Patient Protection, Preventive Care, and Pre-existing Conditions

Patient Protection, Preventive Care, and Pre-existing Conditions

In this week's Health Insurance Reform Update, we're sharing new information about three provisions: "patient protection" regulations, new preventive care regulations, and high risk pools ("pre-existing condition insurance plans"). While there's a lot of information to digest, we're working hard to make sure you and your clients get the most from the law.

Patient Protection Provisions
The Department of Health and Human Services (HHS), the Department of Labor, and the Department of the Treasury filed a 4-part interim final rule (IFR) on June 23, 2010 that provides further detail on requirements related to pre-existing condition exclusions for kids, lifetime and annual limits, rescission, and other "patient protections". Below is an overview of key points:

Pre-existing conditions
The recently enacted health care reform legislation prohibits health plans from using pre-existing conditions to deny health care coverage to an individual beginning in January 2014. Under the IFR, the Department of Health and Human Services requires health plans to implement this provision for children under the age of 19, beginning with plan years on or after September 23, 2010.

Annual limits
The new legislation also prohibits contracts from having lifetime limits and limits a health insurer's ability to have annual limits on "essential health benefits" (which have yet to be completely defined). Regardless of whether the plan is grandfathered, our plans will no longer include lifetime dollar limits for plan years beginning on or after September 23, 2010. We will also be removing certain annual limits. While we continue to wait on additional guidance from HHS that will further define "essential health benefits", we are making a good faith effort to comply with the regulation prohibiting annual limits on these benefits.

Rescission
Rescission is now limited to fraud or intentional misrepresentation of material fact. Based on the recent IFR, a health insurer may only terminate a member's coverage in the event of a mistake in eligibility (without fraud or misrepresentation) prospectively, not retroactively. We were the first health insurer to implement the rescission provision, implementing federal legislation regarding individual market rescissions effective May 1. This was well ahead of the effective date contained in the legislation, building on our leadership in the early implementation of reform legislation.

"Patient Protections"
The legislation also contains a number of other provisions that the Administration is calling "patient protections." This group of provisions includes:

• Primary care physicians - For plans that require a primary care physician, allowing all members to choose any available in-network provider as their primary care doctor, including a participating pediatrician for children
• OB-GYN providers - Allows individuals to seek care from an in-network OB-GYN provider without requiring pre-authorization or referral from a primary care physician
• Emergency room services - Emergency room services protection including no pre-authorization for emergency services and limited cost-sharing for out of network services

Resource: EasyToInsureME http://www.easytoinsureme.com/health-insurance-quotes.html