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Are you prepared for this months health plan changes under the PPACA?


Numerous provisions of the Patient Protection and Affordable Care Act take effect for plan years beginning on or after Sept. 23. Some involve a notification to plan participants. The post-Sept. 23 requirements are:
  • Grandfathered plans: Health plans in effect on March 23, 2010 are exempt from some health care reform provisions. For plans that choose to maintain grandfathered status, participants are entitled to a notice of that intent.
  • Appeals process: Health plans must install an internal and external appeals process. (Does not apply to grandfathered plans.) The internal review process must follow Department of Labor claims procedure; there is no change to self-funded plans. External review process for fully-insured plans must follow state law process, or if none, HHS guidance. External review process for self-funded plans must follow HHS guidance. Plan participants should be given a notice explaining their right to appeal claims decisions.
  • Annual limits: Only restricted annual limits may be placed on health plans except for per beneficiary annual limits on nonessential health benefits. Federal law and/or state law may prohibit specific benefit lifetime limits. Note that some lower lifetime limits on a per beneficiary basis may violate the ADA.
  • Dependent coverage extension: Health plans that offer dependent coverage are required to cover children up to age 26. Plan participants should be notified of this new option. (Grandfathered group health plans are not required to cover adult children up to age 26 if that dependent is eligible for other eligible employer-sponsored coverage.)
  • Lifetime limits: Lifetime limits are prohibited except for specific covered benefits that are not "essential health benefits." Participants who have reached the plan’s lifetime limits are entitled to a special enrollment notice informing them that they are again eligible to have claims paid.
  • Pre-existing conditions: Pre-existing condition exclusions are prohibited for covered children under age 19.
  • Preventive care: Plan sponsors must provide coverage for select evidence-based preventive care, certain immunizations, and certain additional care and screenings for women. This coverage must be provided on a first dollar basis (no cost-sharing with participants: co-pays, coinsurance, etc.) Does not apply to grandfathered plans.
  • Rescission: Health coverage cannot be cancelled except for fraud, etc. This provision generally applies to individual health insurance. It does not prevent the employer from terminating the plan

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