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Patients Rights – Health Reform and Patients Rights

Your Health Insurance Rights Guaranteed by the Affordable Care Act

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Updated April 26, 2013

Patients Rights – Health Reform and Patients Rights

Patients Rights - President Obama and Kathleen Sebelius (HHS Secretary) discuss health reform.

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Patients rights are an integral part of the health reform legislation. On June 22, 2010, President Obama met with the health insurance industry and outlined a Patient Bill of Rights based on provisions in the Affordable Care Act. This announcement coincided with the 90-day anniversary of the signing of the Affordable Care Act.

The Patient Bill of Rights establishes a new set of rules made possible by the Affordable Care Act, which will take effect for most health plans starting on or after September 23, 2010. According to Kathleen Sebelius, Secretary of the U.S. Department of Health and Human Services, these rules “will remove barriers between you and your doctor and help provide the peace of mind that health insurance will be there when you need it the most.”

In addition, President Obama noted that rules "will put an end to some of the worst practices in the insurance industry and put in place the strongest consumer protections in our history — finally what amounts to a true Patient's Bill of Rights.”

For the most part, the new rules apply to your health coverage starting on or after September 23, 2010 – six months after President Obama signed the Affordable Care Act into law. Many of the regulations only apply until 2014, at which time health insurance companies must accept all applicants and a network of health exchanges will be available.

The New Rules – Your Health Insurance Rights

(Note: The sections in quotation marks are excerpts from the Fact Sheet: The Affordable Care Act’s New Patient’s Bill of Rights that was made available when President Obama announced the new rules)

No Pre-Existing Condition Exclusions for Children Under Age 19
“Each year, thousands of children who are either born with or develop a costly medical condition are denied coverage by insurers.”

The new regulations stop health insurance companies from imposing pre-existing condition exclusions on your children. This protection includes sick children who currently do not have insurance and if your child already has coverage, your health plan must cover all your child’s illnesses. These protections apply to all types of health insurance except for individual policies that are “grandfathered.”

No Arbitrary Rescissions of Insurance Coverage
“Right now, insurance companies are able to retroactively cancel your policy when you become sick, if you or your employer made an unintentional mistake on your paperwork.”

Under this regulation, your health plan will be prohibited from cancelling your coverage except if you committed fraud or intentionally misrepresented the facts. If your health plan is seeking to rescind your coverage it must provide at least 30 days advance notice to give you time to appeal. There are no exceptions to this policy.

No Lifetime Limits on Coverage
“Millions of Americans who suffer from costly medical conditions are in danger of having their health insurance coverage vanish when the costs of their treatment hit lifetime limits set by their insurers and plans.”

This regulation forbids your health plan from setting lifetime limits on your coverage. The rule applies to all health plans and insurance policies that are issued or renewed on or after September 23, 2010. This will have an effect on the more than 100 million Americans who have health coverage that imposes such lifetime limits.

Restricted Annual Dollar Limits on Coverage
“Even more aggressive than lifetime limits are annual dollar limits on what an insurance company will pay for health care.” Although much less common than lifetime limits (less than 20 percent of health plans), the consequences for people with medical costs that hit an annual limit can be devastating.

The regulations will phase out the use of annual dollar limits between 2010 and 2014 when the Affordable Care Act forbids them for most health plans. Your employer or health plan can ask the federal government for a delay and be granted permission if they can show that their current annual dollar limits are necessary to prevent a significant loss of coverage or an increase in premiums.

Protecting Your Choice of Doctors
“People who have a regular primary care provider are more than twice as likely to receive recommended preventive care; are less likely to be hospitalized; are more satisfied with the health system, and have lower costs.” Interestingly, many health plans don’t always make it easy for you to see the provider you choose.

The regulations make it clear that you can choose the primary care doctor or pediatrician you want from your health plan's provider network. Additionally, the rules prohibit your health plan from requiring you to obtain a referral from your primary care physician for obstetrical or gynecological (OB-GYN) care.

Removing Insurance Company Barriers to Emergency Department Services
“Some insurers will only pay for health care provided by a limited number or network of providers – including emergency health care.” And, some insurance companies may require that you obtain prior approval before you can receive emergency care at certain hospitals.

The new rules prohibit health plans from charging you a higher amount of cost-sharing (copayments or coinsurance) for emergency services that you received out of your plan’s network. Additionally, your health plan will no longer be allowed to require prior approval before you seek emergency care at a hospital outside your plan's network.

A Dr. Mike Resource: You can read all the details of Affordable Care Act patient protections at HealthCare.gov: Fact Sheet: The Affordable Care Act’s New Patient’s Bill of Rights

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