U.S. Healthcare Issues – News, Affordable Health Insurance, and Editorials

Our entire healthcare system is going in for an overhaul that is going to last 8 years, but the next 4 years hold the biggest changes. Changes will affect medical providers, insurance companies, and consumers.  Some will benefit more than others but all in all it will help a lot of people.  The new law regulates insurance companies even more than they were and requires the insurance companies to provide broader coverage, accept medical conditions, remove policy limits for services, and more.  It is going to take a while to phase in all the changes and there are sure to be “hiccups” along the way.  Here are a 5 things you should know about health care reform and the Patient Protection and Affordable Care Act.

1. Temporary High Risk Pool – Pre Existing Condition Insurance Plan – 2010 -All states are now required to have a temporary high risk insurance pool or participate in the Federal Pre Existing Condition Insurance Plan (PCIP).  The PCIP is only available in states that do have a state run high risk pool.  For example: Pre existing condition health insurance in Florida is available through the federal Pre existing Insurance Plan, while Colorado health plans for pre-existing conditions is through Cover Colorado. The New Pre-Existing Condition Insurance Plan is only available to those who have been denied medical insurance coverage due to a pre-existing condition, who have been uninsured for at least 6 months, AND are a US citizen, US national, or lawfully present in the United States.  The PCIP is a federally run program but not all of the states participate. States have the option to either have their own high risk insurance insurance pool or participate in the federal program.  These plans will no longer be necessary in 2014 since pre-existing condition exclusions will be prohibited and you will have access to the newly formed State Health Insurance Exchanges (2014).  Although the PCIP will be available in every state the program will vary from state to state.  States can choose to participate in the Federally run program or have their own state run program. The PCIP program is designed to cover a broad range of benefits like doctor visits, hospitalization, and prescription drugs. Eligibility is not based on income, an benefits will apply to pre-existing conditions.
2. Pre Existing Condition Exclusions for Children – 2010 - Preexisting condition exclusions for children 19 and under will be prohibited on all employer and individual health plans.  The employer based group health insurance plans are already guaranteed issue so the cost should stay the same. What is not yet clear is how much will the individual health insurance plans cost.  I expect that they will be probably be inline with the current HIPAA limits which in some states can be 150% over a standard premium.  If cost is an issue you should also consider Medicaid or your states Child Health Insurance Program (CHIP), InsureKidsNow.gov.
3. Lifetime and Annual Limits – 2010 – Health plans sometimes place restrictive annual limits on plans in order to lower costs.  Whether it is done to lower premiums or to pay fewer claims or both the end result is the same…you pay more.  Health plans will be prohibited from putting lifetime limits on your health plan and prohibits “restrictive” annual limits on all employer and individual plans.  I still not sure what they mean by “restrictive”. Annual limits for essential benefits are prohibited on all plans, including grandfathered plans. The term “essential benefits” has not been defined yet. However, it should include: Ambulatory patient services Emergency services Hospitalization Maternity and newborn care Mental health and substance use disorder services Prescription drugs Rehabilitative services and devices Laboratory services Preventative and wellness services Chronic disease management Pediatric services. Lifetime maximums will be permitted on Non-essential benefits.
4. Preventative Health Services – 2010 - Not all health plans cover preventative care and even with those that do there are huge differences in the coverage and limits for that coverage. The larger insurance companies tends to have better and broader coverage for preventative and routine care than other carriers and some better than what will be required by law. Other companies like HumanaOne, Blue Cross Blue Shield, Aetna or Cigna offer good preventative care coverage now.  All health insurance companies will have to provide first dollar coverage for preventative care in order to comply with the new regulations.
5. Rate Reform – 2014 - Health insurance premiums are currently based on several factors: age, health status, gender, geographic location, weight, and of course smoking. So healthy people pay lower health insurance premiums than unhealthy people. Young people have lower premiums than older people, and women pay more than men of the same age. The difference in cost can be 10 fold or more. The new provisions will restrict the price difference based on age, geography, or tobacco use by no more than 3 to 1.