The “average number of employees” will be used to determine a group’s employer size. The Affordable Care Act, which includes Medical Loss Ratio provisions and the Mental Health Parity and Addiction Equity Act, requires collection of specific information regarding the average number of employees for your group. Group size information is still applicable for other purposes, especially in terms of state law and eligibility for our group products, so it’s important to note that our collection of average number of employees will not replace our need to also collect information on a group’s total eligible employees, which is what we currently capture on the enrollment summary.
Federal law requires that all employers providing health insurance coverage report the average number of employees they employed for each calendar year 2011 and 2012.
Medical Loss Ratio (MLR) provisions and the Mental Health Parity and Addiction Equity Act (MHPAE) require collection of specific information regarding the average number of employees for your group. We must first collect this information before we can determine if an MLR rebate is required.
Yes, such persons are considered as “employees” for the months in which they were actually employed. Do not include retirees or former employees on continuation coverage (e.g., COBRA) in the calculation.
If the employer group was not in business each month of the 2011 and 2012 calendar years (January to December), the “average number of employees” must be based on 2012 projections. (Helpful information and examples are included in the questionnaire instructions.)
Count the full-time, part-time, and seasonal W-2 employees, regardless of whether they were eligible to participate in insurance coverage. Add together the total employees for all 12 months during the year for which you are calculating the average, then divide by 12 to get an average for that year.
Each part-time or seasonal worker who received a W-2 for 2011 and/or 2012 is counted as one employee. Contract workers who receive a 1099 are not counted as employees.
Florida law requires employers to count only those employees who were eligible to participate in insurance coverage.
Federal law requires employers to count the average number of employees based on the calendar year and includes all W-2 employees, regardless of whether they were eligible to participate in insurance coverage.
The group size information provided on the enrollment summary is a “snap-shot” of a given point in time. It includes former employees on continuation coverage (e.g., COBRA), and excludes seasonal employees. In contrast, the average number of employees is based on the calendar year and includes all W-2 employees, regardless of whether they were eligible to participate in insurance coverage.
If the number is greater than 1 but is less than the next whole number, the number must be rounded up to the next whole number (e.g. 1.2 is counted as 2).
For Employer Group Policyholders: This depends on the eligibility of your employer's plan under MLR. If your employer's plan is eligible for a rebate, you must consult your employer on how they will use the rebate. We recommend that you contact your Benefit Administrator for specific details.
For Individual Policyholders: This depends on your plan's eligibility under MLR. Not all plans will be eligible for a rebate.
Under Federal law, if a rebate is required, insurers must pay the rebate by Aug. 1 of each year. Florida Blue will begin mailing rebates to eligible policyholders in mid-July.
Yes, Federal law requires that insurers notify employee subscribers when a rebate has been issued to their group, Florida Blue will begin mailing employee subscriber notices in mid to late July. Members can view this information, once it is mailed, via the member login at www.floridablue.com.
Yes, Federal law also requires insurers to notify employee subscribers of non-rebate eligible groups. The notice will be mailed along with other compliance information after the above mentioned notices are sent. Members can view this information, once it is mailed, via the member login at www.floridablue.com.
For Group Policyholders: Federal law allows insurers pay rebates directly to employers. Please contact your Benefit Administrator for specific details.
For Individual Policyholders: Federal law requires that insurers pay rebates directly to the individual policyholder.
Federal law allows insurers to send rebates to the policyholder, not the subscriber/member. Sending the rebate to the subscriber may or may not cause tax issues for the subscriber that will be avoided by returning the rebate to the employer that paid the premiums to Florida Blue. Florida Blue does not have access to the employee’s tax information and contribution amounts (nor can it easily obtain this information) which are needed in order to accurately provide the rebate across all groups.
Florida Blue cannot share this information. Please contact your Benefit Administrator for specific details on the rebate that the employer may have received.
If your employer has more than one health plan offering, it is possible that one health plan was rebate eligible while another was not. Please contact your Benefit Administrator for specific details.
Yes, if you were a subscriber in more than one health plan during the last calendar year, you may be eligible to receive a rebate from one or both health plans.
The MLR is a comparison of total claims by market segment divided by total revenue by market segment expressed as a percentage. If the percentage exceeds the required level by market segment then the insurer has met its obligation.
MLR is calculated by an insurer by market segment, which are defined as individual, small employer, and large employer. For MLR purposes, the Federal definition of employer size is used and relates to the average employees during a year where “employees” includes full-time, part-time and seasonal (e.g. anyone who received a W-2), regardless of whether they were eligible to participate in the group’s insurance coverage.
An insurer must meet the following MLR thresholds: individual policyholder market, 80 percent; small employer, 80 percent; and, large employer, 85 percent. For example, in the individual policyholder market as a whole, the insurer must pay 80 percent of the premium dollars it receives toward medical or quality improvement costs over the course of a calendar year.
If an insurer's market segment does not meet the required MLR threshold, a rebate of premiums for the whole market segment is required. The individual's or group's share of any such rebate is determined based on the total premium paid by the individual or group.
The rebates will vary by the employee subscriber’s contract, so an average figure would not fairly represent the rebates paid. Please contact your Benefit Administrator for specific details on the rebate that the employer may have received.
Our premiums are based on the amount of expected claims in a given year. Because health insurance claims can vary greatly, we don’t know what the exact cost of providing your coverage will be until after the end of the year. If we have not met the MLR threshold, we will pay a rebate.
If the employer is no longer in business, Florida Blue will attempt to distribute the rebate amount to the employee subscribers that were insured under the employer’s rebate eligible plan. Florida Blue cannot keep unclaimed rebates. Under Florida law, we are required to send all unclaimed funds to the State, this is known as “escheatment.” After a period of time, the State can use the unclaimed funds at their discretion.
Yes, Florida Blue's administration of rebate payments is in compliance with the law and regulations interpreting the law issued by the Department of Health and Human Services, the authority overseeing MLR www.hhs.gov.
Agents can contact the Agent Service Center at 1-800-267-3156 to request information for a specific group. Rebate amounts will not be released to anyone except the group employer.
MLR is calculated by an insurer by market segment which is defined as individual, small employer, and large employer. For MLR purposes, the Federal definition of employer size is used and relates to the average employees during a year where “employees” includes full-time, part-time and seasonal (e.g. anyone who received a W-2), regardless of whether they were eligible to participate in the group’s insurance coverage.
The MLR is a comparison of total claims by market segment divided by total revenue by market segment expressed as a percentage. If the percentage exceeds the required level by market segment then the insurer has met its obligation.
An insurer must meet the following MLR thresholds: individual policyholder market, 80 percent; small employer, 80 percent; and, large employer, 85 percent. For example, in the individual policyholder market as a whole, the insurer must pay 80 percent of the premium dollars it receives toward medical and/or quality improvement costs over the course of a calendar year.
If an insurer's market segment does not meet the required MLR threshold, a rebate of premiums for the whole market segment is required. The individual's or group's share of any such rebate is determined based on the total premium paid by the individual or group.
We apologize if you are having difficulty understanding the MLR Notice. The Federal government required that all MLR rebate notices use the language exactly as written.
Calculating the rebate amount is very complicated and requires more information than just the rebate percentage and group’s premium contribution amount. In order to calculate the rebate, insurers must make adjustments based on taxes, fees, quality improvements, and the percentage of premium each group contributed toward the entire segment.
No, because they don’t have all of the information needed in order to calculate the rebate amount. Calculating the rebate amount is very complicated and requires that insurers must make adjustments based on taxes, fees, quality improvements, and the percentage of premium each group contributed toward the entire segment.
Florida Blue has followed the available rebate guidance issued by the Federal government and reported our aggregate rebate calculations to the Department of Health and Human Services (HHS), the authority overseeing MLR (www.hhs.gov). HHS may from time to time audit insurers in order to ensure compliance.
Under Federal law, if a rebate is required, insurers must pay the rebate by Aug. 1 of each year. Florida Blue will begin mailing rebates to eligible policyholders in mid-July.
Yes, Federal law requires that insurers notify employee subscribers when a rebate has been issued to their group, Florida Blue will begin mailing employee subscriber notices in mid- to late July.
Yes, Federal law also requires insurers to notify employee subscribers of non-rebate eligible groups. The notice will be mailed along with other compliance information after the above mentioned notices are sent.
Florida Blue is required to send the rebate notices to all subscribers who were enrolled in the employee group at any time between January 1, 2011 and June 1st, 2012.
Florida Blue will not provide this information. Employers may determine which employees they will include in their distribution or use of the rebate according to Department of Labor guidance. There are a number of ways in which an employer can use the rebate, this information is available at: http://www.dol.gov/ebsa/newsroom/tr11-04.html.
Federal law allows insurers to send rebates to the policyholder, not the subscriber/member. Sending the rebate to the subscriber may or may not cause tax issues for the subscriber that will be avoided by returning the rebate to the employer that paid the premiums to Florida Blue. Florida Blue does not have access to the employee’s tax information and contribution amounts (nor can it easily obtain this information) which are needed in order to accurately provide the rebate across all groups.
Yes. If an employer offers health plans with multiple insurers, it is possible that one insurer met the MLR threshold (no rebate required) while the other insurer did not (a rebate is required).
Example: A company offers health plans A and B. Health Plan A, with Insurer 1, does not meet MLR threshold and is eligible for a rebate. Health plan B, with Insurer 2, meets the MLR threshold and is not eligible for a rebate.
Yes, if the employee was a subscriber in more than one health plan during the last calendar year, he or she may be eligible to receive a rebate from one or both health plans.
Florida Blue cannot advise groups on how to comply with the Federal law. Employers must consult their accountant, tax advisor, or legal counsel to determine what their obligations are under the law.
Generally speaking, groups may choose from the following options:
Employer groups subject to ERISA are required to treat the rebate as a plan asset and uses may include, but are not limited to: - Reducing future premiums or premium increases, or - Rebating a portion back to the subscribers.
Employer groups not subject to ERISA are required to use rebates for the benefit of the subscribers in one of the following ways: - To reduce subscribers’ portion of the annual premium for the subsequent policy year for all subscribers covered under any group health policy offered by the plan; - To reduce subscribers’ portion of the annual premium for the subsequent policy year for only those subscribers covered by the group health policy on which the rebate was based; or - To provide a cash refund only to the subscribers who were covered by the group health policy on which the rebate is based.
Generally, a rebate to an employer is non-taxable because Federal law categorizes them as a return of assets to the policyholder. However, exceptions may apply so an employer must consult their tax advisor or counsel for advice.
Rebates are considered a plan asset and Florida Blue recommends that policyholders who do not wish to accept their rebate consult their accountant, tax advisor, or legal counsel to determine what their obligations are under the law. Additionally, Florida Blue cannot keep unclaimed rebates. Under Florida law, we are required to send all unclaimed funds to the State, this is known as “escheatment.” After a period of time, the State can use the unclaimed funds at their discretion.
If the employer is no longer in business, the rebate check must be returned to:
Blue Cross and Blue Shield of Florida PO Box 2210 Jacksonville FL 32202-2210
Florida Blue will then attempt to distribute the rebate amount to the employee subscribers that were insured under the employer’s rebate eligible plan. Florida Blue cannot keep unclaimed rebates. Under Florida law, we are required to send all unclaimed funds to the State, this is known as “escheatment.” After a period of time, the State can use the unclaimed funds at their discretion.
Yes, Florida Blue's administration of rebate payments is in compliance with the law and regulations interpreting the law issued by the Department of Health and Human Services, the authority overseeing MLR www.hhs.gov.
No. We will let you know about changes that may impact you and update our website regularly with helpful information. The new law will be implemented over the next several years and we are committed to making these changes with your best interests in mind. If you have any questions, we encourage you to call your agent, call us directly or visit in person at a Florida Blue Center near you.
No. We’ll let you know about changes that may impact your benefits. If you were enrolled in your plan on or before March 23, 2010, your coverage may be “grandfathered” so that it does not have to include some of the provisions required by the new law. If you have questions about your current coverage, we encourage you to call us directly or visit in person at a Florida Blue Center near you.
No, grandfathered plans are not temporary. Plans will be considered grandfathered as long as they comply with the regulations and are still offered by the health insurance company. In 2014, grandfathered plans will still be exempt from certain health care reform rules. In 2014, individual and small group plans will be required to cover essential benefits (as defined by Health and Human Services). But these plans are not required to cover all of the essential benefits.
Keep in mind that any major benefit changes to a grandfathered plan will cause it to lose its grandfathered status.
Starting in 2014, everyone will be required to purchase health insurance or pay a tax (as determined by the Supreme Court). You will be able to purchase health insurance regardless of your health status and premiums cannot vary because of your health status. Both individuals and small businesses will be able to purchase health coverage through a new State Exchange for Health Insurance. Through the Exchange, subsidies, such as premium and cost-sharing credits, will be available for qualifying individuals or families with incomes up to 400% of the federal poverty level. You will also be able to purchase coverage outside the Exchange, but subsidies will not be available. You can count on Florida Blue to have a number of plans available in and out of the Exchange to meet the needs of you and your family.
Exchanges will be established for each state by January 1, 2014. The Exchange enables individuals and small businesses to shop, compare and purchase health insurance coverage.
Individuals Under 65: The Exchange is intended for use by individuals who are not eligible for Medicaid, Child Health Insurance Program (CHIP) or do not have affordable employer-sponsored insurance. Individuals who have incomes below 400% of the federal poverty level may also qualify for federal subsidies, such as premium and cost-sharing credits.
Small Businesses: Generally, small employers with 1 to 100 employees can purchase insurance through the Exchange when it opens in 2014. However, each state will have the option to limit the Exchange to employers with 1 to 50 employees in 2014 and 2015. In 2017, the Exchange may be available to businesses larger than 100 employees. When the State of Florida makes these decisions and opens the Exchange to more businesses, you can count on us to keep you informed.
Even with a grandfathered plan, there are provisions of the new law that will be added to your coverage on or after September 23, 2010. Some of the important changes include:
Extension of coverage for children up to the age of 26. We understand the importance of providing health care coverage for your children. That’s why last year we added an option to extend coverage up to age 30. The law does not require coverage for a child or spouse of any dependent children.
A change in the cancellation of policies. Health care policies will not be cancelled unless you commit fraud, intentionally misrepresent a material fact in your application or fail to pay your premium according to the terms of the policy.
The removal of lifetime dollar limits from your coverage. This means there are no lifetime limits on covered services and your insurance company will continue to pay their portion as long as your policy is in effect.
Small employers that provide health care coverage to their employees and meet certain requirements are generally eligible for a federal tax credit. The credit is available immediately and eligible employers may count premium contributions made for the entire 2010 tax year when they file their 2010 income tax return in 2011. The maximum credit is 35% of employer costs (25% tax-exempt) for years 2010 through 2013. Eligible employers can claim this credit for all four years.
The amount of the credit available is determined by the number of full-time equivalent employees and the average wages of its employees.
In 2014, the maximum credit increases up to 50% of employer costs (35% if tax-exempt). Eligible employers must purchase insurance through the State Exchange for Health Insurance. The tax credit is limited to the first two years of coverage, starting in 2014. See our Tax Credit information sheet for more information.
If your health insurance plan was effective on or before March 23, 2010 and no major changes have been made to the plan, you have a grandfathered plan that you can keep if you choose to do so.
Grandfathered plans are exempt from certain requirements of the new law, including changes to benefits for preventive care and emergency services. According to the Department of Health and Human Services (HHS), changes in premiums, changes in third-party administrators and changes to comply with state and federal law will not cause the loss of grandfather status. However, the following major changes, according to the HHS guidance, could cause the loss of grandfather status:
Eliminating benefits to diagnose or treat a condition.
Increasing co-insurance above your March 23, 2010 amounts.
Increasing fixed amount cost-sharing (e.g., deductibles and out-of-pocket maximums) by more than the sum of medical inflation plus 15 percentage points from the March 23, 2010 amounts.
Increasing co-payments by an amount that exceeds the greater of: (1) a total percentage (measured from March 23, 2010) that is more than the sum of medical inflation, plus 15 percentage points, or (2) $5, increased annually by medical inflation.
Reducing employer contributions based on the cost of coverage or a formula by more than 5 percentage points below the contribution rate on March 23, 2010.
Reducing an overall annual dollar limit or adding a new overall annual dollar limit, compared to what was in effect on March 23, 2010.
The regulations governing a grandfathered plan are complex and companies may not be able to maintain certain plans if they make major changes. You can call us directly or stop by a Florida Blue Center if you have questions about your current health care coverage.
The credit is available to employers with fewer than 25 full-time equivalent employees (FTEs) and less than $50,000 in average annual wages. Seasonal workers are not included in determining FTEs and annual wages unless they work more than 120 days during the tax year.
Eligible employers must also pay at least 50% of the premium cost under a “qualifying arrangement.” A qualifying arrangement is an arrangement which the employer pays premiums for each employee enrolled in health insurance coverage offered by the employer in an amount equal to a uniform percentage (not less than 50%).
For 2010, the IRS is providing transitional relief. This allows employers to satisfy the uniformity requirement (to be treated as a qualifying arrangement) even if the same percentage is not paid for each employee, as long as the employer pays an amount for each employee that is no less than 50% of the cost of single coverage (even if the coverage provided is family coverage, which is more expensive.) You can call us directly or stop by a Florida Blue Center for more specifics on qualifying for the tax credit.
If a dependent is already covered on their parent’s health plan, Florida Blue will no longer cancel the dependents because they turn 26 or no longer meet the eligibility requirements. This went into effect on June 1, 2010.
If a dependent is currently not covered on their parent’s health plan, they can be added at the next open enrollment period for the employer beginning September 23, 2010. If you have an individual policy (not through an employer), dependents can be added anytime beginning September 23, 2010. For both group and individual coverage, the only eligibility requirement is age.
The SBC is a new requirement under Health Care Reform. It is a standardized template, created by a national coalition, which provides a high-level summary of benefits under a health plan. It outlines cost-sharing information such as copays, coinsurance, and deductibles, as well as exclusions and limitations (what is not covered). It also provides a new section called “Coverage Examples” that shows how cost-sharing between the health plan and an individual would be determined for two common medical scenarios: having a baby and managing Type 2 diabetes.
The SBC applies to all health insurance companies across the United States. The intention is to create a national standard so that individuals can understand and easily compare the benefits of plans from different health insurance companies.
Florida Blue provides members with a variety of items that outline their benefits. The SBC is simply one more way to organize and describe benefits. It is very similar to our current material; it just has a different look and combines benefit information another way.
Members with a standard, actively sold plan can access the SBC on the Florida Blue website (floridablue.com\sbc) beginning September 23, 2012. For help finding the SBC online or to request a copy by mail, members are encouraged to call the Customer Service number on their ID card or 1-800-352-2583.
No. The SBC does not require members to take any action. The SBC is another resource available to help everyone understand and compare health plan benefits.
Coverage Examples show how cost-sharing between the health plan and an individual would be determined for two common medical scenarios. To date, the Federal government has defined two medical scenarios (having a baby and managing type 2 diabetes). However, the Federal government plans to develop additional scenarios. The Coverage Examples are designed to help individuals understand how much financial protection the plan offers, using common medical scenarios to help explain how health coverage works.
No. It is important to understand that the Coverage Examples are illustrative, and not representative of actual costs a person might incur if he/she had the same medical condition. The Coverage Examples are intended to help individuals understand how much financial protection the plan offers, not to predict actual medical costs. The reasons Coverage Examples cannot be used to predict actual medical costs include:
The treatment plans used in the Coverage Examples are just examples. The care an individual receives may be very different based on their doctor’s advice, their age, and how serious the condition is, among other factors.
The treatment costs are based on national averages, and are not specific to an individual’s geographic area. This provides a basis to illustrate the portion of costs that might be covered, but because health care costs vary widely across the country, they are not useful for predicting an individual’s actual costs.
The Coverage Examples assume that all care is in-network, and calculates costs based on in-network cost-sharing. An individual’s care may involve out-of-network providers, which may have different cost-sharing.
The Coverage Examples assume that no deductibles have been met, so any deductibles an individual or his/her family may have accumulated are not included.
The treatment plan begins and ends in the same year, whereas a person’s care may span across multiple years. Deductibles are not carried over from previous years, and benefits may be different from year-to-year, impacting cost-sharing.
For more accurate cost comparisons and help getting the most value from coverage and benefits, Florida Blue members have access to a variety of resources. These include online tools and Care Consultants which are available by phone and in person at our Florida Blue Centers.
The coverage effective date on the SBC is not the date an individual enrolls in a plan; it is the original date the plan took effect. For instance, an individual with employer coverage will see the date coverage was effective for their employer and everyone who works for that company has same date. For someone with an Individual policy, the effective date is the plan's anniversary date, and everyone enrolled in that plan has the same date.
No. Florida Blue will not charge any additional fees for providing the SBC.
Note: Please see the Employer Section at the end of this document for Employer responsibilities related to the printing and distribution of the SBC to employees and dependents.
The national coalition that developed the SBC also developed a glossary of common health insurance and medical terms. Because health insurance companies and medical industries throughout the nation use different terminology and definitions, the coalition standardized the terms so that the nation could have a consistent reference.
The national glossary provides a foundation, but does not account for the unique situations under certain health plans or specific state regulations. Florida Blue uses the Uniform Glossary as a base, and may modify definitions as needed, to more fully and accurately define terms based on our health plans.
SBCs for all standard, actively sold plans will be available at floridablue.com. SBCs for plans that are classified as ‘non-standard,’ ‘closed’ or ‘retired’ are not on the website; however, they are available upon request by calling Florida Blue at 1-800-352-2583.
Delivery timeframes for the SBC depend on the trigger event.
For open enrollment (new sales or renewals): The SBC will be provided to the employer so it can be included with other materials used to support their open enrollment period. As a reminder, SBCs for new or modified plans at renewal will only be provided after the benefits for those plans are finalized. As a result, it will be important for benefit decisions to be finalized in time to support development of an SBC to be included as part of the group’s open enrollment materials.
For renewals where employees are not required to formally re-enroll in a plan: The SBC must be provided 30 calendar days prior to the first day of the new policy effective date.
Special enrollees during the plan year: Eligible employees must be provided with an SBC for the plan selected within 90 calendar days of enrollment.
Benefit changes during the plan year that result in changes to the SBC provided during open enrollment: Eligible employees must be provided with a new SBC or notice that reflects the changes in plan benefits no later than 60 calendar days prior to the effective date of the coverage change(s).
Employers need to continue their efforts to come into compliance with the ACA. Among the many new health care reform provisions that take effect in 2012 and 2013, in 2014 large employers (those with 50 or more employees) must provide group health plan coverage at a certain level of coverage or pay a penalty (the "employer responsibility penalty").
Effective Jan. 1, 2014 under the new law, adult citizens and their dependents will be required to enroll in minimum essential health insurance coverage or pay a tax (as determined by the Supreme Court). You can satisfy this requirement by enrolling in minimum essential coverage through an employer group plan or by purchasing an individual health insurance policy with minimum essential coverage. If an individual is unable to afford coverage and meets certain criteria, subsidies may be available in the Exchange to help assist with lowering the cost of coverage.
Starting in 2014 if your employer doesn't offer insurance, you will be able to buy it directly in an Affordable Insurance Exchange. An Exchange is a new transparent and competitive insurance marketplace where individuals and small businesses can buy affordable and qualified health benefit plans. Exchanges will offer you a choice of health plans that meet certain benefits and cost standards.
The law does not require employers to provide health insurance. Starting in 2014, large businesses (those with 50 or more employees) that do not provide adequate health insurance will be required to pay a penalty if their employees receive premium tax credits to buy their own insurance in the Exchange. The penalty for a large employer that does not offer coverage will be $2,000 per full-time employee beyond the company's first 30 workers.
Starting in January 2014, employers with more than 200 full-time employees must automatically enroll new full-time employees in one of the employer's health benefits plans (subject to any waiting period authorized by law), and continue the enrollment of current employees in a health benefits plan offered through the employer. The law further requires adequate notice advising employees of their right to opt out of any coverage in which they were automatically enrolled.
There are a number of provisions that have already been implemented and will continue to be in effect moving forward. These include:
Under the new law, young adults are allowed to stay on their parent's plan until they turn 26 years old. (In the case of existing group health plans, this right does not apply if the young adult is offered insurance at work.)
All new plans must cover certain in-network preventive services, such as mammograms and colonoscopies without charging a deductible, co-pay, or coinsurance.
Insurers cannot cancel or rescind coverage except in cases of fraud or material misrepresentation or non-payment of premiums.
The law provides consumers with a way to appeal coverage determinations or claims and establishes an external review process.
Under the new law, insurance companies are prohibited from imposing lifetime dollar limits on essential benefits like hospital stays.
Under the new law, annual dollar limits on the amount of insurance coverage a patient may receive is restricted for new plans in the individual market and all group plans.
Starting in 2014, the following provisions will be implemented to your plan:
The law requires insurers to issue coverage to anyone regardless of pre-existing conditions.
In the individual and small group market all new plans will need to cover essential health benefits.
Yes. New plans are required to include the ACA emergency services benefit. The ACA emergency services benefit mandate requires coverage at the same cost share amount whether received in or out of network. All Florida Blue plans cover emergency services generally.
Florida's high-risk pool, called the Florida Comprehensive Health Association, has been closed to new enrollees since 1991. Starting in 2010, Florida began offering health care insurance coverage to residents through the federally established temporary high-risk pool program, which will remain open until the end of 2013. For more information on this program, visit www.PCIP.gov.
The ACA strengthens Medicare and helps seniors take charge of their health. The law provides important benefits, such as free preventive services, free annual wellness visits, slowly reduces the generic prescription drug "donut hole," and immediately provides a 50% discount for brand name prescription drugs. Seniors can also work with their doctor to create a personalized prevention plan.
A great health state is having access to great health care and taking personal responsibility for maintaining a healthy lifestyle. Providers play a crucial role in this question. In fact, Florida Blue's relationship with providers has never been more important. We must continue to work together to create innovative service solutions for members that focus on quality, affordability and accessibility.
Florida Blue is committed to improving the quality, accessibility and affordability of health care. As a mission-based organization, we have a unique role in finding real, meaningful solutions to help people and communities achieve better health.
In 2007, we began to take necessary steps to address administrative costs throughout the organization. Through this effort, we have been able to remove more than $200 million in administrative costs from the system.
Florida Blue has made changes to the way we are delivering products to the marketplace, and we are working to bring a wider array of inexpensive products to residents in Florida.
We are also expanding our retail health footprint to increase access to health insurance. With eight Florida Blue Retail Centers throughout the state, and more on the way, we are utilizing the centers as a way to bring the messages of wellness, preventive treatment, education, and personal responsibility in one's own health directly to Floridians.
Your current premiums will not change as a result of the ACA ruling. You'll be informed of any financial or coverage changes to your health care policy with Florida Blue that might impact you and your premium amounts.
Florida Blue will continue to implement the provisions of the ACA according to the HHS timeline and implementation plan. Some of those provisions have already been implemented. Those include:
Under the new law, young adults are allowed to stay on their parent's plan until they turn 26 years old. (In the case of existing group health plans, this right does not apply if the young adult is offered insurance at work.)
All new and non-grandfathered plans must cover certain in-network preventive services, such as mammograms and colonoscopies without charging a deductible, co-pay, or coinsurance.
The law provides consumers with a way to appeal coverage determinations or claims and establishes an external review process.
Under the new law, insurance companies are prohibited from imposing lifetime dollar limits on essential benefits, like hospital stays.
Under the new law, annual dollar limits on the amount of insurance coverage a patient may receive is restricted for new plans in the individual market and all group plans.
Starting in 2014, the following provisions will be implemented:
The law prohibits new plans and existing group plans from imposing annual dollar limits on the amount of coverage an individual may receive.
The law implements strong reforms that prohibit insurance companies from refusing to sell coverage or renew policies because of an individual's pre-existing conditions.
In the individual and small group market all new plans will need to cover essential health benefits.
You can continue to utilize your health benefits and information from Florida Blue in the same way as always. If you have any specific questions about coverage or other insurance-related issues, feel free to contact us by calling the toll-free number on the back of your membership card.
Have a question about health care reform? Submit your question and we will answer it. You may see your answer on this page.
hcr_content/SI_HCR/SA_takePart/SA_UHealthCareReform/CT_hcrHealth Care Reform
This information is being provided in an effort to share with you some of the changes required under the Patient Protection and Affordable Care Act, otherwise known as Health Care Reform. Please know that plan benefits are subject to change and may be revised based on guidance and regulations issued by the Secretary of Health and Human Services. This information does not cover all of the law’s provisions and should not be used as legal advice for your decisions. We encourage you to seek professional advice regarding how Health Care Reform on how your decisions impact your health insurance.
PPS POS 006 062012
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