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. However, insurers can continue to apply waiting periods for enrollees. Individuals purchasing their own health insurance benefit plan who have a pre-existing condition can be rated accordingly.
This regulation became 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 marketplace or exchange will be non-grandfathered plans.
Lifetime maximums and annual limits
Benefit plans no longer contain a lifetime dollar amount maximum on benefits. This patient protection applies to all group and individual health plans regardless of whether the plan is grandfathered or not.
All health plans, other than grandfathered individual plans, are prohibited from including annual dollar limits for essential health benefits for all plan years as of or after Jan. 1, 2014. From Sept. 23, 2012 to Jan. 1, 2014, insurers may impose a $2 million annual dollar limit.
This portion of the law will have no effect on Blue Cross and Blue Shield of Kansas members as the company does not offer products that have annual dollar limits on essential health benefits.
As defined under these regulations, a rescission is a cancellation or discontinuance of coverage that has 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 or discontinuation is not a rescission if it has only a prospective effect or if it is retroactive because a member failed to pay required premiums.
This regulation is currently in place for all group and individual health plans, regardless of their grandfather status.
Choice of health care professional
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. In addition, consumers will not be required to obtain a prior approval when seeking emergency care at a hospital outside of the plan’s network. Also, a health insurer must apply the same cost-sharing requirements (deductible, copayments and coinsurance) for emergency services received out-of-network as it does in-network.
These protections became effective for plan anniversaries on or after Sept. 23, 2010, but 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 is comprised of 96 percent of all providers in its service area, including 99 percent of all medical doctors and 100 percent of medical facilities. 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.