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U.S. health care reform begins with several consumer –focused provisions Grandfathered plans -The PPACA grandfathered existing health plans and exempted them from some, but not all rules Early Retiree Reinsurance Program- This program pays employers that offer health care to former employees age 55 or older part of the cost of health benefits.
Online resources – Health insurance companies must post health plan options online for consumers Appeals and external review – Health insurance plans must have claims review and appeals processes in place.
Cancellation of coverage (rescissions) – Coverage can’t be retroactively cancelled on any plan, except in fraud cases.
Dependent coverage to age 26 – Health care reform provides benefits to dependents up to age 26.
Doctor choice – Enrollees are allowed to select their primary care physician, pediatrician, and OB/GYN.
Dollar limits on essential health benefits – Health care reform eliminates annual and lifetime limits on essential health benefits.
Emergency care – Emergency services must cost the same in- or out-of-network.
Prohibition in favor of highly compensated individual – Plans can’t give some higher paid employees better benefits.
No pre-existing condition limitations for enrollees under 19 – Plans can’t deny benefits and coverage to individuals under age 19 with pre-existing conditions.
Preventive services/immunizations without cost share – Plans must cover preventive care services and immunizations with no cost to enrollees.
Temporary high risk pools – Reform gives uninsured people with pre-existing conditions benefits until state exchanges are open.
No unreasonable premium increases – The government will review premium increases annually.
Health savings account distribution tax penalty – Reform provision imposes tax penalty on Health Savings Accounts when used to buy items that are not listed medical expenses.
Eliminate the Medicare Part D coverage “Donut Hole” – Health care reform decreases coinsurance for generic drugs, over time, from 100 to 25 percent.
Medical loss ratio – Reform requires annual medical loss ratio reporting to decide if rebates are due.
Over-the-counter drugs – Most OTC drugs can no longer be reimbursed from health accounts without a prescription.
Encouraging integrated health systems – Integrating health care systems could improve quality of health care.
Summary of Benefits and Coverage – Provides a standardized Summary of Benefits and Coverage.
Quality of care reporting – New reform reporting rules could improve the health outcomes and reduce costs.
Reducing paperwork and administrative costs – The PPACA requires secure electronic health information transfer.
Comparative Effectiveness Research Fee – Tax on individual and group health plans to fund the Patient Centered Outcomes Research Institute.
Women’s Health Amendment – Beginning August 1, 2012, non-grandfathered plans without a religious exemption were required to cover additional preventive care services for women, with no cost sharing.
W-2 Reporting – employers who distribute 250 or more Form W-2s are required to report the value of employer-sponsored coverage.
Flexible spending account limits – Health care reform limits yearly contribution amount on Flexible Spending Accounts to $2,500.
Expanded authority to bundle payments – Health care professionals work together to improve the coordination and quality of care.
Increased Medicare Part A tax on wages and investment income – Health care reform taxes higher incomes to help fund Medicare Part A.
Health Insurance Marketplaces/Exchanges – Health care reform creates state exchanges for buying health insurance.
Individual mandate – Health care reform requires each person to have minimum essential coverage.
Essential health benefits – The PPACA requires new plans to cover essential health benefits.
No pre-existing conditions for all ages – Health care reform prevents plans from denying coverage or limiting benefits on pre-existing conditions.
Clinical trials – Under health care reform, plans can’t deny participation or limit routine costs for those in clinical trials.
Dollar limits on essential health benefits: annual – Beginning in 2014, the PPACA halts annual limits on the dollar value of essential health benefits.
Cost-Sharing Limits – Limits on how out-of-pocket maximums apply to some plans.
Wellness Program Incentives – Maximum reward is 30% of costs, or 50% for programs related to tobacco use.
Guaranteed availability/renewability – Reform requires carriers to accept all groups or people that apply for coverage.
Waiting periods – Reform requires waiting periods to no longer than 90 days.
Auto enrollment – New enrollment rules for employers with more than 200 full-time employees.
Health insurance industry fee – New taxes for health insurance and pharmaceutical companies.
Reinsurance fee – New fee to fund program intended to lessen the impact of adverse selection in the individual market.
Employer mandate – Employers must offer health insurance or pay a penalty.
Large Employer Reporting Responsibilities – Applies to all employers subject to the employer mandate.
Minimum Essential Coverage Reporting – Information required by the IRS for insurers and self-insured plan sponsors.