Feds Issue Interim Final Rules Under PPACA for Preexisting Conditions, Lifetime and Annual Limits, Rescissions and Patient Protections
On June 28, 2010, the Departments of Treasury, Labor and Health and Human Services issued interim final rules under the Patient Protection and Affordable Care Act for group health plans and health insurance issuers. The interim final rules pertain to preexisting condition exclusions, lifetime and annual limits, rescissions and certain patient protections under the PPACA. They become effective August 27, 2010.
Preexisting Condition Exclusions: The current rules in effect regarding preexisting condition exclusions apply only to group health plans and group health insurance and permitted limited exclusions under certain circumstances. The new rules prohibit any preexisting condition exclusion from being imposed by group health plans or group health insurance coverage and extend this protection to individual health insurance coverage. This prohibition takes effect in plan or policy years on or after January 1, 2014 but for enrollees under 19 years of age, it takes effect on and after September 23, 2010.
Lifetime and Annual Limits: Group health plans and health insurance issuers offering group or individual health insurance coverage may not impose lifetime or annual limits on the dollar value of health benefits. This restriction on annual limits does not apply to certain account based plans such as flexible spending arrangements (FSA), Medical Savings Accounts (MSAs), Health Savings Accounts (HSAs) and Health Reimbursement Arrangements (HRAs). While the statute prohibits annual limits on the dollar value of benefits generally, it allows “restricted annual limits” with respect to essential health benefits (as defined in section 1302(b) of the Affordable Care Act) for plan or policy years beginning before January 1, 2014.
Prohibition on Rescissions: For plan years on and after September 23, 2010, a group health plan or a health insurance issuer offering group or individual health insurance coverage, may not rescind coverage except in the case of fraud or an intentional misrepresentation of a material fact. The standard applies to all rescissions, whether in the group or individual insurance market, and whether insured or self-insured coverage and regardless of any contestability period that may otherwise apply. This rule changes prior rescissions permitted on the basis of misrepresentations that were not intentional or made knowingly.
Patient Protections: For plans or health insurance coverage with an established network of providers, the plan or insurance issuer must notify each participant of its requirements for designation of a participating primary care provider (and other primary care specialists) and that they may choose any participating primary care provider who is available to accept their designation. Emergency care services must be provided without the individual or the health care provider having to obtain prior authorization and without regard to whether the health care provider furnishing the emergency services is an in-network provider. Cost-sharing requirements, such as co-payments, imposed for out of network emergency services cannot exceed what would be imposed if the services were provided in-network.
These interim final regulations for certain patient protections do not apply to grandfathered health plans.