Health Reform Step-by-Step: No More Preexisting Condition Exclusions for Children Under 19
The Patient Protection and Affordable Care Act is a long, complicated document that will cause real changes in the way that you and your family access and pay for health insurance. Texas Impact is committed to helping you understand the bill and making sure that you get the benefits available to you. In the coming weeks, we will pick apart the bill-- starting with the provisions that go into effect in 2010-- so you can see who will be affected.
Prohibition of Health Condition Exclusions for Children Under 19
The Affordable Care Act makes provisions for children who are currently have difficulty obtaining health insurance because of previous or existing health conditions. A preexisting condition exclusion is a plan provision that limits benefits or excludes benefits or plan coverage because a health condition was present before the effective date of coverage.
For health plans beginning on or after September 23, 2010, insurance companies are required to cover young people under the age of 19 who have a pre-existing condition that has excluded them from coverage in the past. This provision applies to all grandfathered and new group plans (including self-insured plans) and all new individual plans. The new provision applies to all under age 19, regardless of employment, marriage or other status.
In Texas, individuals with preexisting conditions have been able to obtain coverage through the High Risk Pool. Now, adults with preexisting conditions can obtain coverage through the federal Preexisting Condition Insurance Plan, if they have not had coverage for the past 6 months and meet certain other eligibility requirements. Beginning in the 2014 plan year, with the health exchange, no preexisting condition exclusions for any individual will be permitted.
For more information on health care options for families, visit www.healthcare.gov.
A Health and Human Services Fact Sheet provides an FAQ about the provision:
Previous Health Reform Step-by-Step articles:
Health Reform Step by Step: An Overview
Extension of Young Adult Coverage
Health Reform Step by Step: An Overview
Health Reform: Step-by-Step
The Patient Protection and Affordable Care Act of 2010 is a long, complicated document that will cause real changes in the way that Texans access and pay for health insurance and health care. Texas Impact is committed to making sure that you understand the bill and know what benefits are already available to you.
New insurance plans begun on or after September 23, 2010, are required to include recommended preventative services without payment of a deductible, co-payment or coinsurance. For many Americans, this provision will allow access to important screenings and treatments that might have previously been cost-prohibitive.
Eliminate Medicare Part D Drug Benefit Coverage Gap: The Doughnut Hole
Medicare beneficiaries enrolled in a “Part D” prescription drug plan experience a gap in coverage that occurs once they have used up $2500 of drug payment benefits and before they have spent $4550 in out-of-pocket payments. The Affordable Care Act will help seniors who face this “doughnut hole” gap by gradually phasing in subsidies for medication, starting in 2011. In 2010, a one-time, a tax-free, $250 rebate check will automatically be mailed to Medicare enrollees who qualify based on drug expenditures.
Extend Coverage for Young Adults
Beginning on September 23, 2010, insurance companies are required to permit children who do not have insurance through their employer to stay on their parents' insurance until they turn 26. This applies to all plans in the individual market, new employer plans, and existing employer plans, and applies to both unmarried and married children.
Provide Tax Credit to Small Businesses
To help small businesses shoulder the burden of providing health insurance coverage to their employees, the federal government is offering tax credits to certain small businesses who offer coverage. About 4 million small businesses throughout the country will benefit from this provision, including an estimated 223,000 Texas businesses. Employers must have fewer than 25 full-time employees with average annual wages of less than 50,000, and must cover at least 50% of the cost of health insurance for their employees.
Insure Adults with Pre-Existing Conditions
The Affordable Care Act sets up an insurance pool for uninsured adults (over age 19) who have pre-existing medical conditions. The newly designed federal insurance pool, known as the Pre-Existing Conditions Insurance Plan (PCIP), allows previously uninsured individuals to obtain insurance and pay premium rates equal to standard market rates. Texas has a High-Risk Pool for individuals with pre-existing conditions, but individuals cannot transfer from the state to the federal pool. To qualify for the federal plan, an individual must have been uninsured for at least 6 months. By 2014, insurance companies will no longer be able to refuse coverage to those who have historically been considered un-insurable.
Prohibit Pre-Existing Condition Exclusions for Children under Age 19
Beginning September 23, 2010, all health insurance plans, new or existing, will be prohibited from denying coverage to children under age 19 due to a pre-existing condition.
Prohibit Lifetime Benefit Limits in all Plans
Beginning September 23, 2010, all health insurance plans will be required to eliminate lifetime benefit limits on what are deemed “essential health benefits.” While the full definition of these “essential” benefits has not yet been determined, these will include things like hospital stays and ambulance rides. Health insurance providers will be prohibited from issuing any new plans with lifetime or annual benefit limits after September 23, and existing annual limit requirements will be phased out by 2014.
Prohibit “Rescission” (retroactive cancellation of health insurance)
Effective September 23, 2010, all insurance plans will be prohibited from rescinding, or cancelling, insurance policies when individuals get sick, except in proven cases of fraud.
Review Premium Increases Starting in 2010, states will able to apply for federal grant funds allowing them to annually review insurance plans for excessive premium rate increases. States will report on trends, approve rate increases if justified, and may sanction insurance companies if premium increases are found unjustified.
Strengthen Consumer Appeals Process
New health plans beginning on or after September 23, 2010 must have internal and external appeals processes for coverage and claims denial. Consumers will have the right to appeal decisions made by their health plan directly to the company and also through an independent, outside agent.
Establish State Health Insurance Ombudsman
Starting in 2010, states will be able to apply for federal grant funds available to establish an independent office of the ombudsman. This office will help consumers with insurance-related tasks such as filing complaints and appeals, enrolling in insurance plans, selecting a primary care physician, and taking advantage of their available benefits.
The list of provisions is limited to those that will apply in 2010.
More detailed information about the Affordable Care Act is also available at www.healthcare.gov.
Health Reform Step-by-Step: Pre-Existing Conditions Insurance Plan
The Patient Protection and Affordable Care Act is a long, complicated document that will cause real changes in the way that you and your family access and pay for health insurance. Texas Impact is committed to helping you understand the bill and making sure that you get the benefits available to you. In the coming weeks, we will pick apart the bill-- starting with the provisions that go into effect in 2010-- so you can see who will be affected.
Pre-Existing Conditions Insurance Plan (PCIP)
One of the Affordable Care Act’s most important changes to the health insurance system is its provision for individuals who are unable to obtain private health insurance coverage because of pre-existing medical conditions. For the past 12 years in Texas, the High Risk Insurance Pool has served as a “safety net” for those excluded from regular coverage. This year, new federal guidelines under the Affordable Care Act establish a federal insurance pool for the previously uninsurable, run by the U.S. Department of Health and Human Services to run the program instead.
The newly designed federal insurance pool, known as the Pre-Existing Conditions Insurance Plan (PCIP), will allow previously uninsured individuals to obtain insurance, and pay premium rates equal to standard market rates. In order to qualify for the federal plan, one must:
- Be a US citizen, or lawfully present in the US,
- Have been uninsured for at least 6 months,
- Provide a recent (within 6 months) insurance company coverage rejection letter.
The “rolling implementation” of the Affordable Care Act means that by 2014, insurance companies will no longer be able to refuse coverage to those who have historically been considered uninsurable. Twenty-eight states are improving their health insurance systems to include a risk pool, and 22 other states (including Texas) are relying on the federal PCIP to serve as a “stop-gap safety net” for the next four years.
Beginning July 1, applications for the Pre-Existing Conditions Insurance Plan can be submitted, and those who enroll in the plan before July 15 can anticipate coverage beginning August 1.
More information about the plan can be found at www.pcip.gov.
Health Reform Step-by-Step: Free Preventive Care
Health Reform Step-by-Step: Temporary High-Risk Pool
Health Reform Step-by-Step: The Doughnut Hole
Health Reform Step-by-Step: Small Business Tax Credits
Health Reform Step-by-Step: Young Adult Coverage
Health Reform Step-by-Step: Free Preventive Care
The Patient Protection and Affordable Care Act is a long, complicated document that will cause real changes in the way that you and your family access and pay for health insurance. Texas Impact is committed to helping you understand the bill and making sure that you get the benefits available to you. In the coming weeks, we will pick apart the bill-- starting with the provisions that go into effect in 2010-- so you can see who will be affected.
Free Preventive Care
If you and your family enroll in a new insurance plan on or after September 23, 2010, your insurance company will be required to pay for recommended preventative services under your plan. Many types of preventive care will be available to plan holders without payment of a deductible, co-payment or coinsurance. For many Americans, this provision will allow access to important screenings and treatments that might have previously been cost-prohibitive.
Healthcare.gov, the US Health and Human Services web portal for understanding the Affordable Care Act, outlines some of the most probable services that will now be available to new plan enrollees in September. While dependent on the specific insurance plan and patient profile, these include:
- Blood pressure, diabetes, and cholesterol tests
- Many cancer screenings
- Counseling from your health care provider on such topics as quitting smoking, losing weight, eating better, treating depression, and reducing alcohol use
- Routine vaccines for diseases such as measles, polio, or meningitis
- Flu and pneumonia shots
- Counseling, screening and vaccines for healthy pregnancies
- Regular well-baby and well-child visits, from birth to age 21
The new requirements for insurance companies are more in a series of immediate changes that will help lower health care costs for Americans by proactively preventing disease.
To see a video statement by First Lady Michelle Obama and Dr. Jill Biden, click here.
To see more information at Healthcare.gov, click here.
Health Reform Step-by-Step: Temporary High-Risk Pool
Health Reform Step-by-Step: The Doughnut Hole
Health Reform Step-by-Step: Small Business Tax Credits
Health Reform Step-by-Step: Young Adult Coverage
Toxic Chemicals Spew from BP Texas Refinery Before the Gulf Disaster
Two weeks before the BP disaster in the Gulf of Mexico, BP’s Texas City refinery began spewing an enormous quantity of toxic chemicals into the Texas air. The release of toxins began on April 6 and lasted for 40 days unnoticed by BP. The refinery discharged an estimated half a million pounds of benzene, carbon monoxide, nitrogen oxides, and other toxins.
This appears to be one of the largest chemical releases to happen in the last decade. The amount of chemicals released greatly exceeds the limit that the state and federal government permits. It is unclear whether the pollutants have had any health impacts on any of the Texas City residents.
According to BP and Texas officials, the catastrophe stemmed from BP’s decision to repair key equipment while still producing and selling gasoline. BP discovered the seriousness of the problem after analyzing data from a monitor that measures emissions from a flare 300 feet above the ground, a flare that was supposed to incinerate the toxic chemicals.
Michael Marr, a BP spokesman, said BP believed the plant's existing monitors would detect any excess emissions. The existing monitors are located just a few feet above the ground level and approved by Texas regulators. Without looking closely at the monitors these emissions would have stayed undetected.
Currently the BP refinery is still in operation and relying on fence-line monitors that are not adequately detecting harmful air pollutants. Additionally, BP immediately received measurements from a separate monitor that took readings from the flare. BP did not notice the emissions were exceeding permitted limits until June 4.
This incident along with others has Texans asking why is BP not adequately monitoring these flares, how often do major releases go undetected and why is the state regulatory agency not enforcing strict air emission policies? The state agency accountable for air emissions and refinery regulation in Texas is the Texas Commission on Environmental Quality, or the TCEQ.
To read the complete Texas Observer article, click here. To learn more about TCEQ, click here.
- Andrea Earl's blog
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Health Reform Step-by-Step: The Doughnut Hole
The Patient Protection and Affordable Care Act is a long, complicated document that will cause real changes in the way that you and your family access and pay for health insurance. Texas Impact is committed to helping you understand the bill and making sure that you get the benefits available to you. In the coming weeks, we will pick apart the bill-- starting with the provisions that go into effect in 2010-- so you can see who will be affected.
Medicare Part D Drug Benefit Coverage Gap: The Doughnut Hole.
Since 2006, Medicare beneficiaries enrolled in a Medicare Part D prescription drug plan have experienced a gap in coverage that occurs once they have used up $2500 of drug payment benefits and before they have spent $4550 in out-of-pocket payments. This gap, known as the “doughnut hole,” typically affects about 4 million seniors who reach their full amount of medication benefits and do not quality for Medicare low-income assistance.
Beneficiaries who reached the “doughnut hole” in the first quarter of 2010 have already had a tax-free, $250 check mailed to them. Throughout 2010, this one-time rebate check will automatically be mailed to Medicare enrollees who qualify based on drug expenditures.
The Affordable Care Act will help seniors who face this benefit gap by gradually phasing in subsidies for medication, starting in 2011. Next year, seniors who reach the “doughnut hole” will experience a 50 percent discount on all brand-name medicines, with additional discounts for brand-name and generic drugs being added until the gap is closed in 2020.
The Kaiser Foundation offers a brief analysis of this provision of the law. To view it, click here.
For more information about this provision from Healthcare.gov, click here.
To read more about how the healthcare reform bill will affect Texas, click here.
Health Reform Step-by-Step: Extension of Young Adult Coverage
Health Reform Step-by-Step: Temporary High-Risk Pool
Health Reform Step-by-Step: Small Business Tax Credits
Health Reform Step-by-Step: Free Preventive Care
Insurance for the Un-Insurable
One of the Patient Protection and Affordable Care Act’s (PPACA) most important changes to the health insurance system is its provision for Individuals who are unable to obtain private health insurance coverage because of pre-existing medical conditions. For the past 12 years in Texas, the High Risk Insurance Pool has served as a “safety net” for those excluded from regular coverage. This year, Texas had the option of adapting the high risk pool to follow new federal guidelines, but decided to opt out, allowing the U.S. Department of Health and Human Services to run the program instead.
The newly designed federal insurance pool, known as the Pre-Existing Conditions Insurance Plan (PCIP), will allow previously uninsured individuals to obtain insurance, and pay premium rates equal to standard market rates. Texas' high-risk pool costs consumers twice as much as the federal one, but there’s no switching of plans allowed—in order to qualify for the federal plan, one must have been uninsured for at least 6 months.
The “rolling implementation” of the PPACA means that by 2014, insurance companies will no longer be able to refuse coverage to those who have historically been considered uninsurable. Twenty-eight states are improving their health insurance systems to include a risk pool, and 22 other states (including Texas) are relying on the federal PCIP to serve as a “stop-gap safety net” for the next four years.
Beginning today, July 1, applications for the Pre-Existing Conditions Insurance Plan can be submitted, and those who enroll in the plan before July 15 can anticipate coverage beginning August 1. More information about the plan can be found at www.pcip.gov.
Sources: Austin American-Statesman, “Texans can apply for U.S. health insurance pool.”
Healthcare.gov
- Aerin's blog
- Login or register to post comments
Health Reform Step-by-Step: Small Business Tax Credits
The Patient Protection and Affordable Care Act is a long, complicated document that will cause real changes in the way you and your family access and pay for health insurance. Texas Impact is committed to helping you understand the bill and making sure you get the benefits available to you. In the coming weeks we will pick apart the bill-- starting with provisions that go into effect in 2010-- so you can so who will be affected.
Small Business Health Care Tax Credit
Small businesses have struggled for years to provide health insurance coverage to their employees. To help them shoulder the burden of this cost, the federal government is offering tax credits to certain small businesses who offer health insurance coverage to their employees.
The credit will cover up to 35% of the employer's contribution to health insurance, with an increase to 50% on January 1, 2014. About 4 million small businesses throughout the country will benefit from this provision, including an estimated 223,000 Texas businesses.
To qualify for the tax credit, an employer must:
- cover at least 50% of the cost of health insurance for employees
- not have more than 25 full-time equivalent employees
- have annual average wages of less than $50,000
To read more about the tax credit provision, you can visit the IRS website here.
To read about this provision on the health reform website, click here.
To read more about how the healthcare reform bill will affect Texas, click here.
Health Reform Step-by-Step: Extension of Young Adult Coverage
Health Reform Step-by-Step: Temporary High-Risk Pool
Health Reform Step-by-Step: The Doughnut Hole
Health Reform Step-by-Step: Free Preventive Care
Health Reform Step-by-Step: The Temporary High-Risk Pool (UPDATED!)
The Patient Protection and Affordable Care Act is a long, complicated document that will cause real changes in the way that you and your family access and pay for health insurance. Texas Impact is committed to helping you understand the bill and making sure that you get the benefits available to you. In the coming weeks, we will pick apart the bill—starting with the provisions that go into effect in 2010—so you can see who will be affected.
The Temporary High-Risk Pool
One goal of healthcare reform is to expand access to affordable insurance to those who cannot afford it. To that end, the Patient Protection and Affordable Care Act establishes broad coverage provisions that take effect in January 2014. Until then, however, the Act sets up a temporary high-risk pool for people who have pre-existing medical conditions and are without insurance.
Beginning on June 21, 2010, all individuals who have a pre-existing condition and how have not had health insurance for six months are eligible to enroll in the Temporary High-Risk Pool. This pool is meant to serve as a final safety net for those without insurance. To discourage people from switching from private insurance into this plan, the Act mandates that individuals must be without insurance for six months before enrolling.
The Temporary High-Risk Pool provides benefits that many plans, including Texas' own high-risk pool, do not offer. Kathleen Sebelius, Secretary of Health and Human Services, will determine the minimum benefits in the package, but right now we know that this plan must cover at least 65% of healthcare costs, that out-of-pocket spending is limited to $5,950 for individuals and $11,900 for families, and that premiums must be set as if for a 'standard' population, rather than a 'high-risk' population. Hopefully, the provisions will help keep this plan affordable for Texans. The federal pool, though, does allow for premium variation by age, geographic area, family composition and tobacco use.
States had various options as to how they would choose to administer this program. HHS Commissioner Tom Suehs told Secretary Sebelius on April 30, 2010 that he would allow the federal government to operate the pool in Texas. More information about how the federal government will operate the program will be forthcoming.
Updates on the Temporary High Risk Pool (PCIP)
To see the Kaiser Foundation's analysis of this provision, click here.
To see Secretary Sebelius' letter to states about developing a high-risk pool, click here.
For more information about how the Affordable Care Act will affect Texas, click here.
Health Reform Step-by-Step: Free Preventive Care
Health Reform Step-by-Step: Extension of Young Adult Coverage
Health Reform Step-by-Step: The Doughnut Hole
Health Reform Step-by-Step: Small Business Tax Credits
Health Reform Step-by-Step: Extension of Young Adult Coverage
The Patient Protection and Affordable Care Act is a long, complicated document that will cause real changes in the way that you and your family access and pay for health insurance. Texas Impact is committed to helping you understand the bill and making sure that you get the benefits available to you. In the coming weeks, we will pick apart the bill-- starting with the provisions that go into effect in 2010-- so you can see who will be affected.
Extension of Coverage for Young Adults
Beginning on September 23, 2010, insurance companies are required to permit children who do not have insurance through their employer to stay on their parents' insurance until they turn 26. This applies to all plans in the individual market, new employer plans, and existing employer plans. This provision applies to both unmarried and married children.
Texas law currently allows children up to age 25 to stay on family policies. Because of the gap in age requirements, many children who turn 25 before this provision goes into effect could loose coverage for a few months. Twenty-five year olds will, however, be allowed to re-enroll in their family's plan in September.
Secretary of Health and Human Services Kathleen Sebelius is working with insurance companies to encourage them to voluntarily expand coverage to children who would fall off their parents' coverage between now and September. United Healthcare, WellPoint (which administers some BlueCross BlueShield plans), Humana and Kaiser Permanente have all put in place measures that will allow children to stay on their parents' plan until September.
The Kaiser Foundation offers a brief analysis of this provision of the law. To view it, click here.
To read a statement from Secretary Sebelius about expansion efforts, click here.
For more information about how the Affordable Care Act will affect Texas, click here.
Health Reform Step-by-Step:Temporary High-Risk Pool
Health Reform Step-by-Step:The Doughnut Hole
Health Reform Step-by-Step:Small Business Tax Credits
