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Preventative Care Benefits under Reform

Under the Affordable Care Act, you and your family may be eligible for some important preventive services—which can help you avoid illness and improve your health—at no additional cost to you.

What This Means for You

If your plan is subject to these new requirements, you would not have to pay a copayment, co-insuranceor deductible to receive preventive health services, such as recommended screenings, vaccinations and counseling.

For example, depending on your age, you may have free access to preventive services such as:

• Blood pressure, diabetes, and cholesterol tests
• Many cancer screenings, including mammograms and colonoscopies
• Counseling on such topics as quitting smoking, losing weight, eating healthfully, treating depression and reducing alcohol use
• Routine vaccinations against diseases such as measles, polio or meningitis
• Flu and pneumonia shots
• Counseling, screening, and vaccines to ensure healthy pregnancies
• Regular well-baby and well-child visits, from birth to age 21

Some Important Details

• This preventive services provision applies to people enrolled in job-related health plans or individual health insurance policies created after March 23, 2010. If you are in such a health plan, this provision will affect you as soon as your plan begins its first new “plan year” or “policy year” on or after September 23, 2010.
• If your plan is “grandfathered,” these benefits may not be available to you.
• If your health plan uses a network of providers, be aware that health plans are only required to provide these preventive services through an in-network provider. Your health plan may allow you to receive these services from an out-of-network provider, but may charge you a fee.
• Your doctor may provide a preventive service, such as a cholesterol screening test, as part of an office visit. Be aware that your plan can require you to pay some costs of the office visit, if the preventive service is not the primary purpose of the visit, or if your doctor bills you for the preventive services separately from the office visit.
• If you have questions about whether these new provisions apply to your plan, contact your insurer or plan administrator.  If you still have questions, contact your State insurance department.
• To know which covered preventive services are right for you—based on your age, gender, and health status—ask your health care provider. 

Please call the shoppe with any questions....

Thanks,

Jordan

What Does Having a "Grandfathered" plan mean under reform?

The Affordable Care Act exempts most plans that existed on March 23, 2010--the day the law was enacted--from some of the law’s consumer protections. This will preserve consumers’ rights to keep the coverage they already had before health reform.

What This Means for You

If you have health coverage from a plan that existed on March 23, 2010--and that has covered at least one person continuously from that day forward--your plan may be considered a “grandfathered” plan.

This is true whether you are covered by an individual health insurance policy that you had on that date, or you are covered by a job-based health plan that your employer first established before March 23, 2010. This is true even if you enrolled in that job-based plan sometime later.

A grandfathered health plan isn’t required to comply with some of the consumer protections of the Affordable Care Act that apply to other health plans that are not grandfathered.

Here’s a look at which consumer protections do and don’t apply to grandfathered plans.

Consumer Protections in the Affordable Care Act that DO Apply to Grandfathered Plans

Many of the Act’s consumer protections that took effect on September 23, 2010 apply to all plans, whether or not the plans are grandfathered.

Please note that these consumer protections will be added to your plan when it begins a new plan year orpolicy year on or after September 23, 2010.

All health plans:

• Are prohibited from applying lifetime dollar limits to key health benefits.
• Are not permitted to cancel your insurance coverage solely because of an honest mistake that you or your employer made on your insurance application.
• Must extend dependent coverage to an enrollee’s adult children until they turn 26 years old (with one temporary exception: Click here for more details).

Consumer Protections in the Affordable Care Act that DO NOT Apply to Grandfathered Plans

Unlike other health plans, job-based plans and individual insurance policies that are grandfathered arenot required to:

• Provide certain recommended preventive services at no additional charge to you.
• Offer new protections for consumers who are appealing claims and coverage denials.
• Protect your choice of health care providers and your access to emergency care.

Consumer Protections in the Affordable Care Act that DO NOT Apply to Grandfathered INDIVIDUAL Plans

Grandfathered individual health insurance policies are not required to adopt the provisions of the law that:

• Phase out annual dollar limits on key benefits.
• Eliminate pre-existing condition exclusions for children under 19 years old.

Some Important Details

Grandfathered plans can lose their grandfathered status if they make certain significant changes that reduce benefits or increase costs to consumers. (Read more about changes that will cause a health plan to lose grandfathered status).

Although grandfathered plans can make only limited changes to the percent of the premium the employer contributes, grandfathered plans may still increase their total premium amount without losing grandfathered status.

If your plan loses its grandfathered status, all of the Affordable Care Act consumer protections would apply to you when your plan begins a new plan year or policy year.

To find out if your health plan is grandfathered:

• Check your plan’s materials. Beginning with the first plan or policy year starting on or after September 23, 2010, health plans must disclose their grandfathered status in any plan materials describing the plan’s benefits that are distributed to beneficiaries or primary subscribers. These materials must also contain contact information for questions and complaints.
• Check with your employer and/or your health plan’s benefits administrator. If you are in a group health plan, the date you joined may not reflect the date the plan was created. New employees and new family members may be added to a grandfathered group plan after March 23, 2010.

For additional questions please contact the shoppe.

Thanks,

Jordan

Insurance Protection for Children

Under the Affordable Care Act, health plans cannot limit or deny benefits or deny coverage for a child younger than age 19 simply because the child has a “pre-existing condition”—that is, a health problem that developed before the child applied to join the plan.

What This Means for You

Until now, plans could refuse to accept anyone because of a pre-existing health condition, or they could limit benefits for that condition. Now, under the new law, health plans that cover children can no longer exclude, limit or deny coverage to your child under age 19 solely based on a health problem or disability that your child developed before you applied for coverage. This new rule applies to all job-related health plans as well as individual health insurance policies issued after March 23, 2010. The rule will affect your plan as soon as it begins a plan year or policy year on or after September 23, 2010.

Some Important Details

• This rule applies whether or not your child’s health problem or disability was discovered or treated before you applied for coverage.
• The new rule doesn’t apply to “grandfathered” individual health insurance policies. A grandfathered individual health insurance policy is a policy that you bought for yourself or your family (and is not a job-related health plan) on or before March 23, 2010 (the date that the new law was passed).
• These protections will be extended to Americans of all ages starting in 2014.

Example

On October 1, 2010, Sally purchased a new individual health policy for herself and her 13-year-old child, Miranda, who has been treated for asthma in the past. The new health policy excludes coverage for treatment of pre-existing conditions for all enrollees. On November 1, 2010—one month after coverage began for Sally and Miranda—Miranda is hospitalized for an asthma attack. Her insurance company denies payment for the hospitalization, because under the policy Miranda’s asthma is considered a pre-existing condition.

Under the new law, the insurer can’t deny payment for the hospitalization based on Miranda’s pre-existing asthma condition. Miranda is under the age of 19; Sally’s policy is new and therefore subject to the pre-existing condition rules of the new health care law. Sally’s policy year began after September 23, 2010, when the law’s rules on pre-existing conditions began to take effect.

Please call the shoppe with questions.

Thanks,

Jordan

Appealing a decline in coverage

Your Benefit Appeal Rights Under the Affordable Care Act

If your health plan was created after March 23, 2010, the Affordable Care Act ensures your right to appeal, or to ask that your plan reconsider its decision to deny payment for a service or treatment. New rules, now in effect, govern how your plan itself must handle your initial appeal. If your plan upholds its decision after its internal review, the law permits you to appeal to an independent reviewer who does not work for your health plan.

What This Means for You

• When an insurance plan denies payment for a treatment or service, you can appeal to the plan to review its own decision. Your plan must explain how to appeal when it informs you of the denial.

• When you appeal, your plan must give you its decision within:
  • 72 hours for denials of urgent care.
  • 30 days for denials of non-urgent care you have not yet received.
  • 60 days for denials of service you have already received. 

• If the plan still denies your request, it must explain why and tell you how to appeal for an independent review of the decision. In some cases involving urgent care, you may be able to have the internal and external review take place at the same time.

• If you do not speak English, you may be entitled to receive all appeals-related information in your native language.

Some Important Details

• The appeals provision applies to all health plans created or purchased after March 23, 2010  and affects each plan as that plan starts a new “plan year” or “policy year” on or after September 23, 2010.
• How much the law will change your appeal rights depends on the State you live in and the type of plan you have.  
• Some employers’ plans may have more than one internal review before you’re allowed to seek an external review.
• If you have questions about whether the appeals provision applies to you, ask your health plan orState insurance regulator. Your State may also have a health care consumer assistance program that can help.

Please call the shoppe with any questions...

thanks,

Jordan

Which Carrier to Apply for Coverage With?

All carriers will have a benefit that stands out amongst others.

When looking for plans that are the most competitive in premium, one carrier will stand out in Cook County, Blue Cross and Blue Shield of Illinois (BCBSIL).  Hands down, when comparing quotes, BCBSIL will be the lower priced plan 90% of the time.

Does this mean that you should apply to BCBSIL?  Unfortunately not.

With BCBSIL, all pre-existing conditions will not be covered for the 12 months of coverage.  This means any condition that was consulted, diagnosed or treated within the 12 months prior to coverage, excluding birth control.  BCBSIL along with all carriers other than Aetna can exclude coverage on specific medical conditions.

So...if you are Asthmatic and take Generic or Brand Name medications, these would not be covered for the first year, making BCBSIL not the best option.

If the prospective insured is currently taking medications, Humana, and UnitedHealthCare (UHC) may be a better option.  These carriers do not have a pre-existing condition waiting period and will cover your Rx from day one.  However, depending on the cost of your Rx, quoted premium can increase to cover the cost of medication.

Aetna can be an option but will only waive the 12 month pre-ex waiting period if the prospective insured was covered continuously for 12 months with no longer than a 63 day gap in coverage.  Aetna will not place exclusions on a policy but can increase the quoted premium.  Aetna all does not cover Mental and Illness.

For more information on plans please contact the shoppe.

-Jordan