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The Affordable Care Act (Obamacare): If You Have Health Insurance

Protections Concerning Health Insurance Policies

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Guarantee Issue: Individual (in the market and in the Exchange) and small group market plans may not exclude coverage based on pre-existing conditions.

Waiting periods for coverage: Plans cannot include waiting periods for coverage to start of greater than 90 days.

Pre-existing health conditions for adults: Existing group, individual (in the market and in the Exchange) and small group market plans can no longer include pre-existing condition exclusions for adults. No new pre-existing coverage exclusions are allowed.

Dependent Coverage: The Act requires insurers to provide dependent coverage for children up to age 26 for all individual and group policies. This includes both new and existing policies.

Pre-Existing health conditions for children:

  • New plans are prohibited from including pre-existing condition exclusions for children.
  • Existing individual and group plans must eliminate pre-existing condition exclusions for children.

Annual Limits: New individual and group health plans are prohibited from placing annual limits on the dollar value of coverage. 

Lifetime Limits: Individual and group health plans are prohibited from placing lifetime limits on the dollar value of coverage. This limitation does not apply to existing individual policies. Group plans must eliminate lifetime limits on coverage.

Rescission: Insurers are prohibited from ending coverage except in cases of fraud. This limitation applies to existing individual and group plans.

Consumer Assistance: States must establish an office of health insurance consumer assistance or an ombudsman program to serve as an advocate for people with private coverage in the individual and small group markets. 

Appeals: For new plans, appeals are standardized, including a right to an independent, external review board. The appeals process will be available even when coverage is canceled.

Minimum Health Insurance Coverage The Act creates an essential minimum health benefits package that provides a comprehensive set of services and limits the annual cost-sharing. All health benefit plans, including plans offered through the Exchanges and plans offered in the individual and small group markets outside the Exchanges, must at least meet the essential health benefits package, except for grandfathered individual and employer-sponsored plans. ( "Grandfather" refers to existing policies issued before March 2010 which have not been changed substantially. They are being allowed to remain in force.)

Abortion coverage cannot be a required part of the essential health benefits package.

Clinical trials: Costs associated with clinical trials have to be covered. Policyholder cannot be discriminated against for being part of a clinical trial. (For more information, click here.

Standardized policies: All new policies (except stand-alone dental, vision, and long-term care insurance plans), including those offered through the Exchanges and those offered outside of the Exchanges, must comply with one of the four benefit categories. Existing individual and employer-sponsored plans do not have to meet the new benefit standards.

Limitation on Deductibles: Deductibles on health plans in the small group market are limited to $2,000 for individuals and $4,000 for families unless contributions are offered that offset deductible amounts above these limits.

Premium Rating: Individual (in the market and in the Exchanges) and small group market premiums are only allowed to vary based on:

  • Age (a maximum of 3 for older people to 1 for younger people)
  • Geographic area
  • Family composition
  • Tobacco use

Prevention: Qualified health plans are required to provide basic preventive coverage without cost-sharing.

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