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What We’ve Implemented and Future Changes- November 2011

There is a lot to know when it comes to health care reform. That’s why we’ve created a summary with details about how we’ve implemented some of the most significant provisions impacting members and providers in 2010 and 2011. Except where indicated, these provisions were effective for members in non-grandfathered plans upon renewal on or after September 23, 2010. In some cases, we implemented provisions for grandfathered members as well, even though the provision did not require us to do so. Policy benefits vary based on grandfathered and non-grandfathered status, the size of the member’s group, and other factors. In order to know how benefits apply to a specific policy, please continue to verify eligibility and benefits for all patients.  

Provision Details
Dependent coverage to age 26 
For many plans, we implemented this provision early to avoid a coverage gap for spring 2010 graduates. Members with group plans were given the opportunity to enroll dependents younger than 26 at their first open enrollment after September 23, 2010. We implemented this provision for dependents to age 26 for most vision and dental plans as well, even though the health care reform law does not apply to these benefits. 
No lifetime dollar limits/Restricted annual dollar 
limits on essential health benefits 
We removed lifetime dollar limits from plans where required and provided a one time open enrollment period for members who had reached their lifetime maximum limit. We implemented the annual limits provision, removing annual dollar limits. In some limited cases, employers could apply to the government for a waiver of this requirement. In order to understand how benefits apply to a specific policy, please continue to verify eligibility and benefits for all patients. 
No member cost share for in-network preventive 
care/Preventive services expansion 
We expanded our standard preventive care list and updated non-grandfathered plans to cover these services with no member cost share. We also chose to include this coverage in some grandfathered plans. 
Patient protections 
This provision gave members more flexibility in choosing a primary care doctor and accessing OB-GYN services without a pre-auth or referral. It also requires copays and coinsurance for out-of-network emergency medical care received in an ER to not exceed those required for in-network emergency care. We decided to include these provisions in all plans, even though they were not required for grandfathered plans. 
Pre-existing conditions 
Beginning with renewals after September 23, 2010, we provide coverage for members under the age of 19, regardless of pre-existing conditions.  
Spending account changes 
Effective January 1, 2011, prescriptions are required for spending account reimbursement of over-the-counter drugs other than insulin. 
Revised appeals process and adverse benefit 
If it was not already in place, we created a standard appeal process for members to comply with health care reform, including providing certain information to members, and allowing members to review their file and present evidence during the review. We’ve also coordinated external review for self insured plans through three accredited independent review organizations. As we move forward, we will implement this review process for other plans as well. 
On 07/01/11, we began including the following information on all Adverse Benefit Determinations (member EOBs, letters to the member, etc.), if not already included:  
Date of service
Health care provider name
Claim amount (if applicable)
Statement that diagnosis code, treatment code and their meanings are available upon request
Denial rationale (include a discussion of the decision)
Any standards used denying the claim (e.g., medical policies, etc.)
The denial code and reason (this information is contained on the EOB)
Description of the internal appeals and external review procedures
Contact information for consumer assistance or Ombudsman program
Looking ahead, there are still many parts of health care reform that will impact providers, members, and the way we all work together. Here are some of the significant provisions which will be implemented through 2016. As we continue to navigate through the many upcoming phases of health care reform, we will share additional details about how these changes may impact the way we do business with you. 

Provision Details Implementation Date
Revised appeals process and adverse benefit determinations  
Appeals process – bypass internal: Claimants will have the right to bypass internal appeals and go to external appeal or litigation if the insurer or plan fails to comply with the rule (exceptions for minor violations that are not reflective of a pattern or practice of noncompliance). 
Next plan year
on or after 1/1/12 
Language notifications: We will provide notices to certain members on how to request an adverse benefit determination in a language other than English. 
Next plan year
on or after 7/1/12 
Women’s preventive services expanded 
Approved women’s preventive services will be added to the preventive care list to be covered at 100% with no patient cost sharing. We are unsure at this time if these services will be added at one time or upon renewal. More information will be provided as it is available.  
08/01/12 or upon renewals starting 08/01/12 
Pre-existing Conditions 
Pre-Existing conditions will no longer apply to non-grandfathered plan members (over the age of 19). 
January 2014 
Administrative simplification 
This provision requires the HHS Secretary to adopt and regularly update the standard, implementation, specifications and operating rules for electronic exchange and the use of health information for the purposes of financial and administrative transactions. Providers will need to continue to work with their clearinghouses to ensure that they are compliant with standards for electronic exchange.  
January 2013 - 2016 
Health insurance exchanges 
States will begin to operate health insurance exchanges, which are envisioned to be marketplaces for individuals and some employer groups to obtain private health insurance. Employers will also be able to purchase coverage outside of the exchanges.  
Expected to be set up before 2014. 
Coverage for clinical trials 
Non-grandfathered plans must include coverage of routine patient costs for clinical trials of life-threatening diseases. 
Individual mandate 
All U.S. Citizens and legal residents are required to have health care coverage. For citizens without health care coverage, a penalty will be phased in. Penalties are the greater of $95 per year in 2014, phasing in to $695 per year by 2016 or 1% of taxable income phasing in to 2.5% of taxable income by 2016. Some exemptions will be allowed for low-income individuals. 
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