Table of Contents. Introduction Summary of the PPACA Patient Protection Requirements Grandfathered versus Non Grandfathered Plans...

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2 Table of Contents Introduction... 1 Summary of the PPACA Patient Protection Requirements... 2 Grandfathered versus Non Grandfathered Plans... 3 Nondiscrimination... 4 Overview of Consumer Protection Mandates... 5 Coverage of Preventive Care... 5 Annual Maximums... 5 Lifetime Limits... 5 Extension of Dependent Coverage to Age No Pre-Existing Condition Waiting Periods... 6 Access to OB/GYN Physicians... 6

3 Introduction The PPACA includes several provisions which are referred to as immediate market reforms. Rocky Mountain Health Plans (RMHP) will be sending amendments to your Evidence of Coverage and Group Service Agreement in September. All of the requirements described in this guide will be effective October 1,

4 Summary of the PPACA Patient Protection Requirements Effective October 1, 2010 Requirement Change to Current Plans Additional Information Dependent Coverage No Pre-existing Exclusions for Children Under 19 Adult children will be eligible for coverage up to age 26, regardless of marital status or financial dependency on parents. The pre-existing condition limitations will be removed for all dependents under age 19. Lifetime Limits The lifetime limit of $2,000,000 will be removed on all RMHP PPO plans. Annual Maximums Preventive Services Emergency Services Appeals Annual dollar limits on specific benefits, including rehabilitative and habilitative devices and nonbiologically based mental health services will be eliminated. There will be no cost sharing for specific preventive services. No changes to your plan. The appeals process will be revised to provide Members the opportunity to review their file at any level of the appeals process. The month prior to your anniversary is your Open Enrollment period, in which employees can add new dependents. The new dependent eligibility criteria will be included in your amended Evidence of Coverage. Effective October 1, 2010, RMHP plans will no longer impose a pre-existing condition waiting period on children under age 19 who did not have creditable coverage at the time of enrollment. Specific preventive services include colonoscopies and certain lab work performed with preventive office visits. PPACA requires all emergency services be covered in the same manner, regardless of whether the facility is considered a network provider. RMHP plans currently cover ER care in this manner. The revised appeals process will be included in your Evidence of Coverage. 2

5 Grandfathered versus Non Grandfathered Plans In PPACA, new grandfather rules allow plans that were in existence (and had at least one person on the plan) on the day the law was signed (March 23, 2010) to make certain changes and maintain grandfathered status. The following actions will NOT cause a plan to lose its Grandfathered Plan status: Adding new family members to a grandfathered plan Adding new employees to a grandfathered plan Employees voluntarily making a plan change to a different plan that was in place on March 23, 2010 (This applies to employers offering more than one plan design, and all plans had at least one person enrolled in the plan on March 23, 2010) Amendments required to conform to legal requirements/changes (Federal and State mandates) Voluntary adoption of other PPACA consumer protections* *RMHP will be adopting all PPACA consumer protection mandates to all small and large group grandfathered and non grandfathered plans, effective October 1, See pages 5 and 6. The following actions WILL CAUSE a plan to lose its Grandfathered Plan status: Employer making a plan change at renewal Employer changing health plan carriers Lowering employer contributions to the health plan by more than 5 percent Merging or acquiring a business for the primary purpose of covering individuals on a grandfathered plan If a plan is a grandfathered plan, disclaimers on all plan documents, including the Evidence of Coverage your employees receive, must be included. To ensure your employees receive the proper notices, RMHP requests to be notified if there is a change to your contribution toward your health plan coverage. Any merger or acquisition of a business requires RMHP involvement as described in your Group Service Agreement. The above list is only a short summary of changes that can affect grandfather status. For more information on what changes will cause employers and insurance plans to lose their grandfather status, please visit 3

6 Nondiscrimination Another important immediate market reform includes a new employer rule: Nondiscrimination of highly compensated individuals. This rule applies to plans that are non grandfathered. An employer that has specific eligibility criteria in place or contribution limits or benefits that discriminate against employees may result in penalties to be paid by the employer. Examples of discriminatory actions may include: Eligibility criteria that excludes specific classes of employees from participating in the health plan Contribution limits or benefits that treat specific employees or classes of employees differently than other employees We encourage you to discuss your specific circumstances with your broker, legal counsel or tax advisor when making coverage decisions. If you do not have a broker, your Rocky Mountain Health Plans Account Manager can offer assistance. 4

7 Overview of Consumer Protection Mandates Coverage of Preventive Care Beginning October 1, 2010, the new law requires group and individual health plans to provide coverage, without Member cost sharing, for: Health care services that received an A or a B (recommended) grade from the U.S. Preventive Services Task Force. Immunizations recommended by The Centers for Disease Control and Prevention. Evidence-based preventive care screenings for women, infants, children, and adolescents supported by the Health Resources and Services Administration. Rocky Mountain Health Plans on Coverage of Preventive Care We will be in full compliance with these requirements on October 1, Annual Maximums Certain health care services are considered to be Essential Benefits. These Essential Benefits will be required to be included in all benefit plans, without annual dollar limits, beginning January Effective October 1, 2010, health plans must meet specific requirements on annual limits for the coverage of Essential Benefits. Rocky Mountain Health Plans on Annual Maximums Detailed information on Annual Maximums will be included in the amendment to your Evidence of Coverage, which you will receive in September. Lifetime Limits Beginning October 1, 2010, group health plans may not establish lifetime coverage limits on the dollar value for the coverage of Essential Benefits, per Member. Lifetime maximums are allowed for coverage of Non-Essential Benefits. Rocky Mountain Health Plans on Lifetime Limits While the definition of Essential Benefits has not been clearly defined, Rocky Mountain will modify our Group PPO plans to comply with this requirement and remove lifetime limits, effective October 1, Extension of Dependent Coverage to Age 26 For health plan contracts beginning October 1, 2010, the law requires health care coverage for adult dependent children, married and unmarried, until age 26. It does not require coverage for children of dependents. Rocky Mountain Health Plans on Extension of Dependent Coverage to Age 26 Effective immediately, Rocky Mountain Health Plans is extending our current eligibility criteria for dependent coverage up to age 26 for new and existing Members. 5

8 On October 1, 2010, we will extend health coverage to dependents up to age 26 in accordance with the requirements the new law. No Pre-Existing Condition Waiting Periods Beginning October 1, 2010, health plans are prohibited from imposing any pre-existing condition exclusions or waiting periods for children, up to age 19, who are enrolled in a group health plan. This means coverage for any specific health condition will not be delayed for new Members, under age 19. Rocky Mountain Health Plans on No Pre-Existing Condition Waiting Periods We will eliminate all pre-existing waiting periods for children up to age 19 on October 1, Access to OB/GYN Physicians Beginning October 1, 2010, health plan Members who are required to designate a Primary Care Physician (PCP) must be allowed to see a participating Obstetrics/Gynecologist without preauthorization or a referral. Rocky Mountain Health Plans on Access to OB/GYN Physicians At Rocky Mountain Health Plans, this access is already included in all individual and group plans. No referral or pre-authorization requirements exist for access to these providers. Additionally, any Rocky Mountain Health Plans participating OB/GYN who chooses to be a PCP can be selected as a PCP. Beginning July 1, 2010, Rocky Mountain Health Plans Members on group plans will pay the PCP co-payment when they see a participating OB/GYN, regardless of their designated PCP. 6