Good Neighbor Insurance (www.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.

Some plans cover preventive care after an office visit copay. Can a copay still apply or must coverage be at 100%?
The regulations clarified that co-pays, deductibles and coinsurance are not permitted for preventive care services. If a plan uses a provider network, coverage is required at the in-network level only. Coverage of preventive care is permitted but not required out-of-network. If coverage is provided out-of-network, it can be subject to co-pays, deductibles, and coinsurance.

It appears that the preventive care legislation actually does not impact grandfathered plans. Please clarify this.
The prohibition on cost-sharing for preventive care does not apply to a grandfathered plan. Any plan in effect on March 23, 2010 would be a grandfathered plan, and the prohibition on cost-sharing for preventive care would not apply as long as the plan maintains its grandfathered status. Events that might cause a plan to lose its grandfathered status in the future have been clarified in regulations provided by the Secretary of Health and Human Services.

My plan covers preventive care at 100% up to a plan year maximum of $600. Charges that exceed the maximum then apply towards coinsurance (no deductible). How will the legislation impact that benefit?
Because preventive care is considered an essential health benefit, an annual or lifetime dollar limit is not permitted in-network. In addition, application of coinsurance to charges for preventive care services exceeding $600 would not be permitted under the in-network coverage.

My understanding of cost-sharing is that the customer will not have to pay a copay / coinsurance / deductible for preventive services. Do you know if this applies to both in-network and out-of-network doctors, or to in-network doctors only?
The PPACA regulations clarified that a plan can satisfy this requirement by eliminating patient out-of-pocket expenses solely for in-network preventive care services.

When will this no-cost-sharing-for-preventive-care requirement take effect?
The no-cost-sharing-for-preventive-care health requirement is effective for plan years beginning on or after September 23, 2010 (October 1, 2010 for plan years beginning on October 1, 2010), but is not applicable to grandfathered plans.

How is the recent healthcare reform legislation affecting vaccinations and the delivery of vaccines?
Under the new health care reform law, all non-grandfathered health plans will be required to provide a preventive benefit package that covers routine immunizations. Regulations from the Secretary of Health and Human Services require coverage of all immunizations and vaccines that are recommended by the Advisory Committee on Immunization Practices (ACIP).

Doug Gulleson loves to scuba dive overseas and makes sure he has his US health care and overseas health care, www.gninsurance.com , information with him at all times when he travels   Keep our blog close by you, www.gntravelinsurance.com, for continual updates on the changes with the US health care system.