The two federal health care reform bills are: the Senate Bill - Patient Protection Affordable Care Act - signed 3/23/2010 and the House Bill - Health Care and Education Reconciliation Act of 2010 - signed 3/30/2010.
The purpose of these two health care bills are to improve access to health care. There are several mandates within the bills, and some of these mandates apply to only grandfathered plans, new plans or both. A grandfathered health insurance plan is a plan that existed before 3/23/2010 and does not make significant changes to their plan to lose grandfathered status. PEHP currently believes they are a grandfathered plan; however they have not yet been informed of their status.
Grandfathered Plan Mandates:
After 9/23/2010
1. No pre-existing condition exclusion for children under the age of 19.
- Currently PEHP requires a 9 month waiting period.
- This will be an additional cost for PEHP.
2. Two types of limits on benefits:
- No lifetime limits on dollar value benefits or type of care
- Only allowed "reasonable" lifetime or annual limits on nonessential benefits.
- PEHP plans to change to annual limits for both types of changes to keep this as cost neutral as possible.
3. Dependent children will be allowed to stay covered on employee health insurance plan until age 26, regardless of whether or no they are a dependent. This does not apply to the child if they have their own group coverage.
- Spouses or dependents of the dependent are not covered, only the dependent child.
- Only allowed to be added to insurance plan at the insurance carrier's open enrollment date.
- This will be an additional cost to PEHP.
4. No recession or termination of coverage without prior notice, with the exception for intentional misrepresentation or fraud.
- Does not apply to PEHP.
After 1/1/2011
1. Underwriting conditions - 85% threshold required for large employers (employers of 50 or more employees).
- If a plan falls below the threshold in a year, the plan shall refund premiums to employees on a pro-rated basis.
- This should not affect PEHP, as PEHP is a self-funded plan, always within 90% threshold.
After 3/23/2012
1. PEHP will be required to provide uniform summary plan description.
- Content and format required by statue.
- Must provide notice no later than 60 days notice to a change in plan.
- PEHP is not affected.
After 1/1/2014
1. No waiting period larger than 90 days, for every one of all ages.
- This will be an additional cost to PEHP.
2. No pre-existing exclusion may be applied to all, at any age.
- This will be an additional cost to PEHP.
3. Essential benefits can no longer have lifetime limits, only reasonable annul limits.
- PEHP is trying to keep costs neutral.
4. Dependent coverage required up to age 26, even if they are eligible for another insurance plan.
- This will be an additional cost to PEHP.
Government Plan Issue - Effective Immediately
Health Insurance plans for government employees can choose to be exempt from four federal health care regulations, including the Mental Health Parity Act, Women's Cancer Right's Act, the Newborn Act and Michelle's Law. Currently PEHP complies with all of these federal laws with the exception of the Mental Health Parity Act. Amendments made to this part of the federal health care reform bills do not clarify if government plans will have to comply with all four of these specific health care regulations. PEHP is waiting for an answer as they are currently unsure whether or not they will have to comply with the Mental Health Parity Act. If so, this would be an additional cost to PEHP.
