In 2010, the Affordable Care Act mandated a number of changes to health coverage here in the United States. The intent is to provide benefits for an increasing number of people at a more affordable price. There will be changes for both employees and employers in coverage offered through employee benefit plans.
Summary of Benefits and Coverage (SBC)
As a result of the Affordable Care Act it will be necessary for all benefit plans and insurers to provide their members with a Summary of Benefits and Coverage (SBC), a clear explanation of coverage that will help them compare different insurance plans.
The SBC will include:
- What the plan covers
- What the plan does not cover
- Examples of coverage
- Contact phone number and website where further information can be obtained
- Exclusions and cost sharing provisions
Automatic Enrollment Summary
All employers that have more than 200 full-time employees must enroll new full-time employees in benefit plans, but allow them to opt out.
Coverage of Children Age 26
The act requires that a child of a member can be covered under the benefit plan until the child reaches age 26, whether the child is married or unmarried, is employed or unemployed, or lives with the parent.
Pre-Existing Medical Condition Exclusions
Under the act, a child under the age of 19 cannot be refused coverage because the child has been diagnosed with a pre-existing medical condition.
Preventive Health Services
The act broadens the coverage of preventive health services to 100 percent for routine immunizations, preventative care and screening for women and children, breast cancer screenings, blood pressure checks and other services.
Appeals and External Reviews
The act stipulates that benefit plans must have an internal appeals and claims process, as well as the option to refer to a third party for a review.
Cancellation of Coverage
Cover can only be cancelled if facts were misrepresented on the application for benefits or if fraud is suspected.
Essential Health Benefits (EHBs)
The act requires that a minimum coverage level is provided for 10 essential health benefit areas. These are emergency services, maternity care, ambulatory patient services, hospitalization, mental health, pediatric services, prescription drugs, laboratory services, rehabilitative and habilitative services, and wellness and preventive services.
The Lexington, South Carolina insurance agents at Tidwell Agency will be happy to explain how the Health Care Act will affect your business or personal insurance portfolio.