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New Plans: Nurses can help patients navigate new laws during re-enrollment
U.S. Department of Health & Human Services: http://www.hhs.gov/ HHS? HealthCare.gov consumer site: healthcare.gov
Pre-Existing Condition Insurance Plan: pcip.gov
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This year, following new healthcare reforms that went into effect in September, patients and nurses may have something extra to be thankful for ? and probably lots of questions about what their health plans cover and don?t cover. Among other things, the new reforms extend coverage to adult children, offer free preventive services and end lifetime caps on health insurance. Besides ballots, pumpkins and turkeys, November is the month of open enrollment for employee benefits for many workers, and this year brings the added benefits bestowed by the Affordable Care Act.
It?s important for nurses to be informed so they can help patients ? and themselves ? discover how they might benefit from the new laws, says Rose Gonzalez, RN, MPS, director of government affairs for the American Nurses Association. Consumers and providers need to ?look at the resources available and ask the questions to get the care.?
Start with the U.S. Department of Health and Human Services and state departments of insurance websites, which explain coverage for people with pre-existing conditions, says Juby George-Vaze, RN, MBA, CCM, a New York-based nurse care manager and team lead for WellPoint Inc., the country?s largest health benefits company.
George-Vaze also recommends consumers go to their insurer?s website ? the insurer may be an insurance company or an employer ? to find out exactly what benefits are covered, when their ?plan year? starts, when the next open enrollment or renewal period begins, and what choices will be available during that period. The new rules also have made it easier to appeal any denial of insurance coverage, and nurses should be aware of the appeals process so they can help patients who are told a certain service is not covered, she says.
Here is an overview of what the new reforms cover and where to go for more information.
Extending Coverage to Young Adults
What the law says: All plans must allow adult children younger than 26 to remain on their parents? insurance regardless of location, education, marriage or job status.
What it means: Children younger than 19 and already on a parent?s plan can stay on until they are 26, provided the parent renews coverage each year. Children who have gone off their parents? plan and want to get back on may have to wait for a 30-day enrollment period required by law. This might be during an open-enrollment session, or another time, but it must happen by the beginning of the first plan year after Sept. 23, 2010, and insurers must provide written notice.
When the law doesn?t apply: In grandfathered group plans ? those that were in effect before Sept. 23 ? adult children are not eligible if they can get insurance through their employer. By 2014, plans must cover all adult children younger than 26 even if their employer offers a plan. The new regulation applies only to plans offering dependent coverage.
Questions to ask the insurer or employer: When can I sign up my adult children younger than 26? Will the plan cover adult children who have insurance through an employer?
Healthcare Choices
What the law says: Health insurance plans issued after March 23, 2010, cannot require referrals from primary care providers before seeking coverage for OB/GYN care from a participating OB/GYN, and they cannot require higher co-payments, co-insurance or prior approval for emergency care outside the plan?s network.
What it means: Patients with non-grandfathered plans may choose any primary care provider and OB/GYN in their network, and can go to an ED outside their network without getting approval. But patients may still be billed for the difference between what their plan normally pays and what the out-of-network provider bills for emergency care.
When the law does not apply: Grandfathered health plans ? group and individual plans in existence before March 23, 2010, that have not made significant changes since then ? do not have to comply with this rule.
Questions for the insurer: May I choose any provider or OB/GYN specialist under this plan? Will the plan pay for emergency care at out-of-network hospitals?
Free Preventive Care
What the law says: All new insurance plans must cover certain preventive services without a co-pay or deductible.
What it means: If an out-of-network provider performs the service, the insurer may charge a fee. Also, if the service is provided as part of an office visit, the patient may be charged a co-pay for the visit.
When the law doesn?t apply: This regulation applies only to plans created after March 23, 2010. Most group plans will be grandfathered, and not required to provide free preventive services. They must state their grandfather status in their materials. Some insurers say they will offer free preventive services even for plans eligible to be grandfathered.
Questions to ask the insurer or employer: Does this plan include free in-network preventive services? Which services are covered? Does it charge a fee for services done by out-of-network providers, and how much is that fee?
Insurance Cancellations
What the law says: An insurer cannot refuse or cancel coverage because of an honest mistake or omission on an insurance application. This provision applies to all plans starting on plan years that begin after Sept. 23, 2010.
What it means: If an insurer decides to rescind coverage, there must be a 30-day notice to allow the insured person to appeal the cancellation or find new insurance.
When the law doesn?t apply: Insurers can still rescind coverage if someone provides intentional false information on an application or premiums are not paid on time.
Questions to ask the insurer or employer: What specific health information needs to included on the application for health insurance?
Eliminating or Increasing Caps
What the law says: Lifetime limits on most benefits are prohibited in policies issued or renewed on or after Sept. 23, 2010. All group plans and individual policies issued after March 23, 2010, may not set annual limits under $750,000 for plan years starting before Sept. 23, 2011. This amount will gradually rise over three years to $2 million. In 2014 annual caps on most benefits will be eliminated.
What it means: The new annual limits will take effect after the beginning of the plan year. But plans still can put dollar limits on benefits they consider ?non-essential.?
When the law doesn?t apply: The new annual limits are not required for grandfathered individual health insurance policies ? those issued to an individual before March 23, 2010. Some plans may receive waivers from the annual limits if they show they must significantly reduce benefits or increase premiums to comply with the limits. As of Sept. 30, 30 plans have received year-long waivers for limited benefit plans, called mini-meds.
Questions to ask the insurer or employer: At the beginning of the new plan year, will this plan have annual limits for essential benefits? What are they? Is this plan grandfathered (for individual plans only)? Does this plan have a waiver for annual limits? Which benefits are considered essential and which ones non-essential? Are the non-essential benefits subject to annual or lifetime limits?
Children with Pre-existing Conditions
What the law says: Health plans that cover children no longer can deny, exclude or limit coverage to any child younger than 19 based on a health problem the child had before the parent applied for coverage. The rule applies to individual policies issued after March 23, 2010, and all group plans. The rule will go into effect at the start of the first policy year or renewal period after Sept. 23, 2010, and will apply to all Americans starting in 2014. In the meantime, adults with pre-existing conditions who have been without coverage for more than six months can enroll in their state?s pre-existing condition insurance plan.
What it means: Insurers cannot limit enrollment of children with pre-existing conditions to specific periods if they enroll healthy children year-round. Until 2014, individual policies may cost more for children with pre-existing conditions, depending on state laws.
When the law doesn?t apply: Individual insurance policies, including child-only plans, that existed before March 23, 2010, and do not significantly change their benefits or costs, are exempt from the law.
Questions to ask the insurer or employer: Do you cover pre-existing conditions in children? Do you charge more for children with pre-existing conditions, and how much more? Do you have an enrollment period for children (for child-only policies), and when is it?
Cathryn Domrose is a staff writer.
To comment, e-mail editorNTL@gannetthg.com.
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hundreds of nurses and hospital employees met on September 14 in the main lobby of the Central DuPage Hospital in Winfield, ILL., listening to an announcement that the hospital had managed to Magnet recognition. 
