Insured Individuals and Members
Whether you have insurance on your own or are covered by your employer, the law affects your coverage. Follow the appropriate link below to learn how the law changes dependent coverage, preventive care, preexisting condition exclusions, claims appeal processes, and more.
I have insurance on my own
If you purchase your own health plan, you’ve probably already noticed some major changes due to the health care law. More changes are coming in the future. Here are some of the provisions that have been or will soon be implemented as part of the new health care law:
- People will be required to have health insurance or pay a penalty
- Many single people and working families may get money from the government to help pay a portion of the monthly premium costs and some will also receive assistance with paying for ways in which costs are shared.
- Health plans offered to people who purchase health insurance on their own must include 10 core benefits, know as essential health benefits.
- There are no lifetime or annual dollar maximums on what health plans can spend by providing essential benefits or prescription drug benefits.
- Some designated preventive care services are covered at 100 percent, so you do not have to pay cost-sharing fees, such as deductibles, copayments, or coinsurance, when you receive these services.
- The law creates four levels of coverage or metallic tiers for plans offered to people who purchase their own insurance. Plans will be assigned to metallic tiers — bronze, silver, gold and platinum — based on how much of the cost of health care services is covered by the health insurance company.
- Dependents can be covered to age 26.
- Health insurance companies cannot deny coverage to people because they have health problems.
- Health insurance companies must enhance their internal appeals and external review processes.
- Your health plan cannot be rescinded (cancelled retroactively) except in cases of fraud, intentional misrepresentation of material fact, or nonpayment of premium.
- Many state Medical Assistance programs, also known as Medicaid, are expanding by offering health plans to more people who are uninsured. At this time, Pennsylvania has not decided whether it will expand the state Medical Assistance program.
- There will be a new way to buy health insurance called the Health Insurance Marketplace.
- Rates for individual and small group plans (50 or fewer employees) will be based on who will be covered under the health plan, their age, where they live, whether they use tobacco, and the health plan selected.
I have insurance through my employer
If you work for a large company or organization that provides your health insurance today, most likely you will continue to get your insurance through them in the future.
However, you may notice some changes depending on certain factors, such as: the size of your employer, how much employees are paid, the type of coverage the company currently provides, and whether your employer-based plan has qualified for “grandfathered” status.
If you work for a company with 50 or more full-time employees, your employer must provide health insurance, and the plan it offers must meet minimum coverage and affordability requirements. Starting in 2015, your employer may be assessed a penalty if they do not offer coverage at all or if the coverage is not minimum or affordable. Employer with less than 50 full time or full time equivalent employees do not have to offer health insurance and will not be assessed a penalty.
If you have a “grandfathered” plan, your employer must meet some but not all provisions of the health care law. For example, grandfathered plans are subject to the following provisions:
- They cannot set lifetime or annual dollar limits on coverage of essential health benefits.
- They cannot retroactively cancel your coverage except in cases of fraud, intentional misrepresentation of material fact, or nonpayment of premium.
- They must cover dependents until they reach 26 unless they are eligible for coverage elsewhere. By 2014, they must offer dependent coverage even when those dependents have other insurance options.
- They cannot deny coverage to children under age 19 who have preexisting health conditions.
In addition, grandfathered plans are exempt from some of the law’s provisions. They do not have to:
- Eliminate cost-sharing requirements for certain preventive care services
- Meet nondiscrimination testing requirements for group health plans
- Allow pediatric members to have pediatricians as their primary care physician (IBC already complies with this provision)
- Allow women to receive OB/GYN services without a referral (IBC already complies with this provision)
- Establish internal appeals and external review procedures (IBC already complies with this provision);
- Allow members to seek emergency services without preauthorization whether members seek services from network or out-of-network providers. In addition, members’ cost-sharing fees must be the same for in network and out-of-network providers. (IBC already complies with this provision)
Large employers even those that do not have grandfathered status, do not have to provide essential health benefits or cover 100 percent of the cost of certain preventive services.
You can have peace of mind if your employer offers an IBC plan. We make sure our plans comply with the provisions of the new law as they go into effect. In fact, we incorporated many provisions long before their implementation dates. Your company’s benefits administrator has a broad portfolio of IBC products and services from which to select. He or she can answer any questions you have about how the health care law affects your coverage.
For more information
Visit the Key Provisions section to see specific parts, or provisions, of the health care law. Click on the Frequently Asked Questions section for more in-depth information about some of the law’s major provisions.
Fewer than 25 full-time employees and average annual wages of less than $50,000.
The prescription drug coverage program offered under Medicare.
A Medicare program to help people with limited income and resources pay Medicare prescription drug program costs, such as premiums, deductibles, and coinsurance.
A method of cost-sharing in a health insurance policy that requires a group member to pay a stated percentage of all remaining eligible medical expenses after the deductible amount has been paid.
These services are covered under reform at 100 percent meaning without copayment, and they are valued as helping to improve overall health and reduce health care expenses. They include child immunizations, breast/prostate/cervical/colon cancer screening, bone mass measurement, and routine physical exams.
A retroactive cancellation that treats the coverage as void from the time of enrollment or a cancellation that voids benefits previously paid before the cancellation.
Any condition, illness, or injury for which medical advice or treatment was recommended or received before a person obtains health insurance. Examples include diabetes, heart disease, and cancer. Most health plans, even grandfathered ones, already may not deny coverage of or benefits to children under age 19 who have a pre-existing health condition; this extends to adults in 2014. Certain enrollment period limitations apply.
Part of traditional Medicare but offered through private insurance companies. MA plans can include a variety of health plans such as HMO or PPO, prescription drug plans, as well as wellness and prevention benefits. Approximately 10 million, or 25 percent of Medicare-eligible seniors are enrolled in Medicare Advantage plans.
A set of health care service categories that must be covered by certain plans, starting in 2014, including doctor office visits, hospitalizations, and prescriptions. Insurance policies must cover these benefits to be certified and offered in exchanges, and all Medicaid plans must cover these services by 2014.
An account that withholds pre-taxed income in reserve for health-related expenses. Expenses for over-the-counter medications and drugs (excluding insulin and doctor-prescribed medications) will no longer be a distribution used for qualified medical expenses, eligible for tax-free payment or reimbursement, effective January 2011.
An account that withholds pre-taxed income in reserve for health-related expenses. A tax penalty on distributions from HSAs that are not used for qualified medical expenses increases from 10 percent to 20 percent in 2011. Expenses for over-the-counter medications and drugs (excluding insulin and doctor-prescribed medications) will no longer be a distribution used for qualified medical expenses, eligible for tax-free payment or reimbursement.
An account that withholds pre-taxed income in reserve for health-related expenses. Expenses for over-the-counter medications and drugs (excluding insulin and doctor-prescribed medications) will no longer be a distribution used for qualified medical expenses, eligible for tax-free payment or reimbursement from any of these accounts, effective January 2011. A tax penalty on distributions from MSAs that are not used for qualified medical expenses increases from 15 to 20 percent of the amount includable in gross income.
An employee health spending account funded and owned by the employer. HRAs can be used to reimburse employees for certain qualified health services and expenses not covered by the company's health plan, including copayment, coinsurance, and deductibles. Funds remaining in the account at year-end go back to the employer. . Expenses for over-the-counter medications and drugs (excluding insulin and doctor-prescribed medications) will no longer be a distribution used for qualified medical expenses, eligible for tax-free payment or reimbursement.
A health plan under which an employer or group sponsor is financially responsible for paying plan expenses, including claims made by group plan members.
A gap in Medicare Part D prescription drug coverage that, under reform, provides recipients not already receiving Medicare Extra Help who reach the gap, with a one-time rebate for biologic drug expenses at varying rates: $250 in 2010, 50 percent of gap expense coverage in 2011, and additional discounts in successive years, until the gap coverage phases down to 25% in 2020.
The reform law establishes financial assistance, on a sliding scale for individuals and families with incomes from 133 to 400 percent of the federal poverty level, to help people buy coverage through the exchanges.
A national or state-by-state marketplace where consumers and small businesses can shop simply and quickly for health insurance, comparing products and prices. Exchanges would work with state insurance departments to set and enforce insurance reforms and protections. If a public plan is offered, it would be included in the health exchange, along with private insurance plans.
Individual and group health plans issued on or before March 23, 2010 are “grandfathered” and do not have to comply with some of the provisions of the new law. If an existing health plan changes, however, it my lose its grandfathered status.
Generally determined by the Internal Revenue Service as one of 5 highest paid officers, a 10 percent stakeholders in a business, or among the top 25 percent of employees ranked by compensation within a business. Fully insured group plans are prohibited from establishing eligibility rules for coverage that favor highly compensated individuals. The benefits under such plans may not discriminate in favor of this group either. Grandfathered plans are exempt.
A substance made from a living organism or its products and is used in the prevention, diagnosis, or treatment of disease. Biological drugs include antibodies, interleukins, and vaccines.