The next round of provisions in the Patient Protection and Affordable Care Act goes into effect Thursday, Sept. 23. New or expanded options as well as consumer protections for health insurance coverage are included in many of these provisions and could represent major changes to policy options during open enrollment or when renewing an individual health policy, according to the National Association of Insurance Commissioners, Kansas City, Mo.
For those with employer-covered health insurance coverage, the new benefits and protections will be added to their policies on the subsequent renewal date after Sept. 23, the NAIC says. An individual health insurance policy, however, has differing dates. The new provisions for insurers that specified a "policy year" for coverage will become effective on said date. Otherwise, when annual deductibles and annual limits reset each year, the new benefits and protections will be appended. For policies with no annual deductible or limit, these changes will become effective on Jan. 1, 2011.
Grandfathered plans are exempt from most changes required by the PPACA, the NAIC states. However, if the plan's benefits are significantly reduced or deductibles, copayments or an employee's share of premium contributions are raised, the grandfathered status and its exemptions will be lost.
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At the new plan year, all plans may not contain lifetime limits on essential benefits. With the exception of grandfathered individual plans, annual limits will be phased out through 2014, the NAIC says.
The PPACA also bans rescissions, except in cases of fraud or intentional misrepresentation of material fact. Notification must be served prior to the cancellation, and all types of health insurance plans must adhere to this provision, the NAIC cites.
All plan types covering dependent children must extend coverage until the child's 26th birthday, and adult children cannon be charged more than other dependents, the NAIC notes. Group health plans will be required to cover adult children before 2014 only if the adult child is not eligible for employer-sponsored coverage.
Additionally, preventive health services, including immunizations, well baby and child screenings, and well women exams, must be covered without cost sharing under all nongrandfathered plans, the NAIC says. Children under 19 years of age cannot be denied coverage or benefits based on medical status or past illnesses, which applies to all plans, except grandfathered individual plans.
For nongrandfathered plans, consumers are allowed their choice of primary care providers, and emergency services without prior approval, regardless of the provider's network status, must be covered, the NAIC says. Nonparticipating providers must limit cost sharing to the equal amount of a participating provider for emergency services. A female patient is to receive obstetric or gynecological care – as a child is to receive pediatric care – from a participating provider and any authorization is to be treated the same as that of a primary care provider.
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