You Really Need to Read This: 10 Ways the New Healthcare Law Affects YOU Today and in 2014

Whether you need health coverage or have it already, the Affordable Care Act (ACA) offers new rights and protections that make coverage fairer and easier to understand. Some rights and protections apply to plans in the Health Insurance Marketplace/Exchange or other individual insurance, some apply to job-based plans, and some apply to all health coverage. These rights and protections are designed to provide more choice and control over your health coverage when key parts of the law take effect in 2014.

1. Creates the Health Insurance Marketplace/Exchange: A new way for you to get health coverage

2. Requires insurance companies to cover you if you have a pre-existing health condition: For plan years beginning in 2014, most health plans can’t turn you down or charge you more because you’re sick or have a health condition. They also can’t charge women more than men.

3. Provides free preventive care: Many health plans are required to cover certain preventive care services at no cost to you. You may be eligible for free preventive screenings, like blood pressure and cholesterol tests, mammograms, vaccines, etc., and new preventive services for women.

4. Covers young adults under age 26: If you’re under 26 years old, you may be able to get insured under a parent’s plan. You can join, remain, or return to a parent’s plan even if you’re:
• married
• not living with your parents
• attending school
• financially independent
• eligible to enroll in your employer’s plan (there is an exception)

5. A clear Summary of Benefits and Coverage: You have the right to get an easy-to-understand summary about a health plan’s benefits and coverage. Insurance companies and group health plans must provide you with:
• A short, plain-language Summary of Benefits and Coverage
• A Uniform Glossary of terms used in health coverage and medical care

This information allows you to make “apples-to-apples” comparisons when you’re looking at different plans. All individual and group health plans must use the same standard form to help you compare plans.

6. Holds insurance companies accountable by reviewing rate increases and making sure you get more value for your premium dollars:
• Rate Review: helps protect you from unreasonable rate increases. Insurance companies must now publicly justify any rate increase of 10% or more before raising your premium.
• 80/20 Rule: The rule generally requires insurance companies to spend at least 80% of the money they take in on premiums on your healthcare and quality improvement activities instead of administrative, overhead, and marketing costs. Insurance companies selling to large groups (usually more than 50 employees) must spend at least 85% of premiums on care and quality improvement. If your insurance company doesn’t meet these requirements, you’ll get a rebate from your premiums.

7. Makes it illegal for health insurance companies to arbitrarily cancel your health insurance just because you get sick or because you made an honest mistake on your insurance application or left out information that has little bearing on your health.

8. Protects your choice of doctors:
• You can choose any available primary care provider in your insurance plan’s network.
• No referrals needed for OB-GYN services
• Insurance plans cannot require higher co-payments or co-insurance if you get emergency care from an out-of-network hospital.
• These rights don’t apply to health plans created or bought before March 23, 2010, which are known as grandfathered plans.

9. Ends lifetime and yearly dollar limits on coverage of essential health benefits:
• Lifetime Limits: Insurance companies can’t set a dollar limit on what they spend on essential health benefits for your care during the entire time you’re enrolled in that plan.
• Yearly Limits: Insurance companies can still set a yearly dollar limit of $2 million on what they spend for your coverage for plan years or policy years starting before January 1, 2014. No yearly dollar limits on essential health benefits are allowed for plan years starting January 1, 2014.

10. Guarantees your right to appeal a health plan decision: You can request an appeal when a health plan denies payment for a treatment or service. When your plan gets your request it is required to review its own decision. When your plan denies a claim, it’s required to notify you of:
• The reason your claim was denied
• Your right to file an internal appeal
• Your right to request an external review if your internal appeal was unsuccessful
• The availability of a Consumer Assistance Program (if your state has one)


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