Affordable Care Act

As of September 23, 2010, access to health care will improve for many Monterey County residents, especially children and adult children. Some provisions of the new law going into effect are particularly beneficial for the health of California’s children. These include:

Young adults can remain on their parents’ health plan until age 26.

-      The following conditions must be met to take advantage of this provision:

• Their parent has coverage through an employer or buys family coverage in the individual market.
• Their parent’s health plan provides “dependent coverage”—that is, it covers children, spouses, or other family members.
• The young adult cannot have a job that offers coverage, unless the parent’s plan is either a plan purchased in the individual market or a plan that did not exist before March 23, 2010.

-      For more information: http://www.hhs.gov/ociio/regulations/adult_child_fact_sheet.html

Children can no longer be denied coverage for pre-existing conditions.

-      This ban applies to two former practices: 1) Benefit limitations (e.g., an insurer refusing to pay for chemotherapy for a child with cancer because the child had the cancer before getting insurance) and 2) outright coverage denials (e.g., when the insurer refuses to offer a policy to the family for the child because of the child’s pre-existing medical condition) for children under 19.

-      For more information: http://www.hhs.gov/ociio/regulations/children19/factsheet.html

New plans must provide free preventive services to all enrollees.

-      Interim final rules have been released that define the range of services to be covered, but the rule may still be altered after September 23, 2010 based on comments received from the public.

-      For more information: http://www.healthcare.gov/law/about/provisions/services/lists.html or http://www.healthcare.gov/center/regulations/prevention/regs.html

Other Provisions Effective September 23, 2010

Insurance plans can no longer impose lifetime caps or restrictive annual limits on coverage.

-      This provision prevents your insurance company from:

• Setting lifetime limits that cause the loss of coverage at the very moment when patients need it most, and
• Setting annual coverage limits lower than $750,000.

-      For more information: http://www.healthreform.gov/newsroom/new_patients_bill_of_rights.html

Consumers’ choice of doctors will be protected.

-       New federal rules make clear that health plan members are free to designate any available participating primary care provider as their provider, parents may choose any available participating pediatrician to be their children’s primary care provider, and insurers and employer plans are prohibited from requiring a referral for obstetrical or gynecological (OB-GYN) care.

For more information: http://www.healthreform.gov/newsroom/new_patients_bill_of_rights.html

Insurers cannot arbitrarily rescind coverage.

-      This provision prevents your insurance company from:

• Retroactively canceling your policy when you become sick or if you or your employer made a mistake on your paperwork.

-      For more information: http://www.healthreform.gov/newsroom/new_patients_bill_of_rights.html

Consumers will have the right to appeal decisions by their insurers.

-       Consumers in new health plans have the right to appeal decisions, including claims denials and rescissions, not only through their health plan’s internal appeals process, but also to an outside, independent decision-maker.

-       For more information: http://www.healthcare.gov/news/factsheets/protectconsumers_factsheet072210.pdf

Insurance companies will remove barriers to emergency services.

-       Health plans and insurers will not be able to charge higher cost-sharing (copayments or coinsurance) for emergency services that are obtained out of a plan’s network.

-       For more information: http://www.healthreform.gov/newsroom/new_patients_bill_of_rights.html

Also note that some of these restrictions do not apply to health plans that are “grandfathered.”

-      Those consumers who are happy with the health plan they already have are able to keep their coverage under this provision. 

-      For more information: http://www.healthreform.gov/newsroom/keeping_the_health_plan_you_have.html or http://www.familiesusa.org/assets/pdfs/health-reform/Grandfathered-Plans.pdf