual limits on the dollar value of essential health benefits are allowed until 1/1/2014.
- Lifetime and annual limits continue to be allowed for non-essential health benefits.
- Individuals who reached their lifetime limit prior to 9/23/2010 and are still eligible for coverage must be notified that the lifetime limit no longer applies and their coverage can be reinstated
Pre-existing condition exclusions (phase in by 1/1/2014)*
- Children under 19 with pre-existing conditions can’t be denied health insurance.
- A health plan can’t exclude condition-specific benefits because the condition was present before the enrollment date.
- Those age 19 and over with pre-existing conditions can’t be denied coverage in plans renewing on and after 1/1/2014.
Rescission prohibition (9/23/2010)*
- Rescission is cancellation of coverage that has a retroactive effect. For example, if a plan voids a policy back to the policy’s effective date.
- Coverage may still be canceled or not renewed for these reasons: failure to pay premiums, fraud or intentional misrepresentation of material fact, withdrawal of product or issuer from market, movement of individual or group outside of service area, bona fide association coverage, cessation of association membership. This is not considered rescission.
- Plans must provide at least 30-days’ notice when canceling or rescinding coverage.
Emergency services coverage(9/23/10)*
- All health plans must cover emergency care at out-of-network hospitals at the same copay or coinsurance level as in-network hospitals.
- Health plans may no longer require prior authorization or a referral for emergency services.
- Out-of-network providers may balance bill the member for the amount charged that is above a “reasonable amount.” For this reason, it’s smart to seek services from an in-network emergency department when available.
- Services provided by out-of-network providers may also apply to a separate out-of-network deductible and out-of-pocket maximum.
Selection of primary care physician (9/23/2010)*
- Members can choose their own PCP (women can choose an OB/GYN and parents can choose a pediatrician for their children), as long as the doctor is accepting patients.
- If a plan requires a PCP, then it can’t require referral or authorization for a woman to seek care from an in-network OB/GYN specialist.
- The plan must provide a list of member rights with the summary plan description or summary of benefits.
Salary non-discrimination of benefits (9/23/2010)*
- Employers can’t offer better benefits to “highly compensated” employees at the top of the salary schedule.
- Health plans can require lower dollar or premium percent contribution from employees with lower compensation.
- Definition of highly compensated employees follows Section 105 of the Internal Revenue Code.
- Groups that establish simple cafeteria plans are exempt.
Early Retiree Reinsurance Program (ERRP) (expires 1/1/2014)*
- Employers that offer coverage for early retirees can apply to receive money back from the government for medical claims for early retirees who aren’t Medicare-eligible (age 55 to 64) and their spouses, surviving spouses and dependents.
- To be eligible, employers must have or plan to implement programs and procedures to help plan participants with chronic or high-cost conditions save money.
- Employers must use the money to reduce health care costs, lower participants’ premium contributions/copays/deductibles or both.
- Program runs from 6/1/2010 to 1/1/2014, but may end sooner when the program reaches its cap of $5 billion.
Small business tax credit (2010 tax year)*
- Small businesses can receive tax credits from the federal government to help make providing health insurance more affordable.
- Credits are available for an estimated 4 million businesses (including non-profits).
- Maximum credit is 35% for taxable employees and 25% for tax-exempt.
- Eligible employers must:
- Pay at least 50% of the total premium costs
- Employ fewer than 25 full-time equivalent employees
- Pay average annual wages of less than $50,000
Tax treatment of OTC drugs (1/1/2011)*
Beginning 1/1/2011, pre-tax expenses for over-the-counter (OTC) drugs purchased through an HRA, FSA or HSA will require a doctor’s prescription. The sole exception is for insulin which will not require a prescription for reimbursement.
*May not apply to grandfathered plans that are already in place.
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