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The Beginning of the Reform PDF Print E-mail
Thursday, 23 September 2010 13:15


The long awaited and much anticipated reforms start NOW


Key provisions go into effect 6 months after the healthcare bill was signed into law


  • Dependent Children up to Age 26

- All new plans will have to cover dependent age children up to age 26

- Most of us who get our insurance from our employers will not see this go into effect until the new plan year on January 1

- Grandfathered plans do not have to offer this coverage if the dependent child is offered insurance through their own employer – applies to everyone else (in 2014 – it applies to everyone)

- Married and financially independent children are eligible but not their families

- Dependent children with pre-existing conditions will continue to face the current restrictions on signing up – i.e. waiting periods/being denied – varies by state

- Costs for this will vary by employer/insurance group


  • Children no longer denied insurance because of pre-existing conditions

- While slightly confusing with dependent children coverage up to age 26, the new rules Eliminate pre-existing condition exclusions from group health plans for children under the age 19

- In 2014, all exclusions for pre existing conditions go away for adults


  • Plans will no longer be able to drop you when you get sick

- Rescission is the practice of canceling coverage after you submit medical claims for an illness

- Rescission would still be permitted if an individual committed fraud or made an intentional misrepresentation on their application


  • Free Preventative Care

- Elimination of all co-payments, co-insurance and deductibles for preventative services

- Mammograms, colonoscopies

- Does not apply to grandfathered plans

- Remember, you still pay for your insurance you just don’t pay for these services if you have insurance


  • Elimination of Lifetime limits on health insurance

- Many, if not all plans, have lifetime limits on the amount they will pay out if you get sick.  For many of us, that number is 1M to 2M

- Far less common - Annual limits will be eliminated by 2014 – starting September 23, if your plan has an annual limit, the minimum level of coverage will be 750K – this amount increases by 2014 when it is then eliminated


  • Unrestricted Doctor Choice

- Pediatricians and obstetricians/gynecologists are now given primary care physician status

- If your insurance plan requires you to see a “gatekeeper” before going to a specialist, these doctors now qualify and no referral is necessary

- Does not apply to grandfathered plans


  • One of my favorites, level charges for emergency room visits – this applies to all of us who have gone to the emergency room of an IN NETWORK hospital only to find out the doctor who sees you is out of network

- Health plans must cover emergency services without requiring pre-authorization

- For out of network services, insurance companies MUST reimburse the doctor the greater of

- The median in-network rate, the usual and customary rate (using the plan's formula), Medicare rate

- Does not apply to grandfathered plans

- You can still be balanced billed for the difference


  • Patient friendly appeals process – if you are tired of fighting with your insurance company over whether a service should be covered, you will like this one:

- Insurance plans have to establish a new internal and external appeals process for paying claims

- When an insured member complains that a claim was denied inappropriately, the insurance company must continue to pay all insurance claims, including those related to the episode that caused the denial, while the appeal is under way.  The actual denied claim must be responded to within certain time lines but does not get paid until the appeal is complete

- Does not apply to grandfathered plans


  • Grandfathered Plans:

- If you like your insurance you can keep it – under healthcare reform, large employer plans were exempted from some of the immediate benefits being mandated

- An employer sponsored insurance plan loses its exempt status (and has to apply with the above) if they shift new and/or additional costs onto the employees

- Increases in co-pays/deductibles by inflation plus 15% or an increase in the % covered for medical services

- Elimination of a covered service

- Employer reduces their contribution towards a premium by more than 5%, and other rules

- The government expects most grandfathered plans to lose their exempt status by 2018

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Last Updated on Thursday, 18 November 2010 20:06