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October 2010 St@teside

States and Health Plans States Respond to Federal Insurance Reforms Effective September 23

The Affordable Care Act (ACA) stipulated that several insurance reforms would take effect six months after enactment of the legislation—September 23, 2010. Accordingly, many state insurance departments began enforcing the following new requirements:

  • Plans can no longer limit or deny benefits for children under 19.
  • No lifetime or annual benefit limits are allowed.
  • Plans can no longer rescind benefits for honest mistakes on applications; they must be able to prove fraud.
  • Those with insurance have a right to both internal and external appeal of decisions to deny coverage for care.
  • Plans must cover dependents up to age 26.
  • Benefit requirements were added including preventive services with no cost-sharing, an ability to see a pediatrician or OB/GYN without a referral, and the right to use the nearest emergency room without penalty.

Most of the reforms are being slowly implemented by plans with limited market disruption and premium impact. One report estimates the impact on premiums to be about 1 to 2 percent. However, the requirement for guaranteed issue for children caused several health plans to stop issuing child-only policies. Both federal and state regulators are still working with insurers to find a way to cover children; options on the table include covering some children in a state’s high risk pool or experimenting with an open enrollment process. In addition, several companies, including McDonald's, successfully appealed to the U.S. Department of Health and Human Services to be able to continue to offer policies with annual benefit limits ranging from $2,000 to $10,000.