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Women's Preventive Health Services

Effective at renewals and for new contracts beginning August 1, 2012, Blue Cross of Idaho will provide coverage with no cost sharing for specific preventive health services for women.

If you have any questions about these benefit changes, please select this link or contact your local Blue Cross of Idaho District Office.

Healthcare Reform Timeline

Blue Cross of Idaho is committed to working with the Federal government to implement new healthcare reform laws over the next several years. The timeline below explains in detail what changes members can expect, and when.

The government has yet to give clear guidelines on some short and long-term provisions scheduled for the months and years ahead; however, we will continue to update the dates and information with the latest news when it's available.

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Tax credits for qualifying small businesses

Starting in 2010, the government will provide a tax credit to small employers that pay at least 50 percent of their employees' health insurance premiums. The full value of the tax credit is 35 percent of the small employers' cost for businesses with up to 10 employees and average annual wages of less than $25,000. The tax credit also applies on a reduced sliding scale to small employers with up to 25 employees and average annual wages of $50,000. This credit is available to both grandfathered and non-grandfathered plans.

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Rebates for those who hit the Medicare gap in prescription drug coverage

In 2010 only, people enrolled in Medicare Part D will receive a $250 rebate when they hit the donut hole, or gap in prescription drug coverage that occurs when spending on covered Part D drugs, including co-pays and deductibles, exceeds $2,830. The Department of Health and Human Services announced in April that rebates would commence June 15. Members hitting the prescription drug donut hole are eligible for a $250 rebate. Medicare sends the check directly to the enrolled person within three months of hitting the donut hole. There's no application process and no private company will be involved in the check-delivery process.

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Consumer information grants to states

Starting in 2010, Health and Human Services will provide $30 million in grants to states to set up health insurance consumer assistance or health insurance intermediary programs to:

  • Assist with the filing of complaints and appeals
  • Collect, track, and quantify problems and inquiries
  • Educate consumers on their rights and responsibilities
  • Assist consumers with enrollment in plans
  • Resolve problems with obtaining subsidies

States receiving grants must collect and report data on the types of problems and inquiries encountered by consumers. The data will be shared with state insurance regulators, the Secretary of Labor and the Secretary of Treasury to identify areas where enforcement action is necessary.

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Grandfathered plan status for policies in effect on enactment date

Health plans with active members on March 23, 2010, either as part of a group or as an individual member, can be grandfathered plans, if they do not make certain changes to the health coverage they offer. These plans have special effective dates for some healthcare reform requirements and are completely exempt from others. Grandfathered group plans can enroll new employees and their dependents and dependents of currently covered employees without jeopardizing their grandfathered status. Similarly, individuals in grandfathered plans may add dependents to their policies. Any plan not in existence prior to March 23, 2010 is a non-grandfathered plan.

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Temporary early retiree reinsurance program

The early retiree reinsurance program, which will pay 80 percent of the claims between $15,000 and $90,000 for early retirees between the age of 55 and 64 in a group health plan, will be running by July 2010. The Department of Health and Human Services has posted details and directions about how employers can apply on their website. Employer groups can complete applications though they will likely require:

  • The projected amount of reimbursement to be received for the first two plan year cycles with specific amounts for each plan year.
  • A statement that policies and procedures are in place to detect and reduce fraud, waste, and abuse.
  • A description of the procedures or programs the employer has in place to generate cost savings with respect to chronic and high-cost conditions.
  • An assurance that the employer has a written agreement with its health insurance carrier or group health plan to provide Health and Human Services information and data necessary to verify compliance with program requirements.
  • A summary of how the employer will use the money to lower employer health benefit costs or premiums, or premiums, deductibles, coinsurance or copayments for plan participants.
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HHS internet portal for individuals and small group

The web portal will help consumers navigate their options in the individual and small business private market and help them determine if they may be eligible for a variety of existing public programs, including high-risk pools, Medicaid, Medicare and the Children's Health Insurance Program (CHIP).

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Medicare Part D discounts for those who hit the gap in coverage

Between late June and early September, people with Medicare Part D prescription coverage who have reached the donut-hole coverage gap in 2010 should receive a $250 rebate. For more information on the donut-hole coverage gap and who qualifies to receive the rebate, see the “Rebates for seniors who hit the Medicare gap in prescription drug coverage” description in the January, 2010 entry on this timeline.

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HHS regulations on state exchange waivers

Health and Human Services will consider requests from states to be exempt from multiple reform provisions, such as exchanges, essential benefits and mandates. In order to get such a waiver, states would have to present an alternative plan that would provide coverage at least as comprehensive and affordable, to at least a comparable number of residents, as the federal legislation would achieve.

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Health information technology standards

Health and Human Services will provide standards on how health plans will be required to manage various kinds of data and conduct financial transactions.

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Dependent coverage extended to age 26

All group health plans that offer coverage for their employees' children must extend eligibility to married or unmarried children of covered employees up to age 26. There are no additional criteria to qualify other than being a child of a policyholder under age 26. For plans not in existence (non-grandfathered plans) on or before March 23, 2010, they have to do this starting with the first plan year beginning after Sept 23, 2010. Plans that existed (grandfathered plans) on or before March 23, 2010, have to do this with the first plan year beginning after Sept. 23, 2010, but only for adult children up to age 26 who are not eligible for employer-sponsored coverage elsewhere.

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Restrictions on rescissions

Starting with plan years after Sept. 23, 2010, no health plan can rescind (cancel) health coverage for premium paying members except in cases of fraud.

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No pre-existing condition exclusion for children

Anyone under 19 with a pre-existing condition cannot be denied coverage for that condition at any time starting with the first plan year beginning on or after Sept. 23, 2010. In addition, insurers cannot impose waiting periods for coverage of pre-existing conditions for people under 19. This will change in 2014 for everyone as the bill requires all carriers to accept everyone, regardless of health status.

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Preventive services with no cost-sharing

Starting with plan years beginning on or after Sept. 23, 2010, plans must provide coverage without cost-sharing for:

  • Select services recommended by the U.S. Preventive Services Task Force
  • Immunizations recommended by the Advisory Committee on Immunization Practices of the CDC
  • Preventive care and screenings for infants, children and adolescents supported by the Health Resources and Services Administration
  • Preventive care and screenings for women supported by the Health Resources and Services Administration
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No lifetime limits and restricted annual limits

Beginning with the first plan year on or after Sept. 23, 2010, plans may not place lifetime limits on essential health benefits, and only restricted annual limits (to be defined by HHS) will be permitted on essential benefits (this annual limit provision does not apply to grandfathered individual plans). Beginning with plan years starting after Jan. 1, 2014, there will be no annual limits on essential health benefits.

Health and Human Services still has to define essential health benefits.

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Medical loss ratio reporting

Medical loss ratio (MLR) is the percentage of health insurance premiums spent by an insurance company on healthcare services. The reform law requires that large group plans spend 85 percent of premiums on clinical services and activities for the quality of care for enrollees. Small group and individual market plans must devote 80 percent of premiums to these purposes. Beginning Sept. 23, 2010, health plans will be required to report MLRs to Health and Human Services.

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Patient protections

All new plans starting on or after Sept. 23, 2010, that provide for designation of a primary care provider must allow the choice of any participating primary care provider who is available to accept them, including pediatricians. A plan may not require authorization or referral for a female patient to receive obstetric or gynecological care from a participating provider and must treat their authorizations related to OB/GYN services as the authorization of a primary care provider.

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Emergency services

If a plan provides coverage for emergency services, the plan must do so without prior authorization, regardless of whether the provider is a participating provider. Services provided by nonparticipating providers must be provided with cost-sharing that is no greater than that which would apply for a participating provider and without regard to any other restriction other than an exclusion or coordination of benefits, an affiliation or waiting period, and cost-sharing.

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Medical loss ratio rebates

Medical loss ratio (MLR) is the percentage of health insurance premiums spent by an insurance company on healthcare services. Starting Jan. 1, 2011, insurers must provide a rebate to consumers if the percentage of premiums expended for clinical services and activities that improve healthcare quality is less than 85 percent in the large group market and 80 percent in the small group and individual markets.

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Increased penalty for non-medical health savings account withdrawals

Starting Jan. 1, 2011, the penalty for withdrawals from Health Savings Accounts not used for qualified medical expenses will increase from 10 percent to 20 percent, and the penalty for unqualified withdrawals from Archer Medical Savings Accounts will increase from 15 percent to 20 percent.

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Medicare Advantage Changes

For some individuals with Medicare Advantage plans, coverage will stay the same or improve. For others, benefits may decrease or cost sharing may increase. Reduced Medicare Advantage benefits will include other highlights not often associated with these kinds of plans, such as reduced cost sharing, free eyeglasses and gym memberships. Blue Cross of Idaho is working to minimize impacts and to ensure that our Medicare Advantage plans receive reimbursement for providing high quality care. There won't be a reduction in Original (basic) Medicare benefits.

  • 2010 payments frozen for 2011
  • Authority to deny plan bids (MA/PDP)
  • Limits on out of pocket costs
  • Provisions for 50 percent discount on brand-name drugs in the Medicare Part D coverage gap
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Physician payment reforms and incentives to form "accountable care organizations"

Awaiting government regulation.

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Value-based purchasing programs

Awaiting government regulation.

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Implementation of uniform standards for electronic exchange of health information

Awaiting government regulation.

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Cap on health flexible spending account contributions

Flexible Spending Account contributions are limited to $2,500 per year, indexed for inflation.

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National pilot programs on payment bundling for Medicare

Awaiting government regulation.

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Increased Medicaid payment for primary care doctors

Awaiting government regulation.

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Health insurance fee to fund comparative effectiveness research

Awaiting government regulation.

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Health insurance exchange is established for individual and small group markets

Individuals (U.S. citizens and legal immigrants) and small employers with an average of 100 or fewer employees in the previous calendar year may purchase insurance from state-run exchanges beginning in 2014 (or small employers with an average of 50 or fewer employees in the previous calendar year if the state so permits until 2016). If the state agrees, large employers with an average of at least 101 employees in the previous calendar year may also purchase from the exchange beginning in 2017.

All carriers doing business in Idaho may participate by offering products on any of the five tier levels of the exchange:

  • Bronze — provides minimum essential benefits, covers at least 60 percent of actuarial value* of covered benefits, with out-of-pocket limit equal to current limits on HSAs ($5,950 for individuals and $11,900 for families, in 2010)
  • Silver — provides minimum essential benefits, covers at least 70 percent of actuarial value* of covered benefits, with HSA out-of-pocket limits
  • Gold — provides minimum essential benefits, covers at least 80 percent of actuarial value* of covered benefits, with HSA out-of-pocket limits
  • Platinum — provides minimum essential benefits, covers at least 90 percent of actuarial value* of covered benefits, with HSA out-of-pocket limit.
  • Catastrophic — similar to high-deductible health plan, except available only to individuals up to age 30 in the individual market and persons not able to find affordable coverage (less than 8 percent of income)

Reduced out-of-pocket limits apply to individuals with incomes up to 400 percent of the federal poverty level.

*Actuarial value means that the health insurance coverage selected is estimated to cover a certain percentage of a member's costs. Therefore, a plan with a 60 percent actuarial value is estimated to cover 60 percent of a member's total healthcare costs, leaving the member responsible for the remaining 40 percent. This is an average estimate for a standard population. How much the plan actually covers can vary significantly from person to person.

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Guaranteed issue requirements

Health insurance carriers won't be able to deny applicants healthcare coverage based on pre-existing medical conditions and must apply the same rates as other's receiving the same coverage, though there may be slight variances based on age and geographical location. At this time, there are no guidelines available for how the guaranteed issue component will operate. As 2014 approaches, expect more details.

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Individual health coverage mandate

Citizens and legal residents are required to have "minimum essential coverage." Beginning 2016, the tax penalty for noncompliance is the greater of $695 per year, up to a maximum of $2,085 per family, or 2.5 percent of modified gross income. Lower penalties apply during the phase-in period in 2014 and 2015. The $695/$2,085 penalties are indexed for inflation beginning 2017.

The government will make exceptions for financial hardship, religious objections, Native Americans, those without coverage for less than three continuous months, whenever the lowest cost plan option costs more than 8 percent of income, or whenever the individual’s income is below the tax filing threshold, which is $9,350 for individuals, $18,700 for couples under age 65 without children, and $26,000 for couples under age 65 with two or more children in 2010.

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Employer mandate

Employers with an average of at least 50 employees during 121 days or more in the preceding calendar year are required to offer minimum essential coverage to full-time employees and their dependents. Employers can convert part-time workers to full-time equivalents by adding all hours worked by part-time workers during the month and dividing by 120 to determine whether the employer has more than 50 full-time employees, but they must exclude seasonal employees from the calculation. To determine penalties, employers can exclude the first 30 employees from their calculations.

Employers with more than 50 full-time employees that do not offer coverage or that offer coverage that does not qualify as minimum essential coverage must pay an assessment of $2,000 times the number of full-time employees if at least one full-time employee receives government-subsidized coverage through an insurance exchange. If the employer offers minimum essential coverage, but a full-time employee receives government-subsidized coverage through an insurance exchange anyway, the employer must pay an assessable payment equal to the lesser of $3,000 for each employee receiving a subsidy or $2,000 for each full-time employee. There is no assessment if the employee’s share of the cost of coverage is between 8 percent and 9.5 percent of income.

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Prohibition of pre-existing conditions

Health insurers must accept all applicants regardless of pre-existing condition and health status and must use adjusted community rating. They must also guarantee renewal for individuals.

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Elimination of annual limits on insurance coverage

Final phase in the removal of annual dollar limits on health plans.

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Tax on health insurance imposed

Awaiting government regulation.