Weadock and Associates, LLC Insuring Your Quality of Life

• U.S. Preventive Services Task Force                                                                      (services rated A or B)
  
• Advisory Committee on Immunization Practices  
  
  Health Resources and Services Administration (not yet published)
  

• 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

"Restrictive" Annual Limits

• 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

Note: This list is determined by the Secretary of HHS and is not yet final.

• 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.
  
• Those age 19 and over with pre-existing conditions can't be denied coverage in plans renewing on and after 1/1/2014.
  

• 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.
  
• Plans must provide at least 30-days' notice when canceling or rescinding coverage.
  

• All health plans must cover emergency care at out-of-network hospitals at the same copay or coinsurance level as in-network hospitals.
  
• Health plans may no longer require prior authorization or a referral for emergency services.
  
• Out-of-network providers may balance bill the member for the amount charged that is above a "reasonable amount." For this reason, it's smart to seek services from an in-network emergency department when available.
  
• Services provided by out-of-network providers may also apply to a separate out-of-network deductible and out-of-pocket maximum.

• 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.
  
• The plan must provide a list of member rights with the summary plan description or summary of benefits.
  

• 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.
  
• Groups that establish simple cafeteria plans are exempt.
  

• 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.