Exec Summary - Consumer Protections

Health Reform Consumer Protections


Who:  Anyone covered by an individual or group insurance policy.  All fully insured and self-insured plans may be affected.  Persons covered by “grandfathered” plans may not have all of the new coverages or consumer protections available to them.   


When: On September 23, 2010 many of the consumer protections took effect for new insurance purchases or upon renewal of an existing policy.  Some coverages and consumer protections start on a later date – see dates in Executive Summary.  


Executive Summary:  When purchasing a new policy or when a new plan year begins, the following coverage expansions and consumer protections will apply starting September 23, 2010 (or later as indicated):


All Plans (including Grandfather plans):

(1)         Prohibition on rescissions of coverage based on a mistake on an application;

(2)         Ban on lifetime dollar limits on benefits;

(3)         Restriction on the use of annual dollar limits on coverage;

(4)         Access to dependent coverage for adult children under the age of 26, if they don’t already have access to their own job-based coverage;

(5)   Distribution of Uniform Notice of Coverage:

(6)         Prohibition on the denial of children because of a pre-existing condition (Adults in 2014);

(7)      Cost Loss Ratio Requirements: (Beginning January 1, 2011);

(8)      Waiting Period Restrictions (Beginning January 1, 2014);


All Plans (Grandfather Plans Exempt):

(9)         Coverage of preventive services with no deductible, copayment, or coinsurance;

(10)     Choice of any available primary care doctor or pediatrician in a plan’s network;

(11)     Access to an OB/GYN without a referral;

(12)     Access to out-of-network emergency care without prior authorization or higher cost sharing than would otherwise be charged;

(13)     Improved appeals processes;

(14)     Information reporting to HHS regarding claims, enrollment, claims denied, rating practices, non-network cost-sharing, and enrollee and participant rights;

(15)     Employer Annual Reporting Requirements regarding Quality of Care (March 23, 2012);

(16)     Non-Discrimination. Fully-Insured employer plans must not establish any eligibility rules, or levels of coverage that discriminate in favor of higher-wage employees;

(17)     Mandated Claims Appeals Process: an external procedure to review disputed claims;

(18)     Guaranteed Availability and Renewability of Coverage. (January 1, 2014);

(19)     No Discrimination Based on Health Status (January 1, 2014);

(20)     Mandated Cost-Sharing Limits: health plans must limit cost-sharing amounts (January 1, 2014); and

(21)     Mandated Coverage for Clinical Trials. Health plans must provide coverage for routine costs associated with clinical trials. (January 1, 2014).


Action Required:  Employers need to decide if they meet or will maintain a grandfathered status. There are new reporting requirements that employers will have to satisfy. Most employers will want to discuss the legislation and requirements with their agents or consultant.   


The information presented and contained within this article was submitted by Ronald E. Bachman, President & CEO of Healthcare Visions. This information is general information only, and does not, and is not intended to constitute legal advice. You should consult your legal advisors to determine the laws and regulations impacting your business.