Insurance Reform | Description | Applicable to |
(PHSA §) | Grandfathered | |
| Plans? | |
Plan Years Beginning On September 23, 2010 | ||
Prohibition on lifetime/ annual limits § 2711(a) | Prohibits group health plans and health insurance issuers offering group or individual health insurance coverage from establishing lifetime limits and annual limits on the dollar value of benefits. Group health plans and health insurance issuers offering group or individual coverage may not impose a preexisting condition exclusion or discriminate based on health status Group health plans and health insurance issuers may not rescind health coverage after coverage begins except in the case of fraud or intentional misrepresentation | Yes |
Prohibition on | Yes | |
preexisting condition |
| |
exclusion of enrollees under age 19 § 2704 |
| |
Prohibition on rescissions § 2712 | Yes | |
Insurance Reform (PHSA §) | Description | Applicable to Grandfathered Plans? |
Coverage of adult | Group health plans and health insurance issuers offering group or individual health insurance coverage that provide dependent coverage must continue to make such coverage available to children until age 26 | Yes |
children | ||
§ 2714 | ||
Uniform explanation of | Requires the Federal government to develop standards for use by group health plans and health insurance issuers in compiling and providing an accurate summary of benefits and explanation of coverage for applicants, policyholders or certificate holders, and enrollees. The explanation of coverage must describe any cost sharing, exceptions, reductions, and limitations on coverage, and give examples to illustrate common benefits scenarios | Yes |
coverage | ||
§ 2715 | ||
Bringing down the cost of | Requires health insurance issuers offering group or individual health insurance coverage to submit annual reports to the Federal government on the percentages of premiums that the coverage spends on reimbursement for clinical services and activities that improve health care quality, and to provide rebates to enrollees if this spending does not meet minimum standards for a given plan year | Yes (provision |
health coverage | applies to | |
(minimum medical loss | insured plans | |
ratio) § 2718 | only) | |
Applicable only to fully |
| |
insured plans |
| |
Coverage of preventive | Group health plans and health insurance issuers offering group or individual health insurance coverage must cover certain preventive services, immunizations, and screenings, without any cost sharing | No |
care (without cost | ||
sharing) | ||
§ 2713 |
Insurance Reform (PHSA §) | Description | Applicable to Grandfathered Plans? |
Provision of additional information (transparency requirements) § 2715A | Requires group health plans and health insurance issuers offering group or individual health insurance coverage to disclose, to the Federal government and the State insurance commissioner, certain enrollee information such as claims payment policies and practices and enrollee rights. Requires such plans and issuers to provide information to enrollees on the amount of cost-sharing for a specific item or service | No |
Nondiscrimination rules for insured plans § 2716
Applicable only to fully insured plans. | Prohibits fully-insured group health plans from discriminating in favor of highly compensated individuals with respect to eligibility and benefits | No |
Certain reporting requirements (statutory heading is “Ensuring Quality of Care”) § 2717 | Requires the Federal government to develop guidelines for use by health insurance issuers to report information on initiatives and programs that improve health outcomes. Prohibits a wellness program from requiring the disclosure or collection of any information relating to the presence or storage of a lawfully possessed firearm or ammunition in the residence or the lawful use, possession or storage of a firearm or ammunition by an individual | No |
Claims appeal procedures § 2719 | Group health plans and health insurance issuers offering group or individual health insurance coverage must provide an effective internal appeals process of coverage determinations and claims and comply with any applicable State external review process. If the State has not established an external review process that meets minimum standards or the plan is self- insured, the plan or issuer shall | No |
| ||||||||||||||||||||||||||||||||||||||||||
Insurance Reform (PHSA §) | Description | Applicable to Grandfathered Plans? |
Guaranteed availability of coverage (applicable to health insurance issuers) § 2702 | Health insurance issuers in both the individual and group markets must accept every employer and individual in the state that applies for coverage, but are permitted to limit enrollment to annual open and special enrollment periods for those with qualifying lifetime events. | No |
Applicable only to fully | ||
insured plans | ||
Nondiscrimination based | Retains the HIPAA nondiscrimination provisions for group health plans and group health insurance issuers. Specifically, plans and group health insurance issuers may not set eligibility rules based on factors such as health status and evidence of insurability – including acts of domestic violence or disability. Provides limits on the ability of plans and issuers to vary premiums and contributions based on health status. The Affordable Care Act adds new provisions regarding wellness programs. | No |
on health status | (grandfathered | |
§ 2705 | plans remain | |
| subject to the rules in effect before health care reform) | |
Prohibition on | Prohibits discrimination by group health plans and health insurance issuers against health care provid- ers acting within the scope of their professional license and applicable state laws. | No |
discrimination against | ||
providers | ||
§ 2706 | ||
Comprehensive health | Requires health insurance issuers in the small group and individual markets (and large group markets in state exchanges) to include coverage which incorporates defined essential benefits, provides a specified actuarial value, and requires all group health plans to comply with limitations on allowable cost sharing. | No |
insurance coverage | ||
(requirement to provide essential benefits and OOP and deductible cost sharing provisions) § 2707 |
Insurance Reform (PHSA §) | Description | Applicable to Grandfathered Plans? |
Participation in clinical | Prohibits health insurance issuers from dropping coverage because an individual (who requires treatment for cancer or another life-threatening condition) chooses to participate in a clinical trial. Issuers also may not deny coverage for routine care that they would otherwise provide because an individual is enrolled in a clinical trial. | No |
trials | ||
§ 2709* |
* Due to drafting errors, there are two sections 2709 of the PHSA after PPACA. The section referred to in the table is a new section. The other section 2709 (relating to disclosure of information) is renumbered from prior law PHSA section 2713. Grandfathered plans remain subject to the pre-PPACA require- ments that are still in effect.