Health Care Reform Update: Major provisions into effect this week

Health Care Reform Update: Major provisions into effect this week

On Thursday, September 23, 2010 the first round of Health care reform provisions of the Patient Protection and Affordable Care Act went into effect. Among such the provisions are the following:

Adult Children Coverage up to age 26: All plans must cover dependent children up to the age of 26. This is regardless of the dependent's marital status, financial dependence, student status, or employment status. Grandfathered plans do not have to cover dependents that are eligible for employer coverage other than through their parents.

Ban on lifetime and annual benefits: Lifetime or annual benefit limits cannot be imposed by group health plans.

Ban on rescissions of health coverage. Health insurance issuers may not rescind an enrollee's health coverage (in either the group or individual market). The exception to this provision is if an individual has engaged in fraud or has deliberately misrepresented facts which are prohibited under the terms of the plan.

100 percent coverage of preventive care services to be provided: All plans (except grandfathered plans) are required to cover preventive services and immunizations that are recommended by the U.S. Preventive Services Task Force and the Centers for Disease Control (CDC). Check with your insurance broker or your health insurance provider to determine what services are covered without cost share per your specific plan.

Health Insurers to Develop Standards for Benefits: The Department of Health and Human Services (HHS) has been ordered to develop standards for group health plans and health insurers to provide a summary of benefits and explanation of coverage. The summaries are to incorporate standardized and consistent definitions of insurance and medical terms that use straightforward and easy to understand language. Cost-sharing, exceptions, reductions, and limitations on coverage are some of the topics that must be reviewed in the summary. (Note: The HHS has two years to publish regulations that provide criteria for health provider reimbursement structure. Within 180 days of the publication of regulations, the Government Accountability Office must submit a report to Congress reviewing the impact of the requirements on the quality and cost of care.)

Health Insurers required to maintain minimum loss ratios: Insurers offering group and/ or individual health insurance are now required to annually report on the percentage of health premiums used for claims reimbursement and maintain a determined minimum medical loss ratios. If the insurer does not maintain the minimum, rebates must in turn be provided to the health plan participants.

Insured health plan compliance with nondiscrimination rules: Insured group health plans (except grandfathered plans) must comply with existing nondiscrimination rules for self-funded plans. These include rules for eligibility and benefits.

Implementing effective claims appeals and grievance processes: Health insurers and group health plans must implement an effective process for appeals of coverage determinations and claims, including an internal and external claims appeal process and employee notification. Grandfathered plans are not required to meet these requirements. In guidance issued September 20, 2010, the Department of Health and Humans Services granted a grace period until July 1, 2011 for the implementation of changes to urgent care claim turnaround times, EOBs and language requirements for notices.

Expanding Enrollee's choice of health care professionals: Health insurance plans must allow enrollees to select any participating primary care provider available, including a pediatrician for children, and to cover emergency services provided at a hospital emergency department regardless of the hospital's participation in the plan preferred provider network and without prior authorization requirements. Plans must allow females to access Ob/Gyns without a referral or preauthorization from another health care provider or pediatricians to be named as a child's primary care provider.

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