WHAT YOU SHOULD KNOW ABOUT HEALTHCARE REFORM

Improvements to healthcare in America begin today

New York--  If you are currently covered by health insurance and are satisfied, and as long as your insurer continues to offer the plan, you can keep it.

Health plans that were in place on March 23, 2010, the day healthcare reform passed, are “grandfathered” meaning they are past policies that are allowed to essentially remain the same. Reform allows insurers and employers to innovate and contain costs by making routine changes without losing grandfather status. However, plans will lose their grandfather status if they choose to significantly cut benefits or increase out-of-pocket spending for consumers—and consumers in plans that make such changes will gain new protections.

The following improvements in coverage apply to all health plans, including those grandfathered plans:

Some plans currently have annual and lifetime monetary limits on how much your insurer will pay for your medical care which cause major problems for people who have long term illnesses. Going forward, there can be no annual or lifetime limits.

In New York, insurers cannot refuse to sell anyone health insurance just because they have a pre-existing condition. However, in all states, even New York, the insurer can refuse to pay for care for that pre-existing condition for the first year. Going forward, insurers must cover pre-existing conditions for children age 18 or younger immediately and adults will receive the same protections in 2014.

If insurers offer family coverage, it must now cover your children until they turn age 26. New York State has ensured that parents could buy insurance through their employer’s group policy for children up to age 29.  This is generally less expensive than buying individual insurance.

In the past, when individuals suffered from expensive illnesses, insurers could look for small errors in insurance applications and use them as an excuse to cancel policies. Going forward, policies can only be rescinded for fraud, not unintentional errors. This past August, Governor Paterson signed ‘Ian’s Law’ which will grant additional protections to New Yorkers who suffer from costly medical conditions.

The following changes apply to group and individual policies that are not grandfathered:

Insurers may not require you to receive prior authorization for emergency services, a provision we already have in New York. In addition, your co-payment or co-insurance amount cannot be higher if you utilize an out-of-network hospital or provider in an emergency.

The most commonly used preventive services, such as immunizations and screenings, must be provided to children and adults at no cost to you, meaning there will be no co-payment or deductible. New York currently requires coverage of well-child visits and immunizations for children through age 19 without cost-sharing.

If an insurer refuses to cover some medical treatment, it must provide a means for the consumer to appeal that decision both within the company and to an independent outside entity. New York already requires this kind of appeals process.

If your plan allows you to pick a primary care provider, then it must allow you to choose any participating primary care provider who is available to accept patients and women do not need a referral from a primary care doctor to receive obstetric or gynecological care from a participating provider, which is already a provision in New York.

The next important question is when will these provisions apply to you? Improvements are required to start when your first new policy year starts after September 23, 2010. So if your policy year starts January 1, then you will have many of these new benefits starting January 1, 2011. If your policy year starts July 1, then for you it is July 1, 2011. If you don’t know when your policy year starts, ask your employer, benefits administrator or your insurer. However, if you buy a new individual or group policy the new benefits start immediately.

Healthcare reform does not have to be complicated. Our advice is to not take any crap from your healthcare insurer-- always consult your employer or union representative if you feel you are being taken advantage of or that you feel "something is just not right" with your coverage.  To obtain more information, please visit this website sponsored by the state of New York.

(photos by Ove Overmyer)