Thread: A few health care questions answered

http://www.cnn.com/2010/HEALTH/03/24...ex.html?hpt=C1

(CNN) -- With the passage of the health care reform bill, CNN has been flooded with viewer questions about specifics of the measure and how their lives may be affected. In response, we're providing answers here, based on our reporting research, that address some of the issues you're raising most often. Got another question? E-mail us at healthcare@cnn.com.

Question: Can you explain whether the elimination of lifetime caps under the new health care bill applies to existing policy-holders as well as new insurance sign-ups?

Answer: Yes, within six months, the private insurance plans will have to stop some practices, such as setting lifetime limits on coverage and canceling policy-holders who get sick, on all new policies and current policies.

Question: I have been watching all of the debating. I still cannot figure out, what does this mean to me? I'm an unemployed 56-year-old. Lost my health care. Cannot afford COBRA. Now, what is there for me? I have a daughter in college. My insurance company refused to pay for therapy on my knees, calling it pre-existing. My unemployment just ran out. Now what?

Answer: When the insurance exchange opens, as required by the health care bill, people who are self-employed or whose employers don't offer coverage can purchase a plan. If you lost a job, you could get insurance through this new marketplace. Also, once this exchange opens, private insurers will no longer be able to turn away people with medical problems or charge them more. Individuals would be required to purchase coverage or face a fine of up to $695 or 2.5 percent of income, whichever is greater, starting in 2016. The plan includes a hardship exemption for poorer Americans. Exemptions will be granted for financial hardship, those for whom the lowest-cost option exceeds 8 percent of an individual's income and those with incomes below the tax filing threshold (in 2009, the threshold for taxpayers under age 65 was $9,350 for singles and $18,700 for couples).

Question: What happens to the cost of insurance to the company that is providing the insurance to the employee? Is there a set amount or percentage of the total premium that the employer is required to pay? Will it change the mix that already exists between employer and employee responsibility?

Answer: By no later than 2014, states will have to set up Small Business Health Options Programs, or SHOP exchanges, in which small businesses will be able to pool together to buy insurance. Small businesses are defined as those with no more than 100 employees, though states have the option of limiting pools to companies with 50 or fewer employees through 2016; companies that grow beyond the size limit will also be grandfathered in. But until the SHOP exchanges are set up, there will be a tax break for small businesses that goes into effect right away: Tax credits of 35 percent to 50 percent of premiums will be available to small businesses that offer coverage.

Question: I am living with HIV and cannot get health care coverage. If this reform passes, how long before I am able to get coverage?

Answer: By 2014, that there would be no discrimination based on pre-existing conditions. You could not be denied based on an infection or some sort of pre-existing illness. That's four years away, though.

Question: What will happen when there are not enough doctors to oblige all the patients?

Last year, the American Academy of Family Physicians predicted a shortfall of 40,000 primary care doctors, and that was before the signing of the health care bill. That will put another 32 million people into the system -- with a promise of free preventive care -- and insurance to pay for regular doctor visits. Some physicians have expressed concern about this. Patients could see increased wait times, as in Massachusetts, where since "RomneyCare" went into effect, residents wait an 10 extra days to see the doctor. But others say the bill will help create more community health centers, so primary care can happen at these centers instead of expensive emergency rooms

Question: Isn't defensive medicine a big factor leading to overtreatment both at the beginning and at the end of life?

Answer: A recent Gallup Poll found that nine in 10 doctors admit having practiced defensive medicine at some time during their career. Some estimates put the cost at hundreds of billions of dollars in a year. If you look at all the lawsuits, there are about a million people who claim some sort of harm in any given year. But only about 11,000 lawsuits are actually paid out. Medical malpractice represents really only about 2 percent of the health care budget.

Question: Is there anything in the bill about rationing health care?

Answer: No one is using the term "rationing" as part of the bill. But there is a term called comparative effectiveness. And that's this idea that we figure out what works in medicine and make sure to pay for those things. This also means that there are a lot of things being done right now where there's not scientific proof that it works and maybe those things won't get paid any more. Some people call that rationing. Other people say, look, rationing exists under the current system. It's just that the insurance companies are essentially rationing by denying payment or dropping people off their coverage.

Question: I recently had to go to the ER for a rash. I had a $100 co-pay. If the new health care bill passes, would the co-pays for ER visits go down?

Answer: Not necessarily. In 2014, you will be able to buy a standardized health plan through a state-based exchange, with tiers of benefit packages available, if you do not have insurance through your employer, Medicare or Medicaid. You will be able to choose whether you want a plan with a higher premium and lower cost-sharing or a lower premium and higher cost-sharing. It will be very clear what the responsibilities will be for co-pays. Also, through the exchanges, there will be two multistate private plans under contract with the federal government, one of which must be nonprofit. But none of this means that your co-pays for ER visits will necessarily go down.

Question: I am on a Blue Cross Blue Shield PPO plan where I pay $252 now. It has been increasing every year, and I may have been to the doctor probably once or twice a year for physical. I do not smoke and am in perfect health, but every year for some reason, my they keep raising my insurance costs. With the new reform, are they going to have some checks and balance on these companies, who before did not have to answer to anyone? Or can I change my insurance to a government-run cheaper insurance?

Answer: Beginning in 2011, companies that spend more than a specified portion of premiums on administrative costs and profits must give a rebate to enrollees. In other words, large insurance companies will need to give rebates if they spend less than 85 percent of money from enrollees on medical costs. In the individual market, that figure is 80 percent. Also, the health care exchanges could reject premium increases that insurers propose if they think they are too high.

In 2014, on the individual market, you can buy your own insurance through the exchanges if you do not have health insurance through your employer, or through Medicare or Medicaid. These exchanges are supposed to provide plans that are as good as employer-based plans, which generally have good benefits. If you do have employer-based coverage, however, and don't spend more than 9.5 percent of your income on premiums and the plan covers at least 60 percent of medical costs, you are not eligible for premium subsidies. But if your employer-based coverage does not meet this standard, you will be able to get insurance through the exchange, and your employer is required to pay a penalty.

Question: Over 30 million couples suffer from infertility in the United States. Most insurers will not cover this problem. Will the new bill finally address this as a significant health problem?

Answer: There is nothing in the bill regarding this issue. One benefit is that insurance companies cannot deny coverage to couples who suffer from infertility because it was deemed a pre-existing condition. However, in terms of covering infertility treatments or in-vitro fertilization, none of that is made mandatory under the bill for insurance companies.

Question: Is there any provision for a part-time employee getting health insurance from their employer under the new health care bill?

Answer: It's not in the employer responsibility provision to offer health insurance to their part-time employees under the new law.

However, employers who have more than 50 full-time employees are required by 2014 to offer coverage to employees or pay a $2,000 penalty per employee after their first 30 if at least one of their employees receives a tax credit.

I haven't been following this closely, but one thing stands out to me.

Insurance companies can not charge more or deny coverage for someone with pre existing conditions... Obviously conditions such as HIV/AIDs and cancer are going to have a pretty hefty bill for the insurance companies to foot, I guess that means much higher premiums for everyone?

Please tell me I am missing something there...

Originally Posted by QuickLightning

I haven't been following this closely, but one thing stands out to me.

Insurance companies can not charge more or deny coverage for someone with pre existing conditions... Obviously conditions such as HIV/AIDs and cancer are going to have a pretty hefty bill for the insurance companies to foot, I guess that means much higher premiums for everyone?

Please tell me I am missing something there...

By insuring more people and letting the healthy in these exchanges, you pool the risk and bring down costs. Plus, there is a proposal to set up a commission to oversee insurance premium hikes.