120 Unit 2 The Healthcare Environment Copyright Goodheart-Willcox Co., Inc. rescissions. Insurance companies do this to avoid covering the cost of an individual’s healthcare needs. Group health plans and health insurance companies offering group or individual insurance coverage are now prohibited from cancelling coverage once the enrollee is covered, except in cases of fraud or intentional misrepresentation. Enrollees must be notified before their coverage is cancelled. · Health Insurance Exchange. Each state has developed a health insurance exchange or defaulted to the federal exchange. A health insurance exchange is a marketplace in which individuals and small businesses can purchase health insurance. · Medicaid Expansion. States that elected to participate in the Medicaid expansion changed their eligibility requirements to receive Medicaid coverage. This entailed covering anyone within 133%–400% of the federal poverty level. · Banning Lifetime/Annual Caps. Health insurance issuers cannot establish financial limits on the payout amount for their members on a lifetime or an annual basis (Figure 7.2). · Business Health Insurance Tax. Companies with 50 employees or more, and with at least one full-time employee, must provide health insurance or pay a fine to the government. · Preventive Services. Certain preventive services are considered “essential benefits” and co-payments, co-insurance, or deductibles cannot be required. Medicaid and Medicare The Centers for Medicare and Medicaid Services (CMS) is a division of HHS that directs the Medicaid and Medicare programs. Medicaid provides healthcare benefits to the poor, and Medicare provides health- care insurance to those who are eligible. People eligible for Medicare are 65 years of age or older who have paid taxes for a minimum required period, and those younger than 65 years of age who have a particular disability or end-stage renal disease. Image Point Fr/Shutterstock.com Figure 7.2 The ban on lifetime or annual caps on healthcare was designed to help people who require extensive care, such as cancer patients who need expensive chemotherapy treatments. Who else might benefit from this ban on lifetime or annual caps?