Individual Market

No. The new law will be implemented over the next several years. Blue Cross Blue Shield of Massachusetts will continue to provide excellent service and will work to implement the new changes in a way that best serves our members. We will be communicating with our members, accounts, and brokers as changes occur that may affect them.

There are many reforms that are already in place, and still more that will be implemented in the upcoming years.

The following provisions became effective in 2010:

• Beginning in plan years on or after March 23, 2010, pre-existing condition exclusions became prohibited for children under age 19.
• Beginning in June 2010, a temporary reinsurance program was established to help employers who provide coverage to their retirees under age 65 maintain this coverage.
• Beginning in July 2010, individuals with health problems who have been uninsured for six months became eligible to obtain coverage through a new high-risk pool program.
• Beginning in plan years on or after September 23, 2010:
• Dependents up to age 26 will become eligible to obtain coverage through their parents' health plans.
• For policies that are not grandfathered, routine preventive care will be covered without cost sharing (e.g., copayments and deductibles).
• Certain annual and lifetime dollar limits on coverage will be eliminated.

These requirements generally will apply at the beginning of the new plan year, which, for many individuals, will be January 1, 2011.

Starting in 2014, individuals who do not have coverage (through Medicare or their employer, for example) will be required to purchase health insurance or pay a penalty. Individuals will be able to purchase health insurance regardless of health status, and premiums cannot vary because of health status. Both individuals and small businesses will be able to purchase coverage through state-based exchanges. This coverage will cover specified minimum benefits established in the new law. For individuals purchasing coverage in the individual market through the exchange, subsidies will be available on a sliding scale to help individuals or families with incomes up to 400 percent of the federal poverty level. Individuals also will be able to purchase coverage outside the exchange, but subsidies will not be available to them.

Yes. Blue Cross Blue Shield of Massachusetts supports guaranteeing that everyone is able to purchase health insurance coverage, regardless of health condition. We also believe in ensuring that everyone obtains and maintains coverage. Beginning in 2014, the new law requires that individuals obtain coverage, and that insurers offer coverage to anyone, regardless of health status, and without premiums that vary based on health status. This coverage will be available during an annual Open Enrollment period, or when individuals become ineligible for their current coverage.

Yes, with very few exceptions. Beginning in 2014, U.S. citizens and legal residents will be required to buy health insurance or pay a penalty. The penalty will be phased in, beginning at the greater of $93.50 per person or 1 percent of a person's applicable household income that is in excess of the applicable tax-filing threshold in 2014. The penalty will then increase to the greater of $695 per person or 2.5 percent of a person's applicable household income that is in excess of the applicable tax-filing threshold in 2016. For individuals under the age of 18, the penalty is half of the above amount. The penalty will never be greater than the average national premium for policies offered through exchanges, however.

Individuals may be exempt from the mandate, for example, if they cannot afford health insurance, as defined by the government, or if their income does not meet the federal tax-filing threshold.

We believe that average premiums will increase as a result of the provisions that make it easier for high-cost individuals to obtain coverage and guarantee richer levels of benefits than those currently held by individuals who purchase their own insurance. The extent to which premiums increase will depend on how the government implements the new reforms. New taxes on insurance mandated by the new law may also increase the cost of premiums as the taxes are phased in. Government payments may offset some or all of these costs for those who are eligible for subsidies.

Blue Cross Blue Shield of Massachusetts will continue to work with doctors, hospitals, employers, and consumers to maintain costs and insurance premiums while improving access to quality health care.

Beginning in 2014, state health insurance exchanges will enable consumers to compare benefits, prices, and networks of health care providers, and to purchase coverage. In 2014, subsidies also will be made available (as noted in the following question on affordability).

Beginning in 2014, individuals with incomes less than 400 percent of the federal poverty level who purchase coverage on their own, may qualify for federal subsidies to help purchase coverage. While the federal agencies must work out how the subsidies will be paid, the Congressional Budget Office estimates that about 20 million American households will be eligible for subsidies.

In addition, eligibility for Medicaid, the federal-state program that provides health coverage to millions of Americans, will expand to cover families with incomes up to 133 percent of the federal poverty level. Measured in today's dollars, that means adults under 65 will qualify for coverage in 2014 if they earn no more than $14,404 for a single adult and $29,326 for a family of four.

For policies that are not grandfathered, beginning with the first renewal on or after September 23, 2010 (including new policies with an effective date on or after September 23, 2010), members will be able to receive certain preventive services without having to pay deductibles, copayments, or co-insurance. The types of services include several evidence-based cancer and disease screenings, as well as specific immunizations. Contact your account executive to find out what services are covered.

"Policy year" means the 12-month period that is designated as the policy year in the individual health insurance coverage policy documents. For specific information related to the policy year, please check the coverage policy document.

If there is no designated policy year in the policy document (or no such policy document is available), then the policy year is the deductible or limit year used under the coverage. If deductibles or other limits are not imposed on a yearly basis, the policy year is the calendar year.

Please note that policy year is defined differently for group policies.

No. The law does not interfere with the choice of doctors our direct-pay members have today. However, it is important to remember that, from time to time, doctors do leave health insurance networks or change which health plans they accept.

Treatment decisions will continue to be made between members and their doctors. However, in an effort to improve the health care system overall, the government will increase funding for research into evidence-based outcomes to improve quality of care. This means that, over time, options that are available today may change if some treatments or procedures are found to be more effective than others. This already happens today, and could help improve overall care.

Not if they purchase coverage in the individual health insurance market. The excise tax on high-cost health coverage is on employer-based group health plans.

For plans that are not grandfathered, the new law generally states that coverage for emergency department services must be provided without prior authorization of services. In addition, out-of-network emergency services must be covered and reimbursed the same as in-network emergency services, including cost-sharing requirements (i.e., copayments, co-insurance, etc.) for both in-network and out-of-network services.

The new law includes many provisions that are designed to improve women's health. The new law will eliminate cost sharing for certain preventive screenings and ensure direct access to obstetricians and gynecologists. Many additional benefits will be made available to women beginning in 2014, including:

• Covering maternity services on all coverage
• Eliminating pre-existing coverage exclusions for women who are pregnant, have had a previous cesarean, or are the victims of domestic violence
• Eliminating gender rating in most policies that may cause women to pay more than men for insurance at certain ages