Health Care Reform Begins Now

The first wave of regulations under the Patient Protection and Affordable Care Act (PPACA) began on September 23, 2010. Regulations promulgated by the Internal Revenue Service, the Department of Labor, and the Department of Health and Human Services require all plans renewing on or after this day to include certain provisions and patient protections. The provisions and patient protections that must be included depend on whether the plan remains grandfathered under the new rules or not.

For all plans, grandfathered or not, the regulations require plans to:

  • Extend dependent coverage to age 26, but only if the child is not eligible to enroll in other employer provided coverage

  • Eliminate pre-existing condition exclusions from group health plans for children under the age 19

  • Eliminate coverage rescissions unless under the circumstance of fraud or intentional misrepresentation

  • Eliminate lifetime and certain annual limits on coverage of essential benefits

For plans that lose grandfathered status under the rules, the regulations require plans to:

  • Follow non-discrimination rules under Section 105(h) (for insured plans, self-funded plans already were subject to these rules)

  • Follow new rules for claims appeals, and internal and external claim review processes

  • Permit women to select an OB-GYN as a PCP

  • Permit the designation of a pediatrician as a PCP for a child

  • Permit anyone to designate their own PCP as long as the PCP is in-network and accepting patients

  • Extend dependent coverage to age 26, regardless of the child’s eligibility to enroll in other employer provided coverage

  • Eliminate cost sharing for preventative care

  • Cover emergency room services without pre-authorization whether the provider is in or out of network, not impose any additional administrative requirements if ER care is received out of network, and not impose out-of-network cost sharing requirements that exceed in-network levels.

Lastly, the regulations require plan administrators to distribute four notices regarding (1) the extension of dependent coverage to age 26, (2) the elimination of lifetime limitations, (3) patient protection changes, and (4) if the plan is a grandfathered plan under PPACA.