PROVISION: Fair health insurance premiums
SUMMARY OF PROVISION: Health insurance issuers may not charge discriminatory premium rates. The rate may vary only by whether such plan or coverage covers an individual or family, rating area, actuarial value, age, and tobacco use.
APPLICATION TO GRANDFATHERED PLANS: Not applicable; also does not apply to large group insurance market coverage in states that do not allow such coverage to be offered through the state exchanges.
PROVISION: Guaranteed availability of coverage
SUMMARY OF PROVISION: Not applicable
APPLICATION TO GRANDFATHERED PLANS: Not applicable
PROVISION: Guaranteed renewability of coverage
SUMMARY OF PROVISION: Not applicable
APPLICATION TO GRANDFATHERED PLANS: Not applicable
PROVISION: Prohibition of preexisting condition exclusion or other discrimination based on health status
SUMMARY OF PROVISION: Group health plans and health insurance issuers offering group or individual coverage may not impose a preexisting condition exclusion or discriminate based on health status.
APPLICATION TO GRANDFATHERED PLANS: Applicable to grandfathered group health plans and group health insurance coverage. Not applicable to grandfathered individual health insurance coverage.
PROVISION: Prohibiting discrimination against individual participants and beneficiaries based on health status
SUMMARY OF PROVISION: Retains the HIPAA nondiscrimination provisions for group health plans and group health insurance issuers. Specifically, plans and group health insurance issuers may not set eligibility rules based on factors such as health status and evidence of insurability - including acts of domestic violence or disability. Provides limits on the ability of plans and issuers to vary premiums and contributions based on health status. The Affordable Care Act adds new provisions regarding wellness programs and extends all the nondiscrimination protections to the individual market.
APPLICATION TO GRANDFATHERED PLANS: The HIPAA nondiscrimination provisions are applicable to grandfathered group health plans and group health insurance issuers. The new Affordable Care Act extensions are not applicable to grandfathered group health plans and group health insurance coverage. Not applicable to grandfathered individual health insurance coverage.
PROVISION: Nondiscrimination in health care
SUMMARY OF PROVISION: Not applicable
APPLICATION TO GRANDFATHERED PLANS: Not applicable
PROVISION: Comprehensive health insurance coverage
SUMMARY OF PROVISION: Not applicable
APPLICATION TO GRANDFATHERED PLANS: Not applicable
PROVISION: Prohibition on excessive waiting periods
SUMMARY OF PROVISION: Prohibits any waiting periods that exceed 90 days for group health plans and group health insurance coverage.
APPLICATION TO GRANDFATHERED PLANS: Applicable
PROVISION: Coverage for individuals participating in approved clinical trials
SUMMARY OF PROVISION: Not applicable
APPLICATION TO GRANDFATHERED PLANS: Not applicable
PROVISION: No lifetime or annual limits
SUMMARY OF PROVISION: Prohibits group health plans and health insurance issuers offering group or individual health insurance coverage from establishing lifetime limits and annual limits on the dollar value of benefits. Prior to 2014, plans and issuers may establish certain restricted annual limits (as defined in regulations).
APPLICATION TO GRANDFATHERED PLANS: Prohibition on lifetime limits: Applicable; Prohibition and limits on annual limits: Applicable to grandfathered group health plans and group health insurance coverage; not applicable for grandfathered individual health insurance coverage.
PROVISION: Prohibition on rescissions
SUMMARY OF PROVISION: Group health plans and health insurance issuers may not rescind health coverage after coverage begins except in the case of fraud or intentional misrepresentation.
APPLICATION TO GRANDFATHERED PLANS: Applicable
PROVISION: Coverage of preventive health
SUMMARY OF PROVISION: Not applicable
APPLICATION TO GRANDFATHERED PLANS: Not applicable
PROVISION: Extension of dependent coverage
SUMMARY OF PROVISION: Group health plans and health insurance issuers offering group or individual health insurance overage that provide dependent coverage must continue to make such coverage available to children until age 26.
APPLICATION TO GRANDFATHERED PLANS: Applicable
PROVISION: Development and utilization of uniform explanation of coverage documents and standardized definitions
SUMMARY OF PROVISION: Requires the federal government to develop standards for use by group health plans and health insurance issuers in compiling and providing an accurate summary of benefits and explanation of coverage for applicants, policyholders or certificate holders, and enrollees. The explanation of coverage must describe any cost sharing, exceptions, reductions, and limitations on coverage, and give examples to illustrate common benefits scenarios.
APPLICATION TO GRANDFATHERED PLANS: Applicable
PROVISION: Provision of additional information
SUMMARY OF PROVISION: Not applicable
APPLICATION TO GRANDFATHERED PLANS: Not applicable
PROVISION: Prohibition on discrimination in favor of highly-compensated individuals
SUMMARY OF PROVISION: Not applicable
APPLICATION TO GRANDFATHERED PLANS: Not applicable
PROVISION: Ensuring quality of care
SUMMARY OF PROVISION: Not applicable
APPLICATION TO GRANDFATHERED PLANS: Not applicable
PROVISION: Bringing down cost of health care coverage (medical loss ratio provisions)
SUMMARY OF PROVISION: Requires health insurance issuers offering group or individual health insurance coverage to submit annual reports to the federal government on the percentages of premiums that the coverage spends on reimbursement for clinical services and activities that improve health care quality, and to provide rebates to enrollees if this spending does not meet minimum standards for a given plan year.
APPLICATION TO GRANDFATHERED PLANS: Applicable to insured grandfathered plans
PROVISION: Appeals process
SUMMARY OF PROVISION: Not applicable
APPLICATION TO GRANDFATHERED PLANS: Not applicable
PROVISION: Patient protections
SUMMARY OF PROVISION: Not applicable
APPLICATION TO GRANDFATHERED PLANS: Not applicable
