National Health Care Reforms Are Already Beginning

September 20, 2010

September 23, 2010 marks six months since our new national health care reform law, also known as the Patient Protection and Affordable Care Act (PPACA), became effective. It remains a controversial undertaking for some, yet a positive step for others. The law’s implementation is a long and complex journey.

Much of the spotlight has been on PPACA reforms that begin in 2014, such as:

• A requirement for American residents to have health insurance

• Expansion of Medicaid

• New health insurance “Exchanges” where people can compare and shop for insurance

• Financial subsidies to help people pay for health insurance in the Exchange

• Penalties for many businesses that do not provide health insurance for their employees

• Insurance reforms–such as requiring insurers to offer coverage to everyone, regardless of health status, and prohibiting using a person’s health status as a factor in premium rates

But some pretty significant reforms have already taken place – some tied to the six-month mark – and I wanted to highlight them for you because they may be helpful to you and your families. Please spread the word!

A new website was created by the federal government to provide information to consumers and small businesses about their insurance options. People can also determine if they may be eligible for existing public programs, including Pre-existing Condition Insurance Pools, Medicaid, Medicare and the Children’s Health Insurance Program. This website does not allow consumers to buy insurance, but instead is a tool that provides information until the new insurance Exchanges start in 2014. Click here to access the website:

A new “Pre-existing Condition Insurance Pool” program, or PCIP, was created for adults with pre-existing medical conditions who have been uninsured for at least the past six months. The PCIP will end Jan. 1, 2014 when the Exchanges begin, and people in the PCIP will then transition to the Exchange for their insurance coverage. Eligible Michigan residents can apply today for coverage in the Michigan PCIP for coverage slated to begin Oct. 1, 2010. The monthly insurance premiums are set at a price for the standard population–not for a population with medical conditions. Out-of-pocket costs are capped for PCIP participants. Visit the website of the Michigan Department of Energy, Labor, and Economic Growth’s Office of Financial and Insurance Regulation for more information.

Tremendous efforts are underway by insurers and businesses to implement “near-term” insurance reforms that take effect with plan years beginning on or after Sept. 23, 2010. For many insured individuals, the “plan year” begins on Jan. 1, 2011, but you should check on your plan year date. “Near-term“ insurance reforms you may be interested in include:

Dependent coverage extended to age 26: If coverage is offered for employees’ children, eligibility must be extended to married or unmarried children of covered employees up to age 26. “Grandfathered plans” that existed on or before Mar. 23, 2010 have to do this for adult children up to age 26 who are not eligible for employer-sponsored coverage elsewhere. Starting in 2014, dependents up to age 26 must be allowed to be covered on their parents’ policy even if they have access to employer-sponsored health coverage.

No lifetime limits or restrictive annual limits: There are no lifetime limits allowed on essential health benefits, and annual limits on essential benefits must be phased out by 2014. Please note that the federal government has not yet fully defined “essential health benefits.”

No pre-existing condition exclusion period for people under age 19: During a specified enrollment period, children under age 19 cannot be denied coverage due to a pre-existing condition, nor can there be any periods where medical services related to that pre-existing condition are not covered. In 2014, PPACA requires all insurers to guarantee insurance coverage to all individuals without charging higher amounts based on a person’s health status. In Michigan, BCBSM has acted as the state’s insurer of last resort and has always accepted anyone, regardless of health status.

Prohibiting rescissions with limited exceptions: Health coverage cannot be rescinded except in cases of fraud or material misrepresentation. Rescinding means retroactively voiding the health insurance contract. As a side note, BCBSM has never rescinded policies for any reason other than fraud or material misrepresentation.

Preventive services with no cost-sharing: Certain preventive services must be included in health care coverage–without cost-sharing. This includes a large list of screenings, immunizations, and other services recommended by entities such as the U.S. Preventive Services Task Force, a Centers for Disease Control advisory committee, and the federal Health Resources and Services Administration.

Emergency services without prior authorization & cost sharing: If emergency services are a covered benefit, prior authorization for these services cannot be required. Also, cost sharing required to be paid by the insured individual for services provided by nonparticipating health care providers cannot be more than for participating providers.

These immediate and near-term insurance changes mark the beginning of health reform’s impact on all of us. Whether you are a Blues member or not, please check out our company’s health care reform website for some valuable information about reform. And for the policy wonks out there, you can find a comprehensive summary of PPACA on the Kaiser Family Foundation site and two related CHRT publications on this website: a policy brief on state and local opportunities in the Act, and an issue brief on the impact of reform on coverage in Michigan.

Good health to you all.


Lynda Rossi is vice president of Public Policy and Social Mission for Blue Cross Blue Shield of Michigan and a member of the CHRT board of directors.