Health provisions begin phasing in Thursday - USATODAY.com

Health provisions begin phasing in Thursday



Several key consumer protections under the nation's new health law begin taking effect Thursday — six months after its enactment.

Insurers can no longer set a dollar limit on the amount of care they'll provide over a person's lifetime or deny coverage to sick children. Young adults can stay on their parents' health plans until age 26. And consumers get greater rights to appeal insurers' decisions.

"It's really putting in place long overdue consumer protections," Health Secretary Kathleen Sebelius said in an interview with USA TODAY. "It's getting rid of some of the worst rules of the industry that prevented people from getting covered at all or, at a time they needed coverage the most, limited the coverage they had."

Many people, however, will have to wait until Jan. 1 for the changes to help them. That's because most of the new provisions apply to insurance policies that begin on or after Thursday. Many plans operate on a calendar year, and this fall will begin enrollment for next year.

"It's not like a switch gets flipped and everything gets changed on Sept. 23," said Jennifer Tolbert, an associate director at the Kaiser Family Foundation, a health policy group.

Some changes won't apply to plans that are considered "grandfathered" under the law, meaning they existed when the law was signed March 23 and haven't substantially changed. Those plans are supposed to notify policyholders of their grandfathered status, Tolbert said.

Once plans make a substantial change — such as significantly raising co-payments or significantly reducing benefits or the amount an employer contributes — they are no longer grandfathered.

The Thursday changes are designed to help consumers between now and 2014, when the most significant provisions of the health law take effect. That's when new health insurance marketplaces, called exchanges, will be created and most Americans will be required to purchase insurance. "This is sort of a bridge strategy," Sebelius said.

Sebelius said some insurance companies have recently begun notifying policyholders that their premiums will increase in 2011 because of the benefits that take effect this week. Karen Ignagni, president and CEO of the industry group America's Health Insurance Plans, said, "The fact is if you increase benefits, you increase costs."

Ignagni said the new law contributes to insurance rate increases, as do other factors, such as the rising costs of prescription drugs and medical care, and a growing number of Americans who are older or require care for chronic health conditions.

Sebelius sent a letter this month to Ignagni alleging that insurers are sending letters to consumers "falsely blaming premium increases for 2011" on the health law and warning that the Department of Health and Human Services (HHS), in partnership with states, "will not tolerate unjustified rate hikes."

She said analyses of the law's impact by various groups — including HHS, the Urban Institute and the Pennsylvania insurer Highmark — estimate a 1% to 2% impact on premiums.

Steve Findlay, a senior health policy analyst at the non-profit watchdog group Consumers Union, said consumers need to focus on the law's benefits, "what it does for them and their loved ones — rather than listen to politically driven criticisms and attempts to undermine the law."


What's changing

USA TODAY's Alison Young looks at key provisions of the new health law starting to take effect Thursday. For more information, go to www.healthcare.gov:

Keeping young adults covered

  • The basics: Teens and young adults can stay on or be added to their parents' health insurance plan until age 26. They don't need to live with their parents or be financially dependent on them. They can even be married.

Be aware:

  • This right to coverage applies to all types of plans that offer dependent coverage. However, in "grandfathered" employer group plans -- policies that existed before the law and haven't changed substantially -- children are not eligible to go on parents' plans if the children have access to coverage through their own workplace.

Free preventive care

  • The basics: Insurers must completely cover a wide range of recommended preventive services -- such as immunizations, mammograms and colonoscopies -- and can no longer charge co-payments, co-insurance or deductibles for them.

Be aware:

  • This applies only to new plans, not to grandfathered plans.
  • For plans that had limited preventive services, this benefit may contribute to higher premium costs.

Coverage for sick children

  • The basics: New rules prevent insurers from denying coverage to children under age 19 with pre-existing medical conditions, such as asthma or cancer.

Be aware:

  • Insurers may limit when children are signed up to certain open enrollment periods.
  • This does not apply to grandfathered individual plans.
  • Similar protections for adults with pre-existing medical conditions won't begin until 2014. In the meantime, adults with medical conditions who have been uninsured for at least six months can purchase coverage through federal high-risk pools created by the health law this summer.

Protection against canceled coverage

  • The basics: Insurers no longer can use a mistake or technical error in a consumer's application to cut off their coverage after they get sick.

Be aware:

  • Consumers are not protected if they make an intentional misrepresentation of important facts or engage in fraud.
  • In such cases, the insurer must give at least 30 days notice before the plan can be canceled.

No lifetime coverage limits

  • The basics: The amount a plan will pay in a person's lifetime cannot be capped.

Be aware:

  • This applies to all health plans.
  • Insurers must notify people who exceeded their lifetime limits before Sept. 23 that those limits no longer apply.
  • For plans that had lower premium costs because of lifetime limits, this benefit may contribute to higher premium costs.

Restrictions on annual coverage limits

  • The basics: Insurance companies with annual limits on essential health benefits must provide an increasing amount of coverage. Initially, their annual limit can be no less than $750,000, rising to $1.25 million in September 2011 and $2 million in 2012. Annual limits are prohibited in 2014.

Be aware:

  • This applies to new individual and group plans, as well as grandfathered group plans.
  • It does not apply to grandfathered individual plans.
  • It does not apply to "mini-med" plans that provide limited health benefits.

Greater consumer appeals rights

  • The basics: Consumers have the right to appeal insurers' decisions through their plans' internal review processes, as well as to an independent, third-party reviewer.

Be aware:

  • This does not apply to grandfathered plans.
  • Most states already have rules allowing some form of external appeal of insurance problems. The level of protection varies greatly, and states have until next summer to meet all federal standards, or the federal government will run the appeals programs in those states.
  • Residents of Alabama, Mississippi and Nebraska -- states that lack any external appeals law -- will have access to an interim external review process administered by the federal Office of Personnel Management. Consumers in these states who have questions about an external appeal can call 1-877-549-8152 beginning Sept. 23.

Sources: Kaiser Family Foundation, the Commonwealth Fund, U.S. Department of Health and Human Services, America's Health Insurance Plans and Consumers Union