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Affordable Care Act Major Coverage & Administrative Changes

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Oxford Health Plans - UHC

Administrative Simplification

Annual Limits


Dependent (Adult Child) Coverage to 26

Early Retiree Reinsurance

HIPAA 5010 & ICD-10

Lifetime Limits

Medicare Advantage and Prescription Drug Benefit Programs Final Rule

Medicare Part D

Patient Protections

Pre-Existing Conditions Under 19

Preventive Care Services


Annual and Lifetime Limits

Dependent Age 26

Pre-Existing Coverage

Empire - Anthem Blue Cross/Shield

Health Care Reform Overview - Guide

Sample Employer Disclosure Template

Introduction to Health Care Reform Video

Navigating the Next Phase of Health Care Reform

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Children's Pre-Existing Conditions  source: healthcare.gov

Under the Affordable Care Act, health plans cannot limit or deny benefits or deny coverage for a child younger than age 19 simply because the child has a “pre-existing condition” — that is, a health problem that developed before the child applied to join the plan.

See More on Healthcare.gov

Lifetime & Annual Limits  source: healthcare.gov

The Affordable Care Act prohibits health plans from putting a lifetime dollar limit on most benefits you receive. The law also restricts and phases out the annual dollar limits a health plan can place on most of your benefits — and does away with these limits entirely in 2014.

See More on Healthcare.gov

Young Adult Coverage  source: healthcare.gov

Under the Affordable Care Act, if your plan covers children, you can now add or keep your children on your health insurance policy until they turn 26 years old.

What This Means for You

Before the health care law, insurance companies could remove enrolled children usually at age 19, sometimes older for full-time students. Now, most health plans that cover children must make coverage available to children up to age 26. By allowing children to stay on a parent's plan, the law makes it easier and more affordable for young adults to get health insurance coverage.

Your children can join or remain on your plan even if they are:

There is one temporary exception. Until 2014, “grandfathered” group plans do not have to offer dependent coverage up to age 26 if a young adult is eligible for group coverage outside their parent’s plan.

Some Important Details

See More on Healthcare.gov

65 or Older  source: healthcare.gov

The Affordable Care Act strengthens Medicare, offers eligible seniors a range of preventive services with no cost-sharing, and provides discounts on drugs when in the coverage gap known as the “donut hole.” Learn how the health care law affects people age 65 or older.

Medicare Preventive Services

If you have Medicare, you are eligible for a number of cost-free preventive services.

Medicare Drug Discounts

Eligible seniors who are in the coverage gap known as the “donut hole” automatically receive a discount on prescription drugs in 2011 and beyond.

See More on Healthcare.gov

Flexible Spending Account Changes  source: healthcare.gov

As of January 1, 2011, the costs of over-the-counter medications will be reimbursed under a Flexible Spending Account (FSA), Health Savings Account (HSA), or Health Reimbursement Account (HRA) only if the medications are purchased with a doctor’s prescription. These restrictions do not apply to the purchase of insulin.

Note: Flexible Spending Accounts are sometimes called Flexible Spending Arrangements. Health Reimbursement Accounts are sometimes called Health Reimbursement Arrangements.

For More Information

Posted on: December 2, 2010

Appealing Health Plan Decisions

The Affordable Care Act ensures your right to appeal health insurance plan decisions--to ask that your plan reconsider its decision to deny payment for a service or treatment. New rules that apply to health plans created after March 23, 2010 spell out how your plan must handle your appeal (usually called an “internal appeal”). If your plan still denies payment after considering your appeal, the law permits you to have an independent review organization decide whether to uphold or overturn the plan’s decision. This final check is often referred to as an “external review.”

Your state may have a health care Consumer Assistance Program that can help you file an appeal or request a review.

See More on Healthcare.gov

Administrative Simplification  source: healthcare.gov

The Affordable Care Act accelerates adoption of standard “operating rules” for health insurance plan administration. Operating rules are the business rules and guidelines for electronic transactions with health insurance plans, and the current non-standard environment is a source of waste, unnecessary cost, and frustration for small business owners and others. Under administrative simplification, there will be one format and one set of codes for claims, remittance advice, service authorization, eligibility verification, and claims status inquiry.

By establishing uniform operating rules, the Affordable Care Act ensures that small businesses, health plans, physicians, hospitals, and patients are all speaking the same language. Benefits include:

The Affordable Care Act requires standard operating rules for eligibility and claims status to be adopted by July1, 2011 and fully implemented by January 1, 2013.

Doctor Choice & ER Access  source:  healthcare.gov

The Affordable Care Act helps preserve your choice of doctors by guaranteeing that you can choose the primary care doctor or pediatrician you want from your health plan’s provider network. It guarantees that you can see an OB-GYN doctor without needing a referral from another doctor. The law also ensures that you can seek emergency care at a hospital outside your plan’s network without prior approval from your health plan.

See More on Healthcare.gov

Government Links


Consumer Assistance by State

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Health Care Reform Section

Timeline - What’s Changing and When

Small Business Tax Credit  by the IRS                                  

Timeline Past Present & Future Health Care Exchange Medical Loss Ratio (MLR) Business Tax Credit Essential Health Benefits Coverage & Admin Employer Mandates Grandfathered Plan

Health Care Reform Tools

Preventive Care Summary of Benefits