Patient Protections

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It’s called the Patient Protection and Affordable Care Act. Here are the patient protections.

Overview

The Patient Protection and Affordable Care Act created a number of new patient protections, many of which became effective with the first renewal on or after September 23, 2010. Other patient protections become effective on the plan’s first renewal date in 2014. Some of these changes are grandfathered, meaning that a plan in effect on March 23, 2010 does not have to implement them, while others are non-grandfathered and must be included in all plans.

Some of these changes include:

  • Guaranteed issue coverage with no pre-existing condition exclusions, limitations, or surcharges. Effective in 2010 for children and 2014 for adults.
  • No rescissions of coverage except in the case of fraud or intentional misrepresentation
  • Ability to pick your doctor from any available primary care physician in the network and to pick any available pediatrician for your children
  • No referrals needed for OB-GYN services
  • Access to out-of-network emergency room services with in-network cost-sharing and no prior authorization requirement
  • Young adults eligible to enroll in parents’ coverage until age 26 even if not living at home, not a full-time student, not a tax dependent, or married
  • Unlimited, up-front preventive care with no cost sharing
  • No annual or lifetime dollar limits on essential benefits
  • Guaranteed right to appeal through an external appeals process
  • No discrimination based on gender in the individual and small group markets beginning in 2014

Source: Healthcare.gov article “How does the health care law protect me?

Regulations and Guidance

Regulation: Final Rule and Proposed Rule | Public Comments
This document contains interim final regulations implementing the rules for group health plans and health insurance coverage in the group and individual markets under provisions of the Patient Protection and Affordable Care Act regarding preexisting condition exclusions, lifetime and annual dollar limits on benefits, rescissions, and patient protections. (06/28/2010)
Patient Protection Model Notice | en español
When applicable, it is important that individuals enrolled in a plan or health insurance coverage know of their rights to (1) choose a primary care provider or a pediatrician when a plan or issuer requires designation of a primary care physician; or (2) obtain obstetrical or gynecological care without prior authorization. Accordingly, the interim final regulations regarding patient protections under section 2719A of the Affordable Care Act require plans and issuers to provide notice to participants of these rights when applicable. The notice must be provided whenever the plan or issuer provides a participant with a summary plan description or other similar description of benefits under the plan or health insurance coverage. This notice must be provided no later than the first day of the first plan year beginning on or after September 23, 2010.
Lifetime Limits Model Notice | en español
Plans and issuers are required to give written notice that the lifetime limit on the dollar value of all benefits no longer applies and that an individual, if covered, is once again eligible for benefits under the plan and, if not covered, is eligible to enroll in the plan. The notices and enrollment opportunity must be provided beginning not later than the first day of the first plan year beginning on or after September 23, 2010.

Videos

HHS Video: Health Reform & Strengthening Consumer Protection

Posted June 9, 2010. Explains some of the new consumer protections built into the Affordable Care Act. Conducted in a Q&A format.


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