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The new federal health care reform law requires health insurers to remove annual dollar limits on covered services from most Individual and group policies by 2014. This applies to services that the U.S. Department of Health and Human Services (HHS) considers “essential health benefits”. In the meantime, the law permits implementation of an annual dollar limit for all essential health benefits combined.
To maximize our members’ benefits and avoid the confusion of annual adjustments, Regence will implement a $2,000,000 annual dollar limit immediately. This applies to most plans that are new or renewing effective October 1, 2010 or later.
Due to this change, we will reprocess claims with dates of service on or after October 1, 2010 for members that have reached their annual dollar limits. You will:
For more information, please read answers to the most frequently asked questions about how benefit specific dollar limits will be removed on the majority of Regence policies.
Initial guidance on annual limits was released in June 2010; however, this guidance did not specifically address benefit-specific dollar limits. In late September 2010, HHS clarified that annual dollar limits on specific essential benefits are not permissible.
The new law identifies general categories of benefits that are included as essential benefits, but not specifically which benefits. Here are the categories:
As the definition of essential benefits in the new reform law is broad, and specific clarification through federal rulemaking is not expected until late 2011, Regence will treat all benefits we offer as essential benefits, except dental and vision services.
Additionally, vision screening for children up to age five and oral health risk assessment for preschool children are considered essential benefits for all Regence plans.
Yes, beginning September 23, 2010 all essential benefits can be limited to an aggregate annual dollar limit of at least $750,000. Beginning October 2011, the limits rise to at least $1,250,000 and from October 2012 until 2014, $2,000,000. (Annual dollar limits on essential benefits are prohibited beginning in 2014).
Regence has chosen to implement the $2,000,000 annual dollar limit on all essential benefits effective immediately in order to limit yearly adjustments to this provision on most plans new or renewing on or after October 1, 2010.
Yes, while the law explicitly prohibits benefit-specific dollar limits, alternative limits remain permissible, such as days/visits, etc. Therefore, plans are not required to make changes to non-dollar limits.
HHS and state regulators have shown some flexibility in allowing carriers’ to replace some dollar limits with non-dollar limits.
What will happen to claims that were processed for affected members on or after October 1, 2010 that exceeded the benefit specific annual dollar limits?
Due to this change, we will reprocess claims with dates of service on or after October 1, for members that have reached their annual dollar limits. You will: