Q: Exactly what can insurance companies deny now that we have the new laws in place?
A: Benefit plans sold through health exchanges will be required to provide certain essential services, including inpatient and outpatient care, wellness and prevention services, maternity and newborn care, among others. You can find a more complete listing of essential services under the law at Healthcare.gov.
Beyond complying with this requirement, however, each health insurer will be allowed to design benefit plans as it chooses (complying with state and federal law, of course). For that reason, it is essential that you understand the terms of your individual plan and follow the rules set forth in your policy to ensure that your care is paid for.
Q: Some insurance companies have discontinued sales of some policies, such as those for juveniles with pre-existing conditions. Have the insurers found a loophole in the law?
A: As of September 2010, a provision of the health reform law that prohibited insurance companies from excluding children younger than 19 with pre-existing health conditions went into effect. In response, many insurance companies dropped out of the child-only market instead of taking on the cost of these potentially expensive policies. In this case, insurers did, in fact, find a loophole.
A number of states, however, have taken legislative or regulatory action to keep insurers in the child-only insurance market. In California, one of a handful of states to take such action, insurers who refused to sell child-only policies would be forbidden to sell any policies in the lucrative private market for five years. As a result, all insurers jumped back into the child-only market effective Jan. 1, 2011.
“That’s the point of having aggressive regulation at the state and federal level,” says Anthony Wright, executive director of the health care advocacy organization, Health Access California. Legislators will be in the position of identifying and plugging loop holes in an effort to continually improve upon the law.
“There needs to be vigilance because insurers have shown they may need to be dragged kicking and screaming into a newly reformed world,” Wright says.