Application Of The New Health Reform Provisions Of Part A Of Title Xxvii Of The Phs Act To Grandfathered Plans (Page 3 of 4) in pdf

This chart contains an illustrative summary of some of the new health reform provisions and does not cover all the

specifics of the provisions. This chart provides an informal explanation of the new health reform provisions and should

not be considered legal advice or interpretive guidance.

§2715 Development and

Requires the Federal government to develop

Applicable

utilization of uniform

standards for use by group health plans and

explanation of coverage

health insurance issuers in compiling and

documents and standardized

providing an accurate summary of benefits and

definitions

explanation of coverage for applicants,

policyholders or certificate holders, and

enrollees. The explanation of coverage must

describe any cost sharing, exceptions,

reductions, and limitations on coverage, and

give examples to illustrate common benefits

scenarios.

§2715A Provision of additional

Requires group health plans and health

Not applicable

information

insurance issuers offering group or individual

health insurance coverage to disclose, to the

Federal government and the State insurance

commissioner, certain enrollee information such

as claims payment policies and practices and

enrollee rights. Requires such plans and issuers

to provide information to enrollees on the

amount of cost-sharing for a specific item or

service.

§2716 Prohibition on

Prohibits fully-insured group health plans from

Not applicable

discrimination in favor of

discriminating in favor of highly compensated

highly-compensated individuals

individuals with respect to eligibility and

benefits.

§2717 Ensuring quality of care

Requires the Federal government to develop

Not applicable

guidelines for use by health insurance issuers to

report information on initiatives and programs

that improve health outcomes. Prohibits a

wellness program from requiring the disclosure

or collection of any information relating to the

presence or storage of a lawfully possessed

firearm or ammunition in the residence or the

lawful use, possession or storage of a firearm or

ammunition by an individual.

§2718 Bringing down cost of

Requires health insurance issuers offering group

Applicable to insured

health care coverage (medical

or individual health insurance coverage to

grandfathered plans

loss ratio provisions)

submit annual reports to the Federal government

on the percentages of premiums that the

coverage spends on reimbursement for clinical

services and activities that improve health care

quality, and to provide rebates to enrollees if this

spending does not meet minimum standards for

a given plan year.

§2719 Appeals process

Group health plans and health insurance issuers

Not applicable

offering group or individual health insurance

coverage must provide an effective internal

appeals process of coverage determinations and

claims and comply with any applicable State

external review process. If the State has not

established an external review process that

meets minimum standards or the plan is self-

insured, the plan or issuer shall implement an

external review process that meets standards

established by the Federal government.

Application Of The New Health Reform Provisions Of Part A Of Title Xxvii Of The Phs Act To Grandfathered Plans Page 3

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