Good Neighbor Insurance (dev.gninsurance.com and www.gninsurance.com) is continuing to update our clients on the new health insurance laws. There are six major coverage options for those in the US and even though some of the rules and regulations are similar for all many differences are there and it all depends on how old you are and for whom you work. Many critical details of this new insurance law will be clarified in the months and years to come.
These six major coverage options are:
(1) Individual or family coverage (private health care plans)
(2) Employee/employer group option for small businesses (typically under 50 employees)
(3) Employee/employer group option for large businesses (typically larger than 50 employees)
(4) Exchange options through the state you are residing in (fully integrated 1-1-2014 and are quasi-government and private insurance coverage combined)
(5) Medicare (which include Parts A, B, C, and D) for those 65 years onwards
(6) Full government health plans like Medicaid, CHIP, TRICARE, VA and other coverage plans as may be designated by the Department of Health and Human Services based mostly on financial criteria and/or military service.
Health plan coverage for your dependents
Dependents, up to the age of 26, are eligible for coverage under your group health plan, as long as your plan includes dependent coverage. Dependents may not be eligible for coverage if they are able to enroll in their own employer-sponsored group plan. A dependent whose coverage or benefits ended because they reached a prior age limit must be given written notice that dependent coverage is available and informed of their 30-day enrollment (or re-enrollment) opportunity. Employees and dependents under age 19 cannot be denied coverage because of a preexisting medical condition.
For health plans effective on or after September 23, 2010, certain preventive services must be covered without charging a deductible, copayment or coinsurance when these services are provided by a network provider. The types of preventive services covered are defined by federal law and can vary based on your age, gender and health status. There may be services you had in the past that will now be covered as preventive at no cost to you. And, there may be services you received in the past that were considered preventive that may no longer be covered as preventive under the new guidelines. The preventive services included in this provision are described at www.healthcare.gov.
Lifetime and Annual Limits
For health plans effective on or after September 23, 2010, there will be no lifetime or annual dollar limits on your health benefits. Other non-dollar limits on essential benefits, such as the number of allowable visits, may apply. Nonessential benefits may continue to have dollar or frequency limits as outlined in your plan. For an explanation of services considered “Essential health benefits” go to http://www.healthcare.gov/.
Emergency Room Services
You are not required to get prior approval before seeking emergency care at a network or non-network hospital. In a true medical emergency, the copayment or coinsurance you pay will be the same regardless of whether the emergency room was in- or out-of network. This is not a change in coverage.
Mental Health Coverage
Beginning July 1, 2010, mental health and substance abuse treatment claims will be covered at the same benefit level as medical claims. This means that copayments will be the same as medical copayments and there are no longer any limits on the number of visits for mental health and substance abuse treatment. Certain types of mental health and substance abuse treatment may require pre-notification and authorization. Visit www.healthcare.gov for more specifics.
Flexible spending accounts (FSAs)
Effective January 1, 2011, you will no longer be able to use your health care flexible spending account (FSA) to pay for over-the-counter (OTC) medications at a pharmacy, supermarket or other retail store without a prescription from your doctor. In some cases, if the medication is prescribed by a physician, you may still be able to use your FSA to pay for it. The final definition of OTC medications, subject to this new law, has yet to be fully defined. OTC medications typically include non-prescription pain relievers, allergy, and cold and flu medications. Health reform also made it clear that FSAs will still be able to be used to pay for insulin. Most major grocery, department, retail and drug stores will be able to identify, at the cash register, what OTC medical supplies may be purchased with an FSA debit card beginning January 1, 2011.
Health savings accounts (HSAs)
Effective January 1, 2011, you will no longer be able to use your health savings account (HSA) dollars to pay for over-the-counter (OTC) medicines at a pharmacy, supermarket or other retail store without a prescription from your doctor. If you have a health care debit card you can still use it to pay for prescription medicines, including insulin, if those are eligible expenses under an employer’s health plan. If you have a prescription for an OTC medicine, such as Zyrtec or Prilosec, and use your HSA to pay for it you will need to keep copies of the prescription and receipt for the purchase with your tax records. Beginning January 1, 2011, if your HSA is used to pay for items or services that are not qualified medical expenses, the IRS penalty will increase from 10 percent to 20 percent of the HSA dollars used.
Doug Gulleson loves to scuba dive overseas and makes sure he has his US health care and overseas health care information with him at all times when he travels (check out his diving travels at www.douggulleson.com). Keep our blog close by you, www.gntravelinsurance.com , for continual updates on the changes with the US health care system.