- No one can be denied coverage for pre-existing conditions. Furthermore, no one will be rated higher for pre-existing conditions for health Insurance in Oklahoma or anywhere in the United States. The rating factors will be for smoker versus non-smoker, age of the individual, and county of residence. Also, no one can be cancelled for any reason other than non-payment of premium or fraud.
- There can be no lifetime maximum payout for services rendered. This means there is no cap on medical services during your lifetime. There is the possibility for the Health insurance company to put restrictions on annual services; however this is still highly regulated under the law
- In order to be compliant with the new laws every plan must cover what are referred to as the 10 essential health benefits:
- Emergency Service
- Laboratory Service
- Maternity and Newborn Care
- Mental Health, Substance Abuse, and Behavioral Health Treatment
- Prescription Drugs
- Habilitative/rehabilitative services and devices
- Preventative and Wellness services and Chronic Disease Management
- Ambulatory Patient Service
- Pediatric services including oral and vision care
4.The law has a provision known as the medical loss ratio aka MLR. It states that on premium income generated by the health insurance company they must pay between .80-.90 cents of every dollar earned on medical costs or improving medical care. The exact amount .80 vs. .90 is dependent on the size of the employer that is providing the coverage or if the person is purchasing an individual plan. If the health insurance company fails to pay the required percentage on medical costs or medical improvements during any calendar year they are then required to send a refund to the policyholders the following year.
5.Dependent children are eligible to be covered under their parent’s health insurance plans until age 26. The dependent children are not required to be in school to stay on their parents plan. This even applies to adult children living outside of the household, regardless of if they are married, and regardless of if they are filing their own taxes.
6.Subsidies will be determined by each person’s/household’s income from last/current year as well as their projections for the upcoming year. At this point in time the subsidies are only guaranteed if the plan is purchased through one of the exchanges. This means that for Oklahomans, since Oklahoma governor, Mary Fallin, opted not to have a state exchange, they will have access to the federal exchange.
7.The Federal Exchange (marketplace) will be available one of four ways. There is the healthcare.gov website that person’s/household’s can visit and fill out the required financial paperwork to see if they qualify for a subsidy and then, based on any subsidy dollars, they then choose a plan that fits their needs. The second option is to call healthcare.gov’s call center where customers can call and speak to a “negotiator.” The “negotiator” is the term given to representatives that the federal government will have in place to assist/facilitate the customers of the exchange in filling out the paperwork, determining if they qualify for a subsidy, and assisting them in answering questions regarding which plan to select. Or you can contact your local agent and they can assist you with determining your eligibility for a subsidy and completing the necessary paperwork. The fourth and most daunting option is to obtain a paper application, fill it out and mail and wait 2 weeks for a response on your subsidy eligibility before selecting a plan.
8.On the federal exchange all participating health insurance companies compliant plans will be listed alongside one another so that customers can compare the different rates available to them. Each carrier may provide plans that will be listed in one of four metal types: bronze, silver, gold, and platinum. Each metal type represents a tier of coverage. Bronze is the lowest tier and platinum is the highest. Not all carriers offer plans in each metallic level. It is usually at the platinum level that carriers opt not to offer any plans.
9.Any person or group that has had a health insurance plan in place before March 23, 2010, and has made no changes to their coverage since that date, is considered “grandfathered,” and can keep their plan indefinitely.
10.Your healthcare premiums will now be listed on your W-2 forms and reviewed by the IRS in subsequent tax years. You will also receive either a 1095A or 1095B form to file along with your taxes. Depending on where you obtain your health insurance (ie. Healthcare.gov, through an employer, government agency, or direct from a carrier) determines which exact form you will receive. If you fail to accurately project your income for the upcoming year and received a subsidy that you should not have received, the IRS will deduct that from any available tax return you are eligible for.