HealthChoice and Health Care Reform

HealthChoice ceased having Grandfather Status under the Affordable Care Act (ACA) as of January 1, 2012.

Health plans which do not have Grandfather Status are subject to the following requirements:  

• No Lifetime Limits – Plans may not establish lifetime limits on the dollar value of ”essential benefits” for any participant or beneficiary under group coverage. Lifetime caps may be placed on nonessential benefits covered under the plan or policy.
• No Annual Limits – Plans may only establish restricted limits on the dollar value of annual benefits for participants and beneficiaries.
  • Effective January 1, 2014, the prohibition on annual benefit limitations will be unrestricted.
  • Annual caps may be placed on nonessential benefits.
• Plans may not rescind coverage except in the case of an individual’s fraud or intentional misrepresentation and, then, only after notice to the enrollee.
• Plans may not deny coverage to children under age 19 for their preexisting conditions.  Effective January 1, 2014, this exclusion will be generally applicable to all adults enrolling or enrolled in group coverage.  HealthChoice already meets both of these standards and has no preexisting condition limitations.
• Dependent Child Coverage – Plans must make health care coverage available to a participant’s or beneficiary’s adult child until he/she turns 26.
• Coverage of Preventative Services – All plans must cover, without cost sharing:
  • Services recommended by the U.S. Preventative Services Task Force.
  • Immunizations recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (CDC).
  • Preventative care and screening for infants and children supported by the Health Resources and Services Administration (HRSA).
  • Preventative care and screening for women supported by HRSA.
  • Breast cancer screening in accordance with current recommendations.
• Prohibition Against Discrimination in Favor of High-Paid Employees.  HealthChoice benefits and premiums are identical for any enrollees in that plan and therefore already comply with this provision.
• External review process - All plans must comply with state external review processes that, at a minimum, include the consumer protections in the National Association of Insurance Commissioners (NAIC) model act.  HealthChoice has a review process currently in place which substantially mirrors the requirements of this provision.
• Enrollee Protections - An employer group health plan or health insurer which requires the selection of a primary care physician (PCP) must permit: an enrollee to select any PCP in the network, regardless of geography; or parents to select a pediatrician as their child’s PCP.  Women must be permitted to seek treatment from an OB/GYN, without a PCP referral. HealthChoice is already in compliance with this provision.
• Emergency services must be covered, without prior authorization, even when the provider is not in the health plan’s network.
• Appeals Process – Group health plans and health insurers must implement an effective process for appeals of coverage determinations and claims, including an internal claims appeals process.  Employer group plans and health insurers must use existing DOL claims and appeals procedures and update them to reflect new DOL regulations when issued.  HealthChoice has an appeals process currently in place which substantially mirrors the requirements of this provision.

If you have any questions in regards to the provisions of ACA that HealthChoice is required to meet, please contact HealthChoice Member Services at 1-405-717-8780 or toll-free 1-800-752-9475. TDD users call 1-405-949-2281 or toll-free 1-866-447-0436.