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Health Reform Package Changes

Here is a list of near term changes to individual and group health plans as part of the health reform package:

Access to Pediatricians

The New Law: Beginning October 1, 2010, health plan Members who are required to designate a Primary Care Physician (PCP) must be allowed to designate a PCP that specializes in pediatrics.

Appeals Processes

Beginning October 1, 2010, health plans must implement an effective appeals process for coverage determination and claims decision. The process must comply with certain state and national guidelines.

Emergency Services

Beginning October 1, 2010, coverage of visits to an emergency room of a hospital must be provided without pre-authorization and regardless of whether the facility is a participating provider. Cost sharing is also limited.

Extension of Dependent Coverage to Age 26

For health plan contracts beginning October 1, 2010, the law requires health care coverage for adult dependent children, married and unmarried, until age 26. It does not require coverage for children of dependents.

Access to OB/GYN Physicians

The New Law: Beginning October 1, 2010, health plan Members who are required to designate a Primary Care Physician (PCP) must be allowed to see a participating Obstetrics/Gynecologist without pre-authorization or a referral.


Beginning October 1, 2010, covered individuals may not be cancelled by the health plan, except for fraud. This provision does not prohibit a health plan from cancelling a contract due to non-payment of premium.

No Pre-Existing Condition Waiting Periods

Beginning October 1, 2010, health plans are prohibited from imposing any pre-existing condition exclusions or waiting periods for children, up to age 19, who are enrolled in a group health plan. This means coverage for any specific health condition will not be delayed for new Members under age 19. There is disagreement on the interpretation of this provision, which has been argued to mean guaranteed enrollment of children up to age 19. The Secretary as well as congressmen have come out very strongly in support of guaranteed enrollment, however clarifying regulation has yet to be provided.

Prohibition of Non-Discrimination by Employer

Employer groups effective or renewing on or after October 1, 2010, may not establish eligibility rules for any full time employees that are based on the total hourly or annual salary of the employee. Additionally, an employer group may not establish rules that discriminate in favor of higher wage employees.

Lifetime Limits

The New Law: Certain health care services are considered to be Essential Benefits. Specifics regarding Essential Benefits will be defined by The Department of Health and Human Services.

Beginning October 1, 2010; group health plans may not establish lifetime coverage limits on the dollar value for the coverage of Essential Benefits, per Member. Lifetime maximums are allowed for coverage of Non-Essential Benefits.

Coverage of Preventive Care

Beginning October 1, 2010, the new law requires group and individual health plans to provide coverage, without any Member cost sharing, for:

Health care services that received an “A” or a “B” (recommended) grade from the U.S. Preventive Services Task Force. Immunizations recommended by The Centers for Disease Control and Prevention. Evidence-based preventive care screenings for women, infants, children, and adolescents supported by the Health Resources and Services Administration.

Annual Maximums

Essential Benefits will be required to be included in all benefit plans, without annual limits, beginning January 2014. Prior to that date, health plans may impose reasonable annual limits, per Member, on the dollar value for the coverage of Essential Benefits. The annual limits for Essential benefits prior to 2014 will be approved by the federal government.

Internet Portal

Requires the Secretary of Health and Human Services to create an Internet website. The site is to help individuals and employer groups gather information on health insurance coverage options and costs. Phase One of the website is expected to be released July 1, 2010, and will include the following health plan information:

  • Medical plans available in the individual and small business markets
  • Types of products offered (HMO/PPO/POS)
  • Financial ratings of health plans
  • Health plan contact information
  • Links to provider networks, formulary and product descriptions

Phase Two is expected to be released on October 1, 2010, and will include detailed pricing and benefit information, including cost sharing, coverage limitations, and exclusions. Beginning in 2011, the web portal will include:

  • Performance Ratings
  • Percent of policies rescinded
  • Percent of claims denied
  • Number and nature of appeals
  • Medical loss ratio information
  • Eligibility criteria

Future Deadlines

2011— Medical Loss Ratio Reporting

Beginning January 1, 2011, health plans are required to report claims and other expenses for individual and employer group plans. If medical loss ratios are less than 80 percent for individuals and small employer groups and less than 85 percent for large groups, the health plan must rebate the difference.

2012 — Plain Language Documents

Beginning March 2012, health plans will issue standardized Summaries of Benefits and other coverage documents. Standards will be issued from the Secretary of Health and Human Services.

2014 — Exchanges Plans and More

Beginning January 1, 2014, each state is required to establish one or more Health Insurance Exchanges. The exchange will help individuals and small employer groups purchase health insurance through Qualified Health Plans.

Many other provisions will become effective in 2014, such as:

  • Premium rate approval
  • Requirements surrounding mental health coverage
  • Wellness programs
  • And more

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