Summaries of Benefits and Coverage: Simplifying Shopping for Health Insurance

As of September 23, the “wild west” of shopping for health insurance coverage has been at least partially tamed, thanks to the Affordable Care Act (ACA). Consumers can now get standardized, simplified summaries of benefits and coverage (SBC) that will help them understand what’s covered by an insurance policy and allow them to make apples-to-apples comparisons among plan options. These summaries are modeled on the labels we use to compare ingredients in our food, and are designed to be easy to read, with medical and insurance terms that are defined in a standard, easy-to-understand way. According to public opinion tracking polls by the Kaiser Family Foundation, this provision is one of the most popular provisions in the ACA.

For me, these forms are the culmination of hundreds of hours of effort as part of a statutory working group tasked with developing the templates for these forms. Put together by the National Association of Insurance Commissioners (NAIC), the working group represented state insurance regulators, consumers, insurance companies, health care providers and insurance brokers. We spent over a year working through the content and format of the form, and the Obama Administration adopted our recommendations with very few changes.

The U.S. Department of Health and Human Services (HHS) notes the following important details about the SBC:

• The provision applies to ALL health plans, whether you get coverage through your employer or purchase it directly, starting September 23, 2012.
• Insurers need to provide the SBC to consumers at the time they apply for coverage, and to enrollees upon renewal.
• The form includes coverage scenarios for two common situations: normal delivery of a baby and treating type 2 diabetes. These scenarios can give interested consumers an approximate picture of their future out of pocket costs under the policy.
• Non-English speakers can request the SBC in their native language – insurers are required to translate the form into common languages such as Spanish and, in some states, Chinese, Tagalog and Navajo.

Consumers’ Union has provided a very helpful “explainer” on the SBC, you can check it out here. Going forward, it will be interesting to see how accessible the forms truly are for consumers, and whether and how consumers use them to shop for insurance. I’m hopeful these forms can help empower consumers with better information so they can make better decisions about what coverage is best for themselves and their families.

For information on developments like this—and much more—be sure to check in with CHIRblog‘s series on “Implementing the ACA.” 

Sabrina Corlette
Georgetown University Center on Health Insurance Reforms

(This blog was originally posted on the Center on Health Insurance Reforms blog site here )

HIV/AIDS Coverage and Care: Before, During, and After ACA Implementation

The Affordable Care Act, passed in 2010, is expected to expand insurance coverage and care for millions of people in the U.S., including people living with HIV. The provisions of the ACA will dramatically impact access to care, specifically antiretroviral therapy (ART), which is critical for the health of people with HIV.

Traditionally, there have been numerous sources of insurance coverage for people living with HIV. Most notably are public programs, such as Medicaid and Medicare, and the Ryan White HIV/AIDS program. Currently, Medicaid is estimated to cover the largest share of people with HIV and a significant portion of people with HIV rely primarily on Ryan White, operating as the “payer of last resort” for people with HIV who are uninsured or underinsured.

Prior to the implementation of the ACA, people living with HIV were more often than not, shut out of the individual market due to the fact that insurers consider HIV an uninsurable, pre-existing, condition. Medicaid, Medicare and public programs were therefore, important pathways for people living with HIV to receive coverage. However, prior to the ACA, federal law excluded non-disabled adults without dependent children from Medicaid, presenting a catch-22 for many low-income people with HIV who could not qualify UNTILL they were disabled even though Medicaid covers medications that delay and hinder the development of HIV-related disability. Ryan White has often supplemented these other forms of coverage, providing additional services where needed.

The ACA is currently in a transition period until its full effect date of 2014. Until then, the ACA has established a temporary program in which every state allows people with pre-existing medical conditions, such as HIV, to purchase coverage through a Pre-Existing Condition Insurance Plan (PCIP). The transitional ACA plan also prohibits individual and group plans from placing lifetime limits on coverage, preventing people will expensive illnesses, like HIV, from exhausting their coverage. 

Additionally, a new state Medicaid option was developed to cover childless adults with incomes up to 138% of the federal poverty level (FPL), however, limits to coverage or continued ineligibility result in the continued use of the Ryan White program. 

The full extent of ACA’s coverage expansions will go into effect in 2014. With this full implementation, insurers will no longer be able to deny coverage to people with pre-existing conditions, and with this, the temporary Pre-Existing Condition Insurance Plan will no longer be needed. Annual limits on coverage will also be prohibited and health insurers will be required to guarantee issue and renew health insurance regardless of health status. Individuals will be able to purchase coverage through state-based “health insurance exchanges”, and people without access to employer-sponsored coverage will be eligible for subsidies to purchase coverage within the exchange.

Finally, the ACA also establishes a new Medicaid eligibility category for people with incomes up to 138% FPL, thus removing categorical eligibility requirement that have often limited people with HIV in the past.

The ACA has increased and improved access to care for people living with HIV and following its full implementation in 2014, it is expected to further expand and enhance access.


*To read Kaiser Family Foundation’s full take on the issue, please see the article
How the ACA Changes Pathways to Insurance Coverage for People with HIV

*To get access to more articles, fact sheets and blog posts on the issue, check out http://www.hivhealthreform.org/

The University of Chicago Medicine is Implementing Health Care Reform

The University of Chicago Medicine, along with other health care providers, is moving ahead with changes under health care reform following the U.S. Supreme Court’s decision in June upholding the Patient Safety and Affordable Care Act of 2010.  Not since 1965, when the Medicare and Medicaid programs became law, has the nation faced a more monumental shift in health care.

Fulfillment of the Affordable Care Act will produce many changes. Among the first is a significant reduction in the number of uninsured Americans, which eventually will improve public health and lower costs.  As more people obtain health coverage, there is a responsibility for providers to use scarce resources in the most cost-effective manner possible.  In Illinois, where a state fiscal crisis recently led to reductions in Medicaid payments to providers, it is critical that we focus on delivering appropriate care in the right places and at the right time.

To address these challenges, health care providers must support innovative approaches to patient care that produce the best outcomes while keeping a lid on costs.  The ideal that all Americans should have access to care regardless of health status or income means that near-term logistical and financial realities must be addressed by the public, the state and health care providers.

A number of initiatives at the University of Chicago Medicine will facilitate the delivery of high-quality patient care and improve public health while controlling costs.  For example, the South Side Healthcare Collaborative connects patients seen in our hospitals with community health centers.  This focus on care coordination meets the needs of patients, improves quality of care and lowers readmission rates.

The Center for Medicare & Medicaid Innovation, established by the Affordable Care Act, is encouraging novel models to transform health care.  CMMI recently announced the intention to award grants, including two to University of Chicago Medicine faculty, to support local initiatives that aim to deliver better care and improve health at lower costs.  

One initiative, led by David Meltzer, MD, PhD, will focus on Medicare patients at high risk of hospitalization by offering a personal physician to care for them not only when they are hospitalized, but also when they leave the hospital.  Under this new Comprehensive Care Program, these patients will receive continuous care from a physician who knows them, which will improve care and patient outcomes while lowering costs.  

Another project, CommunityRx, led by Stacy Tessler Lindau, MD, will deliver personalized information about community resources for wellness and disease management as part of the doctor-patient encounter.   New health information technology systems will support self-care by promoting use of community resources and linking local health and human services organizations with information they can use to tailor their programs and services.

These kinds of innovative solutions aim to create a healthier, better-resourced population cared for by committed community physicians, rather than those based at hospitals, thus saving Medicare and Medicaid millions of dollars annually.

The resources of an academic medical center, available at the University of Chicago Medicine, allow us to test new models to solve difficult problems.  We are working with the communities and people we serve to create a strong health care system that directly addresses the needs of our patients.

Kenneth S. Polonsky, MD
Executive Vice President for Medical Affairs, University of Chicago Dean, Biological Sciences Division and Pritzker School of Medicine

(This blog was originally posted on the University of Chicago Medicine website here).

Illinois Begins Essential Health Benefits Discussion

Governor Pat Quinn recently announced that the benchmark plan for Illinois’ Essential Health Benefits (EHB) package will be chosen by September 30, in order to meet the Federal deadline for selecting a plan. A public meeting on Wednesday, September 12th, will provide the public and other stakeholders an opportunity to weigh in on this crucial piece of the health care law’s implementation in Illinois.

The EHB package defines the baseline of services covered by health insurance plans offered to individuals and small businesses in the state.

Last December, The Department of Health and Human Services released a bulletin with guidelines for states to select their own EHB plans. The guidelines feature 10 different categories of benefits that each plan must cover, such as “emergency services,” “rehabilitative and habilitative services,” “prescription drugs,” and “mental health and substance abuse services.”

States must select a health insurance plan that is currently operating within the state to act as the EHB benchmark, with the largest small group market plan in the state acting as the default benchmark if the state fails to meet the September 30 deadline. If the selected plan does not provide adequate coverage of one of the ten benefits categories, that category will be supplemented with a coverage package from a different potential plan.

Once selected, the EHB will define the level of care that individual and small group insurance plans must offer in Illinois. Benchmark plans can specify the scope or duration of benefits, but they cannot place dollar limits on copays or deductibles, as well as lifetime annual dollar limits on coverage. Plans offered to consumers in health insurance exchanges will be required to meet the level of coverage ensured by the EHB package. However, insurance companies will have the opportunity to make substitutions within the ten categories of benefits, as long as those substitutions are not found to reduce the value of coverage offered.

The Illinois Health Care Reform Implementation Council will be hosting a meeting on Wednesday, September 12, 2012, where the public and other stakeholders will be able to make comments on the state’s EHB selection. The committee will continue to accept comments until September 19. Comments can be submitted through the Governor’s health reform website.

Check back soon for an update on the EHB selection process following Wednesday’s meeting!

The Affordable Care Act: Helping the "Young Invincibles"

Just who are these “young invincibles”?  The term describes young adults between the ages of 18-29 who may seem uninterested in health insurance and believe they can afford to go without coverage— and are therefore, “invincible”. Unfortunately, this belief is false. Of course, not all young adults think they are invincible and none of them actually are. While this is a mostly healthy demographic, many of them desperately need health insurance to obtain necessary health care, and many more of them know that they should have it in case of emergency.  In addition, the parents of many of these young adults are keenly aware that if their son or daughter experiences a significant medical need, it is they who will be paying for it, one way or another. These parents want coverage for their child, even if it is not a priority for the young adult.  If given the chance to have affordable health insurance, many young adults leap at the opportunity. And thanks to the Affordable Care Act (ACA), as of November 2011, 13.7 million young adults aged 19-25  did just that, by either staying on their parents’ health insurance or rejoining it. 

These not-so-invincible young invincibles often struggle with obtaining, navigating, and affording health insurance. The uninsured rate among this group in 2009 was 14.8 million, an increase of 4 million from the past decade. This group is a large part of the 50 million people in 2010 living in the United States without health insurance and the ACA addresses their coverage directly. The dependent coverage provision encompassed in this law permits young adults under the age of 26 to remain on their parents’ private health insurance plan, even if the adult child lives in a different house in a different state, or even if the child is married. This policy went into effect on September 23, 2010; six months after President Obama signed the ACA into law. Since then, millions of young adults have gained or retained health insurance through their parents.

But young people must confront more than misconceptions about their own mortality—there are other reasons this group lacks health insurance. One unfortunate practice that serves as a barrier for young women’s access to health care is the practice of gender rating. Women are routinely charged more than double the premium compared to the amount men pay for the same health insurance coverage. This existing practice causes young adult women to delay getting needed health care because of the cost. Some states banned this practice, but in states where gender rating is not prohibited, 95% of bestselling health insurance plans charge women more for the same exact plan. The ACA makes it against the law in 2014 in all states for health insurance companies to charge women higher premiums solely based on gender. This provision reflects the ACA’s mission to make quality health insurance accessible and affordable.

Another reason this group often lacks coverage is simply the high cost of insurance. A national survey reported 40% of young adults had outstanding medical bills and were in medical debt. Often falling through the cracks of our healthcare system, there are many uninsured young adults in this country who lack reliable, affordable access to basic medical care. This is also a group that is likely to just be starting out in their careers, and making difficult choices about whether to pay for health insurance or rent. Luckily the ACA provides a new category of Medicaid eligibility for single, childless adults who have a household income at or below the 133% Federal Poverty Level (FPL) — or about $14,800 annual income for a single individual.  Currently, the eligibility criteria for Medicaid excludes low-income young adults from Medicaid if they do not have a disability or a child, thus leaving many young adults uninsured. For example, a 19-year-old who has just lost their AllKids insurance—Illinois public health insurance for children—may likely join the uninsured population. Under this ACA provision, however, the Medicaid program will change its eligibility criteria in 2014 to include single, childless adults.

Changing the Medicaid eligibility will finally allow many low-income young adults to receive much needed health care. Individuals who will be insured in 2014 because of the Medicaid changes will be called the newly eligibles, and the cost of their care is covered at 100% by federal funding until 2020, and after that, it will be covered at least at 90%.  This provision has the potential of covering 429,300 residents in Illinois.

While many young adults will be newly eligible for Medicaid or eligible to remain on their parent’s insurance, not everyone will be. For young adults for whom neither Medicaid nor the dependant coverage provision is available, there is an alternative of signing up to buy health insurance from their state’s Exchange in 2014.  An Exchange is an online site that will offer many comprehensive health insurance plans. It will allow the consumer to shop and compare plans so that they can ultimately find the one that best suits their needs and budget. Through the Exchange, there will be a variety of private health insurance plans available in a central online location that is both easy to navigate and written in plain English to allow for full transparency. There will also be financial assistance in the form of subsidies and tax credits available for those who qualify. The financial assistance will be available for individuals who make an income of up to 400% of the FPL – that’s a monthly income of $3,723 for a young single person.  An Exchange can be created by the state, the federal government, or in collaboration by both state and federal governments to offer quality and affordable health plans. Through the Exchanges, young people will have affordable and quality health insurance options to choose from.

Given the benefits and protection that it provides to young adults, we can see that the Affordable Care Act is working to help them access affordable and quality healthcare. By 2014 when the Exchanges are launched, the Medicaid expansion is in place, and all the other provisions are fully implemented, many more young adults will be able to take care of their health easily, affordably and efficiently. Unfortunately none of us are invincible, but the Affordable Care Act is a great tool in helping young adults (and everyone else) control their own healthcare.

Andrea Kovach, Staff Attorney 
Viviane Clement, Healthy Futures Vista
Sargent Shriver National Center on Poverty Law

(This post originally appeared in the Shriver Brief on August 31, 2012)
 

Health Care Reform Leadership Training for Faith Community and Communities of Color

Strong leaders are needed to speak out now about the development of an Illinois health insurance marketplace and expanding Medicaid, not cutting it.  

The Campaign for Better Health Care's Faith Caucus is inviting you to become a partner because, as a leader in the faith community or community of color, you can bring back the information to your congregation and community so they can join the effort for the full implementation of the new health care law (Affordable Care Act).  Your commitment will be to attend the next five trainings (one per month, each 3 hrs) and to follow through by mobilizing your communities. 

These trainings will help prepare you for a more active role in the pursuit of affordable, accessible and quality health care for everyone.  The leadership training series topics will include Organizing 101, Affordable Care Act, Marketplace, fundraising, legislative advocacy, messaging, social media, community engagement, leadership development, communications and resource development.

The initial five trainings will be held in Chicago, but we are seeking funding to provide trainings statewide.

Help make a difference in shaping our healthcare and the healthcare of those who need you to take action.

You can register by clicking this link.

 

Day	Date	Time	Location	Room
Tuesday	August 28st, 2012	1-4 pm	Mercy Hospital	Great Room
Tuesday	September 19th, 2012	1-4 pm	St. Mary’s Hospital,	1CD
Tuesday	October 16th, 2012	1-4 pm	Mercy Hospital	Room 242
Tuesday	November 13th, 2012	1-4 pm	Mercy Hospital	Penthouse
Tuesday	December 11th, 2012	1-4 pm	Mercy Hospital	Penthouse

Mercy Hospital & Medical Center. 2525 South Michigan Avenue Chicago, IL 60616.

St. Mary’s Hospital, 2233 W. Division St.  Chicago, IL 60622 Parking across the Street–North of Division St.

Laura Leon
Director of Faith Initiatives
Campaign for Better Health Care

Who Has Pre-existing Conditions in Illinois?

A new study by Families USA has delved deep into Obamacare's patient protection provisions, which prevent anyone from being turned down or charged exorbitant rates for a pre-existing condition.

According to the study, over one in four Illinoisans under the age of 65 (the age where they become eligible for Medicare) have a pre-existing condition that could result in denial of coverage prior to the exchanges coming into effect in 2014. That's nearly 2.9 million people!

People with pre-existing conditions live in all counties in Illinois: the proportion of people affected ranges from 24.5 percent in Lake County to 31.1 percent in Jefferson, Marion, Randolph, and Washington Counties. One common factor is that pre-existing conditions tend to become more prevalent as we age: nearly half (49.2 percent) of adults aged 55 to 64 have a pre-existing condition that could lead to a denial of coverage. Right now, the presence of a pre-existing condition at any point in your life can be a reason for health insurance companies to discriminate against you.

To me, the implications are very clear: Obamacare gives people with pre-existing conditions access to affordable insurance. In fact, 59.5% of people with pre-existing conditions in Illinois are within the threshold (below 400% FPL) where either subsidies will be available to help them purchase health insurance or they will qualify for Medicaid. That's a tremendous relief for anyone without or in danger of losing their health care.

Also, as Families USA discusses in the study, not knowing what can happen with you or your family members' health insurance can result in "job lock" where one keeps an inferior job for fear of losing their coverage. Implementation of Obamacare will relieve that fear, and it could even lead to more people taking risks that were impossible before, such as starting a new business. This can lead to a more natural flow of the labor market and towards more job creation, giving Illinois an economic boost.

These are real benefits that people with pre-existing conditions, like me, can look forward to in 2014. In the meantime, IPXP, Illinois's temporary pre-existing conditions plan for the uninsured that was created and subsidized by Obamacare, is doing an incredible job as a stopgap measure to help us get through the next year and a half. I encourage you to spread the word about IPXP to ensure that everyone who needs to can take advantage of these benefits. As we can see from the Families study, there are a lot of Illinoisans with pre-existing conditions who have the chance to take advantage of a great program right now.

David Zoltan,
Guest Blogger, Illinois Health Matters