Health Insurance Regulations – ObamaCare

Might I add, this is just the first few pages of what everyone calls ObamaCare. Our company is slowly processing the data and information involved in ObamaCare and informing the public how to “translate” the legal jargon into common every-day terminology. If you think anything has been mis-translated, give us a comment and we’ll re-review. Now that President Obama has been re-elected, we all have to know what’s in this Act. The following information is what we have so far “in translation”:

  • Insurance companies can no longer cutoff policy holders who have reached their lifetime limit in medical expenses.
  • Annual limits on these coverages will begin to phase out for a period of 3 years
  • Limits will be completely banned beginning September 1, 2014
  • Limit of 1.45 Million after September 23, 2011
  • Limit rises to 2 Million after September 23, 2012
  • These limitations and bans do not apply to those grandfathered in – only new employer sponsored and individual plans
  • Policies may not be cancelled (rescinded) unless it amounts to fraud or misrepresentation of material fact
  • Insurance companies cannot impose cost-sharing requirements for:
    • Evidence-based items or services with A/B Rating
    • Recommended immunizations
    • Infants, children, adolescents of preventative care and screenings
    • Evidence-based preventative care and screenings for women
  • The Secretary can create a value-based insurance design
  • A dependent may be on parents coverage up until age 26
  • The Secretary designs a uniform pamphlet explaining the coverage one is to receive and include medical definitions so that a normal enrollee may understand the pamphlet
    • Must list exceptions, reductions and limitations on coverage
    • Printed in a language the enrollee understands and reads
    • Contact Information and a summary statement of the coverage document itself
    • Failure to provide this information is $1,000 fine for each stated failure
  • The Insurance Company may not establish rules relating to the eligibility of a full-time employee that are based on the total hourly or annual salary – cannot discriminate low-income earners.
    • A plan sponsor can still setup a payment plan for those who have low income


  • The Secretary along with experts and stakeholders must develop reporting requirements for use by Insurance Companies with respect to a plan/coverage and healthcare reimbursement structures:
    • Improve health outcomes (via quality reporting, case management, care coordination)
    • Implement activities to prevent re-admission (via patient-center education, counseling, comprehensive discharge planning)
    • Implement activities to improve patient safety and reduce medical errors (via clinical practices, evidence-based medicine, health information technology)
    • Implement wellness
  • Insurance companies must file an annual report with the Secretary and enrollees regarding whether the benefits under the plan/coverage satisfy the four above
    • Report is made available during open enrollment
    • Reports may be available online through a website made by the Secretary to the public
    • No definite dollar amount for penalties when not in compliance with Report, penalty chosen by the Secretary


  • Wellness and Prevention Programs may be personalized and coordinated, maintained or delivered by a health care provider, a wellness and prevention plan manager or organization that conducts health-risk assessments or offers face to face, telephonic or web intervention regarding the following conditions:
    • Smoking Recession / Heart Disease Prevention
    • Weight-management / Physical fitness / Nutrition / Healthy Lifestyle Support / Stress Management
    • Diabetes prevention


  • An insurance company must submit to the Secretary a report on the percentage of total premium revenue that such coverage expends 1) on reimbursement for clinical services; 2) for activities that improve health care quality; and 3) all other non-claim costs including an explanation of the nature of such costs
    • State taxes and licensing/regulatory fees do not need to be reported
    • These reports are made available to the public on the Department of Health and Human Services website
  • An insurance company must provide an annual rebate to each enrollee under its coverages on a pro rata basis in an amount that is equal to the amount by which premium revenue exceeds: 1) within a group plan, 20% and 2) within an individual plan, 25%
    • The State must ensure that premiums are used for clinical services and quality improvements
    • This terminates on 12/31/2013
  • Each hospital must make a list that is available to the public operating costs and its standard charges including diagnosis related charges

To be continued…