Are You Healthy Enough to Get Covered?

Healthcare Policy Expert, Robin Scott, is a contributing blogger for Protestants for the Common Good. 

Do you have diabetes, high blood pressure, or asthma? What about another health problem or condition? If you have a health problem that developed before you join a health insurance plan, you have what a health insurance company calls a pre-existing condition.  It is hard to believe but being pregnant is considered a pre-existing condition.

In the past, in most states, anyone with a pre-existing condition could be discriminated against, meaning they could be denied insurance altogether or their insurance would not cover that condition.   If the condition was covered, they could be charged a higher premium. 

The Affordable Care Act ends discrimination by health insurance plans against people with pre-existing conditions.  Effective September 23, 2010, health insurers are not allowed to deny insurance to children younger than 19 years of age with pre-existing conditions.  This rule applies whether or not the child’s health problem or disability was discovered or treated before you applied for coverage.  (However, this rule does not apply to grandfathered individual health policies.  A grandfathered individual health insurance policy is a policy that you bought for yourself or family on or before the health reform law was enacted.)

Beginning January 2014, health insurers, regardless of whether the plan is grandfathered, will not be able to discriminate against anyone who has a pre-existing condition, including a disability. Not only will they not be able to deny children and adults coverage for a pre-existing condition, they will not be allowed to charge them more for this coverage. 

Millions of Americans are helped by this Affordable Care Act provision. Pre-existing conditions affect people in all age groups, every racial and ethnic group, and every income group.  An estimated 64.8 million (24.9 percent of) non-elderly Americans have been diagnosed with pre-existing conditions that could lead to a denial of coverage. Nearly 2.9 million non-elderly Illinoisans, more than one out of every four residents under the age of 65, have been diagnosed with pre-existing conditions that, absent reform, could lead to a denial of coverage. 

 

Some people have pre-existing conditions now and cannot wait until 2014 to receive help.  Findings from a 2010 national survey found that 36 percent of non-elderly who lost their jobs and benefits and tried to purchase individual health insurance were turned down, were charged more, or had a specific health problem excluded from their coverage.  

What can they do in the meantime?  The Affordable Care Act provides funds for high-risk pools in states for people with pre-existing conditions.  To be eligible, you must meet certain requirements such as being uninsured for six months and be a U.S. citizen or residing in the United States legally.  The pre-existing condition insurance plans cover a broad range of health benefits, including primary and specialty care, hospital care, and prescription drugs.

The federal government runs the PCIP in 23 states and the District of Columbia.  In the other 27 states, the state or a state-designated nonprofit organization runs the program. In Illinois, the Department of Insurance runs the program.  The Pre-Existing Condition Insurance Plan has already provided coverage to at least 82,000 people, including 2,750 people in Illinois (Illinois Pre-Existing Insurance Plan).

 

What if I become sick while I am insured?

Previously, health insurers sometimes rescinded or retroactively cancelled coverage when a person became sick, if the person made an unintentional mistake on their application.  They would state that the person had not listed a pre-existing condition on their insurance application.  The Affordable Care Act changes that – now, insurance companies cannot deny to cover your benefits just because you get sick.  They can only do that in cases of fraud or an intentional misrepresentation of material fact.

An example of an illegal rescission is if the insurance company denies claims for breast cancer treatment when finding out the insured person forgot to mention two visits to a psychologist visit she had six years earlier. http://www.healthcare.gov/law/features/rights/cancellations/

Next to New Mexico, Illinois had the highest rescission rate from 2004 through 2008.  Illinois’ rate was more than 12 per 1,000 certificates or policies from 2004 to 2008.   That’s a total of 5,279 policies/certificates from 2004-2008.  The national rate is 3.7 rescissions per every 1,000 policies or certificates from 2004 through 2008. 

Good News for Young Adults

Healthcare Policy Expert, Robin Scott, is a contributing blogger for Protestants for the Common Good.

Just because you become an adult does not mean that you have to be uninsured.  In the past, young adults between 18 and 26 years of age might not have had the option of staying insured.  Dropped from their parent’s insurance at 19 (sometimes older if they go to college), being employed in jobs without health insurance or being unemployed are some of the reasons they did not stay insured.  In addition, individual insurance is expensive if available to those with pre-existing conditions.  

The ACA has required since September 2010 that health insurers provide the option for young adults to stay on their parent’s plan until they are 26.  The adult child does not have to be in college, can be married, can live away from their parents, and does not have to be listed as a dependent on a parent’s income tax returns.  If the plan is not grandfathered, the adult child can join or remain on your patient’s plan even if you are eligible to enroll in your employer’s plan.  (Until 2014, grandfathered group plans do not have to offer dependent coverage up to age 26 if a young adult is eligible for group coverage outside their parent’s plan.  Health plans that existed before the health care law are considered “grandfathered” into the new system.) 

According to the most recent survey estimate, as of December 2011, over 3 million additional young adults have already taken advantage of this provision of the ACA and gained health insurance.  (This includes 125,000 young adults in Illinois.) 

Prior to the ACA young adults were much more likely to be uninsured and privately-insured young adults were about twice as likely as older adults to lose private insurance.  According to U.S. census data, in 2009, nearly 15 million young adults ages 19 to 29 were uninsured.  This represented about 1/3 of the young people in this age group.  An overall 45% of young adults reported delaying needed care because of costs and 58% of uninsured young adults had difficulty paying medical bills according to a 2010 Commonwealth Fund study.

Prior to the enactment of the ACA, 37 states already had laws requiring the continuation of dependent coverage for young adults, but the upper age limits and definition of dependent varied.  Since June 2009, Illinois had a law giving parents with insurance policies that cover dependents the right to elect coverage for qualifying dependents up to age 26 and up to age 30 for military veteran dependents.

The below links provide further information:

http://www.healthcare.gov/news/factsheets/2012/06/young-adults06192012a.html

http://aspe.hhs.gov/health/reports/2012/UninsuredYoungAdults/rb.pdf

A survey by the National Center for Health Statistics updates the previous estimate of 2.5 million young adults to 3.1 million young adults.

http://lahealthaction.org/library/rb.pdf

http://insurance.illinois.gov/HealthInsurance/ya_dependent.asp

http://nahic.ucsf.edu/wp-content/uploads/2012/03/CAHL-UCSF-ACA-Young-Adult-Issue-Brief-_Final_Mar22_2012.pdf

The Check's in the Mail

Healthcare Policy Expert, Robin Scott, is a contributing blogger for Protestants for the Common Good.
 

This past month, you may have received an unexpected check in the mail.  This check – a rebate from your health insurance company – is a direct result of the health reform law, the Affordable Care Act. 

Before health reform, over 20% of consumers who purchased coverage in the individual market were in plans that spent more than 30 cents of every premium dollar on administrative costs. Health insurers could spend as much money of your premium as they wanted on what they wanted. Now they must be accountable.  

Depending on the size of the insurance plan, insurers must spend at least eighty or eighty-five percent of your premium on health care and activities that improve your health, not on administrative expenses or profits. This is known as the medical loss ratio rule (MLR) rule. If your insurer doesn’t meet those standards, it must send you--or your employer if you have employer-based insurance--a rebate check. 

Even if the check goes to the employer, it will ultimately benefit you, for example through a lump-sum reimbursement or reduction in future premiums.  It can be complicated, but the good thing is most of the money you pay for health insurance will be used for health care or improving the quality of health care, rather than administrative costs and profits. 

Between January 1 and August 1, nearly 12.8 million Americans were provided with more than $1.1 billion in rebates this year due to this MLR rule.  The largest rebates have been given to consumers in Texas ($167 million) and Florida ($124 million). The average rebate per family in the U.S. is $151. The average rebate per family in Illinois is about $380. Nearly 230,000 Illinoisans will receive $62 million in rebates; about $380 per family.

However the rebate is done, health reform forces insurers to devote the lion’s share of their premiums to patient care. That’s a basic change to the business model of private insurance. And it’s happening now, because of health reform.

Fair Care

Last Wednesday morning, Senator Iris Martinez and the Fair Care Coalition held a hearing on state legislation to hold nonprofit hospitals accountable to their charitable obligations.  

It was my privilege to attend and photograph the event during which Senator Martinez and representatives from the Fair Care Coalition spoke about recent tax exemption denials to three Illinois nonprofit hospitals due to inadequate charity care.

Martinez made it clear that she is not out to punish hospitals, but simply to see that those nonprofit hospitals meet their obligations to serve the uninsured.