Frequently Asked Questions

Patient Protections

updated April 2013

Do the various patient protection requirements apply to all plans or only non-grandfathered plans?

Most of the patient protections apply to all plans, grandfathered and non-grandfathered alike; but there are some that do not apply to grandfathered plans. Specifically, the requirements on lifetime maximums and rescissions apply to all plans, grandfathered and non-grandfathered. The provisions on annual dollar limits apply to all plans other than grandfathered individual plans. The requirements on pre-existing conditions – either for those under age 19 or all others beginning in 2014 – apply to all health plans except grandfathered individual plans. The requirements for choice of health care professional (primary care, pediatrician or OB-GYN) and applying the same cost-sharing formula for out-of-network emergency care as in-network, do not apply to individual or group grandfathered plans; rather, only to non-grandfathered group and individual plans.

What do the patient protections for pre-existing conditions mean? Will insurers still be able to apply waiting periods to receive benefits or charge higher premiums?

Insurers can not deny or limit coverage for any person based on the fact that the condition was present before the effective date of coverage. Beginning Jan. 1, 2014, insurers can no longer apply a waiting period, such as the 240-day waiting period that Blue Cross and Blue Shield of Kansas applies on specific conditions, on all non-grandfathered individual plans sold through the marketplace or exchange, or those sold outside of the marketplace. Insurers may still apply a waiting period to grandfathered individual plans. For group coverage, employers may continue the practice of setting a waiting period for an employee to fulfill before being able to join the group health plan.

When do the patient protections for pre-existing conditions go into effect? How are these requirements affected by the grandfather rules?

This regulation was effective for enrollees under the age of 19 for all plan anniversaries on or after Sept. 23, 2010, and applies to all health plans except grandfathered individual plans. For all other persons, this regulation becomes effective for all plan anniversaries on or after Jan. 1, 2014, and applies to all health plans except grandfathered individual plans. Plans sold in the exchange or marketplace will accept all people with pre-existing conditions.

What do the patient protections mean regarding the elimination of lifetime maximums?

Benefit plans may no longer contain a lifetime dollar amount maximum on benefits.

Will Blue Cross apply annual dollar limits on essential health benefits as allowed by law?

No, Blue Cross and Blue Shield of Kansas does not currently restrict coverage of essential health benefits to annual dollar limits and is not likely to change our policy.

What is a rescission? Under what circumstances can a health insurer cancel my benefits under the new law?

The portion of the law which defines and prohibits rescissions is now in effect for all group and individual health plans, regardless of their grandfather status. The regulations define a rescission as a cancellation or discontinuance of coverage that has a retroactive effect, such as a cancellation that treats a policy void from the time of the individual’s or group’s enrollment or a cancellation which voids benefits paid up to a year before the cancellation. Insurers are prohibited from rescinding a person’s coverage except in cases of fraud or intentional misrepresentation of material fact. A cancellation is not a rescission if it has only a prospective effect or if it is retroactive because a group or member failed to pay required premiums.

What do the patient protections say about receiving out-of-network emergency services and what plans are required to comply?

The regulations prohibit health plans from requiring a member to obtain prior approval when seeking emergency services outside of its network and also require health plans to apply the same cost-sharing requirements (deductibles, copayments and coinsurance) for emergency services received out-of-network as it does in-network. These protections do not apply to grandfathered individual or group plans. This is not a substantial change for Blue Cross and Blue Shield of Kansas plans. In the event of an emergency, whether you are at home or away from home, Blue Cross always recommends that you to go to the nearest available acute care facility.

Will the patient protections increase my access to primary care physicians and pediatricians? Can I go to an OB-GYN when I choose to?

The protections assure that consumers can choose the primary care doctor or pediatrician of their choice from their plan’s provider network, and that consumers can visit an OB-GYN without needing a referral. These protections do not apply to grandfathered individual or group plans.

For the most part, Blue Cross and Blue Shield of Kansas members already enjoy these protections as they are free to receive services from any member of the company’s contracting network. For 2013, the Blue Cross and Blue Shield of Kansas network includes 99 percent of all medical doctors and 100 percent of medical facilities in its service area.

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