|What states are doing|
|Assess your exchange|
|Federal exchange option|
|Costs remain unclear|
|More ACA protections|
|Essential health benefits|
|Your State Exchange|
Today, many health insurers sell "Swiss cheese policies": insurance filled with loopholes. Even if you try to read the fine print, you may not understand all of the exceptions to your coverage – until you become sick. Then, the hole with your name on it opens, like a trap door.
This is when you discover that while your insurance covers surgery, it does not reimburse for the rehabilitation you will need following surgery. Or, that while your policy pays for complications during pregnancy, it won't reimburse for a normal labor and delivery.
Large companies with deep pockets usually provide comprehensive coverage for their employees, and federal law requires that they cover pregnancy and childbirth. But policies sold to individuals and small employers often are riddled with holes.
As a result, in 2011:
But under the health reform legislation that President Obama signed in 2010, those who purchase insurance in state-run exchanges – also known as health insurance marketplaces – won't have to worry. Beginning in 2014, all policies sold in the exchanges – whether to individuals or to small firms with fewer than 100 employees – must cover what physicians and consumer advocates call "essential health benefits":
Thanks to these rules, in 2014:
Reformers believe that if a patient moves from Portland, Oregon to Portland, Maine, he should be confident that his policy still will include these basic benefits. At the same time, they recognize that both patient expectations and the way doctors practice medicine are different in different parts of the country.
As Dr. Donald Berwick, former head of the Centers for Medicare and Medicaid told me not long ago: "One of the challenges of reform is to create policy that is locally responsive."
This is why the Department of Health and Human Services (HHS) is giving the states the freedom to model their benchmark plan for individuals and businesses on either:
But when it comes to those benefits that medical research shows are "essential" for America's health, HHS is not budging. If the ten categories of services listed above are not included in the state's benchmark plan, the state will have to expand the package to include them.
In a final rule published on March 12, HHS underlined its commitment, emphasizing that health plans must "maintain provider networks that "include sufficient numbers and types of providers, including providers that specialize in mental health and substance abuse, to ensure access to all essential benefits particularly in low-income and underserved communities."
Many individuals and small businesses turn to a broker to help them buy health insurance, and that can be helpful, given how complicated a purchase it can be.
The role of brokers is unclear at this point, and really depends on how each state designs its health insurance exchange. For the most part, an exchange removes the need for a broker, providing easy-to-understand information and comparisons of health plans for consumers to use online. Brokers have been unhappy about losing their place in the health care system, so some states may find a way to keep them involved.
There is another way for consumers to get personalized assistance with the exchange, though. The federal government is providing grants to non-profit organizations that will serve as navigators to help people understand and enroll in coverage. There will also be a toll-free hotline to take consumer questions and consumer assistance programs to help with grievances against health plans.
By Steve Anderson
September 25, 2009
There’s something about this huge debate on health care that’s been sorely lacking and … and that something is a discussion of what health reform could mean to entrepreneurs. Remember the American Dream? Where you come up with a great product or service and then open your own business? You work harder, not smarter? The ...(continue reading)