The Patient Protection and Affordable Care Act (PPACA) calls for several coverage provisions.
Regarding individual coverage, insurance companies will no longer be allowed to rescind existing health insurance coverage, except in the event of fraud. This provision went into effect Sept. 23, 2010.
The PPACA eliminates lifetime limits on the dollar value of benefits and impose restrictions on annual limits, effective Sept. 23, 2010. New restrictions on the use of annual limits will be imposed until 2014. The Secretary of Health and Human Services (HHS) will define restrictions that plans may use until that time. Effective Jan. 1, 2014, the bill will prohibit plans from imposing annual or lifetime monetary coverage limits.
Individual and new group plans will be required to cover certain preventive services and immunizations without cost-sharing, which translates into eliminating co-pays and deductibles for such services. Covered services are those recommended by the U.S. Preventive Services Task Force and the Centers for Medicare and Medicaid, and certain child preventive services recommended by the Health Resources and Services Administration. Colonoscopies, mammograms, immunizations, and tobacco-cessation counseling are examples of such services. With regard to dermatology, the zoster vaccine was included in the first round of recommended preventive services. This provision is effective Sept. 23, 2010.
Also effective Sept. 23, 2010, plans will no longer be able to deny coverage for children under the age of 19 with preexisting conditions.
Similarly, insurers are prohibited from denying coverage to individuals sho have preexisting conditions, effective Jan. 1, 2014. Adults who have preexisting conditions will have immediate access to insurance though a temporary insurance program enacted by the law. These state-based, high-risk pools will allow such individuals to purchase subsidized insurance until 2014. At that point, they will be able to transition into the American Health Benefit Exchanges, which are required to be implemented by Jan. 1, 2014.
The law also extends dependent coverage to young adults up to the age of 26. As of Sept. 23, 2010, all individual and group health insurance plans must allow uninsured children to remain on their parents' health insurance through age 26.
Also, insurers are prohibited from requiring individuals to wait for a period of longer than 90 days to enroll in a health plan.
All individuals will be required to have health insurance, with some exceptions, beginning in 2014. Those who go without must pay an annual financial penalty of either $695 per person (up to a maximum of $2,085 per family) or 2.5 percent of household income, whichever is greater. This provision will be phased in between 2014 and 2016. Exceptions include individuals in financial hardship or with religious objections, and American Indians.
Effective Jan. 1, 2014, health plans must follow new guidelines on determining rates that they may charge. Premiums may vary based only on age, family size, geographic region, and tobacco use. They cannot vary based on medical history, health status, genetic information, disability, evidence of insurability, or any other factor determined appropriate by the Secretary.
Regulations