Healthcare Reform - For Members

What changes should I expect when my coverage renews in 2014?

Effective January 1, 2014, all individual/family and small group health plans must include a complete package of “essential health benefits.” Your policy will provide more detailed information on your costs for receiving these covered services:

  • Emergency services
  • Hospitalizations
  • Laboratory services
  • Maternity care
  • Mental health and substance abuse treatment
  • Outpatient, or ambulatory, care
  • Pediatric care
  • Prescription drugs
  • Preventive care
  • Rehabilitative and habilitative (helping maintain daily functioning) services
  • Vision and dental care for children

Also, preventive services are covered 100% with no cost share (you don’t have to pay any copay, coinsurance, or meet a deductible before the service is covered). These benefits include:

  • Services recommended by the United States Preventive Services Task Force (USPSTF) with a current rating of A or B.
  • Immunizations recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (CDC) for routine use in children, adolescents, and adults.
  • Preventive care and screenings for women, infants, children, and adolescents that are provided for in the comprehensive guidelines supported by the Health Resources and Services Administration (HRSA).

Lifetime coverage limits were eliminated in 2012, and in 2014 annual dollar limits will go away.

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Will my premium increase?

There are a lot of things that affect the cost of health insurance, for example what services are covered; how much you pay for care compared to how much your plan pays; coverage limits; a deductible; your medical history, age, gender, and tobacco use, etc. Some of the new requirements will increase the services that plans must cover (including care for pre-existing conditions) and eliminate annual and lifetime limits on coverage, but also provide tax credits for those who qualify. Premiums also won’t be based on gender, and there are new limits on how much premiums can increase for age. That means costs will depend on each person’s unique situation—they could increase for some people, but go down for others.

Remember, most healthcare reform requirements are implemented based on the date a policy begins. For example, if your current policy begins in August 2013, your premium (and benefits) remains in effect for the duration of your contract, until July 2014. Your carrier will send you information about any changes (including updated rates) when it’s time to renew your policy.

Rest assured, all carriers, including Health First, must provide detailed evidence about medical and administrative costs to the appropriate regulatory agencies to review and approve premiums for each plan.

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Will I have to purchase a new plan in 2014?

  • Group and Individual members: Your policy (premium and benefits) remains in effect for 12 months after the effective date. That means if your coverage began on July 1, 2013, it continues until June 30, 2014 unless a “qualifying event” occurs (for example if you change jobs and lose your employer coverage, or if you move out of our service area, etc.)
  • Medicare Advantage, PDP, and Medigap members: Healthcare reform does not affect Medicare.

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How long can my dependent child(ren) stay on my policy and how will this change with ACA? 

An eligible dependent is defined as the subscriber’s lawful spouse, and/or the subscriber’s or covered spouse’s child until the end of the calendar year in which the child reaches age 26. The term “child” includes the subscriber’s or covered spouse’s natural born child, stepchild, foster child or legally adopted child of the subscriber upon placement in the subscriber’s residence, provided proof of such guardianship is presented. In the case of the birth of a newborn adopted child, a written agreement to adopt such child has been entered into prior to the birth of the child.

The Affordable Care Act requires health plans to offer dependent children continuity of coverage until the child reaches the age of 26. In addition, Florida law requires fully-insured plans to offer continuity of coverage for dependent children after the child turns 26 until the end of the calendar year in which he or she turns 30 if the child:

  1. is unmarried without dependents of their own;
  2. is a state resident or a full or part-time student;
  3. is not provided coverage under any other group or individual insurance policy or entitled to Federal or State benefits; and,

To find out if this applies to your benefit plan, please check your plan documents or contact Customer Service.

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What are “essential health benefits”?

Effective January 1, 2014, all individual/family and small group health plans must include a complete package of “essential health benefits”. Your policy will provide more detailed information on your costs for receiving these covered services:

  • Emergency services
  • Hospitalizations
  • Laboratory services
  • Maternity care
  • Mental health and substance abuse treatment
  • Outpatient, or ambulatory, care
  • Pediatric care
  • Prescription drugs
  • Preventive care
  • Rehabilitative and habilitative (helping maintain daily functioning) services
  • Vision and dental care for children

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What is a “grandfathered plan” and do they have to comply with ACA?

When healthcare reform first began in September 2010, health insurance carriers were allowed to “grandfather” those plans that were in pace at that time. That means a plan may not be subject to all the rules of healthcare reform if it has not undergone any significant benefit change since that time. There are specific rules around what benefits/plans may be grandfathered, and once a plan loses its grandfather status all benefits must be brought into compliance with the current requirements.

All of Health First’s Individual and small group health plans continue to be updated to comply with all the terms of the Affordable Care Act as each requirement takes effect, so we don’t provide or support any “grandfathered” plans. 

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