The following applies to self-funded plans:
- Prohibition of lifetime limits
- Dependent to age 26 coverage
- No preexisting condition exclusion for those under age 19
- Prohibition against rescission for other than fraud
- Emergency services always covered in network regardless of provider
- Using any network doctor as a primary care physician (PCP)
- Summary of Benefits and Uniform Glossary (SBC)
- W-2 reporting for employers who send at least 250 Forms W-2
- Premium tax to fund comparative effectiveness research program
- New plans must have established internal claims appeal process and external review procedures
- Employer Play or Pay
- Minimum Value as opposed to Actuarial Value which applies to fully-insured
- individual and small group plans.
The following do not apply to self-funded plans:
- Essential Health Benefits (large groups and self-funded plans must provide at least a 60% minimum value, but are not required to meet any specific actuarial values)
- Premium taxes on insurers which will be passed on to consumers
- Internet enrollment portal
- Medical loss ratios and rebating
- Premium rate review
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