Ask Tim

Health Care Reform Primer: American Health Benefit Exchanges

It's been a couple of weeks since I posted about health care reform, but now it's time to roll up our sleeves and get our hands dirty. Yup, we've reached the part in the book about health insurance exchanges, starting with Section 1311, Affordable Choices of Health Benefit Plans.

Assistance to States

The federal Department of Health and Human Services can award grants to the states to help cover the costs of setting up the exchanges, which the law refers to as "American Health Benefit Exchanges." HHS determines the amounts of the grants at the start of each fiscal year. A state that receives a grant in one year can receive a grant renewal the next year if HHS determines that it is making progress toward establishing its exchange, is implementing the coverage and market reforms we've already discussed, and is meeting other benchmarks HHS has set. The grant program expires in 2015. HHS must assist states to help small businesses participate in Small Business Health Options Program (SHOP) exchanges (I'll get into them later.)

The Exchanges

By January 1, 2014, each state must establish an American Health Benefit Exchange that facilitates the purchase of qualified health plans, creates a SHOP exchanges to help small employers enroll their employees in qualified small group plans, and that meets a number of requirements that I'll discuss in a bit. States can combine the regular and SHOP exchanges if they have the resources to assist both individuals and employers in one exchange.

HHS must issue regulations that create criteria for certifying health plans as "qualified." To get that certification, a plan must at minimum:

• Meet marketing requirements and not covertly discourage people with significant health needs from enrolling
• Ensure a sufficient choice of providers and provide information to current and prospective enrollees on the available of in- and out-of-network providers
• Include in its network available providers who serve low-income, medically-underserved people (however, this does not require a plan to cover any specific medical procedure)
• Be accredited by entities recognized by HHS; accreditation will be with respect to local performance on clinical quality measures, patient experience ratings, consumer access, utilization management, quality assurance, and other areas. Alternatively, it must receive accreditation applicable to all plans in the exchange
• Implement a quality improvement strategy
• Use a uniform enrollment form for individuals and employers to complete; this form must take into account criteria that the NAIC will develop and submit to HHS
• Use the standard format for presenting health benefits plan options
• Provide information to current and prospective enrollees and to the exchanges on any quality measures for health plan performance.

Plans do not have to contract with a health care provider who refuses to accept the plan's "generally applicable payment rates."

HHS must create a rating system to rate qualified health plans offered through an exchange on relative quality and price for each benefits level. The exchange must make the ratings publically available on an Internet portal. HHS must develop an enrollee satisfaction survey system to measure satisfaction with any qualified health plan that had more than 500 enrollees the previous year. The exchange must include the satisfaction information on the Internet portal and make it easy for individuals to compare plans on this basis.

Speaking of Internet portals, HHS must continue to operate the site currently known as HealthCare.gov, help states get their own portals up and running, and make a model template for a portal available to the exchanges for their use. The exchanges can use the portal to direct individuals and employers to qualified health plans, help them determine their eligibility for the exchange or for premium tax credits or reduced cost-sharing, and to present standardized information to make it easier to choose a plan. The template must include access to a uniform outline of coverage for each plan and to a copy of each plan's policy.

HHS must require an exchange to provide for

• An initial open enrollment
• Annual open enrollment periods thereafter
• Special enrollment periods as set by the tax and Social Security laws
• Special monthly enrollment periods for Indians.

In my next post, I'll get into the requirements exchanges must meet.

Leave a Comment

 

Insuring Employees Who Rent Cars For Business

Question from an IIABNY member: Our insured had a question; Even though they have Hired/Non-Owned Auto on their commercial business auto policy with physical damage coverage, they asked these questions:

• Should employees ever put a rental car on in their own personal name or on their own personal credit card?
• Should they purchase the insurance coverage?  Physical damage?  Liability?  Other?

Answer: If an employee rents a vehicle in her name for business use, her personal auto policy covers both her employer and her for liability on a primary basis; the commercial auto policy applies on an excess basis. This is a good deal for the employer, maybe not so much for her. However, this means that there is really no need for her to buy liability coverage from the rental company.

Regarding physical damage, every personal auto policy sold in New York provides coverage for the insured’s obligations for loss of, damage to, and loss of use of a rental vehicle. From a purely coverage standpoint, it is unnecessary to buy the collision damage waiver from the rental company. However, buying the CDW eliminates a lot of hassle if she were to return the vehicle with new damage. From that standpoint, it’s a matter of choice and convenience.

Follow-up Question: Great, but if the Business policy has hired/non-owned physical damage coverage, then they really do not need to buy the property damage coverage, correct?

Answer: This is true, but the employer should ask the insurer to attach ISO endorsement CA 20 54 10 01, Employee Hired Autos, to the policy. It takes the burden off the employee’s auto policy, puts it on the employer’s policy, and removes any coverage need for the employee to buy the collision damage waiver. Again, the employee may decide to get the CDW to eliminate any possible hassles, but that’s an issue separate from the question of coverage.

Next Follow-Up Question: With the CA 20 54, does the insured then NOT need to add Hired Physical Damage Coverage to the policy separately, because this endorsement provides that? Also, do we as the broker request a limit for this endorsement?

Answer: CA 20 54 does not substitute for Hired Auto Physical Damage Coverage; it changes the “other insurance” condition in the BAP so that the policy’s coverage for employee hired autos is primary, rather than excess. It states in part:

Paragraph 5.b. of the Other Insurance Condition in the Business Auto…Forms…(is) replaced by the following:

For Hired Auto Physical Damage Coverage, the following are deemed to be covered "autos" you own:

1. Any covered "auto" you lease, hire, rent or borrow; and

2. Any covered "auto" hired or rented by your "employee" under a contact in that individual "employee's" name, with your permission, while performing duties related to the conduct of your business.

However, any "auto" that is leased, hired, rented or borrowed with a driver is not a covered "auto".

Consequently, the complete Other Insurance condition as amended reads as follows:

a. For any covered "auto" you own, this Coverage Form provides primary insurance. For any covered "auto" you don't own, the insurance provided by this Coverage Form is excess over any other collectible insurance. However, while a covered "auto" which is a "trailer" is connected to another vehicle, the Liability Coverage this Coverage Form provides for the "trailer" is:

(1) Excess while it is connected to a motor vehicle you do not own.

(2) Primary while it is connected to a covered "auto" you own.

b. For Hired Auto Physical Damage Coverage, the following are deemed to be covered "autos" you own:

1. Any covered "auto" you lease, hire, rent or borrow; and

2. Any covered "auto" hired or rented by your "employee" under a contact in that individual "employee's" name, with your permission, while performing duties related to the conduct of your business.

However, any "auto" that is leased, hired, rented or borrowed with a driver is not a covered "auto".

The ISO rules for Hired Auto Physical Damage do not call for a coverage limit. The insurer bases the premium on the amount the insured estimates it will spend on auto rentals during the policy term, not on a limit.

Leave a Comment

Where's the Coverage When An Employee Gets Hurt While Moonlighting On Her Employer's Premises?

Question: A nursing home employee was moonlighting within the nursing home working for a resident when she tripped and fell. As she was not an employee at the time of injury, the worker’s compensation did not respond. The individual has now turned towards the nursing home's general liability insurer for medical costs and compensatory damages. Does the Commercial General Liability policy's Bodily Injury Coverage exclude the claim, as she was performing duties related to the insured’s business? Does its Medical Payments Coverage exclude medical expenses, as she was hired to work for a resident, who is a tenant of the insured? Should she seek damages from the resident unless she can prove negligence on part of the nursing home?

Answer: Interesting question. If the nursing home’s policy is the ISO CGL form, the full exclusion in Coverage A (Bodily Injury and Property Damage Liability) reads like this: 

e. Employer's Liability

"Bodily injury" to:

(1) An "employee" of the insured arising out of and in the course of:

(a) Employment by the insured; or

(b) Performing duties related to the conduct of the insured's business; or

(2) The spouse, child, parent, brother or sister of that "employee" as a consequence of Paragraph (1) above.

This exclusion applies whether the insured may be liable as an employer or in any other capacity and to any obligation to share damages with or repay someone else who must pay damages because of the injury.

This exclusion does not apply to liability assumed by the insured under an "insured contract".

Therefore, there is no coverage if either of these is true: The employee’s injury arose out of in the course of her employment with the nursing home or out of and in the course of performing duties related to the conduct of the nursing home. Also, there is no coverage for the nursing home in its capacity as her employer or in any other capacity. Reasonable people could argue either way as to whether she was performing duties related to the conduct of the nursing home. This exclusion may justifiably apply.

I’m not so sure about the medical expenses exclusion. I’m not a lawyer, but I believe nursing home residents are ordinarily considered to be “patients”, not “tenants.” I think it’s possible that the nursing home may have coverage there.

Again, not a lawyer, but I think it will be hard for the claimant to prove negligence on the part of the patient for whom she was working, so I don’t know that a claim against the patient will succeed. I think the claimant’s best source of recovery is the Employers Liability Coverage under the Workers’ Comp policy. It covers bodily injury arising out of and in the course of the injured employee’s employment by the named insured, excluding any obligations under the workers’ comp law. So, if the claimant is considered to be an employee for purposes of the CGL policy, then the EL Coverage should apply to her injuries. If she is not considered to be an employee for EL Coverage purposes, then the CGL policy should apply. One or the other should apply. Hopefully, the same carrier is providing both coverages.

Leave a Comment

Does Additional Living Expense Coverage = Lifestyle Maintenance?

Christine Barlow brings up some interesting points regarding the Homeowners policy's coverage for additional living expenses. In her interpretation, the policy should pay for an insured who lived like a king before the loss to live like one afterward:

As the FC&S editor who answers homeowners’ insurance questions, I know that one of the most common concerns for claims professionals is additional living expenses (ALE).

No matter how many questions I answer on the subject, there always seems to be another twist or turn in the issue. What is it that makes the ALE coverage so complicated?

For starters, it seems that the broadness of the coverage itself is a sticking point. The standard homeowner’s policy provides coverage for an increase in living expenses incurred by the insured so they can maintain their normal standard of living. That standard of living is the key; how the insured lived before the loss is what needs to be replicated after the loss. So any animals kept on the property get boarded, and if the insured has a swimming pool or hot tub, alternative living arrangements with similar items are required.

Another common issue is food. Some adjusters have balked at buying beer, wine, snacks, and such on the basis that these are not necessary or healthful foods. No matter, if this is what the insured typically eats, this is what the insured gets. If the insured is a gourmet cook and makes gourmet food every night, then once displaced the insured is entitled to gourmet food, even if it involves expensive, five-star restaurants.

The best way to look at additional living expenses is to look at how the insured lived before the loss, and duplicate it as much as possible after the loss. Indoor pets get to stay indoors, and the insured can live on cake and cognac as long as this is how the insured lived before the loss.

via www.propertycasualty360.com

I've never received a question from an IIABNY member on this. I want to echo the question she asked at the end of her piece -- what has been your experience with these claims? What are adjusters' tendencies when they settle them?

Leave a Comment

Health Care Reform Primer: Definitions -- Markets and Employers

After yesterday's heavy topic, Section 1304 of the Patient Protection and Affordable Care Act provides a number of definitions.

Markets

Group market: Market in which individuals get coverage on behalf of themselves and their dependents through a group plan maintained by an employer.

Individual market: Market for coverage offered to individuals other than through a group plan.

Large group market: Market in which individuals get coverage on behalf of themselves and their dependents through a group plan maintained by an employer who employed an average of at least 101 employees on business days during the preceding calendar year and who employs at least one employee on the first day of the plan year.

Small group market: Market in which individuals get coverage on behalf of themselves and their dependents through a group plan maintained by an employer who employed an average of at least one but no more than 100 employees on business days during the preceding calendar year and who employs at least one employee on the first day of the plan year. Until 2016, states have the option of defining the large group market as employers with 51 employees, rather than 101.

What about new businesses that didn't exist the year before? The classification will depend on the average number of employees that the business reasonably expects to have on business days during the current calendar year. For the law's purposes, a business that buys another employer is not a new business.

If a business is able to obtain coverage through a state exchange because it meets the definition of "small employer," but it grows to the point where it no longer meets that definition, it continues to be classified as a small employer for the period beginning with the increase in employee count and ending on the first day on which it no longer offers employees' enrollment through the exchange.

That closes the book on Part I (Establishment of Qualified Health Plans) in Subtitle D (Available Coverge Choices for All Americans) in Title I (Quality, Affordable Health Care For All Americans). Next week, we get into Part II, which begins the provisions on the state health exchanges. Until then, have a good weekend, all! The Geek Cave is closed.

Leave a Comment

Health Care Reform Primer: Abortion Services

I've reached one of the most controversial sections of the Patient Protection and Affordable Care Act. When Congress considered the bill last March, opinions differed widely on the meaning of the words in Section 1303, and that situation hasn't changed. I'll try to reslate, as accurately as I can, the plain text. I know that many people feel very passionately about this subject. Out of sensitivity to both sides, I will strive to keep my words judgment-free.

Sect. 1303: Special Rules Relating to Coverage of Abortion Services

States may prohibit exchange plans from offering abortion coverage by enacting a law; a state enacting such a law has the right to repeal it later. The law does not require qualified health plans in exchanges to cover abortion services. The decision about whether or not to cover these services is up to the plan issuer. The text differentiates between two types of abortion services: Those for which the federal law in effect six months before the start of a plan year prohibits federal funding, and those for which federal law at the same time does not.

As described above, plans may not use federal funds, tax credits or cost sharing reductions to pay for abortions for which Congress has prohibited federal funding. Plans must segregate the actuarial value of funds used for abortion coverage from other funds when they complete their accounting records. HHS must estimate what that actuarial value is on a per enrollee, per month basis. In doing so, HHS must consider the costs of abortion services but not the resulting lower costs from reduction in prenatal care, delivery or postnatal care. It must estimate the costs as if the entire covered population had this coverage, and it may not estimate the cost at least than $1 per enrollee, per month.

These prohibitions do not apply to abortions for which Congress allows federal funding (i.e., those performed where the mother's life is endangered or when the pregnancy is the result of rape or incest.)

No one may discriminate against an individual health care provider or health care facility "because of a willingness or an unwillingness, if doing so is contrary to the religious or moral beliefs of the provider or facility, to provide, pay for, provide coverage of, or refer for abortions."

The PPACA does not pre-empt state laws regarding coverage, funding, or procedureal requirements on abortions, including parental notification or consent requirements where minors are involved. It also does not pre-empt federal law regarding conscience protection, willingness or refusal to provide abortion, or discrimination against anyone on either side of the debate. Specifically, this part of Section 1303 does not change the rights and obligations of employees and employers under the Civil Rights Act of 1964.

Finally, the PPACA does not relieve a health care provider from providing emergency services required by federal or state law.

This was a rather somber discussion, but a necessary one. Is the requirement that abortion coverage funds be segregated on a plan's books enough to keep federal dollars from paying for abortions? Rational people have very different answers to that question, and I won't venture an opinion here. It may have been the best solution Congress could devise; I'll leave it to others to opine as to whether that solution is a good one.

Next time: Special definitions, particular relating to markets.

Leave a Comment

Mich. Congresswoman: Get the Government Out of the Flood Ins. Business

I have serious reservations about this proposal. While it is always a good thing to review and evaluate how any government program is working, looking at in isolation is not. The National Flood Insurane Program has many problems, but what is the alternative? Are private insurers clamoring for the chance to write flood coverage? If they are, no IIABNY members have told me about it.

According to another article, Rep. Miller asked rhetorically, "What in the world is the federal government doing in the flood insurance business?" The answer to that question, of course, is that private insurers found the flood insurance business to be a losing proposition. Congress created the NFIP in the 1960's to fill the void left by private insurers who were losing their collective shirts in it. Have market conditions changed since then to the point where property owners no longer need a government program? I will be curious to hear testimony on that question if and when the relevant congressional committee holds hearings on this bill.

Rep. Miller has done us a favor by opening the debate. She's laid down her cards -- the NFIP should go. Let's have an open, intelligent discussion about how this country should protect property owners from the risk of flood loss.

As always, I'd like to hear your thoughts on this bill and the flood insurance situation in general. So, flood me with your opinions ("flood me" -- get it?) in the comments.

 

Legislation Introduced To Phase Out NFIP

 Share |  

February 8, 2011 By Arthur D. Postal, PropertyCasualty360.com

The legislation to phase out the National Flood Insurance Program, H.R. 435, was introduced by Rep. Candice Miller, R-Mich. (File Photo: AP)

NU Online News Service, Feb. 8, 3:10 p.m. EST

WASHINGTON—Legislation has been introduced in Congress that would phase out the National Flood Insurance Program by the end of 2013.

The legislation, H.R. 435, was introduced by Rep. Candice Miller, R-Mich.

The bill would also immediately end all remapping of the program mandated by prior reauthorizations of the program, thereby ending the agency’s authority to charge more to current customers based on new maps mandated by the 2003 law that remains in effect.

Earlier this month, Rep. Miller had asked colleagues to support the measure.

That Congress may take a long look at the program was also acknowledged earlier this week by Rep. Scott Garrett, R-N.J., chairman of the Capital Markets Subcommittee of the House Financial Services Committee, which has prime jurisdiction over the program.

During an appearance at a housing conference Monday, Rep. Garrett said, “The government's history in pricing risk is extremely poor,” citing the Federal Deposit Insurance Corporation, the National Flood Insurance Program, and the Pension Benefit Guaranty Corp. as three entities with “terrible records of properly pricing for risk.”

The current program expires Sept. 30, the end of the current fiscal year. The program has been extended five times, with several lapses, since the origin

via www.propertycasualty360.com

Leave a Comment

Health Care Reform Primer: Cost Sharing; Coverage Levels; Catastrophic and Child-Only Plans

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.

Leave a Comment

Homeowners Coverage When the Insured Uses a Gun

Question from an IIABNY member: Our insured has a license to carry a gun.  When being confronted by an attempted robbery, he uses the gun but the shot hits a bystander.  I do not see where an exclusion would apply in this case as it was not expected or intended.  Do you agree that his liability insurance would defend him in this situation?  Even if the shot hits the robber, I would think coverage would follow for defense.

Answer: I hope this is hypothetical and not something that happened over the weekend. 

In its entirety, the relevant exclusion states that there is no coverage for the insured’s liability for:

"Bodily injury" or "property damage" which is expected or intended by an "insured" even if the resulting "bodily injury" or "property damage":

a. Is of a different kind, quality or degree than initially expected or intended; or

b. Is sustained by a different person, entity, real or personal property, than initially expected or intended.

However, this exclusion E.1. does not apply to "bodily injury" resulting from the use of reasonable force by an "insured" to protect persons or property;

Therefore, if your insured hits an innocent bystander instead of his target, there is no coverage. However, the exclusion does not apply to bodily injury resulting from the use of reasonable force to protect persons or property. I think the question of what constitutes reasonable force is an open one. What is the robber holding – a gun? A baseball bat? A knife? How reasonable was the insured’s belief that the robber would use the weapon? If he seemed extremely serious and pointed a gun at the insured or attempted to hit him with the bat, I suspect a court would decide that the insured’s belief was reasonable. What if the robber appeared to be drunk or high? Is it reasonable to open fire on him in that circumstance?

A sad example: If a private individual had used a firearm to stop the massacre in Tucson last month, I suspect that Homeowners insurance would have covered a resulting liability claim. The alleged shooter had already fired his weapon at a victim from close range, pretty clearly indicating his seriousness (even if he was mentally disturbed.) However, if this person, rather than firing a gun at Congresswoman Giffords, had taken a swing at her, spat on her or performed some other less serious act, a court might deem shooting a gun at him as more force than necessary, negating coverage.

So, my opinion is that coverage hinges on whether a reasonable person would conclude that use of a firearm was a reasonable response to the situation. Further, because this coverage giveback is an exception to an exclusion, I believe that the burden of proof is on the insured to prove reasonableness (I’m not a lawyer, but that’s my understanding.)

Leave a Comment

Health Care Reform Primer: The Essential Health Benefits Package

It's been a week since my last post about the federal Patient Protection and Affordable Care Act, and during that week a federal judge in Florida ruled that the provisions in Section 1501(b) make the entire law unconsitutional. The Obama Administration has vowed to appeal the judge's ruling, and most pundits believe that the U.S. Supreme Court will eventually settle the question. Under the assumption that the PPACA will remain the law of the land (or at least part of the land) unless and until the nation's highest court rules otherwise, I plan to continue my review. I hope you'll stay around for the ride.

Last time, we had just gotten into the requirements for establishment of qualified health plans and had looked at the definition of a qualified health plan in Sect. 1301. Let's turn now to the requirements for the "essential health benefits package." The law defines this term as meaning coverage that 1) provides essential health benefits; 2) limits cost-sharing for the coverage; and 3) provides "bronze," "silver," "gold" or "platinum" levels of coverage. I'll get into what that means in another post.

The Department of Health and Human Services must define "essential health benefits," but the benefits have to include at least these categories and items and services within them:

• Ambulatory patient services
• Emergency services
• Hospitalization
• Maternity and newborn care
• Mental health and substance use disorder services, including behavioral health treatment
• Prescription drugs
• Rehabilitative and habilitative services and devices
• Laboratory services
• Preventive and wellness services and chronic disease management
• Pediatric services, including oral and vision care.

HHS must ensure that the scope of these benefits is equal to the scope of benefits provided under a typical employer plan. The Labor Department will take a survey of employer-sponsored coverage to determine typical benefits and report its findings to HHS so that agency can make an informed determination. HHS has to report to Congress that actuaries have certified that the essential benefits meet this requirement. When setting and revising the list of essential benefits, HHS must provide public notice and give the public opportunity for comment.

When designing the essential benefits package, HHS

• Must ensure that the list of essential benefits is not unduly weighted toward any one category
• May not design the benefits in ways that discriminate against individuals based on age, disability or life expectancy
• Must take into account the health care needs of diverse segments of the population, including women, children, and the disabled
• Must ensure that no one can be denied essential health benefits against their wishes due to that person's age, life expectancy, present or predicted disability, degree of medical dependency, or quality of life (NOTE: This provision shows that the "death panels" story is a myth.)
• Must provide that a qualified health plan must cover emergency services without requiring pre-authorization, limiting coverage for use of out-of-network providers, or increasing cost-sharing for use of out-of-network providers
• Must treat plans offered on exchanges the same, whether or not they provide stand-alone dental benefits, and
• Must periodically review the essential health benefits and report to Congress on whether enrollees are having trouble getting needed services due to coverage or cost; whether the list of essential health benefits needs updating; how the list will be modified to address gaps in access or changes in evidence; how additional or expanded benefits will increase costs; and
• Must periodically update the list of essential health benefits.

Nothing in the law prohibits health plans from providing benefits greater than those listed in the essential health benefits package.

Next time, we'll look at the requirements for cost-sharing provisions in health plans and how the maximum cost-sharing amounts will adjust each year.

Leave a Comment