Health Care Reform: What HMSA Members Need to Know
The following are provisions of the national health care reform law that may impact
HMSA members. The provisions are listed under the dates of their enactment.
- Lower costs. There will be no lifetime limits on how much health
plans cover for essential health
benefits. For plan years beginning
on or after Sept. 23, 2010, the federal government has set restricted annual limits
for essential health benefits. The rules will phase out the use of annual dollar
limits over the next three years until 2014, when the Affordable Care Act bans them
for most plans. Plans issued or renewed beginning Sept. 23, 2010, will be allowed
to set annual limits not lower than $750,000. This minimum limit will be raised
to $1.25 million beginning Sept. 23, 2011, and to $2 million beginning Sept. 23,
2012. These limits apply to all employer plans and all new individual market plans.
- Protection from loss of coverage. HMSA members will not be dropped
from coverage retroactively except in cases of fraud, intentional misrepresentation,
or failure to pay dues on time.
- More choices. HMSA members will be allowed to choose any participating
primary care provider (PCP) who is accepting new patients. The same applies for
parents choosing a pediatrician for their child. Women will be allowed access to
a participating ob-gyn without a referral.
- Extension of dependent coverage. Dependents will be allowed to
stay on their parents’ health plan until age 26.
- Pre-existing conditions. Starting in September 2010, individuals
under the age of 19 will not be denied coverage based on a pre-existing condition.
This requirement extends to all individuals starting in 2014.
- Preventive care. New health plans will cover
preventive health services at no charge.
- Web portal. The federal government will establish a new website
this year with information about affordable, comprehensive health care coverage
to help consumers choose a health plan.
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Medical Loss Ratio
Health plans must notify every member who purchased coverage about the plan’s health
care spending. This is known as the medical loss ratio provision (MLR). Insurers
that fail to meet the MLR standard for health care spending are required to issue
rebates to members and businesses.
HMSA surpassed the MLR requirements by spending 90.5 percent of large
employer dues on health care, 87.5 percent of small business plan
dues, and 92.2 percent of individual plan dues.
For more information, read the Medical Loss Ratio FAQs.
Preventive Health Services
Health plans (non-grandfathered) are required to cover the following preventive
health services for women without cost share. These preventive services are in addition
to the preventive
health services announced in 2010. Coverage for these services started
July 1, 2012.
- Screening for gestational diabetes for pregnant women between 24 and 48 weeks gestation
and at first prenatal visit for women at high risk for diabetes.
- High risk human papillomavirus (HPV) DNA testing for women age 30 and older every
three years for cervical cancer.
- Annual counseling on sexually transmitted infections (STIs) for all sexually active
women regardless of STI risk.
- Annual HIV screening and counseling for all sexually active women.
- Breastfeeding support and counseling, and rental costs for breastfeeding equipment.
- Annual wellness preventive care visit.
- Annual screening and counseling for interpersonal and domestic violence.
- FDA-approved contraception methods and sterilization procedures as prescribed, along
with education and counseling.
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- Exchange. Employers with up to 100 employees will have access to
the state-based Small Business Health Options Program (SHOP) exchange. The exchange
will include Web portals with standardized information to help with comparing and
purchasing health plans.
- Mandatory coverage. People who do not purchase a health plan may
be fined. The fine will be levied based on a flat dollar amount or a percentage
of the person’s income. Starting in 2014, the lowest fine would be $95 per individual
per year, or 1 percent of a person’s income. By 2016, the fine will increase up
to $695, or 2.5 percent of a person’s income.
- Financial relief. People with incomes under 400 percent of the
federal poverty level may be eligible for tax credits from the federal government
to help pay for their health care plan. There will also be a reduction in the maximum
out-of-pocket amount people under 400 percent of the poverty level have to pay.
A cost-sharing subsidy for out-of-pocket health care costs will also be available.
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This information is based on HMSA’s review of the national health care reform
legislation. This overview is intended for educational purposes and should not be
used as tax, legal or compliance advice. Interpretations of the legislation vary
and some reform regulations differ for particular members enrolled in certain groups.
HMSA will continue to present and update information related to national health
care reform as additional guidance becomes available.