HR, Payroll and Benefits News

Patient Protection and Affordable Care Act: Its Impact on Your Benefits
August 17, 2012

On June 28, 2012, the United States Supreme Court upheld the constitutionality of the Patient Protection and Affordable Care Act (ACA). You may wonder what that means for your health insurance through your employment at the UW. Many of the provisions in ACA have already been included in the State Group Health Insurance (SGH) program, while other changes will occur within the next few years. It is unlikely that the ACA will affect your ongoing eligibility to participate in the SGH plan.

ACA has many aspects, and its impact is far-reaching. We have not attempted to address all of the provisions of ACA but have addressed those that affect your current SGH coverage below.

You may have heard about health insurance exchanges under ACA. The exchange is a government-regulated marketplace of insurance plans with different levels of coverage, offered to individuals without health care or to small companies. Your health insurance is provided through a large employer and should be unaffected by the exchange. However, the exchange may benefit employees who are not eligible for the state group health insurance plan. At this time, there is not a health insurance exchange in Wisconsin.

ACA is being phased in over a number of years. For 2013, you must be provided a Summary of Benefits Coverage (SBC) if enrolled in SGH insurance. That notice will be provided via the It's Your Choice health insurance books in October. You will also receive a required notice from your health plan about its medical loss ratio. All of the health plans met or exceeded the medical loss ratio requirements under ACA.

The following changes will be made to the SGH insurance program to comply with ACA:

ACA also mandates a number of requirements that state group health insurance already provides, such as:

• Preventive services* are covered in full; not subject to coinsurance (1/1/12).
• No pre-existing condition waiting periods for late enrollees. Annual open enrollment offered (1/1/12).
• Employee Reimbursement Account (ERA) - Medical Expense Account - Over-the-counter drugs no longer eligible for reimbursement (1/1/11)
• Removal of lifetime benefit max (1/1/11)
• Dependent eligibility is based solely on the child's age until the end of the month in which the child turns 26 (1/1/11)
• Access to an emergency room without prior authorization
• Access to a pediatrician for children if a primary care provider must be selected
• Access to OB/GYNs without referral
• An internal and external appeals process
• Prohibition of rescission (retroactive cancellation) of a policy back to the effective date of coverage, except in cases of fraud or intentional misrepresentation

*IMPORTANT NOTE: The coding that the provider uses to bill for the service impacts whether or not you will pay a coinsurance. For example, if you go in for a preventive service and discuss treatment of an illness or injury, the provider may bill part of the service related to the illness or injury differently so you would pay a coinsurance for that portion of the visit.

Source: UW System Administration
Categories: Insurance