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Pre-Existing Conditions
Plans may not impose any pre-existing condition limits for enrollees under age 19.
Lifetime Limits
Plans may not impose any lifetime limits on the dollar value of essential health benefits. Regulations impose notice and special-enrollment rules.
Annual Limits
Plans may only impose annual dollar limits on essential health benefits to the extent allowed by regulations.
Rescissions
Plans may not retroactively terminate coverage except in the case of fraud or intentional misrepresentation of material fact as prohibited by the terms of the plan.
Adult Children
Plans must provide coverage to adult children up to age 26. A special rule is available for grandfathered plans. Regulations impose notice and special-enrollment rules.
Nondiscrimination
Fully-insured, non-grandfathered plans may not discriminate in favor of highly compensated individuals.*
Preventive Care
Non-grandfathered plans cannot require cost-sharing (such as copayments or deductibles) for preventive care services that are specified by the federal government.*
Provider Access
Non-grandfathered plans must provide certain access to PCPs/pediatricians, OB/GYNs, and emergency services. Regulations impose notice requirements.*
Internal and External Review
Non-grandfathered plans must comply with new internal claims procedures and external review standards.*
* Indicates grandfathered plans do not have to comply.
