How Will Health Insurance Reforms Affect Us?
I was SHOCKED by this wording .This paragraph seems to indicate that insurance companies will still be able to deny individuals that apply for health insurance on there own. WHAT THE HECK?? isn't that the very people this was suppose to help?? I am STILL going to be discriminated by health insurance companies after 2014?? So whats changing? In California, they already allow"companies" that have people with preexisting conditions join there work plan. So, if you don't have a job that offers health insurance and your not poor enough for medicare/medical your still screwed. The gov "new" temporary high risk pool is only offered to those who have not had health insurance for at least the past 6 months. Then, its at a cost of over $550 a month for 1 person. What ill person can live 6 months without health insurance and even if they could find a way ,how many could afford the $550mo plus Dr copays and Medications on top of that? Those with chronic conditions have alot of Dr copays and medication costs each month. Not to mention ,its a strain on most of us with conditions to work all day being ill. Bottom Line! The goverment is saying if you have a disability we must go back to the vicorian ages and get married because thats your only option for health insurance in the USA....or are they telling us we need to leave our country and go to Europe or Canada to be treated humanly and be cared for. The healthcare Reform bill did NOTHING for individuals that have a chronic illness and need to buy health insurance on there own. Here is the full article www.thearc.org/document.doc?id=2679
How Will Health Insurance Reforms Affect Us?
The new health care reform law, the Affordable Care Act (ACA), and its regulations will bring about many significant improvements for people with disabilities. The law will greatly improve coverage (who can get health insurance) and benefits (what services and products are covered). It will do so largely by limiting or banning many health insurance company practices have been particularly harmful to people with disabilities.
When do the changes take effect?
Many changes of these will go into effect in a few weeks, while others take effect in 2014. The changes described in this issue of National Policy Matters affect health insurance plans that begin on or after September 23, 2010. This means that when these changes affect you depends on when your plan year begins (or policy year in the case of individual policies). For example, if your employer plan year is July 1, 2010- July 1, 2011, then these requirements will not affect your plan until July 1, 2011.
Will all health insurance plans be affected?
No. There are some exceptions. One major type of exception is called “grandfathered” plans. Grandfathered plans are those that were in existence on March 23, 2010 when the ACA became law. As long as health plans do not change significantly, they will not be affected by these changes.
Which changes apply to which type of health insurance plans?
The chart below summarizes which changes apply to all health insurance plans. Each of these is explained further in this issue.
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Pre-existing conditions exclusions for persons under age 19 |
All, except for grandfathered individual plans. |
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Lifetime limits |
All, except for grandfathered individual plans. |
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Annual limits |
All, except for grandfathered individual plans. |
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Dependent coverage through age 26 |
All, except when the dependent has employer sponsored options (exception only through 2014). |
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Rescissions |
All |
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Choice of Doctors |
All, except for grandfathered plans |
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Access to Emergency Room |
All, except for grandfathered plans |
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Appeals of Denial of Claims |
All, except for grandfathered plans |
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PRE-EXISTING CONDITIONS EXCLUSIONS FOR PERSONS UNDER AGE 19 |
Millions of Americans have pre-existing conditions, which include a broad range of health conditions such as cancer, diabetes, seizures, asthma, allergies and many others. People with disabilities are more likely than the general population to have pre-existing conditions and are frequently denied (or excluded from) health insurance coverage and/or benefits.
What is a pre-existing condition?
A condition that was present before the date of enrollment for the coverage - whether or not any medical advice, diagnosis, care or treatment was recommended or received.
How does the law change pre-existing conditions exclusions?
Health insurance companies will not be allowed to deny enrollment or specific benefits based on pre-existing conditions for individual under the age of 19. For example, starting this month, insurance companies cannot deny enrollment to a child who needs heart surgery because the heart defect existed before coverage began. In addition, the insurer will not be allowed to deny specific benefits (in this case heart surgery) needed to treat the pre-existing condition.
When will changes to pre-existing conditions exclusions go into effect?
For people under the age of 19, it will go into effect for health insurance plan years that begin on or after September 23, 2010. For adults (persons 19 an older), it will go into effect for plans beginning on or after January 1, 2014.
Will all plans be affected by the changes to pre-existing conditions exclusions?
No. There is one exception. Individual health insurance plans are exempted. Individual health insurance plans are policies that individuals buy on the open insurance market (they do not include employer sponsored plans).
What if I currently have inadequate individual insurance for my child with a pre-existing condition?
If a family had bought individual coverage for a child with a preexisting condition and the policy had language excluding the costs of treatment for a pre-existing condition, then the family may need to cancel the coverage and purchase a new policy to get around the exemption. The risk is that the price you pay may be more for the new plan.
How many people will be affected by the changes to pre-existing conditions exclusions?
The Department of Health and Human Services (HHS) estimates that 31,000 to 71,000 children who have a preexisting condition and are uninsured will now be eligible for coverage. Many of these children are likely to have disabilities. The regulations also increase coverage for an estimated 90,000 children who have insurance but those plans have a clause that excludes coverage or benefits for a preexisting condition.
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LIFETIME LIMITS |
People with many medical needs fear reaching lifetime and annual limits that some insurers put on plans. For families that have high medical costs and reach the limits, the effects are often catastrophic to the family if they must pay out of pocket for their medical costs. They then face insurmountable medical debt and/or being unable to continue needed treatment.
What are lifetime limits?
A lifetime limit is the total amount of money that a health insurance company will pay for your health care over the lifetime of your policy. According to HHS, the average lifetime limit is $4.7 million.
How common are lifetime limits in current policies?
Currently, the majority of health insurance plans apply lifetime limits, which affects about 102 million people. However, this varies by type of plan:
- 63% of large employer plans
- 52% of small employer plans
- 89% of individual policies
How will the law change lifetime limits?
The use of lifetime limits in health plans and insurance policies issued or renewed on or after September 23, 2010 will be prohibited. Plans cannot establish a dollar amount lifetime limit on the benefits for any individual.
Do the lifetime limit changes apply to all health insurance plans?
No. There is one exception. Individual health insurance plans in existence prior to March 23, 2010 plans are exempted. Individual health insurance plans are policies that individuals buy on the open insurance market (they do not include employer sponsored plans).
Do the lifetime limits changes apply to Flexible Spending Arrangements (FSA) or Medical Savings Accounts (MSA)?
No. FSAs and MSAs are generally not considered group health insurance. These programs are not affected by this provision of the Affordable Care Act
What if I have already hit my lifetime limit?
If you are otherwise eligible for the health insurance, you must be notified that the lifetime limits no longer apply and you should be given an opportunity to enroll. You must be given written notice and have a minimum of 30 days to enroll.
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ANNUAL LIMITS |
What are annual limits?
An annual limit is the total amount of money that a health insurance company will cover for your care in one calendar year.
How common are annual limits in current policies?
Currently, a minority of health insurance plans apply annual limits, which affect about 17 million people. According to HHS, annual limits are used by the following types of plans:
- 8% of large employer plans
- 14% of small employer plans
- 19 % of individual policies
How will the law change annual limits?
The use of annual limits will be phased out over the next three years and end in 2014.
How will the annual limit changes be phased in?
To limit premium increases, the regulations implement a three-year phase-in of the restrictions on annual limits of essential benefits. The restrictions, which apply on an individual-by-individual basis, are as follows:
- For plan years beginning on or after September 23, 2010 through September 23, 2011, the annual limits on the dollar value of benefits may not be less than $750,000
- For plan years beginning on or after September 23, 2011 through September 23, 2012, the annual limits on the dollar value of benefits may not be less than $1.25 million
- For plan years beginning on or after September 23, 2012 through January 1, 2014, the annual limits on the dollar value of benefits may not be less $2 million
What are essential benefits?
The law includes these categories of essential benefits:
- Prescription drugs and laboratory services
- Rehabilitative and habilitative services and devices
- Mental health and substance use disorder services including behavioral health treatment
- Preventative and wellness services and chronic disease management
- Pediatric services including dental and vision care
- Maternity and newborn care
Future regulations will be developed to define these terms. How these terms are defined is very important for people with disabilities. The Arc and UCP will work to make sure that rehabilitative and habilitative services and devices definitions includes a broad listing of therapies that might needed by people with disabilities as well as durable medical equipment and other services and supports.
Do annual limits changes apply to Flexible Spending Arrangements (FSA) or Medical Savings Accounts (MSA)?
No. FSAs and MSAs are generally not considered group health insurance. These programs are not affected by this provision of the Affordable Care Act.
Do the lifetime limit changes apply to all health insurance plans?
No. As with pre-existing exclusions, there is one exception. Individual health insurance plans are exempted. Individual health insurance plans are policies that individuals buy on the open insurance market (they do not include employer sponsored plans).
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DEPENDENT COVERAGE |
Many children with disabilities are covered under their parents’ health insurance plans as dependents. One study found that over half of children with special needs were covered by employer sponsored insurance and about 30% were covered by Medicaid. Continuing to have access to insurance for children with disabilities is critical to maintaining good health given that many have secondary medical conditions requiring medication or other treatments.
How does the law change dependent coverage?
Dependents will now be able to continue to be covered under their parents’ health insurance plans until they turn 26.
Why extend the age of dependent coverage?
Many young adults are uninsured. They often do not have access to employer provided health insurance during the years they are transitioning to adulthood and starting jobs. This is especially true for young adults with disabilities.
Do employers have to provide family or dependent coverage?
No. But, if they do they offer dependent coverage, they must offer coverage to enrollees’ adult children until age 26.
Are all dependents eligible?
The term “dependent” is meant to be broad and include young adults even if the young adult no longer lives with his or her parents, is not a dependent on a parent’s tax return, or is no longer a student. It applies to both married and unmarried children. (although, if a dependent is married, their spouse or children would not be eligible for coverage). Until 2014, if a dependent has other employer sponsored coverage the parent’s plan does not have to cover them.
Are any insurers implementing the dependent coverage changes early?
Yes. About 65 companies are offering coverage for young adults who age off their parents’ insurance before September or the plan year. Check with your insurance broker or your employer to see if your insurance company is offering early coverage.
How will I know how to enroll my dependent child who is under age 26?
Parents should watch for a notice from their insurance company or benefits administrator. Plans must provide both a notice of the benefit and at least a 30 day period to enroll.
Will all dependents under age 26 be treated the same?
Yes. For example, premiums and benefits for a 17-year old dependent would be no different than those for his 25-year old brother under their parents’ plan. The plan could not charge more for the same coverage or offer different plans for these dependents.
Are there any new tax benefits for dependent coverage through age 26?
Yes. The value of any employer-provided health coverage for an employee's child is excluded from the employee’s income through the end of the taxable year in which the child turns 26. This tax benefit applies regardless of whether the plan is required by law to extend health care coverage to the adult child or the plan voluntarily extends the coverage.
Where can I get more information?
http://www.hhs.gov/ociio/regulations/adult_child_faq.html
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RESCISSIONS |
Every year, thousands of Americans lose their health insurance when they get sick. People with disabilities have been disproportionately affected by this harmful health insurance practice, known as a “rescission.”
What is a rescission?
A rescission is when an insurance company voids your health plan from the start of coverage. It usually happens usually when an insurer retroactively cancels your policy when you become sick. Insurers often claim that you had a pre-existing condition or they find some reason to say they would not have offered coverage to you in the first place. This can happen even if it was an unintentional mistake in the paperwork made by you or your employer.
How does the law change rescissions?
Rescissions will be prohibited. Insurance companies won’t be allowed to drop your coverage when you get sick except in the case of fraud or intentional misrepresentation. The insurers must provide at least 30 days advance notice to give people time to appeal the decision.
Will all plans be affected by the rescission changes?
Yes, both new and grandfathered plans are covered.
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CHOICE OF DOCTORS |
How does the law protect choice of doctors?
There are three important changes:
- Insurance companies cannot assign a person a primary care doctor. The person can choose who they want within the network of providers (if that is part of the plan)
- Parents can choose any participating pediatrician to be their child’s primary care doctor.
- Plans are prohibited from requiring a referral for obstetrical or gynecological care
Do the choice of doctor changes apply to all plans?
No, grandfathered plans do not have to include these protections.
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ACCESS TO EMERGENCY CARE |
How does the law make emergency care more accessible?
Plans will not be able to charge higher copayments or coinsurance for emergency services that are obtained out of network. Currently many plans charge more if you have an emergency and do not get prior approval for care or go to the closest emergency room even if it is not in your plan network.
Who decides what is an emergency?
It is generally what “a person with average knowledge of health and medicine would think the injury or situation would, without immediate attention, cause serious harm to the person.”
Do the new emergency care changes apply to all plans?
No, grandfathered plans do not have to include these protections.
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APPEALS OF DENIAL OF HEALTH INSURANCE CLAIMS |
Currently there is a patchwork of protections that apply to some plans in some states. Some types of health plans are regulated at the state level and others at the federal level and they offer varying degree of protections to consumers. For example, a person with cerebral palsy has few recourses when he is denied coverage for a specific type of therapy that has been recommended by his doctor. Under the new law, he will have more opportunity to appeal the health insurance company’s denial of his claim.
What changes are made to strengthen appeal rights?
The new law requires greater consistency and puts standards in place to make the protections more uniform. The ACA makes changes to both the internal appeal process that an individual has with their insurance company and provides for an external appeal to an independent decision maker.
My plan already allows me to appeal a decision how is this different?
New health plans must now have an internal appeals process that meets these standards:
- Allows consumers to appeal when a health plan denies a claim for a covered service;
- Gives consumers detailed information about the grounds for the denial of claims;
- Requires plans to notify consumers about their right to appeal and instructs them on how to begin the appeals process;
- Ensures a full and fair review of the denial; and
- Provides consumers with an expedited appeals process in urgent cases.
What is external review?
Being able to go outside the plan and have the conflict decided by an independent person.
What standards must they meet?
These standards were established by the National Association of Insurance Commissioners (NAIC). States are encouraged to make changes in their external appeals laws to adopt these standards before July 1, 2011. The NAIC standards call for:
- External review of plan decisions
- Clear information
- Expedited access to external review in some cases
- Health plans must pay the cost of the external appeal
- Review by an independent body
- Emergency processes for urgent claims
- Final decisions must be binding
If state laws don’t meet these standards, consumers in those states will be protected by comparable federal external appeals standards.
Do these changes apply to grandfathered plans?
No, they only apply to new plans.
What is the federal government doing to help consumers understand these changes?
The new Consumer Assistance Grants program will provide nearly $30 million in new resources to help States and Territories educate consumers about their health coverage options, empower consumers, and ensure access to accurate information. Grants will be made available to support States’ efforts to establish or strengthen consumer assistance programs that provide direct services to consumers with questions or concerns regarding their health insurance.
Summary
Many important changes to our private health insurance system are upon us. People with disabilities stand to benefit greatly from improved access to coverage and enhanced benefits. As direct service providers, The Arc and UCP’s chapters and affiliates should be prepared to help our constituents take advantage of the many health insurance reforms.
For additional information see:
Health Care.Gov - section for People with Disabilities:
http://www.healthcare.gov/foryou/disabilities/index.html
Health Care.Gov - Find Insurance options (select “for people with disabilities”)
http://finder.healthcare.gov/
Office of Consumer Information and Insurance Oversight
http://www.hhs.gov/ociio/regulations/index.html
Update!!
I wanted you to know that I have read your e-mails requesting an update. I am sorry its been awhile. I have been very busy. As you can see on my website, I now endorse Vemma. This is a product I was already using to help my pain prior to my story coming out in the media. I am telling you this because I have been considering creating a small business to then channel the money they pay me through it. How will this help me? Strangely, In the United states you can create a small business, in California it has to be with two or more people, Then WALA!! insurance companies must take you ....sick or not and without charging you more. Its less then what I currently pay on Cobra. I am considering creating this business with my son. After the Vemma contract ends next year. I have heard in many of your e-mails,that this is a VERY common "secret' practice.. I mean selling small crap and calling it a business just to get the life saving gift of insurance. Maybe I will sell lemonade on the corner of my block. Can you believe we live in the US we must sneak around just to buy what other healthy people or sick people get through there jobs or spouses? Dumb I tell you!
I had someone say that, I am ruining the sanctity of marriage with my platform. I have always stated that I want Love and good health insurance. I would also agree its not right to marry for insurance. So why does the US not give middle class ill people other options??? I was never for or against the current healthcare reform bill. What I am for is insurance companies not being able to deny people with preexisting conditions and affordable premiums for those of us that are ill and can least afford to pay more. Why should we have to chose to buy health insurance or live on the streets.
The dating site has turned into a nightmare. The legalities of such a site has stunted its creation. Lawyers say I could be sued by insurance companies for encouraging insurance fraud.... I was not! and the legalities of someone meeting someone on the site that turns out to be a killer or stalker or something. Geeze, I was trying to help people,offer it for free and yet again,they don't make it easy. Anyone have any suggestions?? I don't want to be sued.
I will try not to may it so long since we chat again. My e-mail is flooded but I will respond to all blog comments.
Good health to you all! xo
Temporary High Risk Pool
Temporary high-risk pool
People without insurance because of pre-existing conditions will be able to tap into a temporary, high-risk pool that will be available within 90 days -- now that the bill has passed -- and be effective until the new health insurance rules take effect on Jan. 1, 2014. Any U.S. citizen or legal immigrant who has pre-existing conditions and who has been uninsured for at least six months will be able to tap into this temporary, high-risk pool.
Both the Senate bill and the reconciliation bill provide the same provisions. All will receive subsidized premiums. The pool will be established based on the rates for a standard population and may vary no more than 4 to 1 due to age. Maximum cost sharing will be limited to current Health Savings Account (HSA) law: $5,950 for an individual and $11,900 for a family in 2010.
HEALTHCARE REFORM VOTE UPDATE!!!!!
I spent all 12 hours watching the health care reform debate yesterday. I am happy and sad all at the same time. I yelled and cheered at my Tv as if I was watching the super bowl. I don't like every part of the bill but of course I like the part of them not being able to deny people with preexisting conditions insurance. I have been very careful not to endorse this bill over the past couple of months because I have mixed feelings about it. As President Obama said, its not a perfect bill. However, its always been my fear that if this bill didn't pass it would be another 20 years before hardworking, ill people like me can get help.
One thing that surprised me is that the new bill immediately bans insurance companies from denying children with preexisting conditions but the law for adults doesn't go into effect until 2014. Government subsidies will not take effect until 2014 Thats horrible and shameful!!! That will be to late for many people who will be bankrupt by then. Which is why I feel the dating site will still help others for the next 4 years until the plan goes into effect.
My other concern,as quoted by John McCain Appearing on ABC's "Good Morning America," this morning. McCain, who was Obama's GOP rival in the 2008 presidential campaign, said that "outside the Beltway, the American people are very angry. They don't like it, and we're going to repeal this." So, with a court battle likely,this may or may not ever take effect.
So, I will continue to fight till we know we get the help we need. What do you think?? Do you have any ideas how I can continue to help others??
Healthcare Reform Bill
I can finally breath enough to start writing on my blog. I will also do my best to answer your questions. Please keep in mind that if you send any inappropriate questions, they will not be answered or posted on my blog.
I wanted to make some comments on the health care reform bill due to be voted on this week. I am often ask how I feel about the bill. I have to admit, I ,like most of America have not read it all the way through to take a stance one way or another. Or course I endorse them forbidding insurance companies from denying people with pre existing conditions and subsidies for people with lower incomes so they can also afford insurance.
There are many things in the bill that I don't agree with . However, my concern is if it doesn't pass it will be another year's before people like me could buy insurance just like everyone else. The bill is a very mixed blessing. Past administration's have not made health care a priority so there is no reason to think they will if this does not pass. My hope, when backed up against the wall is, I hope it passes and then when they realize much about the bill is not working the Republican majority in the next couple years will amend and fix the areas that aren't..At least ,thats my hope. I am not in support of Democrats , Republicans or this bill. I support everyone like me that works hard,pay taxes, is ill and cant get health insurance.
How do you feel??
Why I will Marry for Health Insurance
Where will I go??? I qualify through my Dr as disabled. I would qualify for medical , SSI or SSDI but cant get it . WHY?? Because being home raising children and not working I didn't pay into the fund to collect SSDI from the state of California. Then, I do qualify for SSI except for one problem. They say I have to many ASSETS. I have a small divorce settlement from my 24 year marriage that I try and live on as well as a Pastime Job that just covers the cost of my current health care. Cobra costs me $400 and my medications and Dr co pays another $100 a mo . The government wont let me help myself. I need to first run out of money in my account and thus be on the streets first. Money for the most part that is paying for Health insurance .
Because I don't have access to affordable health care,have a pre existing conditionand the rules for assets are capped at 2k for any assistance, I will be out of money and going to YOU and the government for help years sooner then if I was offered affordable Health ,Available health care . They wont let me help myself. I have never taken a penny from the government. My ex husband actually works for the State of California and “we” paid taxes for 30 years.
Cobra is almost over ,what will I do???. Frankly, I will be better off if I run out of money and suck off the American tax payers and there is something WRONG with that. Ssi i provides $800 a month plus I would get full medical benefits. I would also get food stamps. Why should I continue to suffer each day with whether to eat or pay health insurance,work my ass off and pay taxes...for what????. Shame on all of you that make rules when some of us qualify but fall through the cracks. Please help me with affordable,available health insurance.
The people who are the sickest need the health care the most. Also, people who have a small savings in the bank aren't rich they are trying to survive so YOU don't have to support us. HELP ME HELP YOU!!!! Thank you Terri Carlson
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