Excluding coverage for pre-existing conditions is a thing of the past. Prior to 2014, the ACA prohibited group health plans and health insurance carriers from offering coverage that imposed pre-existing condition exclusion periods on children under the age of 19. Now, this extends to everyone.
Wellmark has chosen to remove pre-existing limitations on Jan. 1, 2014, for all its health plans1. This means you have coverage for pre-existing conditions that may have previously been excluded.
Out-of-Pocket Maximum (OPM) is the total you pay within a calendar year toward out-of-pocket medical services covered by your plan. This has typically included coinsurance and deductibles.
As of plan years on or after Jan. 1, 2014, copayments will also count toward your OPM. This means you could reach your OPM sooner.
The ACA set a limit on the maximum amount you can spend out of pocket on in-network services. In 2014, OPM cost-sharing amounts for non-grandfathered plans cannot exceed $6,350 for an individual and $12,700 for a family. You can rest assured that your existing Wellmark plan has been updated to be compliant with these new limits.
If you have a non-grandfathered plan, your plan may cover Essential Health Benefits. Listed below are 10 categories of required coverage. No annual or lifetime dollar limits will be applied to these items or services. There can, however, be limits placed on these services, such as the number of visits per year.
Essential Health Benefits include:
Employer groups with 50 or more employees are not required to cover Essential Health Benefits in their plans. However, if employers wish to cover Essential Health Benefits, the plan can’t have an annual or lifetime dollar limit imposed on these benefits. If your health plan coverage is purchased through your employer, check with your human resources department to see if Essential Health Benefits are covered within your plan.
1 As of Jan. 1, 2014, pre-existing condition exclusion periods will be removed for individual and fully insured group plans in Iowa and South Dakota. Large, self-funded groups may also use Jan. 1, 2014, as their effective date, or choose a different date if they do not have a Jan. 1 plan year, as long as the exclusion is removed by the beginning of the group’s plan year in 2014.