Individual Provision highlights

Healthcare reform resources for individuals

Whether you get insurance through your employer or you buy an individual health plan, there will be some impact to your coverage as a result of healthcare reform.

Some changes, or provisions, have already been implemented: dependent coverage, preventive care, appeals, and pre-existing condition plans. But the provisions with the greatest impact are coming in 2014. Find out how these changes affect your individual health plan.

Grandfathered health plans - 2010

Under the healthcare reform law, individuals and employers/employees have the right to keep the coverage they had as of March 23, 2010, and are exempt from many reforms. These individual and group plans are known as "grandfathered plans." Collectively bargained plans that were ratified before the date of enactment are grandfathered until the date that the last collective bargaining agreement related to coverage ends. Find out more

Consumer website - 2010 has been created for individual consumers and small businesses to shop for health insurance.

Temporary High Risk Pool  (Pre-existing Condition Insurance Plan – PCIP) - 2010

Provides a health coverage option if you have been uninsured for at least six months, you have a pre-existing condition, or you have been denied coverage because of your health condition. You must be a U.S. citizen residing in the country legally. States or the federal government operates this plan. This program ends on 1/1/14.

If you have not had health coverage for at least six months, find out more about eligibility for this plan, how it works where you live, and how to apply. Visit or call 1-866-717-5826 (TTY:1-866-561-1604).

Dependent coverage to age 26 - 2010

Children may stay on their parents’ individual and non-grandfathered group employer plans until age 26 regardless of marital status. Grandfathered plans are required to offer eligibility to age 26 if coverage isn’t available through the child’s employer. Both married and unmarried children qualify for this coverage.

Beginning in 2014, children up to age 26 can stay on their parents' grandfathered employer plan even if they have another offer of coverage through an employer.

Note:  some states have a higher dependent limiting age pursuant to state law.  In these states, parents can opt to carry their dependents beyond age 26.  If you have questions about such laws, please consult your state regulations or contact your state Department of Insurance.

Lifetime and annual limits prohibited - 2010

Individual and group health plans may not impose lifetime limits on the dollar value of essential benefits. Annual limits will be restricted until 2014 and eliminated altogether starting in 2014. Restricted annual limits do not apply to grandfathered individual plans.

Rescissions prohibited except for fraud - 2010

Rescission means dropped or cancelled coverage. Rescissions will no longer be permitted, except in cases of fraud or intentional misrepresentation of facts.

No pre-existing conditions for children - 2010

Plans may no longer impose pre-existing condition exclusions for children under age 19. This does not apply to grandfathered individual plans.

Preventive services with no cost sharing - 2010

New policies must cover the full cost of preventive care as recommended by the U.S. Preventive Services Task Force. This includes recommended immunizations, preventive care for infants, children, and adolescents, and additional preventive care for women. This does not apply to grandfathered plans.

For some HumanaOne individual medical plans, there is a waiting period of 90 days for preventive services. Please call your agent or contact customer service for more information.

Insurance plan appeals process - 2010

There are new minimum requirements for internal and external claims appeals processes.

Patient protections - 2010

Plans that require or provide for a primary care provider (PCP) designation must allow each member to designate any in-network PCP or pediatrician that is accepting new patients. Plans may no longer require an authorization or referral to an Ob-Gyn. Prior authorization or increased cost-sharing for emergency services is also prohibited.

OTC drugs and spending accounts – 2011

Flexible Spending Accounts (FSAs) and Health Savings Accounts (HSAs) may no longer be used to purchase over-the-counter drugs unless prescribed by a doctor.

Medical loss ratio – 2011

Health plans are required to report the proportion of premium dollars spent on clinical services, quality, and other costs. Plans must provide rebates  to consumers if the share of the premium spent on clinical services and quality is less than 85% for plans in the large group market, and less than 80% for plans in the individual and small group markets.

Summary of Benefits and Coverage (SBC) - 2012

Group health plans and health insurers must provide a Summary of Benefits and Coverage (SBC) document to applicants, policyholders or certificate holders, and enrollees. The SBC document must meet the format and content criteria of the final regulations, in order to provide consumers with a clear, concise summary of their plan benefits and allow them to compare coverage across plans and/or carriers. The SBC must be provided at specified timeframes upon enrollment and at renewal. 

Flexible Spending Account contributions - 2013

Contributions to FSAs for medical expenses are limited to $2,500 per year.

Individual requirement to have insurance - 2014

U.S. citizens and legal residents are required to have qualifying health insurance.  There is a phased-in tax penalty for those without coverage, with some exemptions.  The  penalty will be enforced by the Internal Revenue Service.

Health Insurance Exchanges – 2014

Online marketplaces, or insurance Exchanges, will be created and administered by a governmental agency or non-profit organization. For individuals, this means that in 2014 you will have new options to purchase private health insurance on these Exchanges.

Pre-existing conditions – 2014

Individual and group health plans can no longer impose pre-existing condition exclusions on any person of any age. This does not apply to grandfathered individual plans.

Essential benefits – 2014

Individual and small group plans offered inside/outside the exchange must provide the essential benefits package. The minimum benefit package applies to individual and small group new business in 2014 and non-grandfathered existing business. It includes: Ambulatory patient services, Emergency services, Hospitalization, Maternity and newborn care, Mental health & substance abuse, Prescription drug, Rehabilitative & habilitative services/devices, Lab services, Preventive/wellness, Disease management and Pediatric services including oral & vision care.

No annual limits on coverage - 2014

Annual limits on essential health benefits are prohibited.This does not apply to grandfathered individual plans.

Guaranteed availability of insurance – 2014

Health insurers must guarantee issue coverage. This means insurers must accept every individual and employer who applies for coverage.

Rating restrictions – 2014

Rating restrictions go into effect for new individual and fully insured small group plans. Insurance companies cannot base premiums on health status, claims experience, or gender. Premium can only vary by age, geography, family size, and tobacco use (no more than 1.5:1).

Cost-sharing limits – 2014

For 2014, the out of pocket maximums are the same as the maximum out-of-pocket limits applicable to HSA-compatible high deductible health plans under IRS Code (note that the 2012 maximums are $6,050 for self-only coverage and $12,100 for family coverage). For future years, the 2014 limits are increased by the premium adjustment percentage - the percentage increase in the average per capita premium for health insurance coverage. These limits impact individual, small group and large group new business in 2014 and existing non-grandfathered business.

Transitional reinsurance program – 2014

A temporary reinsurance program will be established for the individual market and funded by individual, group and self-insured health plan assessments ($25 billion in 2014 – 2016). This will provide payments to plans that cover high-risk individuals.

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