Caring for Crohn’s Affordable Care Act Primer Part 1: Consumer Rights & Protections

January 4, 2013 at 9:38 pm Leave a comment

The more I write and talk about the Affordable Care Act, the more I realize people actually are not that familiar with the specific details of the law. I will do my best to summarize the important parts and provide you with the implementation dates. However, for real specific questions, you should visit– it’s an invaluable source providing all the information you could ever want on the law. It’s also where I got all of the information below from.

Because the law is so massive, I will be breaking this down into several posts by category: consumer rights and protections, insurance choices and cost, senior services, and employers.  Today’s post will address provisions related to consumer rights and protections.

Consumer Rights & Protections

There are several parts to the Affordable Care Act that are designed to protect consumers from insurance company practices that previously harmed them. These include:

  • Summary of Benefits & Glossary: We are all familiar with the complicated materials insurance companies give you when you enroll in a plan- it’s written in complicated language and hard to follow. However, the Affordable Care Act changes that. Insurance issuers and group health plans are now required to provide consumers with an easy-to-understand summary (called the Summary of Benefits and Coverage) about your plan’s benefits and coverage. Additionally, they also have to provide you with a uniform glossary that explains commonly used words in health insurance. This regulation was designed to help consumers better understand and evaluate their health insurance options. Effective: September 23, 2012 or soon after
  • Consumer Assistance Programs: Before the Affordable Care Act, consumers were on their own to find affordable health insurance or resolve problems with their plan (such as a claim denial or refusal to pay for treatment). The Affordable Care Act created federal grants to help states and territories build Consumer Assistance Programs that offer hands-on assistance to consumers. These programs can help you file complaints and appeals; enroll in health insurance; and become educated about your rights and responsibilities. Grants awarded October 2010
  • Appealing Insurance Coverage Decisions: The Affordable Care Act ensures consumers right to appeal plan decisions. If your plan denies a treatment or payment for service, consumers can ask your plan to reconsider its decision. Additionally, for health plans created after March 23, 2010, new rules detail how your plan must handle your appeal. If your plan still denies your claim after the appeal, the Affordable Care Act allows you to have an independent review organization decide whether to uphold or overturn the plan’s decision. Effective: new plans beginning on or after September 23, 2010
  • Preventive Care: One of the big parts of the Affordable Care Act is the inclusion of affordable preventive care services. The new law makes consumers and their families eligible for preventive services, like screenings, vaccinations, and counseling, at no additional cost. However, there is one catch: this provision sadly only applies to those enrolled in job-related plans or individual health insurance policies created after March 23, 2010. If you are in an eligible plan, the provision should have begun either in the new plan year on or after September 23, 2010. Click here to see a list of all the preventive services that are covered.
  • Prevention Coverage for Women’s Health: Under the Affordable Care Act, women’s preventive care, like mammograms, screenings for cervical cancer, and other services, are covered with no cost sharing for new health plans. On August 1, 2011, additional Guidelines for Women’s Preventive Services were adopted to cover other services, including well-woman visits, contraception, and domestic violence screening and counseling, without cost sharing in new health plans beginning in August 2012. Additionally, under the law, many private plans must cover regular well-baby and well-child visits without cost sharing. Click here to learn more about the women’s preventive services that are covered.
  • Patient’s Bill of Rights: The Affordable Care Act creates a Patient’s Bill of Rights to help put patient’s back in charge of their own health care. The Patient’s Bill of Rights:
    • Provides coverage to Americans with pre-existing conditions: The Affordable Care Act created a Pre-Existing Condition Insurance Plan to ensure coverage for those who were previously denied coverage due to their health conditions. Effective:July 1, 2010
      • Additionally,effective January 1, 2014, insurance companies will be prohibited from refusing to cover an individual because of a pre-existing condition or charging them higher rates due to gender or health status.
    • Protects your choice of doctors: by guaranteeing that consumers can choose any primary care doctor or pediatrician that is in your plan’s network. It also guarantees consumer’s ability to see an OB-GYN without a referral.
    • Keeps young adults covered: The Affordable Care Act allows parents to keep or add their children onto their health insurance plans until they turn 26. Children who are married, not living at home, attending school, not financially dependent on their parents, or eligible to enroll in their employer’s plan are all eligible under the provision. Effective: health plan years beginning on or after September 23, 2010
    • Ends lifetime limits on coverage: Previously, insurance companies could set a limit on the total lifetime benefits you received from them. For example, they could impose a total dollar limit on benefits or limits on specific procedures. Once that limit was reached, the insurance plan wouldn’t pay for those services. The Affordable Care Act changes that by eliminating lifetime limits- essential for IBD patients who undergo many expensive procedures and tests yearly. Effective: health plan years beginning on or after September 23, 2010
    • Ends pre-existing condition exclusions for children: Similar to the other pre-existing condition provision, plans that cover children, beginning on or after September 23, 2010, can no longer exclude, limit, or deny coverage of a child under 19 years of age based on a health problem or disability developed before you applied for coverage.
    • Ends arbitrary withdrawals of insurance coverage: Insurers can no longer rescind coverage because of an honest mistake or left out information on your insurance application. It can only rescind coverage if they find you intentionally lied on your application or failed to pay premiums. If they do rescind it, they must give you 30 days notice to give you time to find new insurance. Effective: health plan years beginning on or after September 23, 2010
    • Reviews premium increases: Insurance companies must now publicly justify unreasonable rate increases. The new law ensures that any large proposed increases will be evaluated by experts to make sure they are based on reasonable cost assumptions and solid evidence.
    • Helps you get the most from your premium dollars: The new law requires insurance companies spend consumer’s premium dollars primarily on health care by enforcing an “80/20” rule. In other words, insurers selling policies to individuals or small groups must spend at least 80 percent of premiums on direct medical care and efforts to improve quality of care. Insurers selling to large groups must spend 85 percent of premiums on care and quality improvement. If an insurer exceeds what they are allowed to spend on things other than care and quality, it must provide a rebate of the portion of premium dollars that exceeded the limit. Effective: January 1, 2011
    • Restricts annual dollar limits on coverage: Like lifetime limits, the law restricts and phases out annual dollar limits a health plan can place on most benefits. It does away with these limits entirely on January 1, 2014.
    • Removes barriers to emergency services: Under the new law, consumers can seek emergency care at an out-of-network hospital without prior approval.
  • Grandfathered Plans: The new law exempts most plans that existed on March 23, 2010 from some of the law’s consumer protections. This preserves consumers’ rights to keep the coverage they already had before the law was signed into effect. Provisions that apply to grandfathered plans include:
    • Prohibition of applying lifetime dollar limits to key health benefits;
    • Inability to cancel insurance due to an honest mistake on the application; and
    • Extending dependent coverage to children until they turn 26. However, for this provision in grandfathered plans, until 2014, grandfathered group plans do not have to offer coverage for young adults up to 26 if they are eligible for group coverage outside of their parent’s plan.

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The ABC’s of Crohn’s & UC: “O” & “P” Caring for Crohn’s Affordable Care Act Primer Part 2: Insurance Choices & Costs

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Brian Greenberg

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