Jumping back into health care reform today. We've been looking at Section 1302 of the law, Essential Health Benefits Requirements. Let's move on to subsection (c), which deals with cost-sharing requirements.
Annual cost-sharing limits
The law defines "cost sharing" as meaning defuctibles, coinsurance, copayments or similar charges, and any other amounts an individual must spend on qualified medical expenses respect to the essential health benefits. The term does not include premiums, balance billing amounts for non-network providers, or spending for non-covered services.
In 2014, the maximum cost sharing for individual and other-than-individual plans will be set at the IRS maximum (if you have a health savings account, you're already familiar with the annual limits on contributions to your HSA; this limit will be similar.) Starting in 2015, the maximum cost sharing for individual plans will rise by the growth in average per capita health insurance premium for the prior year. The maximum cost sharing for other than individual plans will rise by twice that rate.
Deductibles for small group plans are limited to $2,000 for individuals and $4,000 for others. Employers may increase these amounts by the maximum reimbursement a participant can reasonably expect under a flexible spending account arrangement. As with the cost sharing limits, the maximum deductibles will rise each year (starting in 2014) by the increase in per capita health insurance premium for the prior year (twice that rate for non-individual coverage.)
All of these limits must be applied so as not to affect the plan's actuarial value. Deductibles may not apply to preventive health services.
Levels of Coverage
Remember last time, when I mentioned bronze, silver, gold and platinum coverage? Here's what those terms mean:
Bronze level: Provides benefits actuarially equivalent to 60 percent of the full actuarial value of benefits under the plan.
Silver level: Provides benefits at 70 percent of full actuarial value.
Gold level: Provides benefits at 80 percent of full actuarial value.
Platinum level: Provides benefits at 90 percent of full actuarial value.
The Department of Health and Human Services must issue regulations for determining the actuarial value of benefits based on providing the essential health benefits to a standard population (not necessarily the population that actually receives the benefits.) HHS may issue regulations in which employer contributions to an HSA are considered in determining the plan's level of coverage. HHS also must create guidelines to provide for small variations in the actuarial valuations based on differences in estimates.
Catastrophic Plans
Health plans and insurers can offer catastrophic plans that cover at least three primary care visits with no cost sharing and all other benefits after the insured has met the maximum allowable cost sharing amounts that I described above. For example, if the maximum cost sharing for an individual plan is $3,000, the plan would cover the three primary care visits, but would not pay any other benefits until the insured has paid the $3,000 out of pocket. Catastrophic plans will be available only to individuals under age 30. They will also be available for individuals who have been certified as exempt from the individual mandate to buy coverage due to lack of access to affordable coverage or to personal hardship. They are not available in the non-individual market.
Child-Only Plans
Plans and insurers that offer coverage through an exchange at the various coverage levels must also offer them through the exchange as plans for which only individuals under age 21 are eligible.
Next time, we'll look at some special rules, particularly those having to do with a controversial area.
Thank you! useful information
Posted by: nairobi | February 10, 2011 at 07:35 AM