SEC. 100. PURPOSE; TABLE OF CONTENTS OF DIVISION; GENERAL DEFINITIONS.
Table of contents omitted, please feel free to use the links above to see it.
(c) General Definitions- Except as otherwise provided, in this division:
(1) ACCEPTABLE COVERAGE- The term ‘acceptable coverage’ has the meaning given such term in section 202(d)(2).
Let's skip ahead for a moment and review Section 202(d)(2):
(2) ACCEPTABLE COVERAGE- For purposes of this division, the term ‘acceptable coverage’ means any of the following:
(A) QUALIFIED HEALTH BENEFITS PLAN COVERAGE- Coverage under a qualified health benefits plan.
(B) GRANDFATHERED HEALTH INSURANCE COVERAGE; COVERAGE UNDER CURRENT GROUP HEALTH PLAN- Coverage under a grandfathered health insurance coverage (as defined in subsection (a) of section 102) or under a current group health plan (described in subsection (b) of such section).
What does Section 102 a) and b) say?
(a) Grandfathered Health Insurance Coverage Defined- Subject to the succeeding provisions of this section, for purposes of establishing acceptable coverage under this division, the term ‘grandfathered health insurance coverage’ means individual health insurance coverage that is offered and in force and effect before the first day of Y1 if the following conditions are met:
(1) LIMITATION ON NEW ENROLLMENT-
(A) IN GENERAL- Except as provided in this paragraph, the individual health insurance issuer offering such coverage does not enroll any individual in such coverage if the first effective date of coverage is on or after the first day of Y1.
(B) DEPENDENT COVERAGE PERMITTED- Subparagraph (A) shall not affect the subsequent enrollment of a dependent of an individual who is covered as of such first day.
(2) LIMITATION ON CHANGES IN TERMS OR CONDITIONS- Subject to paragraph (3) and except as required by law, the issuer does not change any of its terms or conditions, including benefits and cost-sharing, from those in effect as of the day before the first day of Y1.
(3) RESTRICTIONS ON PREMIUM INCREASES- The issuer cannot vary the percentage increase in the premium for a risk group of enrollees in specific grandfathered health insurance coverage without changing the premium for all enrollees in the same risk group at the same rate, as specified by the Commissioner.
(b) Grace Period for Current Employment-based Health Plans-
(1) GRACE PERIOD-
(A) IN GENERAL- The Commissioner shall establish a grace period whereby, for plan years beginning after the end of the 5-year period beginning with Y1, an employment-based health plan in operation as of the day before the first day of Y1 must meet the same requirements as apply to a qualified health benefits plan under section 101, including the essential benefit package requirement under section 121.
(B) EXCEPTION FOR LIMITED BENEFITS PLANS- Subparagraph (A) shall not apply to an employment-based health plan in which the coverage consists only of one or more of the following:
(i) Any coverage described in section 3001(a)(1)(B)(ii)(IV) of division B of the American Recovery and Reinvestment Act of 2009 (
Wait, what is that??
(IV) the different coverage is not--
(aa) coverage that provides only dental, vision, counseling, or referral services (or a combination of such services);
(bb) a flexible spending arrangement (as defined in section 106(c)(2) of the Internal Revenue Code of 1986); or
(cc) coverage that provides coverage for services or treatments furnished in an on-site medical facility maintained by the employer and that consists primarily of first-aid services, prevention and wellness care, or similar care (or a combination of such care).
(ii) Excepted benefits (as defined in section 733(c) of the Employee Retirement Income Security Act of 1974), including coverage under a specified disease or illness policy described in paragraph (3)(A) of such section.
Okay, I could not find a good link to the actual text of this exceptions, but I found a website that I feel lists them. Please feel free to research this yourself, but based on what I've read these exceptions include:
• coverage only for accident or disability income insurance, or any combination of these coverages;
• coverage issued as a supplement to liability insurance;
• liability insurance, including general liability insurance and automobile liability insurance;
• workers' compensation or similar insurance;
• automobile medical payment insurance;
• credit-only insurance;
• coverage for on-site medical clinics; and
• other similar insurance coverage, specified in regulations, under which benefits for medical care are secondary or incidental to other insurance benefits.
• health flexible spending accounts (FSAs) offered to employees through a cafeteria plan, to the extent that (i) the maximum benefit payable for the employee under the health FSA for a plan year does not exceed two
times the employee's salary reduction election under the health FSA for the year (or, if greater, the amount of the employee's salary reduction election under the health FSA for the year, plus $500); (ii) the employee has other coverage available under a group health plan of the employer for the year; and (iii) the other coverage is not limited to benefits that are excepted benefits.
• limited scope dental or vision benefits;
• benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof;
• such other similar limited benefits as are specified in regulations
• coverage only for a specified disease or illness, and
• hospital indemnity or other fixed indemnity insurance
(iii) Such other limited benefits as the Commissioner may specify.
In no case shall an employment-based health plan in which the coverage consists only of one or more of the coverage or benefits described in clauses (i) through (iii) be treated as acceptable coverage under this division
Umm, where were we? Oh yeah, Section 202(d)(2)(C)
(C) MEDICARE- Coverage under part A of title XVIII of the Social Security Act.
(D) MEDICAID- Coverage for medical assistance under title XIX of the Social Security Act, excluding such coverage that is only available because of the application of subsection (u), (z), or (aa) of section 1902 of such Act.
Okay, this gets messy. So messy in fact that I think I will link it now, and then continue this post later: http://www.ssa.gov/OP_Home/ssact/title19/1902.htm
(incomplete)
Man, this is crazy, we aren't even past the definition of acceptable coverage yet!
