A major goal of the Affordable Care Act (ACA)—the health care reform legislation President Obama signed into law on March 23, 2010—is to put American consumers back in charge of their health coverage and care.
The Patients’ Bill of Rights helps Americans with pre-existing conditions gain and keep coverage, as well as protect doctor choices and end lifetime limits on the care consumers may receive.
If your company sponsored a plan before March 23, 2010, it may be considered a “grandfathered” plan. Grandfathered plans are exempt from certain health care reform requirements, such as no cost-sharing for preventive care and other patient protections. You should look through your plan’s documents that describe benefits, such as your summary plan description, to determine if your plan is grandfathered.
The purpose of the ACA’s Patients’ Bill of Rights is to help Americans with pre-existing conditions gain and keep coverage, as well as to protect all Americans’ choice of doctors and end lifetime limits on the care consumers may receive.
The Patients’ Bill of Rights regulations detail a set of protections that apply to health coverage starting on or after Sept. 23, 2010. They are:
No Pre-existing Condition Exclusions. Health plans cannot deny coverage based on pre-existing conditions. This ban includes both benefit limitations and outright coverage denials (for example, when the insurer refuses to offer a policy because of the individual’s pre-existing medical condition). These rules apply to all types of insurance except for individual policies that are grandfathered.
No Arbitrary Rescissions of Insurance Coverage. Previously, insurance companies were able to retroactively cancel your policy when you become sick or if you or your employer made a mistake on your paperwork.
Under the regulations, insurers and plans are prohibited from rescinding coverage—for individuals or groups of people—except in cases involving fraud or an intentional misrepresentation of material facts. Insurers and plans seeking to rescind coverage must provide at least 30 days’ advance notice to give people time to appeal. There are no exceptions to this policy.
No Annual or Lifetime Dollar Limits on Coverage. This regulation prohibits the use of lifetime dollar limits on essential health benefits in all health plans and insurance policies issued or renewed on or after Sept. 23, 2010. Annual dollar limits on what an insurance company will pay for health care are also prohibited, beginning with the 2014 plan year. Protections against annual limits apply to most health plans, but they don’t apply to grandfathered individual health plans. Insurance companies can still set a yearly dollar limit of $2 million for plan years or policy years starting before Jan. 1, 2014.
Protecting Your Choice of Doctors. Health plan members are free to designate any available participating primary care doctor as their primary care provider, meaning parents can choose any available participating pediatrician to be their children’s primary care provider. Also, health plans cannot require female participants to get referrals from primary care providers before they can get obstetrical or gynecological care from specialists. These policies apply to all individual market and group health insurance plans except those that are grandfathered.
Removing Insurance Company Barriers to Emergency Department Services. Some insurers will only pay for health care provided by a limited network of providers—and some used to extend this requirement to emergency health services. Others required prior approval before receiving emergency care at hospitals outside of their networks. The ACA limits the amount of cost-sharing for emergency services received out-of-network. This policy applies to all individual market and group health plans except those that are grandfathered.
Photo by Patrick Denker