Pre-Existing Conditions High Risk Pool Creation

I wanted to pass on some information about the regulations around the new Pre-Existing High Risk Pools that are to go into effect later this year. Some of the information is for Administative purpose but could be informative as to the whole process and what an individuals rights are.

Pre-Existing Conditions High Risk Pools will be created (HHS) to operate a high-risk pool program in your State consistent with the provisions in the Patient Protection and Affordable Care Act. As you know, this is a temporary program to provide coverage to your uninsured residents with preexisting conditions. In the interests of providing coverage to as many individuals as possible within the funds available, we encourage States to operate these programs as efficiently as possible.
The contracts awarded through this solicitation will include a start-up period of performance that will run until December 31, 2010, and three additional one-year periods of performance that will run until December 31, 2013. There will be a final closeout period that will run from January 1, 2014 through March 31, 2014.

A.2 DEFINITIONS
Administrative costs refers to reasonable costs incurred by the Contractor to administer
the pool.
Creditable coverage has the meaning given such term under both section 2701(c)(1) of
the Public Health Service Act before enactment of the Affordable Care Act and 45 CFR
146.113(a)(1).
Enrollee refers to an individual receiving coverage from a qualified high risk pool
established under this section.
Nonprofit entity refers to a nonprofit insurer or other organization capable of operating a
qualified high risk pool.
Qualified high risk pool or Pool refers to a program which provides coverage in
accordance with the requirements of section 1101 of the Affordable Care Act of 2010,
as determined by HHS.
Pre-existing condition exclusion has the meaning given such term in 45 CFR 144.103.
Resident means an individual who is legally domiciled in a State.
Service Area refers to the geographic area encompassing an entire State or States in
which a qualified high risk pool furnishes benefits.
State refers to any one of the 50 States or the District of Columbia.

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A.3 BACKGROUND
On March 23, 2010, the President signed into law H.R. 3590, the Patient Protection and
Affordable Care Act (Public Law 111-148), hereafter referred to as the Affordable Care
Act. Section 1101 of the Affordable Care Act establishes a “temporary high risk health
insurance pool program” to provide health insurance coverage to currently uninsured
individuals with pre-existing conditions. The Affordable Care Act authorizes HHS to
carry out the program directly or through contracts with States or private, nonprofit
entities.
This is a non-competitive solicitation for States to establish and administer temporary
high risk health insurance pool programs to provide coverage for eligible individuals
beginning in 2010 and ending on December 31, 2013. On April 2, 2010, HHS issued a
letter to governors and state insurance commissioners asking each State to indicate its
interest in participating in this temporary high risk pool program. This solicitation is
being sent to the designated contacts for all states who indicated a willingness to
participate in establishing this program. In response to this solicitation, States are
asked to submit proposals to establish and administer those qualified high risk pools
under contracts to be issued by HHS.
As a result of this solicitation process, HHS intends to award the proposing States a
negotiated contract for the administration of the high risk insurance pool. HHS will also
establish an account through which each state can draw down their respective benefit
claims.
As stated in the April 2, 2010 letter, HHS will carry out the coverage program in States
that do not submit proposals to operate qualified high risk pools. HHS may pursue a
separate acquisition process to acquire any services it may find necessary to operate
high risk health insurance pools in those States.
HHS’s goal is to grant the flexibility needed to permit successful and expeditious
implementation of the program by States. HHS encourages States to take advantage of
that flexibility in developing proposals, including consideration of the following options:
• Operate a new high risk pool alongside a current State high risk pool;
• Establish a new high risk pool (in a State that does not currently have a high risk
pool);
• Build upon other existing coverage programs designed to cover high risk
individuals;
• Sub-contract with a current HIPAA insurance carrier of last resort or other
insurance carrier, to provide subsidized coverage for the eligible population.

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States may designate a nonprofit entity as the proposed contractor to operate a
qualified high risk pool on behalf of the State. All proposals submitted in response to
this solicitation must include written confirmation that the submitting entity has been
approved to do so by the governor or state insurance commissioner. Only 1 (one)
proposal may be submitted per state. Two or more States may elect to join together to
establish and operate a single qualified high risk pool that covers enrollees in each
State.
The Affordable Care Act establishes standards that a qualified high risk pool must follow
to be eligible for Federal contract funding. To meet the requirements of this solicitation,
a proposal must be structured in a manner that is consistent with the terms described in
service and delivery tasks below.
A.4 SPECIFIC SERVICE AND DELIVERY TASKS OF CONTRACTED STATE HIGH
RISK POOL PROGRAMS
A.4.1 The Contractor shall have the capacity and technical capability to perform all
functions necessary to the design, implementation, and operation of a qualified high risk
pool that will provide coverage to eligible individuals, that is, currently uninsured
individuals with pre-existing conditions. If the Contractor operates another high risk
pool, the Contractor shall segregate funding and expenditures for the two programs and
track all benefits and services separately for enrollees in each program.
A.4.2 The Contractor shall design, implement, and operate a qualified high risk pool
that is compliant with the following basic design requirements of the temporary high risk
pool program.
Important Note: As of the date of this solicitation, the final regulations for the high risk
pool program have not yet been published. If there are significant changes to the
requirements below as a result of Federal regulations, HHS will amend this solicitation
and give States an opportunity to make changes in their proposals prior to the issuance
of contracts.
1) Eligibility for Individuals to Enroll in High Risk Health Insurance Pool Programs –
The Contractor shall develop eligibility criteria for participation in a high risk pool subject
to the approval of HHS. Generally, HHS anticipates Contractors will develop criteria
that include all of the requirements included in A.4.2.1.a and A.4.2.b Subject to the
approval of HHS, the Contractor shall develop eligibility criteria meeting some or all of
the elements included in A.4.2.1.c. That is an individual:
a) Is a citizen or national of the United States or lawfully present in the United
States;
b) Has not been covered under creditable coverage for a continuous 6-month
period of time prior to the date on which such individual is applying for coverage in the
high risk pool program.

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c) Meets the pre-existing condition requirement established for a qualified high risk
pool. HHS anticipates that Contractors will use methods to define pre-existing
condition that include, but are not limited to:
i) Evidence of denial of coverage.
ii) Evidence that coverage is available only with an exclusionary rider.
iii) The presence of certain medical conditions specified by the State and approved
by HHS.
2) Benefits Requirements – The qualified high risk pool may offer one or more
benefit plans, provided that they are actuarially consistent with the statutory requirement
that the issuer’s share of the costs is not less than 65 percent of the total costs of the
benefit. Contractors may propose the benefit and coverage structure to be used by the
qualified high risk pools within the limits of their allotments.
3) A qualified high risk pool must provide to all eligible individuals that it enrolls in a
qualified high risk pool, health coverage that does not impose any pre-existing condition
exclusions with respect to such coverage, and may not deny enrollment based on a preexisting
condition.
4) The premiums charged under the high risk pool may not exceed 100 percent of
the premium for the applicable standard risk rate that would apply to the coverage
offered in the State or States. The qualified high risk pool shall determine a standard
risk rate by considering the premium rates charged for similar benefits and cost-sharing
by other insurers offering health insurance coverage to individuals in the applicable
State or States. The standard risk rate shall be established using reasonable actuarial
techniques. A qualified high risk pool may not use other methods of determining the
standard rate, except with the approval of the Secretary. Premiums charged to
enrollees in the qualified high risk pool may vary on the basis of age, by a factor not
greater than 4 to 1.
5) The qualified high risk pool’s average share of the total allowed costs of the
required benefits must be at least 65 percent of such costs. The out-of-pocket limit of
coverage for cost-sharing for the required benefits may not be greater than the
applicable amount described in section 223(c)(2) of the Internal Revenue Code of 1986
for the year involved.
6) A qualified high risk pool may specify the networks of providers from whom
enrollees may obtain services. The qualified high risk pool must demonstrate to HHS
that it has a sufficient number and range of providers to ensure that all covered services
are reasonably available and accessible to its enrollees.

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7) A qualified high risk pool shall establish and maintain procedures for individuals
to appeal eligibility and coverage determinations. Minimally, the appeals procedures
must provide enrollees and potential enrollees the right to a timely redetermination by
the qualified high risk pool or its designee of a determination concerning eligibility or
coverage, and the right to a timely reconsideration of a coverage redetermination by an
entity independent of the qualified high risk pool or the entity designated to make that
redetermination.
A.4.3 The Contractor shall perform all eligibility determination and enrollment functions.
1) The Contractor shall develop and utilize an eligibility determination process that
will assure that only individuals eligible for coverage (as described in A.4.2.1) receive
benefits from the program.
2) As part of the enrollment application process, the Contractor will obtain the
name, address, date of birth and Social Security number of a person applying for
coverage.
3) The Contractor shall implement a process to confirm that the enrollee is a citizen
or national of the United States or an alien lawfully present in the United States. The
Contractor shall submit to HHS for approval a plan for verifying citizenship in
accordance with the Affordable Care Act.
4) The Contractor shall develop and operate an enrollment process that ensures
eligible individuals timely access to benefits under the qualified high risk pool and that
enrollment is maintained per the eligibility criteria established by the qualified high risk
pool. The Contractor shall submit a description of the enrollment process to HHS for
approval. HHS anticipates that, in general, the enrollment process proposed by the
Contractor will provide that an individual eligible for enrollment who submits a complete
enrollment request by the 15th day of a month must have coverage take effect by the 1st
day of the following month, except in exceptional circumstances that are subject to HHS
approval.
5) The Contractor shall develop and operate a disenrollment process. The
Contractor shall submit a description of the disenrollment process to HHS for approval.
HHS anticipates that the disenrollment process will include provisions that include, but
are not limited to, policies for disenrolling an individual if the monthly premium is not
paid on a timely basis; when an individual no longer resides in the qualified high risk
pool’s service area; when an individual obtains other creditable coverage; and, in the
case of a death of the individual.
A.4.4 The Contractor shall provide customer service functions on behalf of high risk
pool enrollees.
1) The Contractor shall operate a customer service call center that is appropriately
staffed to the number of plan enrollees so as to provide prompt and accurate
information and services to high risk pool program members.

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2) The Contractor shall have the capability to provide customer service and plan
enrollment information in languages other than English to meet the needs of the
population anticipated to be served by the high risk pool program and must also make
customer service and plan enrollment information available in formats that are
accessible by people with disabilities.
A.4.5 The Contractor, at a minimum, shall operate a technical support center, which
may include both a call center and an electronic/automated system, to respond to
health care and pharmacy providers seeking information related to an enrollee’s
benefits, coverage determinations (including exceptions and prior authorizations) and
enrollee appeals.
A.4.6 The Contractor shall be responsible for premium administration for the high risk
pool program.
1) The Contractor shall calculate the appropriate premium amount, bill, and collect
premiums from health risk pool program enrollees or enrollee’s designee.
2) The Contractor shall use premiums collected and any interest earned on
premiums held by the high risk pool program solely to offset the approved administrative
expenses and high risk pool program enrollee claims for health services as included in
this Contract.
A.4.7 The Contractor may develop and implement disease and utilization management
that will assure high risk pool program enrollees have access to necessary health care
services and prescription drugs via a provider network capable and available to deliver
those services for high risk pool program enrollees in a cost-effective manner.
A.4.8 The Contractor shall develop and implement a system for processing and paying
claims for health and prescription drug claims, including a point-of-sale claim system for
prescription drugs.
A.4.9 The Contractor shall develop and implement a plan for marketing and outreach
for the high risk pool program to make potentially eligible individuals and organizations
and providers that interact with potentially eligible individuals aware of the high risk pool
program and the coverage offered by the qualified high risk pool.
A.4.10 The Contractor shall establish procedures to identify and report to HHS instances
where health insurance issuers or group health plans are discouraging high-risk
individuals from remaining enrolled in their current coverage (or discouraging enrollment
in available coverage) in instances in which such individuals subsequently are eligible to
enroll in the qualified high risk pool. Such procedures may include, but are not limited
to:
1) Questions on the high risk pool application form to identify applicants (or their
family members) that are employed, may have, or have had, access to other coverage
including employment based group health coverage, or are getting assistance in the
payment of premiums for the qualified high risk pool from employers or other sources.

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2) Questions on the application form asking applicants to identify their most recent
health coverage and the reasons for leaving or losing that coverage.
3) A requirement that enrollees report changes in their employment status (or that
of a family member) during the course of enrollment.
A.4.11 The Contractor shall develop operating procedures to prevent, detect, recover
(when applicable or allowable), and immediately report to HHS incidences of waste,
fraud, and abuse and shall cooperate with Federal law enforcement authorities in cases
involving waste, fraud, and abuse.
A.4.12 The Contractor shall establish and implement an effective system for routine
monitoring and identification of compliance risks. The system shall include internal
monitoring and audits to evaluate the high risk pool program, including any subcontractors
utilized by the program, in terms of compliance with HHS requirements.
A.4.13 The Contractor shall develop and implement a system for coordinating benefits
for health and prescription drug claims with other payers as needed, such as Workers’
Compensation.
A.5 PAYMENT TO CONTRACTOR
1) The Contractor will not be responsible for the costs of covered health insurance
claims filed by enrollees in the State high risk pool program or for the administrative
expenses of operating those programs to the extent that those claims and
administrative expenses are in excess of the premiums collected by the State high risk
pool program. The contractor will ensure that the claims and administrative expenses
are incurred within the terms of the contract, and the claims and administrative
expenses do not exceed any limits set by HHS. HHS will reimburse the Contractor for
claims for covered services and for administrative expenses that are in excess of the
premiums collected by the qualified high risk pool. Reimbursement for claims and
administrative expenses is contingent on the extent that the Contractor complies with
the terms of the contract, including the Contractor’s responsibility to act in consultation
with HHS to limit the amount of anticipated expenses to the available funds HHS
allocates to the State to operate the high risk pool program.
2) The Contractor shall receive actual cost reimbursement payments from HHS for
allowable and allocable administrative costs and claims costs incurred in the
development and operation of the qualified high risk pool.

Health Care Reform For California Residents

Almost one in every five Californians goes without health insurance, millions more have inadequate insurance, and countless more struggle with accumulating medical bills and discriminatory practices by insurers.
The health reform legislation recently passed by Congress would provide virtually every Californian with affordable health insurance, either on the job, through a newly created Health Exchange, from an expansion of Medi-Cal, or through improved Medicare benefits.
As a result of the federal health reform bills, most Californians will have additional security with the coverage they have, and over 4.1 million Californians now uninsured would have new access to able to purchase coverage in the newly-created Health Insurance Exchange (most with the help of affordability credits). Of those, about 1.7 million Californians (mostly low-income adults without children under 18) would become newly eligible for Medi-Cal.

•Health reform will assure Californians have affordable, quality coverage.
•Strong consumer protections and real benefits: Health insurers cannot deny coverage because of pre-existing conditions, and all health insurance will have robust benefits similar to those paid for by most large employers, with at least 60 cents of every premium dollar being spent on care.
•Affordable coverage: No one will ever need to spend more than a percentage of their income—on a sliding scale, up to 9.5 percent--on premiums. In the exchange, out-ofpocket costs would be capped to no more than $6,200 per individual for copayments or deductibles—with more help for those with lower incomes.
•Health insurance will be available and affordable regardless of major life changes such as loss of your job, divorce, aging off your parents’ coverage, cancer, etc...
•Health reform will insure virtually all (96%) Californians, dramatically reducing the number of uninsured by more than 4 million uninsured over the next decade.
•Expanding coverage: Californians would get coverage on the job, through an expansion of Medi-Cal, through the newly created Health Insurance Exchange, or through strengthened Medicare.
•Opportunities for young adults: Beginning this year, 3.8 million young adults in California will have the opportunity to stay on their parents’ private insurance plan until age 26.
•Health reform will reform the health insurance market, protecting consumers from discriminatory premium pricing or denial of coverage due to pre-existing conditions.
•No pre-existing conditions: After 2014, no one will ever again be denied health insurance because of a pre-existing condition, and beginning this year, insurers can no longer deny coverage to children due to a pre-existing condition

Reform Small Group Tax Credit

The new health reform law gives a tax credit to certain small employers that provide health care coverage to their employees, effective with tax years beginning in 2010. The IRS has issued information on the credit as it applies for 2010-2013, including information on transition relief for 2010. An enhanced version of the credit takes effect in 2014.

Eligible small employers. Small employers that provide health care coverage to their employees and that meet certain requirements (qualified employers) generally are eligible for a federal income tax credit for health insurance premiums they pay for certain employees. In order to be a qualified employer:

•An employer must have fewer than 25 full-time equivalent employees (FTEs”) for the tax year,
•The average annual wages of its employees for the year must be less than $50,000 per FTE, and
•The employer must pay the premiums under a “qualifying arrangement.”
IRS has stated that tax exempt organizations are entitled to the credit, but must calculate the credit under special rules.
Calculation of the credit. Only premiums paid by the employer under an arrangement meeting certain requirements (a “qualifying arrangement”) are counted in calculating the credit. Under a qualifying arrangement, the employer pays premiums for each employee enrolled in health care coverage offered by the employer in an amount equal to a uniform percentage (not less than 50 percent) of the total premium cost of the coverage. If an employer pays only a portion of the premiums, only the portion paid by the employer is counted in calculating the credit. For purposes of the credit (including the 50-percent requirement), any premium paid pursuant to a salary reduction arrangement under a Sec. 125 cafeteria plan is not treated as paid by the employer. IRS has clarified that premiums paid by the employer in 2010, but before the new health reform legislation was enacted on March 23, 2010 may be counted in calculating the credit.

The amount of an employer’s premium payments that counts when calculating the credit may not exceed the average premium for the small group market in the particular state (or an area within the state) in which the employer offers coverage for the same arrangement. The average premium for the small group market in a state (or an area within the State) will be determined by the Department of Health and Human Services (HHS) and published by the IRS. Publication of the average premium for the small group market on a state-by-state basis is expected to be posted on the IRS website by the end of April.

Maximum credit amount. For tax years beginning in 2010 through 2013, the maximum credit is 35 percent of the employer’s premium expenses that count towards the credit.

Maximum credit for a tax-exempt qualified employer. For tax years beginning in 2010 through 2013, the maximum credit for a tax-exempt qualified employer is 25 percent of the employer’s premium expenses that count towards the credit. However, the amount of the credit cannot exceed the total amount of income and Medicare (i.e., Hospital Insurance) tax the employer is required to withhold from employees’ wages for the year and the employer share of Medicare tax on employees’ wages.

Credit reductions. If the number of FTEs exceeds 10 or if average annual wages exceed $25,000, the amount of the credit is reduced. If the number of FTEs exceeds 10, the reduction is determined by multiplying the otherwise applicable credit amount by a fraction, the numerator of which is the number of FTEs in excess of 10 and the denominator of which is 15. If average annual wages exceed $25,000, the reduction is determined by multiplying the otherwise applicable credit amount by a fraction, the numerator of which is the amount by which average annual wages exceed $25,000 and the denominator of which is $25,000. In both cases, the result of the calculation is subtracted from the otherwise applicable credit to determine the credit to which the employer is entitled. For an employer with both more than 10 FTEs and average annual wages exceeding $25,000, the reduction is the sum of the amount of the two reductions. This sum may reduce the credit to zero for some employers with fewer than 25 FTEs and average annual wages of less than $50,000.

Determining the number of FTEs. The number of an employer’s FTEs is determined by dividing (1) the total hours for which the employer pays wages to employees during the year (but not more than 2,080 hours for any employee) by 2,080. The result, if not a whole number, is then rounded to the next lowest whole number. Because the limitation on the number of employees is based on FTEs, an employer with 25 or more employees could qualify for the credit if some of its employees work part-time.

Determining the amount of average annual wages. The amount of average annual wages is determined by first dividing the total wages paid by the employer to employees during the employer’s tax year by the number of the employer’s FTEs for the year. The result is then rounded down to the nearest $1,000. For this purpose, wages means wages as defined for FICA purposes (without regard to the wage base limitation).

Disregarded workers. Seasonal workers are disregarded in determining FTEs and average annual wages unless the seasonal worker works for the employer on more than 120 days during the tax year. A sole proprietor, a partner in a partnership, a shareholder owning more than two percent of an S corporation, and any owner of more than five percent of other businesses are not considered employees for purposes of the credit. Thus, the wages or hours of these business owners and partners are not counted in determining either the number of FTEs or the amount of average annual wages, and premiums paid on their behalf are not counted in determining the amount of the credit. A family member of any of the business owners or partners member of such a business owner’s or partner’s household, is also not considered an employee for purposes of the credit. For this purpose, a family member is defined as a child (or descendant of a child); a sibling or step-sibling; a parent (or ancestor of a parent); a step-parent; a niece or nephew; an aunt or uncle; or a son-in-law, daughter- in-law, father-in-law, mother-in-law, brother-in-law or sister-in-law.

Controlled groups. Members of a controlled group (e.g., businesses with the same owners) or an affiliated service group (e.g., related businesses of which one performs services for the other) are treated as a single employer for purposes of the credit. Thus, for example, all employees of the controlled group or affiliated service group, and all wages paid to employees by the controlled group or affiliated service group, are counted in determining whether any member of the controlled group or affiliated service group is a qualified employer.

Claiming the credit. The credit is claimed on the employer’s annual income tax return. IRS says it will provide further information on how tax exempt organizations are to claim the credit. As a general business credit, an unused credit amount can generally be carried back 1 year and carried forward 20 years. Because an unused credit amount cannot be carried back to a year before the effective date of the credit, an unused credit amount for 2010 can only be carried forward. IRS says that the credit can be reflected in determining estimated tax payments for the year to which the credit applies in accordance with regular estimated tax rules. For a tax-exempt employer, the credit is a refundable credit, so that even if the employer has no taxable income, the employer may receive a refund so long as it does not exceed the income tax withholding and Medicare tax liability,

Effect on employer’s deduction for health insurance premiums. In determining the employer’s deduction for health insurance premiums, the amount of premiums that can be deducted is reduced by the amount of the credit.

Transition relief for tax years beginning in 2010. IRS expects that transition relief will be provided for tax years beginning in 2010 to make it easier for taxpayers to meet the requirements for a qualifying arrangement. IRS says that guidance will provide that, for tax years beginning in 2010, an employer that pays at least 50 percent of the premium for each enrolled employee will not fail to maintain a qualifying arrangement merely because the employer does not pay a uniform percentage of the premium for each employee. Accordingly, if the employer otherwise satisfies the requirements for the credit, it will qualify for the credit even though the percentage of the premium it pays is not uniform for all such employees.

The requirement that the employer pay at least 50 percent of the premium for an employee applies to the premium for single (employee-only) coverage. Therefore, if the employee is receiving single coverage, the employer satisfies the 50 percent requirement if it pays at least 50 percent of the premium for that coverage. If the employee is receiving coverage that is more expensive than single coverage, the employer satisfies the 50 percent requirement if the employer pays an amount of the premium that is at least 50 percent of the premium for single coverage even if it is less than 50 percent of the premium for the coverage the employee is actually receiving.

What you can expect right now from the Health Care Bill

There is a lot of confusion about the new health care reform bill and what it will mean to each of us now and over the upcoming years, this is where I'll try to sort these things out for you.
I'll start with information about the the things that will affect us all first and then move forward.

The following information is straight from the Whitehouse about the parts of the bill that will come into play in the immediate future.


Key Health Care Reform Provisions That Take Effect Immediately

1.SMALL BUSINESS TAX CREDITS—Offers tax credits to small businesses to make employee coverage more affordable. Tax credits of up to 35 percent of premiums will be available to firms that choose to offer coverage. Effective beginning calendar year 2010. (Beginning in 2014, the small business tax credits will cover 50 percent of premiums.)

2.NO DISCRIMINATION AGAINST CHILDREN WITH PRE?EXISTING CONDITIONS—Prohibits new health plans in all markets plus grandfathered group health plans from denying coverage to children with pre?existing conditions. Effective 6 months after enactment. (Beginning in 2014, this prohibition would apply to all persons.)

3.HELP FOR UNINSURED AMERICANS WITH PRE-EXISTING CONDITIONS UNTIL EXCHANGE IS AVAILABLE (INTERIM HIGH?RISK POOL)—Provides access to affordable insurance for Americans who are uninsured because of a pre?existing condition through a temporary subsidized high?risk pool. Effective in 2010.

4.ENDS RESCISSIONS—Bans insurance companies from dropping people from coverage when they get sick. Effective 6 months after enactment.

5.BEGINS TO CLOSE THE MEDICARE PART D DONUT HOLE—Provides a $250 rebate to Medicare beneficiaries who hit the donut hole in 2010. Effective for calendar year 2010. (Beginning in 2011, institutes a 50% discount on prescription drugs in the donut hole; also completely closes the donut hole by 2020.)

6.FREE PREVENTIVE CARE UNDER MEDICARE—Eliminates co?payments for preventive services and exempts preventive services from deductibles under the Medicare program. Effective beginning January 1, 2011.

7.EXTENDS COVERAGE FOR YOUNG PEOPLE UP TO 26TH BIRTHDAY THROUGH PARENTS’ INSURANCE—Requires new health plans and certain grandfathered plans to allow young people up to their 26th birthday to remain on their parents’ insurance policy, at the parents’ choice. Effective 6 months after enactment.

8.HELP FOR EARLY RETIREES—Creates a temporary re?insurance program (until the Exchanges are available) to help offset the costs of expensive premiums for employers and retirees for health benefits for retirees age 55?64. Effective in 2010.

9.BANS LIFETIME LIMITS ON COVERAGE—Prohibits health insurance companies from placing lifetime caps on coverage. Effective 6 months after enactment.

10.BANS RESTRICTIVE ANNUAL LIMITS ON COVERAGE—Tightly restricts the use of annual limits to ensure access to needed care in all new plans and grandfathered group health plans. These tight restrictions will be defined by HHS. Effective 6 months after enactment. (Beginning in 2014, the use of any annual limits would be prohibited for all new plans and grandfathered group health plans.)

11.FREE PREVENTIVE CARE UNDER NEW PRIVATE PLANS—Requires new private plans to cover preventive services with no co?payments and with preventive services being exempt from deductibles. Effective 6 months after enactment.

12.NEW, INDEPENDENT APPEALS PROCESS—Ensures consumers in new plans have access to an effective internal and external appeals process to appeal decisions by their health insurance plan. Effective 6 months after enactment.

13.ENSURES VALUE FOR PREMIUM PAYMENTS—Requires plans in the individual and small group market to spend 80 percent of premium dollars on medical services, and plans in the large group market to spend 85 percent. Insurers that do not meet these thresholds must provide rebates to policyholders. Effective on January 1, 2011.

14.COMMUNITY HEALTH CENTERS—Increases funding for Community Health Centers to allow for nearly a doubling of the number of patients seen by the centers over the next 5 years. Effective beginning in fiscal year 2011.

15.INCREASES THE NUMBER OF PRIMARY CARE PRACTITIONERS—Provides new investments to increase the number of primary care practitioners, including doctors, nurses, nurse practitioners, and physician assistants. Effective beginning in fiscal year 2011.

16.PROHIBITS DISCRIMINATION BASED ON SALARY—Prohibits new group health plans from establishing any eligibility rules for health care coverage that have the effect of discriminating in favor of higher wage employees. Effective 6 months after enactment.

17.HEALTH INSURANCE CONSUMER INFORMATION—Provides aid to states in establishing offices of health insurance consumer assistance in order to help individuals with the filing of complaints and appeals. Effective beginning in fiscal year 2010.

18.HOLDS INSURANCE COMPANIES ACCOUNTABLE FOR UNREASONABLE RATE HIKES—Creates a grant program to support States in requiring health insurance companies to submit justification for all requested premium increases, and insurance companies with excessive or unjustified premium exchanges may not be able to participate in the new Health Insurance Exchanges. Starting in plan year 2011.

Source 2010 "www.healthreform.gov"