Mandates. State and federal law require health insurers to cover certain services and to include certain types of providers in their plans. Not all Affordable Care Act reforms apply to all plans. Generally, a plan may be considered grandfathered, and thus exempt from some provisions of the new federal law, if the plan existed before the law took effect (March 23, 2010) and meets other criteria.
Key reforms under Affordable Care Act include:
- Adult children may stay on their parents' policies up to age 26 even if they no longer live at home or no longer are students or dependents on a tax return. Both married and unmarried children qualify.
- Insurers can no longer use pre-existing conditions to deny coverage in the individual market.
- Preventive services must be provided with no co-pays or other cost sharing.
- Policies may not include any lifetime limits on how much they pay for essential health benefits.
- Annual limits on what policies pay for essential health benefits are restricted.
Federal law identifies 10 categories of essential benefits that must be covered by health benefit plans (excluding grandfathered plans) issued in individual and small group markets both inside and outside the exchange.
Federal regulations require states to select a benchmark plan that reflects services offered by a "typical employer plan." Oregon selected a plan sold by PacificSource Health Plans as its benchmark, then supplemented that plan with pediatric dental and vision benefits and habilitative services to meet federal requirements. Learn more about the essential health benefits selection process here.
Federal subsidies are available to help individuals buy health insurance through exchanges. However, federal subsidies cannot be used to pay for any state mandates that exceed the state’s benchmark plan. When people obtain coverage through the exchange, the state must pay for the costs of any coverage exceeding the state’s benchmark plan that are required by state mandates. Thus, Oregon policymakers will likely weigh the costs of any new state mandates signed into law.