Healthcare Reform: Modification of Benefit-Specific Annual Dollar Limits
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- Marjory Byrd
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1 Healthcare Reform: Modification of -Specific Annual Dollar Limits Background information: Except under certain circumstances, the Affordable Care Act requires health insurers to remove annual dollar limits on covered services deemed essential by the U.S. Department of Health and Human Services (HHS). While HHS has not yet defined exactly which benefits are essential, the law identifies general categories of benefits. Based on this, we are proposing to remove dollar limits on certain benefits and adopt equivalent, compliant limitations on others. The changes should not constitute a reduction in benefits in any area and in some cases constitute an increase in benefits. Once we have regulatory approval, the changes will be effective for most plans renewing on or after September 23, The effective date for Oregon individual plans is January 1, As of February 28, 2011, we have received regulatory approval for these changes to our Oregon group and individual plans and our Idaho individual plans, and expect to receive approval on our remaining plans soon. We began sending notices detailing the changes to affected policyholders in January You can read sample notices on our Web site at Pacificsource.com/reform-notices. Oregon Group Plans The changes listed below will be applicable from a benefit-administration perspective as of the date of your policy renewal on or after September 23, Preferred Plans Proposed Modification Tobacco Cessation Two quit attempts or $500 Two quit attempt Durable Medical Equipment $5,000 per Limit does not apply to the following essential DME items: prosthetic and orthotic devices; oxygen and oxygen supplies; diabetic supplies; wheelchairs; and medical foods for the treatment of inborn errors of metabolism $5,000 Limit changed to one per lifetime Ground: 300 miles per calendar Air: $6,000 per Pulmonary Rehabilitation $1,000 Subject to medical PacificSource Health Plans Essential s Modification Comparison Page 1 of 6
2 Oregon Individual Plans The changes listed below are effective as of January 1, Elect Plans Modification Previous Policy Limitations Annual Maximum No overall limit $2,000,000 Tobacco Cessation Two quit attempts or $500 Two quit attempt Ground: 300 miles per calendar Air: $6,000 per Outpatient Rehabilitation Speech Therapy $1,000 per Combined with Physical Therapy and Occupational Therapy 30 visits per calendar Mental Health Inpatient - $1,000 lifetime maximum Inpatient one day lifetime maximum Durable Medical Equipment $7,500 Limit does not apply to the following essential DME items: prosthetic and orthotic devices; oxygen and oxygen supplies; diabetic supplies; wheelchairs; and medical foods for the treatment of inborn errors of metabolism Transplants $5,000 Subject to preauthorization and medical $250,000 for Participating provider: No limit hospitalization and prescription drugs Cardiac Rehabilitation Phase II $1, sessions PacificSource Health Plans Essential s Modification Comparison Page 2 of 6
3 Idaho Small Group Plans The proposed changes listed below for Idaho Small Group plans (Preferred, SmartHealth, and Traditional), if approved by the appropriate regulatory authority, will be applicable from a benefit-administration perspective as of the date of the policy renewal on or after September 23, Preferred Product Line Outpatient Rehabilitation Preferred Plans Proposed Modification $2,000 per 30 visits per Inpatient Rehabilitation $150, days per condition / 60 days for head and spinal cord injury. Durable Medical Equipment $5,000 per Limit only applies to nonessential $5,000 Limit changed to one per lifetime Ground: nearest facility Air: $6,000 per Pulmonary Rehabilitation $1,000 Subject to medical $100,000 Ground and Air: $10,000 per SmartHealth for Business Product Line SmartHealth Plans Proposed Modification Outpatient Rehabilitation $1,500 per up to 25 visits per $150,000 Inpatient Rehabilitation $150, days per condition / 60 days for head and spinal cord injury. Diabetes Self Management $500 per Three hours per Durable Medical Equipment $10,000 per Limit only applies to nonessential $100,000 per transplant. PacificSource Health Plans Essential s Modification Comparison Page 3 of 6
4 Idaho Small Group Plans continued Traditional PPO Product Line Outpatient Rehabilitation Traditional Plans $1,500 per up to $150,000 Proposed Modification 25 visits per Inpatient Rehabilitation $150, days per condition / 60 days for head and spinal cord injury. Diabetes Self Management Not covered Three hours per Durable Medical Equipment $5,000 per Limit only applies to nonessential $800 (all wheelchairs) $100,000 Ground and Air: $7,500 per Limit changed to one per lifetime $100,000 per transplant. PacificSource Health Plans Essential s Modification Comparison Page 4 of 6
5 Idaho Individual Plans The changes listed below for our Idaho individual plans will be applicable from a benefit-administration perspective as of the date of the policy renewal on or after September 23, BrightIdea Product Line Outpatient Rehabilitation BrightIdea Plans $800 per for each type of therapy Proposed Modification 15 visits per for each type of therapy Cardiac Rehabilitation Phase II $1, visits per Inpatient Rehabilitation $150, days per Diabetes Self Management 3 hours per up to Three hours per $400 Durable Medical Equipment $7,500 Limit only applies to nonessential $100,000 $5,000 Limit changed to one per lifetime Ground: nearest facility Air: $6,000 per $100,000 per transplant. SmartHealth for Individual Product Line SmartHealth Plans Proposed Modification Outpatient Rehabilitation $1,000 per 20 visits per Therapy, Speech, and Cardiac Phase II Therapy Inpatient Rehabilitation $150, days per Diabetes Self Management $500 per Three hours per Durable Medical Equipment $10,000 Limit only applies to nonessential One wheelchair (any type) One per lifetime age 19 and over. Ground and Air: $10,000 per PacificSource Health Plans Essential s Modification Comparison Page 5 of 6
6 Montana Individual Plans The proposed changes listed below, if approved by the appropriate regulatory authority, will be applicable from a benefit-administration perspective as of the date of the policy renewal on or after September 23, Clear One Individual Product Line Clear One Plans Proposed Modification Diabetes Self Management $250 per Three hours per Mental Illness Outpatient: $2,000 per calendar Outpatient: 20 visits per Chemical Dependency - $3,000 per Inpatient Up to $6,000 Five days per /10 day Chemical Dependency - $1,000 per 10 visits per Outpatient Durable Medical Equipment $5,000 per Limit does not apply to the following essential DME items: prosthetic and orthotic devices; oxygen and oxygen supplies; diabetic supplies; and wheelchairs. Transplants $250,000 Participating provider: No limit. Ground: nearest facility Air: $10,000 per Orthotics $250 per No limit. PacificSource Health Plans Essential s Modification Comparison Page 6 of 6
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