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Healthcare Reform Provisions Begin

Janice Simmons, for HealthLeaders Media, September 23, 2010

Lifetime and annual coverage limits:  This will impact those individuals with expensive and ongoing medical treatments. Lifetime limits are banned for all plans; for those who have hit their lifetime limits, they'll be able again to access coverage.

Those plans with annual limits on health benefits coverage will be phased out: Initially, the annual limit will be no less than $750,000, but it will rise to $1.25 million in September 2011 and $2 million in 2012. The annual limits are prohibited in 2014.

The annual limits apply to new individual and group plans, along with grandfathered group plans. They will not apply to grandfathered individual plans or to so-called "mini-med" plans that offer limited benefits.

Primary care and emergency care.  Plans now must allow pediatricians and obstetrician/gynecologists to obtain primary care physician status: This will eliminate requiring patients to get prior-authorization from their insurers or a primary care physician to see a pediatrician or OB/GYN.

Also, emergency services can be provided without prior approval from the plan: insurers can't charge higher co-payments or co-insurance for using out-of-network ER providers.

Rescission:  While the effective date was moved by insurers to May 2010, rescission—when an insurance company retroactively cancels a policy—is now banned, except when cases of "fraud or intentional misrepresentation of material fact" occur. Patients are required to be notified before cancellation. The provision applies to all types of health insurance plans.

 Appeal rights:  Patients will have the right to appeal insurers' decisions through their plans' internal review processes or independent, third-party reviewers. All health plan, except a grandfathered plan, must meet new standards. With urgent medical cases, the insurer must make a decision on the appeal within 24 hours—and has to continue covering the treatments while the appeal is pending.


Janice Simmons is a senior editor and Washington, DC, correspondent for HealthLeaders Media Online. She can be reached at jsimmons@healthleadersmedia.com.
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