Your Health Plan and You: Know Your Coverage Protections
If you have health coverage through a private sector employer plan, there are laws to protect these benefits for you and your family. You probably have heard of some of them, such as COBRA, HIPAA and more recently, the Patient Protection and Affordable Care Act (the Affordable Care Act). Have you been wondering how the Affordable Care Act will affect your health plan and you? Have you had questions about your own plan? It is important to know your benefit rights so that you can make informed decisions when necessary to keep or get health coverage. It is also important to know where you can go for help if you have questions about your rights or your plan. This publication provides an overview of these laws and resources for further information and assistance.
The Affordable Care Act adds many protections related to employment-based group health plans. These include extending dependent coverage up to age 26; prohibiting preexisting condition exclusions; and requiring easy-to-understand summaries of a health plan’s benefits and coverage. Additional protections that may apply to your plan include the requirement to provide coverage for certain preventive services (such as blood pressure, diabetes and cholesterol tests, regular well-baby and well-child visits, routine vaccinations and many cancer screenings) without cost-sharing, and coverage of emergency services in an emergency department of a hospital outside your plan’s network without prior approval from your health plan. Under HIPAA, employment-based group health plans have been subject to certain requirements limiting the imposition of any preexisting condition exclusions since 1996. (A preexisting condition exclusion is any limitation or exclusion of benefits for a health condition because it was present before coverage begins, regardless of whether any medical advice, diagnosis, care or treatment was recommended or received before that day.) The Affordable Care Act expanded these protections by prohibiting the imposition of preexisting condition exclusions for children under age 19, and, starting in 2014, for all individuals.
under the Affordable Care Act, in addition to health coverage through an employment-based group health plan, there will be a new way to get health coverage – the new health insurance marketplace (the Marketplace). The Marketplace will offer health insurance (called qualified health plans) that include comprehensive coverage, from doctors and medications to hospital visits. Qualified health plans in the Marketplace will present their price and benefit information in simple terms so that you can make apples-to-apples comparisons. Starting in October 2013, you will be able to get information about all of the plans available in your area and enroll. For more information about obtaining coverage through the Marketplace, visit www. healthcare.gov. To help ensure widespread coverage, the Affordable Care Act also includes tax credits to ensure affordability and includes provisions relating to the shared responsibility of employees to maintain health coverage and employers to provide affordable coverage that meets certain standards. These provisions are administered by the Department of the Treasury and the Internal Revenue Service. For more information regarding these provisions contact 1-800-318-2596.