Health Care Reform
Grandfathered Health Plans
Is your health insurance plan grandfathered under the Affordable Care Act? Forty-eight percent of covered workers have a grandfathered health insurance plan which does not have to meet the requirements of the Affordable Care Act. Specifically, these employees are not entitled to free (i.e. with no co-pay) preventive care and may experience annual dollar limits on coverage. A plan is grandfathered if your employer established it before March 23, 2010, and has not significantly changed it since then, i.e. raised out-of-pocket expenses or reduced benefits. Although grandfathered plans do not need to meet all requirements of health care reform, they still cannot impose lifetime limits on coverage and must cover dependents under 26 years of age. To find out if your plan is grandfathered, check your plan’s materials or talk with your employer.
Changes in Insurance Coverage Already in Effect:
- Insurers cannot deny coverage to children because of a pre-existing health condition.
- Adults with pre-existing conditions who have been uninsured for a period of six months can access health coverage under a Pre-Existing Condition Insurance Plan” (PCIP).
- Those under 26 years old can be covered by their parents’ health insurance plan.
- Certain preventive services, with no co-pays or deductibles, must be covered in all new private policies. All private plans
will be required to provide this coverage by 2018.
- Lifetime limits on insurance coverage are eliminated, and there are restrictions on annual limits until their removal in 2014.
- Insurance companies cannot rescind/cancel your policy unless you’ve committed fraud.
- Those experiencing the Medicare Part D “doughnut hole” will receive a 50% discount on covered name-brand prescription
drugs. This “donut hole,” the gap between what is covered and what it costs for prescription drugs, will be closed by 2020.
Changes Going into Effect by 2014:
- Mandatory health insurance coverage. Most Americans, with a few exceptions including those who face financial hardships, those who have been uninsured for less than three months, and those who have religious objections, must have health insurance. Individuals can sign on to their employer’s health insurance plan or join state exchanges. If individuals do not buy insurance, they must pay a tax penalty.
- Coverage for all regardless of pre-existing conditions, and elimination of rate discrimination due to pre-existing conditions, gender, and family status. (i.e. private insurance companies and exchanges will replace PCIP’s as the provider of health insurance to this population.)
- Tax credits to help cover health insurance costs for those with an income of up to 400% of the poverty level.
Exchanges and Essential Health Benefits:
- By 2014, each state must have an exchange, either administered by itself or the federal government, which provides health insurance to small businesses (those with fewer than 100 employees) and individuals who do not have affordable or adequate employer coverage and are not eligible for Medicare or Medicaid.
- Exchanges must cover “essential health benefits” (EHB), including ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management, and pediatric services, including oral and vision care. Specific services to be covered will be outlined by each state.
Health Reform: State by State Implementation
Health Reform: Advocacy Agenda
Every plan in a state’s exchange must cover “essential health benefits.” (See summary)
- Will these benefits include the full range of factor treatments?
- Will patients have a choice of medical care provider?
- Will patients have a choice of pharmacies?
Through advocacy, you can make a difference in your state’s answers to these questions regarding YOUR health care.
NEHA will work with members and policy makers in each New England state to help ensure that their exchanges and essential health benefits guarantee the following:
1. A full range of specialists, whether they be at a hospital, outpatient clinic, community health center, doctor’s office, or a federally recognized hemophilia treatment center (HTC).
2. The full range of FDA approved clotting factor products, and other FDA treatment options should they become available.
3. A range of specialty pharmacy providers that adhere to nationally recognized standards of care such as those issued by the Medical and Science Advisory Committee (MASAC).
4. All benefits. There should be no limits on specific or total benefits, or restrictions on treatments. In addition, there should be an appeals process in place, including a requirement that a patient’s physician be consulted if claims are denied.
5. All plans should have to disclose information regarding co-pays, deductibles, and co-insurance. In addition, specialty tier pricing for prescription drugs should be prohibited.