Essential Health Benefits: What’s it mean for people with HIV?

On December 16, 2011, the U.S. Department of Health and Human Services (HHS) announced that states would decide what essential health benefits will be provided under health care reform.  Although we had urged HHS to adopt a uniform, national benefits floor that states could build on, the federal proposal offers important flexibility for states. (Check out our essential health benefits archive.)

So, what does the essential health benefits announcement mean for people with HIV?  The short answer is that we’re working on it.  Here are some of the hoops we’ll have to jump through just to figure out what the benefits might look like in a state.

Which plans are we talking about?  HHS gives states the choice of:

(1) the largest plan by enrollment in any of the three largest small group insurance products in the State’s small group market;
(2) any of the largest three State employee health benefit plans by enrollment;
(3) any of the largest three national FEHBP [Federal Employee Health Benefit Plan] plan options by enrollment; or
(4) the largest insured commercial non-Medicaid Health Maintenance Organization (HMO) operating in the State.

Yeah, we weren’t sure where to start either.  There’s no centralized federal repository of health plan data, since states regulate health insurance.  Every state publishes plan information online differently, or not at all.  We’ll probably have to submit a special data request to each of the 50 state insurance departments.

What benefits does each plan offer?  Once advocates identify the largest plans, the next step is to determine exactly what benefits they offer.  You can bet that Blue Cross doesn’t publish on their website a description of each of their hundreds of plans offered in a state.  We’ll might have to ask companies directly for plan descriptions, or pour through regulatory filings at state insurance departments.

Once we have this information, we can start to figure out what the plans will look like for people with HIV.  Of course, we’ll partner with national and state advocates to gather and analyze information.  At the state level, it’s more essential than ever that advocates work together to figure out the benefit puzzle and don’t duplicate effort.

And here’s an idea:  Could advocates, employers and insurance companies collaborate to gather all this information?  Sure, old adversaries would have to sit at the same conference table to share opinions and information – but that might be just “what the doctor ordered” in the new world of health care.

Read the federal fact sheet
Read the HHS Essential Health Benefits Bulletin
Federal white paper on benefits in small group and state and federal plans
Federal fact sheet on individual market benefits

John Peller, VP of Policy
AIDS Foundation of Chicago
jpeller@aidschicago.org

Originally posted here on HIVHealthReform.org 

What lies ahead for the Patient Protection and Affordable Care Act in 2012?

2011, the first full year for the Patient Protection and Affordable Care Act (ACA), is coming to a close. As we’ve written about in the past blog posts, Facebook posts, tweets or on our home page, the year saw many ACA developments, from the announcement of the definition of “essential health benefits” that are guaranteed under the law, to the initial stages of Illinois’ health insurance exchange legislation, to the rescission of the CLASS Act. This year also saw the early effects of the law’s impact – from the young adults who can now stay on their parents’ health insurance plan, to the seniors whose prescription drug costs in the Medicare “doughnut hole” are shrinking, to the people with chronic conditions who are no longer uninsured due to the availability of the state’s federally funded pre-existing condition insurance plan. 

Of course, many provisions of the ACA will not take effect until 2014, but several provisions of the law are slated to start in 2012, including:

• A series of demonstration projects designed to strengthen Medicare by eliminating fraud, waste, and abuse;
• The Medicare Independence at Home demonstration, which will test out coordinated care medical teams providing care to certain high-need Medicare patients in their own homes;
• A Medicaid demonstration, which will allow bundled payments for medical care that include hospitalizations, as well as extending the Medicaid Accountable Care Organizations savings to pediatric providers within those organizations; 
• A new annual tax on pharmaceutical companies; and
• On October 2012, Medicare payments for hospital readmissions will be reduced, to offset excessive readmissions to hospitals, such as early discharges from a hospital, which could result in a return visit.
   

What will undoubtedly become the biggest news of 2012 will be the Supreme Court case on the constitutionality of the ACA, beginning on March 26, 2011. Due to the number of different arguments against the ACA – ranging from the validity of the individual mandate to the constitutionality of the Medicaid expansion - the outcome of the case could take many different forms, from keeping the law in its entirely, striking down the whole law or portions of the law. The decision is expected in June 2012.

Also in 2012, it will be important to watch how the implementation of pieces of the ACA that are already in effect will continue, most notably, the establishment of a health benefits exchange in each state. Many states, have already begun the implementation, and are at various stages in the process, such as the 15 states (like Illinois) that have already enacted an exchange or intent of establishment legislature. Other states are working to pass such legislation, and others have not taken any steps towards establishing an exchange, either deferring to the federal government to run their exchanges, or riding on the assumption that the ACA will be struck down in the upcoming Supreme Court case. (See here for a recent news article about the status of the Illinois Exchange).

There are still many unknowns about the future of the ACA; however, what’s clear from our eight-part Neighborhood Stories series is that we have a lot of work to do to educate the communities in Illinois about the benefits of the law for small businesses, individuals/families and community organizations. Stay tuned to Illinois Health Matters for interactive features in early 2012, to help YOU understand how health care reform will impact you, your family and your community.

Happy, Healthy Holidays! 

Ensuring Young Adults’ Coverage Now Saves Us All Money Down the Line

Because of the Affordable Care Act, millions of Americans now have access to affordable health care and millions more will soon have coverage, as well. One group of Americans that is especially benefiting from our new law is young adults.

According to the Obama administration, 2.5 million previously uninsured young adults ages 19 through 25 are now covered. The majority of those who have recently gained coverage took advantage of a provision in the Affordable Care Act that allows young adults to stay on their parents’ plan until age 26.

Historically, young adults have been the age group most likely to go without health insurance. Almost 28 percent of 18- to 25-year-olds were uninsured in 2010 compared to only 9.8 percent of children under 18 years of age and 20.5 percent of 26- to 64-year-olds. For young adults, the recession hit particularly hard.

In fact, many recent college graduates had a hard time finding a job with health insurance, or finding a job at all. As a result, even more young adults went without health coverage.

Thanks to the health reform law, young adults no longer have to take this gamble. And, millions of parents have peace of mind, knowing that their young adult children will get good, affordable health care when they need it. For millions of parents around the country, this provides a huge sigh of relief:

They don’t have to worry about going bankrupt if disaster strikes and their child winds up in the emergency room with piles and piles of costly medical bills.

Insuring young adults is not only good for parents and kids; it’s good for us all. Because young adults are typically healthier and are less likely to need expensive medical services, their presence in the insurance pool means that costs for everyone are lower.

Without health reform, millions of young adults would be uninsured once they left college or even high school and the costs of their health care would ultimately be paid for by the insured when they eventually do seek medical attention.

Ensuring young adults are covered now saves us all money down the line and gives parents and their kids the peace of mind that they’ll have coverage they can count on when they need it the most.

By Ron Pollack
Originally posted here on the Health Insurance Resource Center
Ron Pollack is the Founding Executive Director of Families USA, the national organization working to achieve high-quality, affordable health coverage for everyone in the U.S. The Hill, a weekly newspaper covering Congress, named Mr. Pollack one of the nine top nonprofit lobbyists. Modern Healthcare named him one of the 100 Most Powerful People in Health Care.

Let’s Hear it for Prevention

Prevention is not only the best medicine, it’s the cornerstone of the Affordable Care Act (ACA). To ensure that prevention is integrated into our nation's health care systems, the ACA created the National Prevention, Health Promotion, and Public Health Council, composed of the heads of 17 Federal agencies and chaired by the U.S. Surgeon General.

Earlier this year, the Surgeon General announced the National Prevention Strategy,  which is a comprehensive plan to increase the number of Americans who are healthy at every stage of life by moving health care away from a system focused on sickness and disease, to one focused on wellness and prevention.

So how do we turn this plan into reality? The answer is that everyone has a role to play in a healthier community, state and nation.

The Surgeon General, Dr. Regina M. Benjamin, is visiting regions around the country to launch this vision. She believes everyone – businesses, educators, health care institutions, government, communities and every single American – has a role to play.

Thursday December 8, 2011, Dr. Benjamin stopped in Chicago, and urged Illinois community leaders and public officials to take a pledge, committing themselves to do what they can to make healthier choices easier choices for themselves and the people in the communities they serve.

“I will be a leader to make healthier choices easier choices where I live, learn, work, play and pray.”

This is an unprecedented call to action is for individuals, communities, schools, faith institutions and employers to all take part. The pledge, and more information about the National Prevention Strategy is hosted by Community Commons and managed by Health & Disability Advocates and the Trust for America’s Health.

So what are you waiting for? Ask not what your country can do for your waistline. Ask what you can do to make your country healthier.

Take the prevention pledge today.

States Taking the Lead in Strengthening Consumer Protection

Recently, five more States strengthened their laws protecting consumers in disputes with their health insurance plans. The District of Columbia, Massachusetts, New Hampshire, Ohio and Wisconsin have bolstered their laws surrounding the part of the appeals process known as “external review.”  These five States join 33 others that provide these State-based external review protections that ensure consumers have a voice. The remaining States’ consumers are protected by a Federal process.

The strengthened appeals rights are one of several common-sense consumer protections and insurance market reforms established by the Affordable Care Act. Having a meaningful appeals process ensures that you actually receive the benefits that your insurer has promised.

So, what exactly is an external review? 

It means having an independent third party review your insurer’s decision, no matter where you live, thanks to the Affordable Care Act. Often, you can resolve disputes with your health plan by asking your insurer to reconsider its decision, in a process known as an “internal appeal.” But if, for example, your insurer still denies payment after the internal appeals process, you now can ask for an external review by an independent review organization to decide the matter.  Insurance companies must accept the outcome of this external review.  This means that your insurance company no longer gets the final say, and that patients and doctors get a greater measure of control over health care decisions.

These protections are important because when an insurer refuses to pay for a covered health care service, consumers could be faced with a large unplanned bill, and may not be able to afford the care their doctors say they need.

The Affordable Care Act sets these new important appeals standards for consumer protections and encourages States to take the lead in ensuring their own residents benefit from them.  Where States have not yet passed laws implementing these consumer protections, HHS has set up a process to ensure that consumers in these States also benefit from the same protections and standards.  If a State changes its external review process in the future, the State may request a new determination at any time. 

Having DC, Massachusetts, New Hampshire, Ohio and Wisconsin step up to the plate to ensure consumers’ external review rights is a perfect example of how the Affordable Care Act empowers States to protect consumers.

This post was originally published on The HealthCare Blog on November 22, 2011
By Eliza Bangit, Acting Director of the Consumer Support Group

Communications Tips – Supreme Court and the Affordable Care Act

This week, the Supreme Court may grant a writ to hear a case questioning the constitutionality of the Affordable Care Act. There will be a number of questions raised by this action. Consider the following points in talking with colleagues and the press.

Main Points:

1. The Affordable Care Act is supported by the text of the constitution and years of judicial precedent.
a. If one reads the constitution, including the amendments, there is no question that this law is supported by the words in the constitution.
b. At the Appellate level, two very conservative judges have supported the constitutionality of the law (Silverman appointed by Reagan and Sutton appointed by G.W. Bush).
c. The DC Circuit upheld the constitutionality of the health law on 11-8-11.

2. People challenging the law are playing politics—using the courts to attempt to accomplish what they didn’t succeed at through the legislative process.
a. Some people don’t want to rein in insurance companies.
b. They have other priorities; ordinary American families are not one of them.

3. This law provides protections for American families:
a. A child getting sick is no longer a reason for a lifetime of denial of care;
b. Preventive services will give our children and our parents better chances for healthier and longer lives;
c. Insurance companies can no longer take unfair advantage of ordinary Americans with practices like charging women more than men for health insurance.


Those trying to manipulate our judicial process and the constitution for political expediency should reflect on America’s history. George Washington couldn’t clothe his troops because the Articles of Confederation didn’t allow the government to raise funds for his army. The constitution was written so, as our first President said, ‘we can have national solutions to national problems.’

Top Five Facts That Illinois Social Workers Should Know about the Affordable Care Act

Illinois Health Matters will be an exhibitor at the National Association of Social Workers (NASW) Illinois Statewide Conference today, Thursday November 10. We are excited to meet the hundreds of social workers who will be in attendance and to talk about what else? Health reform! As a short primer, we thought we'd list, the top five facts that all Illinois social workers should know about the Affordable Care Act - i.e., the national health care reform law.

1. Demand for Your Services Will Grow 
In 2014, as a result of the Affordable Care Act, over 1.1 million people in Illinois will become eligible for insurance through Medicaid or the new subsidized insurance product on the exchange; thus, social workers will have more insured paying patients.

2. REALLY, Demand for Your Services Will Grow 
Essential Health Benefits are still being defined now but include behavioral health and habilitative and rehabilitative care - services provided by and important to social workers.

3. Your Role Will Be More Important Than Ever
The Affordable Care Act emphasizes coordinated care arrangements through new initiatives such as Accountable Care Organizations and Health Homes both of which rely primarily on the care coordination provided by professionals such as social workers.

4. You Will Be Instrumental in Improved Health Outcomes
In 2014, hospitals will no longer be reimbursed for certain re-admissions so presumably they will invest in discharge planning and social workers to provide transition care to the home and community and avoid re-admissions.

5. More Jobs for Social Workers
Community Health Centers are receiving large increases of funding to provide primary care and coordinated care to the newly insured population and will need to hire social workers to provide care coordination and linkage and referral to low income populations who have not had experience getting into care.

If you have health reform questions, you can find us on twitter at @ilhealthmatters. We will be live tweeting from the NASW conference using the hashtag #NASWIL. Hope to see you there! Or you can always email us at info@illinoishealthmatters.org. We will answer your questions directly and possibly feature them on our website.

Lastly, we are having a one-day raffle for a $50 Amazon.com Gift Card for people who sign up for our e-newsletter today, November 10, 2011. So, be informed and enter to win! Entrants will be notified by email.