Healthcare Reform: What Workers & Job-Seekers Need To KnowSave as Favorite
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Reading through the entire 906-page health care reform bill--formally known as The Patient Protection and Affordable Care Act--is possible, as it's posted on the internet (http://democrats.senate.gov/reform/patient-protection-affordable-care-act-as-passed.pdf).
But to save time, we focus on the provisions most important for those who are working or seeking work, as well as for those in cancer treatment or recovery. They're grouped, for simplicity, into three categories:
- Benefits and services
- New rules for insurance companies
- New routes for workers to obtain coverage
Benefits and Services
All new health plans sold on or after Sept. 23, 2010, or that renew after that date must cover certain preventive health services--such as mammograms, flu shots, colonoscopies and cholesterol checks--without charging a co-pay or deductible or other cost-sharing. Which services are covered depends on the health care plan type and factors such as your age.
Effective Sept. 23, 2010 for new plans (or Jan. 2011, at the beginning of a new year for a health plan), you are provided a way to appeal insurance company coverage determinations--as well as claims. An external review process is now set up. Those enrolled in a health plan must get a notice about available internal and external appeals processes and be told of the availability of assistance to help complete the process.
New Rules for Insurance Companies
Rescinding Coverage Prohibited:
In the past, if you made an error or a technical goof on your application for insurance, the insurance company could use this against you to deny payment once you had a claim. This practice is illegal, effective Sept. 23, 2010. The practice came to light after reports in the media described women with breast cancer losing coverage due to these application errors.
Restrictions and Bans on Coverage Limits:
For health plans beginning on or after Sept. 23, 2010, insurance companies can't impose lifetime dollar limits on benefits deemed essential, such as hospital stays. A liftetime limit is defined as a cap on the total benefits your insurance plan will pay you, either for all benefits, such as a $1 million lifetime cap, or limits on certain benefits, such as a $200,000 cap on organ transplants.
Under health care reform, setting annual dollar limits on essential benefits (such as hospital stays) will be restricted and then banned. For plans beginning on or after Sept. 23, 2010, the use of annual dollar limits on essential benefits will be restricted for group and individual plans; by 2014, these limits will be banned for new plans.
Tougher Rules on Rate Hikes:
States are being encouraged to set up programs requiring their insurance companies to justify their premium increase requests. States that do this will be eligible for $250 million in new grants. Those companies that have excessive or unjustified rate hikes may be excluded from participating in the new health insurance exchanges scheduled to begin in 2014.
New Rules on Insurance Company Spending:
At least 85% of the premiums collected by insurance companies for large employer plans have to be spent on health care services and quality improvement, under the new law. For small employers and individual plans, companies have to spend at least 80% of the premiums on quality improvement and benefits. The penalty? If companies don't do this, they have to give rebates to consumers, beginning Jan. 1, 2011.
New Routes, Rules for Workers to Obtain Coverage
Help for Those with Pre-Existing Conditions:
As of July 1, 2010, new coverage options are available for people who have not had insurance for at least the last 6 months because they have a pre-existing condition. States can run the programs; if a state does not, a plan will be available through the Department of Health and Human Services.
The rule gets tougher in 2014. At that time, insurance companies can't refuse to sell coverage or renew policies due to pre-existing conditions.
Buying Insurance from the Exchange:
Beginning in 2014, you can buy insurance from an exchange if your employer doesn't offer it. An exchange is an insurance marketplace that offers a choice of competitive health plans that must meet certain benefits and cost standards and be affordable. The exchanges will be competitive and open to individuals and small businesses. Members of Congress will get their insurance through these exchanges.
If you can't afford coverage offered by your employer, you may be able to take the funds your employer would have contributed and use them to select a plan from the exchange.
By Jan. 1, 2014, everyone who can afford basic health insurance must obtain it; the alternative is to pay a fee to help offset the cost of care for Americans without insurance. Exception: if affordable coverage is not available, you will be eligible for an exemption.
Tax Credits To Ease the Cost:
By Jan. 1, 2014, tax credits will kick in, making it easier in some instances to afford health insurance if you have a lower income ($43,000 for an individual; $88,000 for a family of four, in 2010 dollars).
To keep up with healthcare reform as it unfolds, check out http://www.healthcare.gov. And for a year by year look at the new provisions, go here http://www.healthcare.gov/law/about/order/byyear.html.