Many of the requirements in the Patient Protection and Affordable Care Act ("PPACA") will have little meaning until federal agencies issue regulations that clarify the statutory language. The Department of Health and Human Services, Department of Labor and Internal Revenue Service are all charged with issuing regulations to implement the Act. Since May, these agencies have issued a steady stream of interim regulations regarding a number of the Act's requirements. Most recently, on June 22, 2010, the agencies jointly issued interim regulations to implement what have been referred to as the "Patient's Bill of Rights" provisions of PPACA. The following provisions will take effect in plan years beginning on or after September 23, 2010.
Preexisting Condition Exclusions PPACA prohibits a group health plan from imposing any preexisting condition exclusion ("PCE") on any individual under the age of 19. The age limit is eliminated for plan years beginning on or after January 1, 2014. In the interim, HIPAA's current PCE rules apply. The interim regulations accept the HIPAA definition of a preexisting condition as a health condition or illness that was present before an individual's effective date of coverage in the health plan, regardless of whether any medical advice was recommended or received before that date. A PCE is any limitation or exclusion of benefits (including a denial of coverage) that applies to an individual due to the individual's health status before the effective date of coverage under the health plan. A benefit limitation or exclusion is not a PCE, however, if it applies regardless of when the condition arose relative to the effective date of coverage.
Lifetime and Annual Dollar Limits on Essential Health Benefits PPACA generally prohibits group health plans from imposing lifetime or annual limits on the dollar value of "essential health benefits," except that "restricted annual limits" on essential health benefits are allowed for plan years beginning before January 1, 2014. These rules do not prohibit a complete exclusion of benefits for any particular condition and are only applicable to essential health benefits. Group health plans may continue to impose lifetime and annual limitations on nonessential health benefits. The interim regulations define "essential health benefits" by cross-referencing the definition in the statute and the applicable (and hopefully soon to be issued) regulations. Until such regulations are issued, the agencies will take into account any good faith efforts to comply with a reasonable interpretation of the term.
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