Health Care in 2011

Because health reform legislation, the Affordable Care Act, was signed into law on March 23, 2010, health care coverage is more available this year.  For most people with or at risk for osteoporosis, the legislation also should improve their health care and make it more affordable.* 

Lowering prescription drug costs

Beginning in 2011, people who fall into the Medicare Part D coverage gap or “doughnut hole,” paying between $2,840 and $6,448 for prescription drugs, will receive a 50 percent discount on covered brand-name drugs and other discounts on generic drugs.  This contrasts with the one-time, tax-free $250 rebate they received in 2010.  (However, for those Medicare beneficiaries with incomes above $85,000 and couples with $170,000, the cost of drug coverage may go up.)

Helping people with pre-existing conditions

States have created new, temporary insurance programs for people who have been uninsured for six months and who have a pre-existing condition.  For the same coverage, premiums will cost the same as those for individuals without pre-existing conditions.  Information is available on these programs at www.health.gov.

Providing free prevention benefits

All new insurance plans will be required to cover prevention and wellness benefits (as recommended by certain organizations) with no deductibles or cost-sharing or co-payments.   This includes adding coverage for a new “wellness visit” and testing for osteoporosis, as recommended by the US Preventive Services Task Force.

Ending unfair insurance cancellations

Insurance companies will be prohibited from arbitrarily cancelling coverage for people who have paid their premiums when they file a claim for benefits.  An insurer cannot cancel a person’s coverage for an honest mistake or if someone left out information that has little bearing on his or her health.

Ending arbitrary limits on coverage

Insurance companies will be prohibited from placing lifetime limits on benefits.  In new plans they will be severely restricted in using annual limits, which will be prohibited completely beginning in 2014 for all plans offering essential benefits.

Providing comparable information about health insurance plans

A consumer-friendly Web site has been created that uses a standard format for consumers to compare health insurance plans (www.health.gov)

Improving consumer appeals process

Consumers will have the right to appeal insurance company decisions to both the plan and an independent reviewer. 

Improving patient protections

If your plan requires that you designate a primary care provider, then you can select any available participating primary care provider as your doctor.

If a plan covers emergency room services, then it must cover them out-of-network without prior authorization, without coverage limitations and with the same cost-sharing requirement as in-network.  (A patient may still be responsible for the difference between insurance coverage and the amount billed.)

Helping young adults stay insured

The law allows young adults until they are 26 years of age who do have an offer of coverage through their employer to stay on their parents’ health insurance policy. 

Helping children with pre-existing conditions

The law prohibits health plans from imposing any preexisting condition exclusion on enrollees who are under age 19. 

Helping Small Business Insure Their Employees

If you are a small business owner with fewer than 25 employees  and you provide health insurance, you  may qualify for a small business tax credit up to 35 percent  (and up to 25 percent for a non-profit ) to offset the cost of their insurance.  This would make the cost of providing insurance much lower. 

Assuring Value for Health Insurance Premiums

All proposed health insurance premium increases at or above 10 percent would be subject to review so that the reasons for the increase are transparent and reasonable.  Also beginning in 2011, insurance companies will be required to spend at least 80 to 85 percent of the premiums they collect for health care services and improvements in the quality of care.  If they do not, they must provide a rebate to consumers.  This provision aims to have most of consumer’s premiums used for quality medical services.   

*On September 23, 2010 new consumer protections – A Patient’s Bill of Rights - began to take effect.  Many of the described benefits are effective for health plan years beginning on or after September 23 and apply to all “non-grandfathered” plans. Grandfathered plans are those in which individuals are enrolled as of March 23, 2010, and plans that are renewed for individuals and allow for enrollment of family members and new employees after this date.   However, many of the benefits already have been incorporated in other plans, so it is best that to check with your insurer.