Health Reform

McBride Group is committed to keeping our clients up to date with current health care reform implementation.  Please return to review periodic updates posts that will provide valuable information.

Health Reform

Health Reform Update

UPDATE:  April 2010

President Obama signed a health reform bill into law on Sunday, March 21st. Based on current information, the health reform legislation involves a number of changes to existing insurance regulations. While a few changes will be implemented in the coming months, many changes will not take effect for several years. Most changes will require guidance from federal regulators and the state insurance commissioner. Hence, the overall impact is yet to be determined.

At this time, there are no immediate plans that would affect our Individual Health policies.

Individual Health Underwriting

Individual health insurance is based on a thorough review of your health history to determine if you qualify. If an offer of coverage is extended, an additional premium could be required. Not everyone qualifies for individual health insurance. People who have been diagnosed with certain conditions may be denied coverage. Medical underwriting is still required for individual health insurance.

Short Term Reform

Several near-term requirements will impact all contracts for new sales and renewals beginning in approximately six months. While there is a provision that "grandfathers" existing plans and allows members in these plans to keep their products, the new law requires us to add several new elements to all contracts, regardless of whether the plan is "grandfathered."

These include elements like:

  • Allowing members to add dependents up to age 26 regardless of student status
  • Eliminating lifetime limits on policies

It is important to note that our preliminary analysis of the "grandfathering" provision indicates that if a subscriber changes products after March 23, 2010, he or she will likely be subject to additional product requirements that are effective in the future.

For new sales and subscribers who change policies after approximately six months, we will be required to make additional changes, such as:

  • Removing any member cost sharing for "preventive" benefits, as defined by the legislation.

Other, more comprehensive insurance reforms will begin in 2014:

  • Many of the more significant changes to the insurance marketplace — such as rating reforms, the individual and employer mandates, Medicaid expansions, the insurance exchanges and the insurance subsidies — are set to be effective on January 1, 2014.
  • Many of the new laws require federal agencies to issue more detailed regulations that will guide implementation, and we will share more information when it is available.

Effective six months from the effective day (when the president signed the bill into law), any new policy or any renewal on an existing policy will have the extended age benefit.  Children under the age of 26 regardless of student status may be added to the parents policy. This should take effect in late September or early October.

We will keep you informed of all the changes that are coming, and update you about any changes that will impact our Individual Health plan clients.

We are committed to continuing to provide our customers with high quality healthcare aimed at improving health every day.

UPDATE:  May 2010Health Reform

Although we, along with the entire health insurance industry, are still waiting for guidance from federal regulators and the state insurance commissioner, we would like to share with you an overview of the short-term changes that were set forth in March 2010.  Additionally, we are providing you with two grids from America’s Health Insurance Plans (AHIP) that outline the short and long-term reforms and an implementation timeline.  We have found these documents to be an easy resource guide to this complicated process.  We hope you find them helpful as well.

90 days

High-risk health insurance pool

¨       Any individual who has been uninsured for at least 6 months and has a pre-existing medical condition can receive coverage through a high-risk pool, which will be funded through a $5 billion federal appropriation.

¨       Premiums will be capped.

¨       As other market reforms take effect in January 2014, the high-risk pool coverage will end.

6 months

Temporary Reinsurance Program

¨       Creates a new temporary reinsurance program to help companies that provide early retiree health benefits for those ages 55-64 offset the cost of coverage.

Eliminate exclusions for medical conditions for children

¨       If a child is accepted for coverage, or is already covered, the insurer cannot exclude payment for treating a particular illness. For example, if a child has asthma, the insurance company cannot create a policy excluding asthma from coverage.

Extending coverage under parent’s health plan for young people

¨       Young people will be allowed to remain on their parents’ insurance policy up to their 26th birthday, at the parents’ request, so long as they do not have another source of employer-sponsored insurance.

Prohibiting Recessions; New Appeals Process

¨       Prohibits recessions except in the case of fraud and requires third-party regulatory review.

¨       Establishes consistent internal and external appeals process.

Mandated Benefit Designs

¨       No lifetime limits on coverage.

¨       No “restrictive” annual limits on coverage.

¨       Preventive Services: Requires plans to cover preventive services with no Copayments and with preventive services being exempt from Deductibles.

Improving Consumer Info via the Web

¨       Requires the Secretary of Health and Human Services to establish an Internet Web site for residents of any state to identify affordable health insurance coverage options in their state. The Web site will include information for small businesses about available coverage options, reinsurance for early retirees, small business tax credits, and other information. “Mini Meds” or “Limited Benefit” plans will be precluded from listing their products on the Web.

New Option for Medicaid Coverage

A new option allowing States to cover parents and childless adults up to 133 percent (133%) of the Federal Poverty Level and receive current law Federal Medical Assistance Percentages (FMAP) will take effect.


UPDATE:  August 2010

Preventive Care Coverage Requirements

 The Patient Protection and Affordable Care Act requires new health plans (non-grandfathered)  to cover preventive health services without imposing cost-sharing requirements for the services.

 This requirement is generally effective for plan years beginning on or after September 23, 2010. It does not apply to grandfathered health plans.

Highlights of the regulations include:

·         An explanation of the recommended preventive services that must be covered without cost-sharing requirements:

·         Clarification regarding cost-sharing that may be imposed when preventive services are provided during an office visit; and

·         Confirmation that cost-sharing can be imposed for out-of-network services.

The interim final rules address the requirement that new (i.e., non-grandfathered) health plans cover certain recommended preventive services and eliminate cost-sharing requirements for such services. For plan years beginning on or after September 23, 2010, new group health plans must cover certain preventive services and may not charge copayments, coinsurance or deductibles for these services when delivered by a network provider.

The recommended preventive services covered by these requirements are:

·         Evidence-based items or services that have in effect a rating of A or B in the current recommendations of the United States Preventive Services Task Force;

·         Immunizations for routine use in children, adolescents and adults that are currently recommended by the Centers for Disease Control and Prevention (CDC) and included on the CDC's immunization schedules;

·         For infants, children and adolescents, evidence-informed preventive care and screenings provided for in the Health Resources and Services Administration (HRSA) guidelines; and

·         For women, evidence-informed preventive care and screening provided in guidelines supported by HRSA, which are to be developed by August 1, 2011.

These recommended preventive services include screening for a number of conditions, as well as counseling for various health-related issues:

 Screening for Abdominal Aortic Aneurys

Screening and Counseling to Reduce Alcohol Misuse

Aspirin to Prevent Myocardial Infarctions

 Aspirin to Prevent Ischemic Strokes

Screening for Cholesterol

Screening for Colorectal Cancer

Screening for Clamydial Infection

Screening for Depression

Screening for Diabetes

Counseling on Nutrition for At-Risk patients

Screening and Counseling for Obesity for At-Risk Patients

Screening for Gonorrhea

Screening for Hearing Loss

Counseling for Sexually Transmitted Infections

Screening for Syphilis

Counseling for Tobacco Use

Screening for Bacteriuria for Pregnant Women

Folic Acid Supplements for Pregnant Women

Interventions to Support Breast Feeding

Screening for Hepatitis B in Pregnant Women

Screening for RH Incompatibility for Pregnant Women

Counseling related to BRCA Screening

Screening for Breast Cancer

Counseling for Chemoprevention of Breast Cancer

Screening for Cervical Cancer

Screening for Osteoporosis for Women 65+

Prophylactic Ointment for Prevention of Gonorrhea in Newborns

Screening for Sickle Cell Disease in Newborns

Screening for Congenital Hypthoyrodism in Newborns

Screening for PKU in Newborns

Chemoprevention of fluoride treatment for children

Screening for Visual Acuity in Children <5

Iron Supplements for At-Risk Children 6 - 12

The complete list of recommended preventive services that must be covered can be found at www.HealthCare.gov/center/regulations/prevention.html

Also included in the Preventive Services Interim Final Rules are immunizations for routine use in children, adolescents, and adults that have in effect a recommendation from the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention with respect to the individual involved. A recommendation of the Advisory Committee is considered to be "in effect" after it has been adopted by the Director of the Centers for Disease Control and Prevention. A recommendation is considered to be for routine use if it appears on the Immunization Schedules of the Centers for Disease Control and Prevention./span>

RRecommended Immunizations of the ACIP appear in four immunization schedules for 2010.  The schedules contain graphics that provide information about the recommended age for vaccination, number of doses needed, interval between the doses, and (for adults) recommendations associated with particular health conditions.  These immunizations are included in the links below:

Recommended Immunization Schedule for Persons Aged 0 - 6 Years

Recommended Immunization Schedule for Persons Aged 7 - 18 Years

Catch-up Immunization Schedule for Persons Aged 4 Months - 18 Years Who Start Late or Who Are More Than 1 Month Behind

Recommended Adult Immunization Schedule

All health plans are required to adopt these changes for any non-grandfathered plans starting with October 1, 2010 renewals.span style="mso-spacerun:yes">  The list of Optima's 10/1/10 Core Benefit Changes that incorporate the HealthCare Reform requirements are attached at the bottom of this newsletter.  As soon as we receive Anthem's, we'll pass them on to you.


Cost Sharing Requirements

The interim final rules also clarify the cost-sharing requirements when a recommended preventive service is provided during an office visit. Whether cost-sharing requirements may be imposed will depend on: (a) whether the preventive service is billed or tracked separately, and (b) whether the preventive service is the primary purpose of the office visit. Cost-sharing is permitted only if:

·         The recommended preventive service is billed separately (or is tracked as individual encounter data separately) from an office visit; or

·         The recommended preventive service is not billed separately from the office visit and the primary purpose of the office visit is not to obtain the recommended preventive service.

Cost-sharing requirements are not allowed in cases where the recommended preventive service is not billed separately, but it is the primary purpose of the office visit.

Example. An individual covered by a group health plan visits an in-network health care provider. While visiting the provider, the individual is given a cholesterol screening (a recommended preventive service). The provider bills the plan for an office visit and for the laboratory work of the cholesterol screening test. The plan may not impose any cost-sharing requirements with respect to the laboratory work. Because the office visit is billed separately from the cholesterol test, the plan may impose cost-sharing requirements for the office visit.

Example. An individual covered by a group health plan visits an in-network health care provider to discuss recurring abdominal pain. During the visit, the individual has a blood pressure screening (a recommended preventive service). The provider bills the plan for an office visit. The blood pressure screening was not the primary purpose of the visit. Therefore, the plan may impose a cost-sharing requirement for the office visit charge.

Example. A child covered by a group health plan visits an in-network pediatrician to receive an annual physical exam (a recommended preventive service). During the office visit, the child receives additional items and services that are not recommended preventive services. The provider bills the plan for an office visit. The recommended preventive service was not billed as a separate charge and was the primary purpose of the visit. Therefore, the plan may not impose a cost-sharing requirement for the office visit. 

Additional Clarifications

The regulations make clear that plans may continue to impose cost-sharing requirements on preventive services that employees receive from out-of-network providers. Also, plans may use reasonable medical management techniques to determine the frequency, method, treatment or setting for preventive services, as long as they are not specified in the recommendation or guideline. 


The Patient Protection and Affordable Care Act (PPACA) was enacted on March 23, 2010 and amended by the Health Care and Education Reconciliation Act of 2010 on March 30, 2010.


Carrier Interpretations

While we have not received definitive guidelines from Anthem or UHC, Optima has created a list of the changes that their groups will see as they renew starting with October 1, 2010 which we have attached for your use.  Remember, these will not affect your plan until your group renews.


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