Transcript IDF 2011 National Conference Healthcare Reform Presentation

What You Need to Know about
The New Health Reform Law
Lisa Codispoti
IDF Board Member and Patient
Senior Counsel, National Women’s Law Center
June 25, 2011
Challenges our Community Faces
Inadequate Insurance Coverage
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Multiple Chronic Conditions
Coverage for specialists of choice
Prescription drug coverage
IVIG or SubQ coverage
Switching to tiers of coverage
Finding & Keeping Affordable,
Comprehensive Health Insurance
• Insurance Rejection due to pre-existing
conditions
• Health Status rating (premiums set
based on your health- also by age,
gender)
• Pre-existing condition exclusions
What the Health Care Law Does
In Effect Now
• Adult children can stay on parents plan to age 26
• No pre-existing condition exclusions for kids <19
• New insurance plans must cover recommended
preventive screenings without cost sharing like
co-pays or deductibles
• Insurance plans for uninsured people with preexisting conditions “PCIP Plans” – no more
expensive than for a healthy person
• Lifetime limits on benefits PROHIBITED
• Annual benefit limits – restricted (prohibited
2014)
Insurance Reforms: 2014
• Guaranteed issue – no insurance company
can reject you from purchasing their
insurance policy due to a pre-existing
condition
• no health status rating- (premiums can only
vary based on age, smoking status, family
size, and geography)
• no pre-existing condition exclusions or
discrimination
“Exchanges”
 New insurance marketplaces to shop for,
compare insurance plans
 For individuals (without affordable employer
coverage) and small employers
 Available plans are categorized into 4 tiers of
coverage: bronze, silver, gold, platinum
 Plans generally cover the same health care
services- the difference is based on how much
you pay out of pocket.
• Bronze – highest cost-sharing;
• Platinum- lowest cost sharing
Comprehensive Benefits
All plans sold in exchanges must cover:
 Ambulatory patient services
 Emergency services
 Hospitalization
 Maternity and newborn care
 Mental health and substance use disorder services,
including behavioral health treatment
 Prescription drugs
 Rehabilitative and habilitative services and devices
 Laboratory services
 Preventive and wellness services and chronic disease
management
 Pediatric services, including oral and vision care
Affordability Assistance
• Medicaid expanded – up to 133% poverty
» Single person: $14,500
» Family of 4: $29,725
• Sliding-scale subsidies –help with premiums, cost
sharing (up to 400% of poverty – or $88,000 for
family of 4)
• Caps on Out-of-Pocket costs – no plan can
charge more than $6,000/$12,000 (single/family)
• Medicare Prescription drug coverage gap –
phased out by 2020 (now: 50% brand name
discount when in the gap)
A few other insurance bits:
• New appeal rights – to challenge insurance
determinations
• Insurers will have to justify and states will review
premium increases
“Shared Responsibility” Provisions
 Employers: Over 50 employees must offer
health insurance to employees or face a fee if
their employees get subsidized coverage through
the exchange
 Individuals: Unless exempt (ie: due to cost or
hardship), must have health insurance or pay a
fee
Is the law perfect?
 Heck no – lots of stuff they didn’t get to, like our
Medicare IVIG home infusion problem
 But it’s a start – and for a lot of people, it’s a lot
more than they had
 They passed Medicare 47 years ago – and it’s
still being tweaked!!
What’s happening now?
 Federal government (US Dept of Health &
Human Services) issuing regulations to provide
greater details on many pieces of the law
 States are starting to pass legislation to operate
the exchanges starting in 2014
 Several lawsuits challenging the law
So what should we be doing until 2014?
 Advocacy at this stage is even more important!
 This is to be sure they get the details of the law
right
 Be ready – when we send an Action Alert- we
need your help!
 IDF was critical in advocacy for the primary
immunodeficiency community leading up to
passage of this law
 IDF continues to advocate on behalf of our
community during implementation
Some questions you may have:
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What will happen to the health
insurance I have through my employer?
Will my immune globulin (IVIG or SubQ)
be covered? Will they cover my brand?
What about my home infusion service?
Will all of my prescriptions be covered?
What about formularies?
Will I be able to see my immunologist of
choice?
Thank You!