Insured Individuals and Members
Whether you have insurance on your own or are covered by your employer, the law affects your health coverage. Follow the appropriate link below to learn how the law changes dependent coverage, preventive care, preexisting condition exclusions, claims appeal processes, and more.
If you purchase your own health insurance plan, you’ve probably already noticed some major changes due to the Health Care Law. More changes are coming in the future. Some of the provisions that have been or will soon be implemented as part of the new Health Care Law include:
- Individuals will be required to have health insurance or pay a penalty.
- Many single people and working families may receive financial assistance 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. Find out if you are eligible for a subsidy.
- 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 amount 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 pre=existing health conditions.
- 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- Your health plan cannot be rescinded (cancelled retroactively) except in cases of fraud, intentional misrepresentation of material fact, or nonpayment of premium.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 is a new way to buy health insurance called the Health Insurance Marketplace. The Marketplace is open to all individuals who think they may qualify for financial assistance or a subsidy from the government.
- Rates for individual and small group plans (50 or fewer employees) can only 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.
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, the Health Care Law mandates that 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, or if the coverage does not meet minimum coverage and affordability requirements. Employers with fewer than 50 full-time or full-time equivalent employees are not required 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 pre-existing health conditions.
In addition, grandfathered plans are exempt from some of the law’s provisions. They are not required 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 (IBX already complies with this provision)
- Allow women to receive OB/GYN services without a referral (IBX already complies with this provision)
- Establish internal appeals and external review procedures (IBX 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. (IBX 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 Independence Blue Cross health 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 IBX products and services from which to select, and 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, and common questions and answers about the Health Care Law.