It’s been a challenging year for Samantha Greene and her family.
In January, Sam’s husband lost his job and, with it, the family’s health insurance. Although Gus was fortunate to find a new position within a few months, the new plan excluded coverage for their young son, Ian.
Ian was born with a heart condition that required surgery in his first days. Although he’s now a healthy three-year-old, he’s considered to have a pre-existing condition.
Sam’s stepson, who recently graduated from college and now lives with them, has a new job―without health insurance. It’s one more worry for the family.
This summer, after feeling weak and tired for months―she assumed it was just a reaction to the stress―Sam was diagnosed with a rare chronic condition. Although it’s highly treatable, the costs are significant–enough to put her over her insurer’s annual and lifetime dollar limits.
Like many other Americans, Sam and her family will benefit from new federal rules governing the nation’s health insurers that took effect on September 23, 2010. Provisions of the Affordable Care Act give consumers new rights and protections―including a ban on pre-existing conditions for children, the elimination of lifetime dollar limits and a reduction in annual limits, and provisions for dependent coverage for young adults.
Washington State has also implemented new health insurance rules, effective October 1, for sole proprietors and the self-employed.
New Washington State Rule for Sole Proprietors and the Self-Employed
Beginning October 1, 2010, sole proprietors and the self-employed will be considered a group of one for health insurance purposes under Washington State law. As a result, they will be able to qualify for insurance in the small group market, rather than the individual insurance market. (A similar rule change will be implemented at the federal level in 2014.)
Before the change, small group health insurance coverage, which is typically less expensive and doesn’t require health screenings, was only available to small businesses with two or more employees.
To qualify for small group coverage under the new rules, you must demonstrate that you’ve run or been employed by the same business for the last twelve months or more, and that you’ve made at least 75 percent of your income from that business―51 percent for agricultural businesses.
For more information on the new rules for sole proprietors and the self employed, contact the Washington State Insurance Commissioner’s office or your insurance agent.
New Federal Rules
A number of provisions of the Affordable Care Act became law on September 23, 2010, including the following.
Choice of Doctor
Your choice of primary care physician or pediatrician in your insurer’s network cannot be limited. In addition, your insurer cannot require you to obtain a doctor’s referral before you see an OB/GYN.
Dependent Coverage
If your health insurance policy covers dependents, your insurer must cover your children until they reach the age of 26, unless they are eligible to participate through an employer’s group health coverage. The requirement applies regardless the child’s marital status, living arrangements (with you or independently), and financial situation.
Children with Pre-Existing Conditions
Insurers that provide health coverage for children under the age of 19 cannot deny or limit benefits or coverage to children with pre-existing conditions.
No-Charge Preventive Services
Your insurer cannot require you to pay for―or share the costs of―health screenings, vaccines and other preventive health services. All told, the new requirement affects more than 100 preventive services, including quit-smoking programs, colorectal cancer screenings for men and women over 50, mammograms for women over 40, and autism screenings for children between 18 and 24 months of age.
Dollar Limits on Health Benefits
Lifetime limits on most benefits for people with costly health conditions are prohibited. Annual limits on benefits aren’t eliminated until 2014, but there are new restrictions on these limits for group and individual health insurance plans issued after March 23, 2010. The amounts are based on policy years that begin on or after September 23, as indicated below.
| From September 23 | To September 22 | Minimum Annual Limit |
| 2010 | 2011 | $750,000 |
| 2011 | 2012 | $1,250,000 |
| 2012 | 2013 | $2,000,000 |
Policy Cancellations, or Rescissions
If you’ve paid your premiums, your insurer can’t cancel your policy to avoid covering your health care costs simply because you or your employer made a mistake in your paperwork. Insurers are prohibited from rescinding your policy when you get sick unless they can demonstrate you committed a fraud.
Appeals Process for Denial-of-Coverage Decisions
New individual and group plans must provide an effective appeals process for appealing decisions that deny coverage. You can require your insurer to reconsider a decision to deny payment. The process must also include the right to appeal to an impartial external review if you’re denied partial or complete coverage.
Emergency Room Care
New health plans cannot require prior approval for emergency room services from an out-or-network hospital or provider and cannot charge you more for such out-of-network emergency services.
Some of the rule changes are universal and apply to all health care plans and policies. Others are only applicable in the context of a new plan or policy. To understand how specific new rules affect your personal situation, contact your health insurance provider.
For more information on these and other newly implemented provisions of the Affordable Care Act, visit healthcare.gov.
