Key Provisions Impact Member Benefits – August 2010
Key Provisions Impact Member Benefits
The recently enacted health care reform legislation includes several provisions that will impact member benefits related to pre-existing condition exclusions, lifetime and annual limits, and various other patient protections. This summary provides you with an overview of some of these key provisions and information about how we are working to implement this legislation. We will continue to provide you with additional information and updates about these provisions as we receive clarification from the U.S. Department of Health and Human Services (HHS).
In general, the new legislation prohibits group health plans and insurers from using pre-existing conditions to deny health care coverage to an individual beginning in January 2014. After September 23, 2010, health plans are required to implement this provision for children under the age of 19, beginning at the policy renewal date.
Lifetime and Annual Limits
This provision prohibits member benefits from having lifetime limits. It also restricts the annual dollar limits on "essential health benefits." This provision applies to medical and pharmacy benefits only, and does not impact dental or vision coverage.
The majority of Empire policies will no longer include annual or lifetime dollar limits for plan years beginning on or after September 23, 2010. Additionally, we will no longer include dollar limits on specific essential heath benefits, as described by the legislation. Certain limited benefit plans may continue to include annual dollar limits if they are eligible for a waiver program, which will be defined in the future by HHS. For some policies, this provision will take effect on September 23, 2010, instead of the policy renewal date. The easiest way to confirm specific member benefits is to continue to verify eligibility and benefits through your normal business processes.
If you are treating an Empire member who previously reached their lifetime maximum and therefore is no longer eligible for coverage, this member will be provided with a special enrollment period to re-enroll in benefits. If your patient is currently enrolled, but not receiving benefits, we will provide notice to the member that limits no longer apply.
Though the HHS has not yet defined “essential health benefits” under the new legislation, HHS has provided the following examples of essential benefits:
| Ambulatory patient services|
| Emergency services|
| Maternity and newborn care|
| Mental health and substance use disorder services, including behavioral health treatment|
| Prescription drugs|
| Rehabilitative and habilitative services and devices|
| Laboratory services|
| Preventive and wellness services|
| Chronic disease management|
| Pediatric services, including oral and vision care|
As we await additional guidance from HHS, we are making a good faith effort to comply with the regulation prohibiting annual limits on these benefits by establishing a list of essential health services. Based on our interpretation of the law, at this time all other limits such as visits and quantities will still apply to policies and benefits. Once we receive final guidance from HHS, we will review and revise our decisions as appropriate based on that information.
Legislation contains a number of other provisions that the Administration refers to as “patient protections.” These provisions impact benefits related to primary care physician selection, referral and preauthorization processes for OB-GYN and emergency room services, and emergency room payment practices. In most cases, we are already compliant with the regulations of these provisions. Where applicable, changes will be made to our current processes that ensure compliance with the outlined requirements. If state laws provide a higher level of benefits than set forth in the patient protections provision, the laws will remain applicable.
Primary care physicians – For plans that require a primary care physician, this provision allows all members to choose any available in-network provider as their primary care doctor, including a participating pediatrician for children. This provision does not require physicians to accept patients if they are not currently accepting new patients.
OB-GYN providers – This provision allows individuals to seek care from an in-network OB-GYN provider without requiring pre-authorization or referral from a primary care physician (pre-authorization for specific obstetrical or gynecological services is allowed).
Emergency room services – In the event of an emergency, this provision allows individuals to seek emergency room services from in or out of network emergency rooms without pre-authorization for services (post-treatment notification requirements are permitted). Insurers must cover out-of-network emergency room services, and copayments and coinsurance for these services cannot exceed those for in-network emergency room services. Other types of cost sharing (e.g., deductibles and out-of-pocket limits) are allowed on out-of-network ER if it is the same cost sharing as imposed on other out of network benefits. Health plans must pay the out of network provider the greater of the following: their median payment to in-network ER providers, the amount that would be paid if the plan used the same method for ER as it uses for other out of network services, or the amount that would be paid by Medicare. Members can continue to be balanced billed by the out of network provider.