Plans:
- May not have a lifetime dollar maximum on any “essential health benefit”
- May not have an annual dollar limit on an “essential health benefit” that is over a certain amount
- Must cover the employee’s dependent children until the dependent reaches age 26 – even if the child is married or employed++
- May not exclude pre-existing condition limitations for children under age 19
- May not retroactively rescind coverage, except for fraud or material misrepresentation or for nonpayment of premium by certain terminated employees
- Must provide first-dollar coverage for specific preventive services+
- Must cover emergency services at in-network level regardless of provider+
- If a primary care physician (PCP) must be chosen, allow each person to choose their own PCP and allow a pediatrician to be the designated PCP+
- Must allow women to see an OB-GYN without a referral+
- Must have a specific and comprehensive process for handling claims appeals+
- May not reimburse over-the-counter drugs under a health FSA, an HRA or an HSA unless the drug is prescribed by the doctor
+ Does not apply to grandfathered plans
++Limited exception for grandfathered plans
