Understanding
Health Care Reform

Blue Cross of Northeastern Pennsylvania
Can Help You Prepare

For Members For Employers
A Timeline for You and Your Family
We know you are busy with important things like working and taking care of your family. BCNEPA can provide the information and resources you need to better understand changes due to Health Care Reform.

Blue Cross of Northeastern Pennsylvania is committed to helping you understand changes to your health insurance.

We’ve put together a timeline of key provisions of the Health Care Reform bill. We have also compiled a list of frequently asked questions and answers. We also provide links to information from a variety of sources that can help guide you on what to do next. To see the entire Act, go to the U.S. Department of Health & Human Services (HHS) website at www.healthcare.gov.

As the provisions evolve and additional guidance is released from the government, we encourage you to visit our website often for updates.

2010 Provisions

Dependent Coverage to Age 26

All health insurance plans that cover dependents must make coverage available to children up to age 26, regardless of whether the adult dependent is married or a student.

  • The provision does not apply to the child of a dependent (e.g., grandchild).
  • Grandfathered group health plans are not required to cover adult dependents who are eligible to enroll in other employer-sponsored group health plans.
  • This provision was effective for plan years beginning on or after September 23, 2010.
What do you need to know?
  • Blue Cross of Northeastern Pennsylvania decided to close the gap and made dependent coverage available even earlier for individuals and fully-insured group plans, starting on June 1, 2010.
  • This coverage is also available, but optional, for customers with self-insured plans.

Elimination of Lifetime Dollar Limits

All health insurance plans are prohibited from imposing lifetime limits on the dollar value of "essential health benefits."

  • Health Care Reform provides a list of general categories to be covered under "essential health benefits," including:
    • Ambulatory patient services
    • Emergency services
    • Hospitalization
    • Maternity and newborn care
    • Mental health and substance abuse disorder services
    • Prescription drugs
    • Rehabilitative and habilitative services and devices
    • Lab services
    • Preventive and wellness services
    • Chronic disease management
    • Pediatric services, including oral and vision care
  • Essential health benefits for Pennsylvania were set by the U.S. Department of Health and Human Services based upon the largest small group health insurance plan in our state. The benefits and services included in the benchmark health insurance plan is the "essential health benefits" package.
  • Lifetime dollar limits on non-essential covered benefits may continue, if permitted under applicable law.
  • This provision was effective for plan years beginning on or after September 23, 2010, for all health plans.
What you need to know:
  • Blue Cross of Northeastern Pennsylvania already offers health insurance plans with unlimited lifetime and annual dollar limits on the essential benefits we cover.
  • For more information on essential health benefits, visit the HHS website.

Emergency Services Coverage

Non-grandfathered plans that cover hospital emergency services must cover those services without requiring prior approval, regardless of whether the provider participates in the health plan's network.

  • Cost-sharing amounts for out-of-network emergency services must be the same as those applied to network services.
  • Out-of-network providers are permitted to bill employees for any balance between the insurer's allowed amount and the providers’ billed charges.
What you need to know:
  • Blue Cross of Northeastern Pennsylvania has long been in compliance with this requirement.
  • Please review your policy and outline of coverage for your specific cost-sharing responsibilities. (Note: if you receive emergency services from a non-network pro­vider, the provider may also bill you for the difference between the plan payment and the provider’s billed charges.)
  • See the final rule and proposed rule on this provision, published in the Federal Register on June 28, 2010.

“Grandfathered” Plans…What Does It Mean?

If your current health insurance plan design offering was in effect on March 23, 2010, you would have been eligible for “grandfathered” status, which means you could be exempt from the following reform provisions:

  • Covering preventive services in full
  • The adult dependent coverage mandate
  • Non-discrimination rules for insured groups
What you need to know:
  • We administer self-insured plans and have determined they are eligible for grandfathered status.

Internal Appeals/External Reviews

As of October 1, 2010, all health insurers and group health plans, except grandfathered plans, must have internal appeals processes and external review processes in place for reviewing adverse benefit determinations.

What do you need to know?
  • Our claims appeal process includes both an internal and external review process for all health insurance plans we offer.

Limitations on Rescissions

All health plans are prohibited from rescinding coverage once an employee or dependent is covered, except when the individual has engaged in fraud or made an intentional misrepresentation of a material fact under the terms of the health plan or policy.

  • Plans that intend to rescind coverage must give the employee advance, written notice at least 30 days before the termination.
  • This provision was effective for plan years beginning on or after September 23, 2010, for all health plans.
What you need to know:
  • Blue Cross of Northeastern Pennsylvania has a longstanding policy of rescinding a member’s coverage only in cases of fraud or intentional misrepresentation.

No Discrimination in Favor of Highly Compensated Individuals

This rule prohibits fully-insured group health plans, except grandfathered plans, from discriminating in favor of employees who are highly compensated individuals with respect to participation and benefits in a group health plan.

  • Although this provision was initially effective for plan years beginning on or after September 23, 2010, the federal regulatory agencies have delayed implementation until further guidance is provided.
What you need to know:
  • When final regulations become available, we will reach out to remind employers to review your benefit plans to ensure they are compliant and make any necessary changes to your health plan documents.

No Pre-Existing Condition Exclusions on Children Under Age 19

No health plan may deny coverage or benefits to children under age 19 who have a pre-existing condition.

  • This provision was effective for plan years beginning on or after September 23, 2010, and will be expanded to apply to all those enrolling in health insurance plans in 2014..
What you need to know:
  • We are pleased to inform you that our group benefit plans are already compliant with this requirement. Our individual plans will also be in compliance with this requirement for 2014.
  • For additional information on children’s pre-existing conditions, visit the HHS website.

Preventive Services Coverage

Non-grandfathered plans must cover certain preventive care services, as recommended by governmental agencies and non-profit entities, without any employee cost-sharing, when they are given by a network provider.

  • Additional guidelines related to coverage of women's preventive services apply to plan years starting on or after August 1, 2012.
  • A new proposed rule regarding coverage of contraceptives was recently released by the HHS and Departments of Treasury and Labor to address concerns raised by both religious employers and eligible, non-profit employers with a religious purpose. For more details, you can read the proposed rule on the Federal Register website.
What you need to know:

Provider Choice

Non-grandfathered plans that require the employee to choose a Primary Care Physician (PCP) must permit the member to designate any PCP or pediatrician who is available to accept the employee.

  • Health plans that provide coverage for Obstetrics and Gynecology (OB/GYN) care may not require a referral from a PCP before a member gets OB/GYN care from a network OB/GYN specialist.
What you need to know:
  • As part of our commitment to providing our members with access to high quality, affordable health care, we’re pleased to tell you that Blue Cross of Northeastern Pennsylvania has long been in compliance with this requirement.

Restrictions on Annual Dollar Limits

All health plans may impose only a restricted annual limit on the dollar value of essential benefits before plan years beginning on or after January 1, 2014.

  • Effective for plan year renewals after October 2010, BCNEPA has removed both lifetime and annual dollar limits from essential benefits.
  • For plan years after January 1, 2014, plans will not be allowed to impose any annual dollar limits on essential health benefits.
What do you need to know?
  • Blue Cross of Northeastern Pennsylvania already offers health insurance plans with unlimited lifetime and annual dollar limits on essential benefits.
  • For more information on annual dollar limits of essential benefits, visit the HHS website.