• prohibition of pre-existing condition exclusions;
• lifetime and annual limits;
• prohibition on rescissions;
• choice of health care professional; and
• emergency services.  

Under the regulations, group health plans and health insurance issuers are prohibited from imposing any pre-existing condition exclusions. For individuals under age 19, the prohibition applies to plan years beginning on or after Sept. 23, 2010.  For individuals age 19 and over, the prohibition applies to plan years beginning on or after Jan. 1, 2014.  The provision applies to all plans, except grandfathered individual health insurance coverage.  

Generally, PPACA prohibits annual dollar limits on coverage; however, “restricted annual dollar limits” are allowed regarding coverage of essential health benefits for plan years beginning before Jan. 1, 2014.  The regulations provide a three-year phase out for restricted annual dollar limits as follows:    

• $750,000 for plan or policy years beginning on or after Sept. 23, 2010 but before Sept. 23, 2011;
• $1.25 million for plan or policy years beginning on or after Sept. 23, 2011 but before Sept. 23, 2012; and
• $2 million for plan or policy years beginning on or after Sept. 23, 2012 but before Jan. 1, 2014.    

”Restricted annual dollar limits” apply to all plans, except grandfathered individual market policies. For plan years beginning on or after Jan. 1, 2014, annual dollar limits on coverage of essential health benefits are prohibited.   

Further, group health plans and health insurance issuers are prohibited from imposing lifetime limits on essential health benefits.  The interim final regulations provide that written notice must be given to individuals stating that the lifetime limit on the dollar value of all benefits no longer applies and model language can be found on the DOL website.  For plan years beginning on or after Sept. 23, 2010, the prohibition on lifetime limits applies to all plans, including grandfathered plans.   

Under prior law, cancelation of a plan may have been allowed if an individual made a misrepresentation of material fact, even in cases where the misrepresentation was unintentional. The interim final regulations provide that group health plans and health insurance issuers cannot rescind coverage unless an individual was involved in fraud or made an intentional misrepresentation of a material fact.  The regulations further provide that in cases where cancelation is permissible, at least 30 days advance notice must be provided.  Beginning on or after Sept. 23, 2010, the prohibition on rescissions applies to all plans, including grandfathered plans.  

For group health plans and health insurance issuers that require the designation of primary care providers, the regulations provide that a participant has the right to designate any primary care provider who participates in the network, including designating a pediatrician as the primary care provider for a child.  In addition, a participant is not required to have prior authorization in order to obtain obstetrical or gynecological care.  Written notice is required alerting participants of these changes and model language can be found in the regulations. Beginning on or after Sept. 23, 2010, this provision applies to non-grandfathered plans (grandfathered plans are exempt).  

The regulations also require group health plans and health insurance issuers that cover emergency services to cover such services without obtaining prior authorization, even if the emergency services are provided out of network.  Further, group health plans and health insurance issuers may not impose higher copayments and coinsurance for out-of-network emergency care.  Beginning on or after Sept. 23, 2010, this provision applies to non-grandfathered plans (grandfathered plans are exempt).  

Comments are being accepted on or before August 27, 2010.  

For more information on the interim final regulations, including a fact sheet, visit the DOL website.  

This article only contains summaries of federal regulatory action and should not be considered a definitive source for the purpose of compliance.  In order to ensure a complete understanding of the requirements outlined on this page, ABC recommends members review official agency guidance and consult with legal counsel whenever necessary.