Effective in 2010
- Small-business Tax Credits
- Donut Hole Rebates
- Grandfathering
- Change in Medicare Enrollment Period
- Early Retiree Reinsurance
- High Risk Pool/PA Fair Care
- 100 percent coverage for preventive care
- Internal Appeals and External Reviews
- Choosing doctors
- Extension of Coverage for Dependents to age 26
- Elimination of lifetime maximums and restrictions on annual limits
- Coverage for Emergency Services
- Non-discriminatory Plans
- Prohibition of pre-existing condition exclusions for children under 19
- Quality of Care Reporting
- Rescissions Ban
Small-business tax credits (effective tax year 2010)
Applies to: Businesses
What are the small-business tax credits?
The small-business health care tax credit provides a sliding-scale credit your business can claim starting with the 2010 tax return for qualified small employers who provide health insurance to their employees. Eligible small employers may qualify for a credit worth up to 35% of premiums they paid in 2010.
What does it mean to me?
If your small-business meets the requirements, you can file for the tax credit beginning with your 2010 tax return. Check out this small business tax calculator to learn how much you can save.
Grandfathering (effective March 23, 2010)
Applies to: Businesses and Individuals
What is grandfathering?
Individual and group health plans issued on or before March 23, 2010, can be "grandfathered," which means they can keep their current plans intact and do not have to comply with some of the provisions of the new law, such as 100 percent coverage of preventive care. Plans must meet the following criteria to be grandfathered:
- benefits to diagnose or treat a particular condition are not terminated;
- no increases in coinsurance;
- increases in deductibles or co-payments must meet the cost-adjustment test established by the reform law;
- no decreases in the amount of the employer subsidy toward the total cost of the premium that exceed 5 percent.
- an insured plan can retain its grandfather status if it changes its carrier, as long as the benefits provided by the new carrier continue to satisfy the grandfathering requirements, and the change of carriers did not occur between September 23 and November 16, 2010.
What does this mean to me?
Health insurers do not decide the grandfathering status for employers. Because we cannot provide you with professional advice, employers may want to consult with their attorney or tax adviser to determine whether their plan is allowed to maintain grandfathering status.
Where can I learn more?
Grandfathering frequently asked questionsDonut hole rebates (effective March 23, 2010)
Applies to: Individuals
What is the donut hole rebate?
Effective this year, beneficiaries with Medicare Part D who reach the "donut hole" will receive a one-time, non taxable $250 rebate. The donut hole is the gap reached when Part D prescription drug costs go over $2,830. At that point, you are responsible for the entire cost of your prescription drugs (versus making copayments) – at least until your out-of-pocket costs reach $4,550.
In January 2011, Part D enrollees who enter the donut hole will receive a 50% discount on brand-name and biologic drugs in the coverage gap.
What does it mean to me?
2010: If you're receiving Medicare benefits and are not already receiving Medicare Extra Help and your prescription drug coverage reaches the donut hole in 2010, you will automatically be mailed a one-time $250 rebate check. There is nothing you need to do. Checks are being mailed monthly throughout the year as beneficiaries reach the "donut hole."
2011: The 50% discount will be applied to all brand-name and biologic drugs in the donut hole. This can mean significant out-of-pocket savings for you.
In the future: Medicare will phase in more discounts on brand-name and generic drugs until your coinsurance in the donut hole phases down to 25 percent in 2020.
Where can I learn more?
IBXmedicare.comEarly-retiree reinsurance (effective June 1, 2010)
Applies to: Businesses
What is the early-retiree reinsurance?
The U.S. Department of Health and Human Services (HHS) will reimburse participating employment-based programs for a portion of the cost of providing health coverage to early retirees (age 55 or older, non-active employees, ineligible for Medicare) and eligible spouses, surviving spouses, and dependents.
What does this mean to me?
Eighty percent of retiree claims between $15,000 and $90,000 within employer-based health plans will be reimbursed.
Where can I learn more?
If your company meets the eligibility requirements, you may apply now for the temporary early retiree reinsurance program through the Health and Human Services website, where you'll find the application and fact sheets, FAQs, and instructions. However, keep in mind that there is a limited amount of money available and that thousands of applications have already been submitted.
100 percent coverage for preventive care (effective October 1, 2010)
Applies to: Businesses, Individuals and Providers
What is 100 percent coverage for preventive care?
Individual, group, and self-funded health insurance plans must cover certain preventive care services without member cost-sharing. Grandfathered plans are exempt.
What does this mean to me?
IBC members will not be charged for certain preventive care services, such as cancer screenings or child immunizations.
What is IBC doing to help?
All non-grandfathered plans will now include 100 percent coverage for preventive services. For small employers, Independence Blue Cross recently introduced Blue Solutions, a new suite of products that comply with health care reform and are designed specifically for the needs of small employers.
Where can I learn more?
Blue SolutionsExtension of coverage for dependents to age 26 (effective October 1, 2010)
Applies to: Businesses and Individuals
What is the extension of health care benefits for dependents to age 26?
Generally, all group plans that offer dependent coverage must make that coverage available until the dependent’s 26th birthday, regardless of the dependent’s marital or student status. As an exception to this general rule, until 2014, grandfathered group plans are not required to cover adult dependents if the adult dependent is eligible for coverage through the adult dependent’s employer.
What does it mean to me?
If your current plan includes dependent coverage, you will be able to keep/add dependents on your policy until they reach the age of 26. As discussed above, if you are a grandfathered plan you may not have to cover adult dependents to 26 if the adult dependent is eligible for coverage through the adult dependent’s employer.
When is coverage to 26 effective?
Check with your benefits administrator about when your extension of dependant coverage is effective. Generally, health care reform became effective for plan years that began on or after September 23, 2010. For most of Independence Blue Cross’s groups, health care reform, including coverage of dependents to 26, becomes effective when the group renews its coverage with IBC after September 23, 2010. For example, if a group renewed with IBC on October 1, 2010, health care reform, including coverage of dependents to 26, became effective on October 1, 2010. As another example, if a group renews with IBC on July 1, 2011, health care reform, including coverage of dependents to 26, will become effective on July 1, 2011.
How to reinstate your child’s coverage.
Individuals under the age of 26 who were denied coverage (or were not eligible for coverage), because of age or a change in student status, are eligible to reenroll in their health plan. Individuals may request enrollment for their dependent children for 30 days from the date of notice. Enrollment will be effective retroactively to the first day of the first plan year or the anniversary of the plan’s renewal beginning on or after September 23, 2010. For more information, contact your plan administrator.
Where can I learn more?
If you have an individual plan and have dependent children over age 26 in need of health insurance, be sure to visit ibx4you.com, or call 1-800-263-1410 for more information about our individual coverage options, or visit Dependent to age 26 FAQs.
If you are covered through your employer’s health plan, your benefits administrator can tell you when your plan renews and when your adult dependents can be added to your coverage.
Non-discriminatory plans (effective October 1, 2010)
Applies to: Businesses
What does the law say about nondiscriminatory plans?
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.
What does this mean to me?
Employers with non-grandfathered fully insured group health plans will need to make sure that their benefits plans comply with this provision beginning on the first renewal after September 23, 2010.
Rescissions ban (effective October 1 2010)
Applies to: Businesses and Individuals
What is the ban on rescissions?
A new ban on rescissions prohibits all health plans – even grandfathered plans – from rescinding coverage of subscribers, except in cases involving fraud, nonpayment of premium, or intentional misrepresentation of material facts under the terms of the health plan.
What does this mean to me?
You may not be retroactively cancelled from your plan unless you provide fraudulent information or do not pay your premiums. Prior notice must be provided at time of cancellation, and any cancellation must not violate the law.
What is IBC doing to help?
Independence Blue Cross remains in compliance with the new law and does not rescind coverage except in cases where a subscriber has committed fraud.
High-risk pool/PA Fair Care (effective July 2010)
Applies to: Individuals
What is the high-risk pool?
The pool provides temporary, transitional health coverage to U.S. citizens and nationals, lawfully present in the United States, who have been uninsured for at least six months, have a preexisting medical condition, and are unable to afford or have access to individual coverage in the period before health insurance exchanges are operating in 2014.
What does this mean to me?
Funding is limited for this program; the pools are scheduled to remain available until January 1, 2014, or until funding exhausts. If you qualify, apply now.
Where can I learn more?
PA Fair CareChange in Medicare enrollment period (effective March 23, 2010)
Applies to: Individuals
What is the change in the Medicare enrollment period?
People with Medicare can enroll in a Medicare Advantage plan or Part D plan during the six-week annual election period (AEP), from November 15 through December 31 for 2010, and from October 15 through December 7 for every year after. Previously, you could also switch plans – from one carrier's plan to another or within the same carrier – during the open enrollment period (OEP), from January 1 through March 31. Beginning in 2010, however, the only time most seniors may enroll in a Medicare Advantage Plan is during AEP.
What does this mean to me?
Seniors may no longer switch plans during the OEP (January 1 through March 31), but a new disenrollment period will extend for 45 days at the start of each year, from January 1 through February 15, when Medicare Advantage enrollees may drop their plans for Original Medicare and enroll in a stand-alone Part D plan. But once most seniors leave Medicare Advantage, they may not reenroll until the next AEP. Medicare Advantage and Part D carriers post the next year's plans and benefits online, usually in October of the prior year; at that time, you should talk to your insurance company, conduct your research, and make the best decision given your circumstances.
What is IBC doing to help?
Independence Blue Cross helps you navigate the complexities of health care reform's effect on seniors on our website where you can compare plan options, find a pharmacy, learn more about Medicare, and more.
Where can I learn more?
IBXmedicare.comMedicare.gov
Internal appeals and external reviews (effective October 1, 2010)
Applies to: Businesses and Individuals
What are the changes to the appeals and reviews process?
Non-grandfathered health insurance plans must have in place a protocol for internal appeals and external review for coverage determinations and claims decisions.
What does this mean to me?
The new law requires that insurers inform you of available internal appeals and external review processes, plus offer claimants assistance with the internal appeals and external review processes concerning decisions made by your insurer. Insurers also must allow you to review your file and present additional evidence during the internal appeals process. Your health plan must provide continued coverage pending the outcome of the internal appeals process. However, these provisions do not apply if your plan is grandfathered.
What is IBC doing to help?
Independence Blue Cross will keep its enrollees updated on changes to its internal appeals and external review processes. IBC intends to comply with the new provisions of health care reform as they pertain to the internal appeals and external review processes and will provide you with ongoing updates and information as we implement the new regulations.
Elimination of lifetime maximums and restrictions on annual limits (effective October 1, 2010)
Applies to: Businesses and Individuals
What are the changes to lifetime and annual limits on care?
All health plans, including grandfathered plans, are prohibited from imposing limits on the dollar value of essential health benefits during your lifetime; they may, however, impose an annual limit on the dollar value of such benefits for plans that go into effect before 2014. For plan years after January 1, 2014, plans will be prohibited from imposing any annual dollar limits on essential health benefits.
What does this mean to me?
A need for costly medical care will not exhaust your health plan coverage going forward, and if your lifetime benefits were exhausted prior to the new law taking effect, you may be able to reinstate your coverage. IBC is eliminating annual and lifetime limits on all plans effective October 1, 2010, and will not phase in these limits as the law stipulates.
The law defines restricted annual limits as:
- $750,000 for plan years beginning on or after September 23, 2010, but before September 23, 2011
- $1.25 million for plan years beginning on or after September 23, 2011, but before September 23, 2012
- $2 million for plan years beginning on or after September 23, 2012, but before January 1, 2014.
What is IBC doing to help?
At Independence Blue Cross, IBC is eliminating annual and lifetime limits on all plans effective October 1, 2010, and will not phase in these limits as the law stipulates.
Prohibition of preexisting condition exclusions for children under 19 (effective October 1, 2010)
Applies to: Businesses and Indviduals
What is it?
Most health plans, even grandfathered ones, may not deny coverage of or benefits to children under 19 who have a preexisting condition. New rules issued by HHS allow for insurers to set specific enrollment times for the coverage. Prohibition of preexisting condition exclusions will extend to adults in 2014. Currently, this prohibition does not apply to grandfathered individual health insurance coverage.
What does this mean to me?
If you are the parent or guardian of a child under 19, your health plan may not deny your child coverage or benefits based on a preexisting condition. If such coverage was previously denied, contact your health plan to reapply for coverage once the provision goes into effect.
Coverage for emergency services (effective October 1, 2010)
Applies to: Businesses, Individuals and Providers
What is it?
The law provides that individual plans, group health insurance plans, and self-funded plans that cover hospital emergency services must do so without prior authorization, whether the provider participates in the health plan's network or not. A subscriber's cost-sharing requirements for out-of-network emergency services must be the same as those applied to in-network services. Grandfathered plans are exempt.
What does this mean to me?
You will be paying the same level of cost-sharing for emergency services regardless of whether you stay in-network or go out of the network for the emergency services. Out-of-network providers may, however, also balance-bill payments for the difference between the providers' charges and the amount collected from the plan and from your copayment or coinsurance amount.
What is IBC doing to help?
Independence Blue Cross currently complies with this provision.
Quality-of-care reporting (effective MONTH 2012)
Applies to: Businesses
What is the quality-of-care reporting requirement?
The quality-of-care reporting requirement provides that all individual, group, and self-funded plans – with the exception of grandfathered plans – must submit an annual report to the U.S. Department of Health and Human Services (HHS), and to enrollees during the open enrollment period, to describe how the health plan's benefits and provider reimbursement policies improve quality of care, including wellness and health promotion activities.
What does this mean to me?
You will receive information on your plan's quality and wellness programs during the open enrollment period.
What is IBC doing to help?
Independence Blue Cross is an industry leader in offering you high-quality preventive and wellness programs, and you can count on us to continue to lead by providing full disclosure on the quality and effectiveness of these services.
Choosing doctors
Applies to: Businesses, Individuals and Providers
What changes are there to a member's ability to choose his or her primary care physicians?
All health plans – except those that are grandfathered – must allow members to designate any participating primary care physician or pediatrician (for a child) who is available to accept the member when that designation is required by the plan.
What does this mean to me?
You may choose any participating primary care physician, and you do not need a referral to see that doctor. The participating primary care physician list includes pediatricians. Additionally, you have direct access to an OB/GYN, and you do not need a referral to see that doctor.
What is IBC doing to help?
IBC currently complies with this provision.
