Posted on Tue, Jul 27, 2010
Here is a list of a few of the provisions that grandfathered medical insurance plans are mandated to comply with. Please note that this is not a complete list.
- Ban on Annual Limits and Lifetime Limits: Beginning with plan years of September 23, 2010 and after, insurers are not allowed to place lifetime limits on essential health benefits. Group medical plans are allowed to place a reasonable yearly limit on essential medical benefits until January 2014. At that point, all group medical plans must get rid of all annual limits.
- Prohibition of Rescissions: Beginning with plan years of September 23, 2010 and after, insurers may not rescind medical insurance coverage after enrolling a member, with the exception of fraud or other limited circumstances.
- Ban on Preexisting Conditions Exclusions: Beginning with plan years of September 23, 2010 and after, insurers cannot decline children under the age of 19 due to preexisting conditions. On January 1, 2014, medical insurers will not be allowed to decline anyone medical coverage due to preexisting conditions.
- Required Coverage for Adult Children: Beginning with plan years of September 23, 2010 and after, insurers that provide dependent coverage are required to cover adult children up to the age of 26 without any conditions of dependency. However, grandfathered health insurance plans may still exclude coverage for adult children with other employment-based coverage available until January 1, 2014.
- Prohibition on Excessive Waiting Periods: Beginning on January 1, 2014, group medical insurance plans cannot impose a waiting period for eligible employees to join an employer plan of no more than 90 days.
Posted on Mon, Jul 26, 2010
While most of Health Care Reform's provisions will go into effect in 2014, there have been some provisions of the Health Care Reform Act that will come into effect this year.
For example, children up to the age of 19 will no longer be declined health insurance beginning with plan years (or a policy year) of September 23, 2010 and later. However, grandfathered individual medical insurance plans are exempt from this provision, but there may be limited exceptions to this exemption. A grandfathered medical plan is a plan that you had in place on March 23, 2010 when the health care reform bill was signed. Grandfathered group health insurance plans are not exempt from this provision.
Another provision is that insurance companies will no longer be allowed to rescind policies unless there is evidence of fraud or intentional misrepresentation of material facts. An insurer will only terminate someone's coverage if it's due to a mistake in eligibility, without any fraud or misrepresentation on the member's part. If the policy is rescinded, the insurance company must notify the member 30 days ahead of the rescission. This provision is applicable to non-grandfathered and grandfathered plans.
Anthem Blue Cross is also making changes to their annual and lifetime dollar limits. They are removing the limits, and will no longer have any annual dollar limits on certain "essential health benefits". The definition of "essential health benefits" has not yet been determined.
Members of Anthem Blue Cross who have already reached their annual or lifetime maximum will be offered a special enrollment time to re-enroll in benefits. Anthem will let their members and terminated members know who are no longer receiving benefits for this reason, so that they can take advantage of the special re-enrollment period. The enrollment period for groups will commence during the group open enrollment at the time of the group's renewal. This provision only applies to pharmacy and medical benefits and does not impact vision or dental coverage.
Anthem Blue Cross will be adopting all patient protection provisions for all of their plans, including grandfathered plans.
For example, for all of Anthem Blue Cross plans that require primary care physicians, including grandfathered plans, Anthem will allow the member to choose any available in-network primary care physician, including participating pediatricians for kids. Also, Anthem will allow individuals to obtain care from an in-network obstetrician/gynecologist without any pre-authorization or a referral. However, pre-authorization for certain obstetrician/gynecologist services will still be allowed.
Another patient protection provision applies to emergency room services. For instance, a pre-authorization will not be required for ER services, in-network or out-of-network. Also, Anthem will be covering out-of-network emergency room services, and the copays and coinsurances for these services cannot be more than those for in-network emergency room services. However, deductibles and out-of-pocket limits will be allowed for out-of-network ER services if it's the same used for other out-of-network benefits.
We will continue to pass along Health Care Reform information as we receive it. Please feel free to call us at 1-877-812-5111 if you have any questions.