Blue Cross of Idaho is committed to implementing new healthcare reform laws over the next several years. We’ve listed the provisions in the Affordable Care Act yet to be enacted.
Please bookmark this page and check back often as we will continue to update the dates and information with the latest news when it's available.
Starting in 2010, the government will provide a tax credit to small employers that pay at least 50 percent of their employees' health insurance premiums. The full value of the tax credit is 35 percent of the small employers' cost for businesses with up to 10 employees and average annual wages of less than $25,000. The tax credit also applies on a reduced sliding scale to small employers with up to 25 employees and average annual wages of $50,000. This credit is available to both grandfathered and non-grandfathered plans.
In 2010 only, people enrolled in Medicare Part D will receive a $250 rebate when they hit the donut hole, or gap in prescription drug coverage that occurs when spending on covered Part D drugs, including co-pays and deductibles, exceeds $2,830. The Department of Health and Human Services announced in April that rebates would commence June 15. Members hitting the prescription drug donut hole are eligible for a $250 rebate. Medicare sends the check directly to the enrolled person within three months of hitting the donut hole. There's no application process and no private company will be involved in the check-delivery process.
Starting in 2010, Health and Human Services will provide $30 million in grants to states to set up health insurance consumer assistance or health insurance intermediary programs to:
States receiving grants must collect and report data on the types of problems and inquiries encountered by consumers. The data will be shared with state insurance regulators, the Secretary of Labor and the Secretary of Treasury to identify areas where enforcement action is necessary.
Health plans with active members on March 23, 2010, either as part of a group or as an individual member, can be grandfathered plans, if they do not make certain changes to the health coverage they offer. These plans have special effective dates for some healthcare reform requirements and are completely exempt from others. Grandfathered group plans can enroll new employees and their dependents and dependents of currently covered employees without jeopardizing their grandfathered status. Similarly, individuals in grandfathered plans may add dependents to their policies. Any plan not in existence prior to March 23, 2010 is a non-grandfathered plan.
The early retiree reinsurance program, which will pay 80 percent of the claims between $15,000 and $90,000 for early retirees between the age of 55 and 64 in a group health plan, will be running by July 2010. The Department of Health and Human Services has posted details and directions about how employers can apply on their website. Employer groups can complete applications though they will likely require:
The web portal will help consumers navigate their options in the individual and small business private market and help them determine if they may be eligible for a variety of existing public programs, including high-risk pools, Medicaid, Medicare and the Children's Health Insurance Program (CHIP).
Between late June and early September, people with Medicare Part D prescription coverage who have reached the donut-hole coverage gap in 2010 should receive a $250 rebate. For more information on the donut-hole coverage gap and who qualifies to receive the rebate, see the “Rebates for seniors who hit the Medicare gap in prescription drug coverage” description in the January, 2010 entry on this timeline.
Health and Human Services will consider requests from states to be exempt from multiple reform provisions, such as exchanges, essential benefits and mandates. In order to get such a waiver, states would have to present an alternative plan that would provide coverage at least as comprehensive and affordable, to at least a comparable number of residents, as the federal legislation would achieve.
Health and Human Services will provide standards on how health plans will be required to manage various kinds of data and conduct financial transactions.
All group health plans that offer coverage for their employees' children must extend eligibility to married or unmarried children of covered employees up to age 26. There are no additional criteria to qualify other than being a child of a policyholder under age 26. For plans not in existence (non-grandfathered plans) on or before March 23, 2010, they have to do this starting with the first plan year beginning after Sept 23, 2010. Plans that existed (grandfathered plans) on or before March 23, 2010, have to do this with the first plan year beginning after Sept. 23, 2010, but only for adult children up to age 26 who are not eligible for employer-sponsored coverage elsewhere.
Starting with plan years after Sept. 23, 2010, no health plan can rescind (cancel) health coverage for premium paying members except in cases of fraud.
Anyone under 19 with a pre-existing condition cannot be denied coverage for that condition at any time starting with the first plan year beginning on or after Sept. 23, 2010. In addition, insurers cannot impose waiting periods for coverage of pre-existing conditions for people under 19. This will change in 2014 for everyone as the bill requires all carriers to accept everyone, regardless of health status.
Starting with plan years beginning on or after Sept. 23, 2010, plans must provide coverage without cost-sharing for:
Beginning with the first plan year on or after Sept. 23, 2010, plans may not place lifetime limits on essential health benefits, and only restricted annual limits (to be defined by HHS) will be permitted on essential benefits (this annual limit provision does not apply to grandfathered individual plans). Beginning with plan years starting after Jan. 1, 2014, there will be no annual limits on essential health benefits.
Health and Human Services still has to define essential health benefits.
Medical loss ratio (MLR) is the percentage of health insurance premiums spent by an insurance company on healthcare services. The reform law requires that large group plans spend 85 percent of premiums on clinical services and activities for the quality of care for enrollees. Small group and individual market plans must devote 80 percent of premiums to these purposes. Beginning Sept. 23, 2010, health plans will be required to report MLRs to Health and Human Services.
All new plans starting on or after Sept. 23, 2010, that provide for designation of a primary care provider must allow the choice of any participating primary care provider who is available to accept them, including pediatricians. A plan may not require authorization or referral for a female patient to receive obstetric or gynecological care from a participating provider and must treat their authorizations related to OB/GYN services as the authorization of a primary care provider.
If a plan provides coverage for emergency services, the plan must do so without prior authorization, regardless of whether the provider is a participating provider. Services provided by nonparticipating providers must be provided with cost-sharing that is no greater than that which would apply for a participating provider and without regard to any other restriction other than an exclusion or coordination of benefits, an affiliation or waiting period, and cost-sharing.
Medical loss ratio (MLR) is the percentage of health insurance premiums spent by an insurance company on healthcare services. Starting Jan. 1, 2011, insurers must provide a rebate to consumers if the percentage of premiums expended for clinical services and activities that improve healthcare quality is less than 85 percent in the large group market and 80 percent in the small group and individual markets.
Starting Jan. 1, 2011, the penalty for withdrawals from Health Savings Accounts not used for qualified medical expenses will increase from 10 percent to 20 percent, and the penalty for unqualified withdrawals from Archer Medical Savings Accounts will increase from 15 percent to 20 percent.
For some individuals with Medicare Advantage plans, coverage will stay the same or improve. For others, benefits may decrease or cost sharing may increase. Reduced Medicare Advantage benefits will include other highlights not often associated with these kinds of plans, such as reduced cost sharing, free eyeglasses and gym memberships. Blue Cross of Idaho is working to minimize impacts and to ensure that our Medicare Advantage plans receive reimbursement for providing high quality care. There won't be a reduction in Original (basic) Medicare benefits.
Awaiting government regulation.
Awaiting government regulation.
Flexible Spending Account contributions are limited to $2,500 per year, indexed for inflation.
Individuals (U.S. citizens and legal immigrants) and small employers with an average of 100 or fewer employees in the previous calendar year may purchase insurance from state-run exchanges beginning in 2014 (or small employers with an average of 50 or fewer employees in the previous calendar year if the state so permits until 2016). If the state agrees, large employers with an average of at least 101 employees in the previous calendar year may also purchase from the exchange beginning in 2017.
All carriers doing business in Idaho may participate by offering products on any of the five tier levels of the exchange:
Reduced out-of-pocket limits apply to individuals with incomes up to 400 percent of the federal poverty level.
*Actuarial value means that the health insurance coverage selected is estimated to cover a certain percentage of a member's costs. Therefore, a plan with a 60 percent actuarial value is estimated to cover 60 percent of a member's total healthcare costs, leaving the member responsible for the remaining 40 percent. This is an average estimate for a standard population. How much the plan actually covers can vary significantly from person to person.
Health insurance carriers won't be able to deny applicants healthcare coverage based on pre-existing medical conditions and must apply the same rates as other's receiving the same coverage, though there may be slight variances based on age and geographical location. At this time, there are no guidelines available for how the guaranteed issue component will operate. As 2014 approaches, expect more details.
Citizens and legal residents are required to have "minimum essential coverage." Beginning 2016, the tax penalty for noncompliance is the greater of $695 per year, up to a maximum of $2,085 per family, or 2.5 percent of modified gross income. Lower penalties apply during the phase-in period in 2014 and 2015. The $695/$2,085 penalties are indexed for inflation beginning 2017.
The government will make exceptions for financial hardship, religious objections, Native Americans, those without coverage for less than three continuous months, whenever the lowest cost plan option costs more than 8 percent of income, or whenever the individual’s income is below the tax filing threshold, which is $9,350 for individuals, $18,700 for couples under age 65 without children, and $26,000 for couples under age 65 with two or more children in 2010.
Employers with an average of at least 50 employees during 121 days or more in the preceding calendar year are required to offer minimum essential coverage to full-time employees and their dependents. Employers can convert part-time workers to full-time equivalents by adding all hours worked by part-time workers during the month and dividing by 120 to determine whether the employer has more than 50 full-time employees, but they must exclude seasonal employees from the calculation. To determine penalties, employers can exclude the first 30 employees from their calculations.
Employers with more than 50 full-time employees that do not offer coverage or that offer coverage that does not qualify as minimum essential coverage must pay an assessment of $2,000 times the number of full-time employees if at least one full-time employee receives government-subsidized coverage through an insurance exchange. If the employer offers minimum essential coverage, but a full-time employee receives government-subsidized coverage through an insurance exchange anyway, the employer must pay an assessable payment equal to the lesser of $3,000 for each employee receiving a subsidy or $2,000 for each full-time employee. There is no assessment if the employee’s share of the cost of coverage is between 8 percent and 9.5 percent of income.
Health insurers must accept all applicants regardless of pre-existing condition and health status and must use adjusted community rating. They must also guarantee renewal for individuals.
Final phase in the removal of annual dollar limits on health plans.