Lita Epstein - The Complete Idiots Mini Guide to Understanding Healthcare Reform

The health care reform law that passed in 2010 will be the most massive change to our health care system since Medicare was passed in 1965. In fact, this law has been credited with extending the fiscal health of Medicare for 12 more years, according to the Medicare Trustees.

Will this law actually lower your medical costs and improve your medical services? Thats still up for debate, and that debate will probably last for years to come. Were not going to delve into the politics of whether or not the law was a good idea. Instead well be looking at how the law will impact your life, year by year, until fully implemented.

Changes in 2010

While 2010 will not end with everyone having access to health care insurance, millions who didnt have it will now have a chance to get it. Lets take a look at the changes that occurred in 2010.

Pre-Existing Medical Conditions

One of the largest groups of new recipients will be children with pre-existing conditions. Under the new law, as of September 23, 2010, any new health plan and all existing health plans can no longer deny coverage to children under the age of 19 who have pre-existing conditions.

The new provisions are not as simple for adults with pre-existing conditions, but they, too, will be helped through a new government pool. Adults will be helped through the Pre-Existing Condition Insurance Plan (PCIP).

In order to get coverage either through your state or through the federal government, you will need to meet three key provisions. You must:

• Be a citizen or national of the United States and must be lawfully present in the United States.
• You must have been uninsured for the last six months.
• You must have been denied insurance within the last six months because of a pre-existing condition.

Some states may use different methods of determining whether or not you have a pre-existing condition. They also may have different ways you must prove you were denied coverage. In fact, some states that guarantee insurance coverage already may consider you for the PCIP if you were denied coverage at a reasonable price. So youll need to check your eligibility on a state-by-state basis.

You can check online in the PCIP section of HealthCare.gov to see what is required in your state (www.healthcare.gov/law/provisions/preexisting/index.html). When you get to the page, use the drop-down menu to pick your state, or click on your state on the map.

New Consumer Protections

Medical consumers will find a number of new health consumer protections that began on September 23, 2010. These will include the ban on rescission of coverage; the ban on lifetime coverage limits on essential services; regulation of annual coverage caps and then, ultimately, banning them for essential services; and the provision of an external review if coverage has been denied by your insurance company.

Insurance Companies Cannot Rescind Coverage

Prior to passage of the new law, insurance companies could search for an error, or other technical mistake, on your health insurance application and use this error to deny payment for services when you or a covered family member got sick.

For example, we used to see media reports regularly citing incidents of breast cancer patients losing coverage even though the patient didnt know she had breast cancer when she filled out the application.

Many insurance companies agreed to end this practice immediately, but as of
September 23, 2010, they didnt have a choice. This practice ended.

There will be an exception, though, in cases of fraud or intentional misrepresentation.

If an insurance company wants to rescind your coverage under the new law, they will have to go through a third-party review of your case and prove that you intentionally misrepresented your health condition or that you committed fraud.

No More Lifetime Caps

Insurance companies used to include lifetime limits on health insurance coverage.

These lifetime limits will be prohibited on essential benefits, such as hospital stays, as of September 23, 2010.

Regulation of Annual Limits

Any new plans started on or after September 23, 2010, will face new regulations if they limit the amount of insurance coverage a patient can receive based on annual dollar limits. In 2014, annual limits will be banned completely for essential benefits such as hospital stays for health insurance plans in the individual marketplace and group plans.

Appealing Insurance Company Decisions

You will be entitled to an external review process if you are denied coverage for care under your health insurance plan. That began on September 23, 2010. If you do receive a notice of denial of coverage, ask your insurance company about appealing the decision through their external review process.

Free Preventive Care

All new health insurance plans that start on or after September 23, 2010, must cover certain preventive services, such as mammograms and colonoscopies, without charging you a deductible, co-pay, or coinsurance.