Anthem Blue Cross Guidelines for Children under 19
Eligible dependents under age 19 that apply to an existing medical insurance policy that was issued after March 23, 2010 (Non-Grandfathered plan), with a primary subscriber over the age of 19, will be medically underwritten for purposes of assigning an appropriate rating tier only. No pre-existing condition exclusions will apply. When applying for a new policy, if every parent/guardian/primary subscriber over the age of 19 is declined coverage, then the dependent under age 19 will also be ineligible for coverage.
Dependents under the age of 19 that are being added to an existing policy that was in effect March 23, 2010 (Grandfathered plan), will be subject to medical underwriting and either assigned an appropriate rating tier or determined not eligible for coverage.
Health Net Guidelines For Children Under 19
Health Net has just announced that they are establishing an Open Enrollment period for children under 19.
However, because state and federal regulations and procedures aren't clarified, they will not be accepting applications for children under the age of 19 until their Open Enrollment period begins. When Open Enrollment begins, they will begin accepting applications for children under family plans. Applications for children's coverage that have already been submitted, and which have not been approved by September 22, 2010, will no longer be considered.
This change will not affect children that are currently enrolled in child-only plans, in employer sponsored plans, or in a family plan with their parents. In addition, children who meet the requirements for guaranteed issue coverage who are "federally eligible" won't be affected. Also, the addition of newborns and/or adopted children to existing family plans that include child dependent coverage won't be affected.
Health Net is continuing to receive applications for family medical insurance plan coverage for dependents aged 19-26.
Anthem Blue Cross has reviewed the healthcare reform provision regarding limiting the medical insurance application of children under the age of 19 with pre-existing conditions and has decided to suspend all child-only applications as of September 23, 2010.
Because some medical insurance companies decided early on to suspend child-only applications, Anthem Blue Cross has stated that it has created an unfair competitive environment. That reason, and the lack of an effective mandate for people to get medical coverage, and the ongoing uncertainty in the market have been cited as the reasons why they have made this decision.
This decision that they have made does not have an impact on any child-only plans that are currently in existence. Also, they will continue to accept children under the age of 19 on family medical plans as long as the primary subscriber is at least 19 years old.
This suspension will apply to all US states, except where a state has a requirement to offer child-only policies. Therefore, child-only plans will continue to be offered in New York and Maine, and also Virginia and Ohio, where they offer open enrollment periods. Also, child only plans will continue to be offered in states where they require a child-only policy for HIPAA eligible children, or if the state requires a conversion plan.
Aetna has suspended sales of their individual child-only plans in the following states effective October 1, 2010:
In addition, the following states will suspend their Aetna individual child-only plans on November 1, 2010:
Aetna has stated that this change was necessary in order to position themselves to handle the changes that will be occurring due to healthcare reform. In addition, according to Aetna, the new rules that require insurers to provide coverage for dependents under the age of 19 without any corresponding coverage requirement could have possibly raised premiums substantially, making their medical insurance coverage unaffordable.
It is important to note that children that have existing policies with Aetna won't be impacted by this decision, and their plans are renewable.
One of the changes allowed within the newly enacted Patient Protection and Affordable Care Act (PPACA) is the ability of employers to introduce limited changes to the health plan they offer their employees. This is known as “grandfathering” the plan.
Only certain changes are allowed under “grandfathering”:
- Holders of a grandfathered plan can add family members
- An employer holding a grandfathered plan can add new employees
- Coverage of persons enrolled on March 23, 2010 can be removed
- Adjustments can be made as needed in order to conform to the new laws
- Employer contributions can be decreased (within certain limits based on the cost of coverage or formula)
A “grandfathered” plan is essentially the same health care insurance package offered by the employer as of March 30, 2010, but with a few changes as specified in the PPACA or as allowed by state or federal law.
Some enhancements are required per the PPACA, and do not need a plan to be “grandfathered” to implement them. The changes should be in place on or before September 23, 2010:
- Members can add dependents aged 26 years and below, regardless of student status
- Pre-existing exclusions for members aged 19 years and below are now removed
- Annual limits on policies can now be adjusted (within the specifications of the PPACA)
- In-network preventive care coverage is now offered 100%
Non-grandfathered plans will now also include some additional benefits:
- In-network preventive services will be offered at totally no cost to the plan holder (100%, no cost-sharing)
- Clinical trials for life-threatening diseases will be covered (subject to the plan’s benefit and out-of-network provider limits)
- Emergency services without prior authorization will be covered with the same cost share as in network
- A pediatrician can now be named as a child’s primary health care provider and women no longer need authorization to visit an OB-GYN
- Health care plan benefits should not depend on salary or company position.
With regards to group policies, certain annual limits can be adjusted under the new laws.
By the year 2019, the total amount spent on healthcare will consume about 20% of the entire economy because of the huge numbers of Americans that will obtain medical insurance because of the new healthcare reform law.
However, money saved because of healthcare reform will be offset by the cost of offering medical insurance to many more people. Therefore, America's healthcare costs is not projected to be much greater than it would've been without reform.
By the year 2019, almost 93% of America is expected to have medical insurance, compared to roughly 84% currently. Without healthcare reform, that percentage would have dipped to 83% within the next 10 years.
By offering coverage to 32.5 million Americans that are currently not insured, it is hoped that hospitals, doctors and other medical professionals will not shift the medical costs of caring for the uninsured onto those with insurance.
It is also estimated that medical care spending will almost double for the uninsured, since many will get the medical care they've been doing without.
To pay for this expansion of coverage, there will be a series of new taxes and fees and reductions in Medicare payments to private medical insurance companies, medical providers and hospitals.
Before healthcare reform was passed, healthcare costs were expected to be $4.5 trillion in 2019. After healthcare reform was passed, healthcare costs are expected to be $4.6 trillion in 2019.
Healthcare costs are expected to grow by 6.3% annually over the next 10 years, which is much greater than the rate of inflation.
Beginning August 31, 2010, California resident who have difficulty getting approved for medical insurance due to pre-existing conditions can apply for a Pre-Existing Condition Insurance Plan (PCIP).
You can apply by contacting us at 1-877-812-5111, or by downloading the application from the website, pcip.ca.gov. Coverage starts in late September.
Applicants must meet the following criteria:
1. Be a US citizen or resident
2. Must be living in California
3. Has been disapproved for medical insurance within the last 12 months, or has been given a quote for a medical insurance premium that is greater than that of the California Major Risk Medical Insurance Program (MRMIP) preferred provider organization (PPO) product
4. Has no insurance for the last 6 months at the time of application
All applicants should have a Social Security number, and must not have any form of medical insurance, including COBRA, CALCOBRA or Medicare for the last six months at the time of application. PCIP does not provide for dependents, and there are no pre-existing condition exclusions to deal with.
PCIP is implemented in parallel with MRMIP, and it is possible to be eligible for MRMIP but not PCIP (and vice versa). The two programs have different requirements for applicants, as well as different insurance plans in terms of benefits and premium cost structure.
People applying for PCIP should fill up two forms, the PCIP Supplemental Application and MRMIP Application, since applicants are assessed for eligibility for both PCIP and MRMIP. This way, people with pre-existing conditions can have more coverage options.
People with PCIP plans pay lower premiums than MRMIP plan holders, but have a higher initial deductible. Their out of pocket limit is the same as MRMIP ($2500). If the policyholder uses brand name drugs, he or she will have to pay a separate deductible. There is no HMO coverage, although PPO coverage is available. There is no annual maximum or lifetime maximum on the backend.
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As a consequence of the Patient Protection and Affordable Care Act, national medical costs are expected to grow 2/10 of 1% quicker per year through the year 2019.
Originally, healthcare reform was meant to decrease costs for medical insurance, but consumers in the U.S. will spend $265 more for medical insurance in 2019. 2019 is when the last stages of the bill will be put in force.
With the new provisions being put into place of healthcare reform, it is expected that national medical expenditures per person will increase from $8,388 this year to $13,652 in the year 2019. That's an increase of $265 more than what was estimated before healthcare reform was passed.
In fact, it is estimated that national medical expenses are 19.6% of the nation's gross domestic product, which is 3/10 of a percent more than without healthcare reform.
One aspect of the healthcare reform bill is that premiums will most likely be increased due to the prohibition of medical insurance companies declining or rating up people because of pre-existing conditions. Right now, the medical insurance market is based just on those individuals that are healthy. In 2014, many sick and unhealthy people will be entered into the healthcare system, which will make costs go up.
The federal mandate which states that all Americans must carry medical insurance in 2014 will certainly increase premiums.
One provision, the "free preventative care" provision, which is set to become effective for new plans this month...really isn't "free". Premiums are rising with this new "free" benefit. Services such as smoking cessation programs, mammograms, pap smears and colonoscopies will be included in new plans effective on September 23, 2010 and later. As a result of this, many insurance companies have filed for rate increases. For example, Health Net was approved to give a 16% rate increase, Anthem Blue Cross was approved to give a 13.5% increase, and Blue Shield is expecting to raise their premiums by 18%. Aetna is awaiting their request for a 19% rate increase.
As new parts of the legislation are being enforced, such as covering dependents up to the age of 26, removing lifetime limits, implementing the pre-existing condition medical insurance plan, it is certain that premiums will continue to rise. It's just a question of its severity and when it will happen.
The cost of individual & family medical insurance is expected to reach 12.8% in 2014, which is 6.1% more than what was estimated before healthcare reform was approved. This is due to the fact that about 16 million new individuals will be signing up for medical insurance through the state medical insurance exchanges.
Medicaid will grow for all people under 65 in homes with household incomes up to 138% of the federal poverty level. The state exchanges will be created to serve a new individual and small businesses market. When Medicaid grows, so will medical insurance premiums.
There's currently about 50 million individuals on Medicaid. When the enrollment in Medicaid goes up, so do your taxes and your private medical insurance premiums.
A study that was just recently printed in the Archives of Internal Medicine stated that the only data that's available to consumers for judging a doctor's quality of medical care just isn't enough.
The University of Pittsburgh, the Rand Corp., and researchers at the New York based Commonwealth Fund utilized 124 indicators from Rand's Quality Assessment Tools system to figure out if there's any correlation between a doctor's characteristics and their performance.
Many times, the only data that a consumer has access to is the name of the medical school that they went to, the number of years they've had as experience, and how many malpractice claims they have had. These few available indicators are not sufficient in determining the quality of medical care that a doctor provides.
Often, the published information isn't even relevant, and at times can be misleading.
Dr. Anne-Marie Audet of the New York based Commonwealth Fund, said that standards need to be raised for data about how successful physicians are at delivering medical care. She also said that patients need to be able to access relevant and accurate data that provides a snapshot of how doctors deliver medical care based on quality measures that are clinically based.
Beginning on September 23, 2010, consumers will begin noticing several changes to medical insurance plans, due to certain provisions of the Patient Protection and Affordable Care Act that are scheduled to become effective.
Medical plans do not have to comply with the provisions until the member's next yearly renewal on or after September 23, 2010...so many people will see their plans change at their renewal time.
Here are some of the changes they will see:
- Elimination of Lifetime Caps
- Young adults can be covered up until their 26th Birthday on parents' plans (unless child has been offered medical coverage through their own employer), at the same price as dependents under the age of 19.
- Prohibiting coverage exclusions for kids with medical pre-existing conditions
- Yearly Dollar Coverage Limits Restricted
Because of these changes, it is expected that employers will begin shifting more of the medical premiums cost to the employee. More than 50% of employers are planning on increasing the price of family coverage disproportionately compared to the increased price for employees only.
Also, companies plan on verifying with employees that their dependents are actually eligible for medical insurance. For example, if there's been a divorce in a family, those children may not live with the parent whose employer is sponsoring the medical coverage, or be financially dependent on them. Therefore, that would possibly make them not eligible for employer sponsored coverage. According to Hewitt Associates, a human resources consultancy, at least 40% of dependents that are not eligible are under the age of 19.
Group and Individual medical plans can no longer decline coverage for a child under the age of 19 because of medical pre-existing conditions. But there is a loophole in this new provision. If a child with a pre-existing condition stays on his or her parents' plan until their 26th birthday, and then applies for their own plan, they can be declined for medical coverage because of a pre-existing condition. The ban on declining coverage for those aged 19 and older doesn't kick in until 2014.
Group and Individual medical plans will no longer be able to put a limit of $750,000 or less on annual coverage for drugs, newborn care, maternity care, emergency services or hospital services. These maximum limits are scheduled to be increased each year, until they're fully eliminated on January 1, 2014.
New plans that are issued on or after September 23, 2010 will include the following new requirements:
- Preventative care covered at 100% (preventative care as defined by the U.S. Preventative Services Task Force)
- Allowing women to go to their OB/GYN without a referral.
Not making plan members pay a higher copay or a higher coinsurance for emergency services that are performed out of network.
The National Business Group on Health reported that last month, its group largely believed that they anticipate medical insurance costs to go up by at least 7 percent in 2010. 63% of businesses who replied in the survey said that they intended to raise the amount that their workers would have to pay towards their medical insurance premiums. There were 72 employers with over 5,000 workers that responded to this survey, all of which offer medical insurance to their employees via a medical insurance administrator.