Chapter 1
Grandfathered Status

• Define the term “grandfathered health plan”;
• Identify the requirements for a grandfathered health plan’s maintaining its grandfathered status;
• Describe the provisions of the Act that are inapplicable to grandfathered health plans;
• Discuss the Act’s provisions that apply to health plans whether or not they are grandfathered health plans;
• List the actions that will cause a grandfathered health plan to lose its grandfathered status; and
• Explain the types of changes to a health plan that will not affect its status as a grandfathered health plan.

Chapter 2
Pre-Existing Condition Exclusion

• Define the term “pre-existing condition exclusion” as used in the Act and Regulations;
• Explain the requirements of the Act and Regulations as they apply to pre-existing conditions exclusions;
• Describe the types of health plans to which the prohibition of pre-existing conditions exclusions apply and the impact of a plan’s status as a grandfathered health plan;
• Explain the effective dates applicable to the Act’s prohibition of pre-existing condition exclusions; and
• Explain the rules governing the use of exclusions applicable to pre-existing conditions in effect under HIPAA until the effective date of the pre-existing condition exclusion provision of the Act.

Chapter 3
Benefit Limits

• Explain the requirements of the Act as they affect the ability to impose annual and lifetime limits on health benefits;
• Explain the applicability of the Act’s provisions concerning annual and lifetime health benefit limits to grandfathered health plans;
• Describe the restricted annual benefit limits applicable to essential health benefits permitted during the phase-in period ending in 2014;
• Define the term “essential health benefits”; and
• Identify the requirements applicable to health plans and health insurance coverage with respect to individuals who have reached a lifetime benefit limit before the effective date of the Regulations.

Chapter 4
Coverage Rescission Limits

• Define the meaning of “rescission” and describe how rescission differs from other types of coverage cancellation;
• Describe the grounds permitted under the Act on which coverage under a health plan or group or individual health insurance may be rescinded;
• Identify the components of fraud under the common law;
• Define the meaning of “material fact”; and
• Explain the Act’s requirements concerning notice when coverage will be rescinded.

Chapter 5
Patient Protections

• Explain the rights of participants in health plans and under health insurance coverage using provider networks to choose a primary care provider;
• Describe the required access available to female participants in network plans to obstetrical and gynecological care;
• Explain the content and timing requirements of disclosures concerning the patient protection provisions of the Act;
• Identify the Act’s requirements related to out-of-network emergency services;
• Define “emergency services”; and
• Describe the factors that must be considered when determining the reasonableness of a health plan’s or insurer’s payment of benefits for out-of-network emergency services.

Chapter 1 - Grandfathered Status

Chapter Learning Objectives

Patient Protection and Affordable Care Act Grandfathers Certain Coverage

Certain Act Provisions Inapplicable to Grandfathered Health Plans

Many Act Provisions Apply to Grandfathered Health Plans

Grandfathered Health Plan Status Unaffected by Certain Changes

Review Quiz #1

Grandfathered Health Plan Status may be Lost

Maintaining Grandfathered Health Plan Status

Disclosure Requirements for Grandfathered Health Plans

Documentation Requirements for Grandfathered Health Plans

Special Rules Applicable to Collectively Bargained Plans

Losing Grandfathered Health Plan Status

Violating Anti-Abuse Rules

Eliminating Benefits

Review Quiz #2

Increasing the Cost-Sharing Requirement

Increases in Percentage Cost-Sharing Requirement

Increases in Fixed Amount Cost-Sharing (Other than Copayments)

Determining Maximum Non-Copayment Fixed Amount Cost-Sharing Increases

Increasing a Fixed-Amount Copayment

Reducing Sponsoring Organization Contribution Rates

Changing Annual Benefit Limits

Review Quiz #3

Transitional Rules

Changes Made On or Before March 23, 2010

Changes Made After March 23, 2010 and Adopted Before Regulation Issuance

Summary

Review Quiz #4

Chapter 2 - Pre-Existing Condition Exclusion

Chapter Learning Objectives

Pre-Existing Condition Exclusion Defined

Exclusion of Coverage For All Participants Not a Pre-Existing Condition Exclusion

Pre-Existing Condition Exclusions Prohibited Under Act

Effect of Grandfathered Health Plan Status

Group Health Plans and Group Health Insurance Coverage

Individual Health Insurance Coverage

Effective Dates for Pre-Existing Exclusion Prohibition

HIPAA Provisions Apply Until Act’s Provisions are Effective

HIPAA’s Group Health Plan Rules

HIPAA’s Individual Market Rules

Conversion Policy May be Available

Summary

Review Quiz #5

Chapter 3 – Benefit Limits

Chapter Learning Objectives

Benefit Limits

Essential Health Benefits

Condition-Based Exclusions of Coverage Permitted under the Act

Annual Benefit Limits Prohibited

Restricted Annual Limits Provide Phase-In of Annual Limit Prohibition

Interim Limits Apply per Individual

Applicability to Grandfathered Plans

Loss of Grandfathered Plan Status

Expected Participant Impact of Annual Limit Prohibition

Review Quiz #6

Lifetime Benefit Limits Prohibited

Prohibition of Lifetime Benefit Limits Applicable to All Grandfathered Plans

Previously-Reached Lifetime Benefit Limits

Written Notice Requirement

Opportunity to Re-establish Coverage

Summary

Review Quiz #7

Chapter 4 – Coverage Rescission Limits

Chapter Learning Objectives

Contract Rescission

Legal Elements of a Contract

Post-Claims Insurer Review of Health Coverage

Coverage Rescission Limited Under Act

Rescission Differs from Prospective Cancellation

Regulations Apply Broadly

Contestable Period End Not a Bar to Rescission

Fraud as Basis for Rescission

Intentional Misrepresentation of Material Fact as Basis for Rescission

Rescission Notice Requirement

Examples

Summary

Review Quiz #8

Chapter 5 – Patient Protections

Chapter Learning Objectives

Choice of Healthcare Providers for In-Network Plans

Designation of Primary Care Provider

Designation of Pediatrician as Primary Care Provider

Patient Access to OB/GYN Care

Patient Protection Disclosure Requirements

Coverage of Emergency Services

Emergency Services Defined

Out-of-Network Cost-Sharing Requirements

Reasonable Payment Standard Established

Anti-Abuse Rule

Effective Date

Grandfathered Plans

Summary

Review Quiz #9

Bibliography

Glossary