Affordable Care Act
Affordable Care Act: The Fine Print
Nearly 50 provisions of the national healthcare reform law have taken effect. Here is a look at the top provisions impacting consumers.
Children cannot be denied coverage due to pre-existing conditions, including asthma, diabetes or heart conditions. When this provision took effect last Sept. 23, all but two insurance companies in Colorado stopped providing child-only health policies, saying that parents were able to wait until their child got ill before buying a policy. The Colorado Division of Insurance immediately intervened by imposing a provision that parents had to buy coverage during two periods each year, or immediately following a “qualifying event” such as a birth or loss of other health insurance. So far, no other insurance companies have returned to the Colorado child-only market. Legislators are now considering a bill that would require insurance companies to offer child-only policies if they sell insurance in the state. Currently, Kaiser Permanente (www.kp.org) and Rocky Mountain Health Plans (www.rmhp.org) are the only companies where parents can buy separate policies for their children.
- What this means for you: Parents can buy policies for children and cannot be turned down due to any health conditions. (You should first check to see if you are eligible for family coverage through your employer or if your children qualify for Medicaid coverage.) You must buy these plans during January or July, or immediately after losing your insurance or having a baby.
Dependent children can remain on parents’ insurance until the age of 26. Some large employers in Colorado already had a similar benefit that extended coverage of dependent children to age 25, says Donna Marshall, executive director of the Colorado Business Group on Health. While it is unknown how many young adults are benefiting, this provision has caused some employers difficulty because adult children often live out-of-state in areas where the employer does not have insurance coverage. Bill Dalton, director of human resources for a division of Colorado-based CH2M-Hill, has employees in Idaho and their insurance is in Idaho. “I’ve actually got dozens of people who came onto the plan (under this provision) who do not live in Idaho and I’ve had to go find policies,” Dalton said.
- What this means for you: If you have a child under the age of 26—even if they are working or married or have a family—they are eligible to be on your health insurance plan IF your plan offers family coverage. Until 2014, adult children are not eligible if they can obtain health insurance through their own employer. Read more at http://www.hhs.gov/ociio/regulations/adult_child_faq.html
Insurance companies cannot cancel policies without proving fraud. Until this provision went into effect, some insurers cancelled policies when they found mistakes in a person’s original application. These policies sometimes were cancelled after a major and costly health problem was diagnosed despite years of being in effect. “This was like bait and switch,” says Dede de Percin, executive director of the Colorado Consumer Health Initiative. “You’d pay for insurance for years then get cancelled because of something way back in your history.” Insurers can no longer cancel policies for “honest” mistakes but must prove fraud. They can, however, raise rates based on history but must have rate increases approved by federal and state agencies.
- What this means for you: You can now rest assured that your insurance plan won’t be cancelled if you apply honestly just because you need costly health care. If your plan is cancelled, you should submit an online “Request for Assistance/Complaint” with the Colorado Division of Insurance at http://www.dora.state.co.us/pls/real/Ins_Complaint.Submit_Form.
Lifetime dollar limits on insurance plans have been banned. Insurance plans can no longer limit the amount of money they will pay for “essential” treatments over the life of the policy. Essential treatments include most physical and mental health services. By 2014, all annual limits will also be banned, with the exception of individual plans (those purchased directly by consumers) before last Sept. 23.
- What this means for you:If you are diagnosed with a costly and lengthy disease, your insurance policy cannot “run out” of benefits. For a more detailed explanation of the services that must be covered without limits, see http://www.healthcare.gov/glossary/e/essential.html
Health Savings Accounts no longer cover over-the-counter health products. Although not a major provision, this is one that could cost consumers money. Beginning Jan 1, consumers can no longer use their tax-free HSAs (or Flexible Spending Accounts) to purchase items such as aspirin, vitamins or other non-prescription health products. If they do, they will have to pay a 20 percent tax penalty on the purchased amount—double the previous fee for improper HSA purchases.
- What this means for you:You can still use your HSA or FSA to purchase insulin, even without a prescription. You can use them to purchase over-the-counter products if you obtain a prescription from your doctor. If you use the fund to purchase non-prescribed items, you will pay regular taxes plus a 20 percent penalty on those purchases. For more information, see http://www.irs.gov/newsroom/article/0,,id=227308,00.html
Medicare members get bevy of new benefits. Eight new provisions that affect Medicare have been implemented in the last year. Although some provisions don’t affect members directly, they might make it easier to find care.
- What this means for you. The most significant provisions for enrollees include:
- 50 percent discount off brand-name prescriptions filled in the Medicare Part D coverage gap; with some federal subsidies for generic prescriptions.
- Free preventive screenings with no out-of-pocket costs for all tests recommended by the U.S. Preventive Services Task Force (http://www.uspreventiveservicestaskforce.org/recommendations.htm). A few of these tests include colorectal cancer screening for people ages 50-75, cholesterol testing for all people over the age of 35, biennial mammograms for women ages 50-74, and diabetes screening for people with high blood pressure.
- Coverage for a personalized health preventative plan, including a comprehensive health risk assessment.
10 percent bonus for doctors providing primary care services to Medicare members, and for surgeons serving in Medicare under-served areas. This provision could help attract more physicians, making it easier for Medicare members to find doctors.