Amid all the publicity and confusion about the government health exchanges, a few health-care coverage mandates went into effect on January 1, 2014. At least 10 of these changes should be reiterated.
Here’s what you should know:
1. The Affordable Care Act (ACA) and its proposed rules state that, “Through at least 2014, Group Health Plans are prohibited from applying waiting periods longer than 90 days after the employee or dependent is eligible for coverage.”
2. There can be no annual dollar limits on essential health benefits after 2013.
3. There are out-of-pocket maximums on essential health benefits imposed on non-grandfathered plans. For 2014, these maximums are $6,350 for single coverage and $12,700 for family coverage. The limit does not have to count balance billing amounts for non-network providers and other out-of-network cost sharing. In addition, if the employer’s coverage uses a separate benefit plan administrator for prescription drug coverage and if the drug plan currently imposes a limit on out-of-pocket costs, the ACA limit will apply separately to prescription drug costs, raising the total limit to $12,700 for individuals and $25,400 for families. If the drug plan does not currently have a limit on out-of-pocket costs, it will not have to impose one for 2014.
4. For plan years beginning on or after January 1, 2014, pre-existing condition exclusions are prohibited for all participants and dependents.
5. Dependents up to age 26 must be extended coverage regardless of eligibility for other employer-sponsored coverage.
6. Plans are not allowed to discriminate on a claim based on who the provider of service is.
7. Non-grandfathered plans must cover an approved clinical trial — one that is conducted in relation to the prevention, diagnosis or treatment of cancer or other life-threatening disease or diagnosis.
8. Non-grandfathered plans must provide coverage without cost sharing for preventive treatments and services for adults and children.
9. Non-grandfathered plans also must provide extended preventive services with-out cost sharing for women.
10. For participation in wellness programs, the ACA allows for increased maximum reward (or penalty) of up to 30 percent of the cost of health coverage and up to 50 percent of the total cost of coverage for tobacco cessation.
For more information, contact Patty Smith at 814/833-3200, 800/815-2660 or psmith@mbausa.org.
