Skip to main content

Healthcare Reform Information

PATIENT PROTECTION AND AFFORDABLE CARE ACT

What is the Patient Protection and Affordable Care Act?

The Patient Protection and Affordable Care Act (commonly referred to as “health care reform” or the “Affordable Care Act”) was signed into law by the President on March 23, 2010. This important legislation will change the delivery and financing of health care over time—and will ultimately result in numerous changes to every American’s health coverage.

The Affordable Care Act requires most legal U.S. residents to obtain health insurance by 2014 and it will provide government subsidies to help lower-income individuals do so through state health insurance exchanges that will be created.

Some of the changes brought about by this new law took effect in 2010 and most of the law’s effects will be felt by 2014. MMBB is committed to helping you understand the new health care reform legislation and how it will impact you and your family.

MAJOR PROVISIONS OF THE AFFORDABLE CARE ACT THAT WENT INTO EFFECT JANUARY 1, 2011

The following changes became effective on January 1, 2011:

  • Restricted annual and no lifetime dollar limits with respect to “essential health benefits”
  • Limitation on cancellation of coverage of plan participants (rescission)
  • No pre-existing condition limitations for enrollees under 19 years old
  • Coverage for adult dependent children up to age 26
  • No cost sharing for certain medical preventive care services

Restricted Annual and no Lifetime Dollar Limits on “Essential Health Benefits”

Lifetime dollar limits on essential health benefits (defined below) are prohibited. In addition, annual limits on spending for “essential health benefits” will only be allowed through December 31, 2013. Beginning January 1, 2014, annual limits on essential health benefits will be prohibited. The PremierHealth plan does not have an annual limit. The plan’s lifetime maximum only applies to out-of-network benefits and was removed effective January 1, 2011.

The ban on lifetime and annual limits applies only to “essential health benefits.” The Secretary of Health and Human Services will define “essential health benefits,” but we expect these services are likely to be considered “essential health benefits”:

  • Durable Medical Equipment
  • Emergency Services
  • External Prosthetic Devices
  • Home Health Care
  • Hospice
  • Mental Health and Substance Abuse
  • Organ Transplant
  • Ostomy Supplies
  • Outpatient Rehabilitation
  • Pharmacy Benefits (Standard Drug List)
  • Preventive Services

Limitation on Cancellation of Coverage (Rescission)

Coverage cannot be cancelled for any reason, unless it is found that you have committed fraud or misrepresentation in obtaining this coverage. While this represents a huge change in the law, this change will not affect you—our members—as we have been in the vanguard of health care plans by not engaging in this practice.

Removal of Pre-Existing Condition Limitations for Enrollees Under 19 Years Old

Plans cannot deny coverage or limit eligibility for individuals under the age of 19 based upon a pre-existing condition of any kind. Under our plan, if an enrollee was not previously insured in a health plan for at least 12 months and had more than a 63-day lapse in coverage between the prior plan and PremierHealth, pre-existing condition limits would apply. These requirements do not apply to dependents under the age of 19 as of January 1, 2011.

Coverage for Adult Dependent Children

As of January 1, 2011, our health plan now extends coverage to your adult children, up to age 26.

Important information for you to know

  • Dependent coverage does not extend to your adult child’s spouse or your grandchildren (or any child of an adult child dependent).
  • Future enrollment materials may ask the health plan status of any adult children you may have for government reporting purposes.

The dependent children extension does apply to our dental coverage as well.

No Cost Sharing for Certain Medical Preventive Care Services

Certain medical preventive services that have strong scientific evidence of their health benefits must be covered at 100% (no co-payments, coinsurance or deductible). Generally, the following services may be included:

  • Evidence-based preventive services (from the current recommendations of the United States Preventive Services)
    • Breast cancer and cervical cancer screenings
    • Colon cancer screenings
    • Screening for iron deficiency anemia during pregnancy
    • Screenings for diabetes, high cholesterol and high blood pressure
  • Routine vaccinations
  • Prevention for children
    • Regular pediatrician visits
    • Vision and hearing screening
    • Developmental assessments
    • Immunizations
    • Screening and counseling to address obesity
  • Certain preventive care measures for women

MAJOR PROVISIONS OF THE ACT THAT GO INTO EFFECT IN 2014

Additional provisions of the Affordable Care Act that will become effective on January 1, 2014 include the following:

Health plans will be banned from imposing:

  • An enrollment waiting period that exceeds 90 days
  • Any pre-existing condition exclusions on covered individuals of any age
  • Annual dollar limits on essential benefits

Automatic Enrollment (for employers with more than 200 employees)

Employers will be required to automatically enroll new full-time employees in their health plan, and the opportunity to opt out if they furnish evidence of health care coverage from another source (such as their spouse’s employer) must be provided.

Individual Mandate

U.S. citizens and legal residents will be required by the government to maintain “minimum essential coverage.” This is called the “Individual Mandate” and failure to maintain coverage for the entire year will result in a penalty or tax to the individual.

Definition of Minimum Essential Coverage

Minimum essential coverage includes:

  • Eligible employer-sponsored coverage
  • Individual health plans
  • Grandfathered health plans
  • Medicare Part A
  • Medicaid
  • CHIP (Children’s Health Insurance Program)
  • TRICARE (Government program for active troops, military retirees and their families)
  • VA
  • Other coverage as may be designated by the Department of Health and Human Services

Exceptions to the “individual mandate” will include:

  • Native Americans
  • Individuals who qualify for a religious exemption (religious groups opposed to accepting insurance benefits that pay for medical care)
  • Individuals not lawfully present in the United States
  • Incarcerated individuals
  • Those who cannot afford coverage (required contributions toward coverage exceed 8% of house-hold income)
  • Taxpayers with income under 100% of the poverty level
  • Those who have received a hardship waiver
  • Those who were not covered for a period of less than three months during the year

NOTICE: This document is for general information purposes only. While we have attempted to provide current and accurate information, this information is provided “as is” and MMBB makes no representation or warranties regarding its accuracy or completeness. The information provided should not be construed as legal or tax advice or as a recommendation of any kind.