Overview
Following is an outline of plan provisions typically required under the ACA. These provisions become effective for group health plans upon renewal after September 23, 2010. Where noted, some provisions may not apply to grandfathered plans.
Pre-Existing Condition Exclusions not Legal
Health plans may not deny or exclude benefits for pre-existing health conditions. This provision applies to all group health plans, regardless of grandfathering status.
Choice of Primary Care Provider
For plans and issuers that require or allow for the designation of primary care providers by participants or beneficiaries (such as an HMO plan), you have the right to designate any primary care provider who participates in that plan’s network and who is available to accept you or your family members. Until you affirmatively make this designation, the health plan designates a primary care provider for you.
Children may designate a pediatrician as the primary care provider. Women may designate a health care professional who specializes in obstetrics or gynecology. You do not need prior authorization from the health plan or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care.
The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For information on how to select a primary care provider, and for a list of the participating primary care providers or participating health care professionals who specialize in obstetrics or gynecology, contact your health plan. This provision does not apply to grandfathered plans.
Grandfathered Status
Some of health plans plan may be “grandfathered health plans” under the Affordable Care Act (ACA). This means a grandfathered health plan can preserve certain health coverage features that were already in effect when the ACA was enacted. It also means that the plan is exempt from some of the new health plan requirements of the ACA, for example, the requirement that preventive health services be provided without any cost sharing. However, grandfathered health plans must comply with certain other consumer protections in the ACA, such as the elimination of lifetime limits on benefits.
External Claims Review
Plans and issuers are required to establish both internal and external review procedures in accordance with state or federal guidelines, as appropriate. Please refer to your health plan certificate of coverage for complete claim appeal and review procedures. This provision does not apply to grandfathered plans.
Rescission of Coverage
Coverage may only be rescinded or cancelled if there is fraud or intentional misrepresentation of fact, as prohibited by plan terms of coverage. Plan must provide 30 days advance notice before coverage can be rescinded. Rescission of coverage will be treated as a claim denial and may be appealed in accordance with the claim appeal procedures of the plan. This provision applies to all group health plans, regardless of grandfathering status.
Medical Loss Ratio Rebates
The plan must meet minimum loss ratio standards established by the ACA. Plans that do not meet the minimum requirement must rebate excess premium to the employer. Your employer is required to apply that rebate equitably for the benefit of all currently enrolled employees. Funds may be used to offset future premium increases or to enhance future plan benefits. Cash rebates will not be issued. This provision applies to all group health plans, regardless of grandfathering status.
Submission of Fraudulent Claims
If you (or any covered dependents) submit fraudulent claims to the plan, your coverage may be terminated.