Patient’s Protection and Affordable Care Act Mandates

What changes went into effect for policies beginning or renewing after

September 23, 2010

Warning

Although most health insurance plans aresubject to the new mandates there are still some that are not. To avoid embarrassment

and fiscal frustration, read your policy in its entirety before you start insisting on your rights.

Adult Children to Age 26Most health insurance plans implemented this change earlier in the year but those that did not are required to cover all adult children until they are age 26

Keep in mind, this provision does not begin until your plan renews after September 23. That may not be until January 1, 2011 if you are on a group plan.

Also, be advised that if your child has a bona fide offer of health insurance from their employer they may not be able to stay on your plan, even if it is less expensive.

No Preventive Care Co-PaysDoctors are not allowed to collect a co-pay from you for preventive care if you have certain types of health insurance. They are to bill 100% of their fee directly to your health insurance company.

No Preventive Care DeductiblesHospitals , labs and imaging centers are not allowed to charge a deductible before providing certain preventive testing, like mammograms for women over 50 and colonoscopies for men over 50.

Guaranteed Issue for JuvenilesChildren under the age of 19 are guaranteed to be approved for health insurance if they apply, regardless of any pre-existing health issues.

No RescissionHealth insurance companies are not allowed to cancel a policy unless they can prove it was obtained by fraud.

Direct Access To PhysiciansInsurance companies cannot dictate what doctor you see provided the doctor you elect is willing to grant you an appointment

No “Out of Network” Emergency Room PaymentsIf you elect to use an Emergency Room and it is a true emergency, insurance companies are no longer allowed to charge you more for using a hospital that is not contracted with them than they would one that has agreed to a payment schedule.

Begin Annual Limit Phase OutThis is one of the most confusing parts of the bill. Annual limits are not eliminated immediately. They are phased out over a couple of year.

For the next year insurance companies may limit benefits in a year to $750,000.

The following year the limit is raised to $1,250,000.

The following year the limit is raised to $2,000,000.

No Lifetime LimitsAlthough some plans may still have annual limits, new plans or plans renewing after September, 23, 2010 are not allowed to have any lifetime limits.

Assuming your plan is based on a calendar year, it is possible for an individual to use up their annual benefit prior to December 31 but they will begin again on January 1.

These next 3 elements of the PPACA were implemented

earlier in 2010

High Risk PoolsMany state already had a high risk pool with more generous benefits than what was offered by HHS.

Those that did not or were unwilling to set up such a plan were required to opt in to the federal program for people who have pre-existing medical issues and have gone without health insurance for at least 6 months.

Early RetireesEarlier this year a series of grants were made available through HHS to reimburse select employers for some of the cost of health insurance for people over the age of 50 who have retired buy are not eligible for Medicare.

Small Business Tax CreditsMany employers with fewer than 25 employees may be eligible for partial tax credits for their costs in offering group health insurance.

Be advised the qualifications for the tax credit are rather complex. Small business owners should seek guidance from a tax expert before assuming they will participate in the tax credit.