Texas Commissioner: Health Insurance Reforms Effective Sept. 23

The federal Patient Protection and Affordable Care Act (PPACA) and related Health Care and Education Reconciliation Act, enacted by Congress in March 2010, include significant insurance market reforms effective for most group and individual health insurance policies with plan years that begin on or after Sept.23, 2010.

Under the Act, most health benefit plans in Texas (including both fully insured and self-funded ERISA plans excluded from state regulation) are affected by these provisions. Fully insured plans that are subject to Texas Department of Insurance (TDI) regulation must file with TDI health benefit plan amendments or policy revisions that are made in order to comply with the federal benefit requirements.

Per the Act, the following are health insurance market reforms that apply for plan years that begin on or after Sept. 23, 2010:

• Health plans must provide a required set of preventive services to enrollees, waiving any applicable in-network deductibles, co-pays and co-insurance in most cases
• Health plans may not require referrals for in-network pediatrician and ob-gyn care
• Prior approval requirements for emergency care are prohibited, regardless of in- or out-of-network status
• Health plans which offer dependent coverage must allow all dependents who lack access to their own employer-sponsored coverage to remain on a parent’s plan to age 26
• Health plans may not deny coverage or apply pre-existing condition exclusions to coverage for children under age 19
• Health plans may not impose lifetime dollar limits on essential limits
• Annual dollar limits on health insurance coverage are restricted, and may not be less than $750,000 unless the plan receives a waiver
• Rescissions of health insurance coverage are prohibited, absent fraud or intentional misrepresentation
• Consumers have a right to internal and external appeals of claim and coverage denials; appeals standards and processes have been strengthened

TDI advises consumers to be aware of health insurance market reforms, and to understand how and when their policies may be affected. Some of the provisions will not apply to health plans that were in existence prior to March 23, 2010, and have complied with the requirements necessary to maintain a “grandfathered” status. For consumers with existing health plans, the law changes will not apply until the beginning of a new plan year. Consumers should seek plan-specific information from their employer, health plan sponsor, or insurance carrier.

Topics Texas Market