• 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
  

• For plan years that begin:
  
• 9/23/2010 - 9/22/2011, the annual limit is $750,000
  
• 9/23/2011 - 9/22/2012, the annual limit is $1,250,000
  
• 9/23/2012 - 12/31/2013, the annual limit is $2,000,000
  
• 1/1/2014, annual limits on essential benefits are no longer allowed
  
• Annual limits must apply to each individual (not each family)
  
• Annual limits may take into account only essential benefits
  

• Ambulatory patient services
  
• Emergency services
  
• Hospitalization
  
• Maternity and newborn care
  
• Mental health and substance use disorder services, including behavioral health treatment
  
• Prescription drugs
  
• Rehabilitative and habilitative services and devices
  
• Laboratory services
  
• Preventive and wellness services and chronic disease management
  
• Pediatric services, including oral and vision care
  

• 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.
  

• 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.
  

• 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.
  

• 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.
  

• 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.


TAX TREATMENT of OTC DRUGS
Applies to: grandfathered and non-grandfathered plans

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.


GRANDFATHERED STATUS

Under the health reform legislation, groups who like the health plan they have can keep it.
This is called "grandfathered status." Grandfathered health plans do not have to follow
some reform provisions including those requiring: