Affordable Care Act Features


Group Marketing Services

Group Marketing ServicesKey Features of the Affordable Care Act

You will soon have access to health coverage, even if you have a pre-existing condition. And premium tax credits and other financial assistance will help you pay for health insurance if you are eligible.

Below are some things you should know about the Affordable Care Act. If you want to get more detailed information about the new health care law.


Group Marketing ServicesAnnual and Lifetime Dollar Limits

Your Health Plan Won't Limit the Amount It Will Pay for Essential Health Benefits within a Year or Over the Lifetime of Your Plan

Your health insurance plan cannot limit how much it will pay for essential health benefits. Essential health benefits cover your basic health needs and include preventive services and some prescription drugs.

Previously, insurance companies could limit what they would spend, either yearly or for the entire time you were enrolled in a plan (the "lifetime"). Under the new health care reform provisions, there are no lifetime limits on most benefits you receive. The law also restricts annual limits and does away with them entirely in 2014.

Important Notes:

The new rule on annual dollar limits does not apply to grandfathered individual health insurance plans.

Group Marketing ServicesAppeals and External Reviews

You Can Ask Your Health Plan to Reconsider Decisions about Paying Claims, Eligibility for Coverage or Ending Coverage

Under the new law, there are new ways to ask your plan to reconsider its denial of payment for a service or treatment. This is called an "internal appeal."

You will receive an explanation of the appeals process if you are ever denied coverage. In addition, you'll have the opportunity to have your appeal reviewed by an independent review organization if payment is still denied following the appeals process. This step is called an "external review."

Group Marketing ServicesCoverage of Adults with Pre-existing Conditions

Most People Will Be Able to Get Insurance Coverage, Even Those With A Pre-existing Condition

With the new law, starting in 2014, you can get health insurance — even if you already have an illness or are pregnant (pre-existing condition).

Children under age 19 can't be denied insurance because of a pre-existing condition. Right now, the new law applies to family plans that offer child coverage. This does not apply to grandfathered individual insurance policies.

Group Marketing ServicesCoverage of Children with Pre-existing Conditions

Health Coverage Is Available for All Kids, Even Those with Pre-existing Conditions

Children under age 19 may receive health coverage, even if they already have an illness or disability (otherwise known as a pre-existing condition).

Group Marketing ServicesCoverage of Children to Age 26

Young Adults Can Now Stay on Their Parent's Health Plan Up to Age 26

Right now, most insurance plans cover children to age 26. In 2014, all group health plans will have to cover young adults until age 26, even if they are eligible for health insurance through their employer.

For plans with dependent coverage

Children under age 26 can't be turned down, even if they:

Group Marketing ServicesEssential Health Benefits (EHB)

Health Plans Will Include More Benefits Considered Essential to Good Health

Beginning in 2014, certain health plans must cover your basic health needs. The new law defines this coverage as essential health benefits. Essential health benefits include:

Starting next year, all new individual health care plans must cover these essential health benefits. Many group health plans will also cover these benefits.

Plans that are not required to cover these benefits cannot set annual or lifetime dollar limits on them — except grandfathered individual plans may have annual limits. Be sure to ask what the plan you are getting covers. This is especially important if you have a condition that requires ongoing medical care.

Group Marketing ServicesGrandfathered Health Plans

Some Insurance Plans Are "Grandfathered"

Are you enrolled in the same plan that you had on March 23, 2010? You may have a type of plan called a "grandfathered" insurance plan. With a grandfathered plan, you may not get all of the new law's health care changes.

Here's a look at some of the changes that are and aren't in grandfathered plans:

Changes in ALL insurance plans

Changes NOT in grandfathered plans

Even though other plans will offer essential health benefits, grandfathered plans aren't required to:

Also, grandfathered individual health policies are not required to:

Group Marketing ServicesHealth Coverage Cancellations

Your Health Plan Cannot Cancel Your Coverage If You Made a Mistake on Your Initial Application

Rescission is the retroactive cancellation of health coverage. Under the Affordable Care Act, group health plans and health insurers are prohibited from "rescinding" or canceling your coverage if you made a mistake on your initial application. They can cancel your plan if the information you provided was intentionally false. A group health plan or health insurer must give written notice at least 30 calendar days before coverage may be canceled.

Group Marketing ServicesHealth Insurance Penalty

You'll Be Required to Purchase Health Insurance If You Don't Already Have It

Starting in 2014, you will be required to have health insurance or pay a penalty if you don't. However, you may be exempt from this requirement if you meet 1 or more of the following:

If you do not meet any of these exemptions and are without coverage, you will pay 1 of the penalties below, whichever is greater:





2016 and Beyond


To help you pay for health insurance, you may be eligible for a tax credit.

Group Marketing ServicesMedicaid Expansion

The Medicaid Program Will Be Expanded in Some States to Allow More People to Qualify for the Program

The Affordable Care Act is expected to help more people get Medicaid, beginning in 2014. In some states, more low-income adults who qualify — including people with disabilities and those with children — will be able to get Medicaid. If you are eligible to receive Medicaid, you will be referred to your state's Medicaid program when you apply for insurance on the exchange.

Group Marketing ServicesMedical Loss Ratio (MLR)

Health Insurance Companies Must Devote 80% to 85% of the Premiums They Collect to Provide Health Care Services to Customers

The Medical Loss Ratio (MLR) standard of the Affordable Care Act ensures that only 15% of the premiums an insurance provider collects can be spent on administrative costs. The rest must be spent on medical care and programs that can help improve the quality of health care.

If an insurer does not meet these MLR standards, it will pay rebates to its customers. Given the inherently unpredictable nature of health care costs and utilization, it is not surprising that health plans may pay rebates to some customers in certain markets.

Group Marketing ServicesPreventive Health Services

Preventive Care Comes With No Out-of-pocket Cost

You may be able to get preventive health services — that can help you stay healthy — at no cost. This means you may not have to pay a copayment, coinsurance or deductible.

You may get — at no costpreventive services such as:

Some Important Details

Group Marketing ServicesSummary of Benefits and Coverage and Uniform Glossary

Simplified Coverage Descriptions Will Be Available

When you shop and enroll in insurance, you'll be able to get a summary of benefits and coverage (SBC) offered by the plan, with easy-to-understand descriptions and examples that explain the benefits.

The SBC also has Coverage Examples to help explain the benefits offered for specific common health care scenarios like having a baby or managing Type II Diabetes.

The SBC is consistent across all health insurance plans and will include:

The items in the SBC represent an overview of coverage; they are not a complete list of what is covered or excluded. The full terms of coverage are located in the insurance policy.

When shopping for health insurance, you can request an SBC before you buy, but you must also get a copy at the time of application, enrollment, yearly upon re-enrollment and any time you ask for it.

The new law also requires health insurers to provide you with a uniform glossary. This is a list of commonly used insurance-related terms and medical terms that will help when comparing terms of coverage and medical benefits.


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