Senate Democrats

Implementing Health Reform that Works for Middle-Class Americans

Earlier this year, Congress passed and the President signed landmark health insurance reform legislation, the Patient Protection and Affordable Care Act (P.L. 111-148) and the Health Care and Education Reconciliation Act (P.L. 111-152), and Americans are already experiencing the benefits.  These two laws put control over health care decisions in the hands of the American people, not insurance companies.  Senate Democrats are committed to implementing health reform that holds insurance companies accountable, brings costs down for everyone, and provides Americans with the insurance security and choices they deserve.  The following fact sheet provides an overview of recent health reform implementation activity.  Previous updates on health reform implementation and other information are available from the DPC. [DPC]

Web Portal for Consumer Information on Insurance Options

The Patient Protection and Affordable Care Act enables creation of a new web portal to facilitate informed consumer choice of health insurance options.  On July 1, 2010, the Administration will launch www.healthcare.gov, which will help individuals and small businesses identify insurance options in their state.  In addition to helping individuals navigate private insurance options in the individual and small group markets, the web portal will assist users in determining if they are eligible for various public programs, including existing high risk pools, the new pre-existing condition insurance plan created by the Patient Protection and Affordable Care Act, Medicaid, Medicare, and the Children’s Health Insurance Program (CHIP). [HHS, undated]  The Department of Health and Human Services issued regulations and other information about the web portal on April 30, 2010. [HHS, 4/30/10; 4/30/10]

Consumer Protections and a Patients’ Bill of Rights

The Patient Protection and Affordable Care Act includes numerous consumer protections and a Patients’ Bill of Rights – provisions that Senate Democrats have been fighting to enact for nearly a decade.  On June 22, 2010, the Departments of Health and Human Services, Labor, and Treasury issued regulations to implement these new patient protections, which take effect for policy or plan years beginning on or after September 23, 2010, and apply to various types of health insurance plans, as noted below. [HealthReform.gov, 6/22/10

·         Required coverage of preventive care with no cost-sharing.  Insurers will be required to provide free coverage of preventive health care services.  This provision applies to all new plans in all markets.

·         No coverage rescissions when Americans get sick.  Insurers will be prohibited from rescinding health coverage when a beneficiary gets sick as a way of avoiding paying that person’s health care bills.  This provision applies to all new and existing plans in all markets.

·         No lifetime limits on coverage.  Insurers will be prohibited from imposing lifetime limits on benefits.  This provision applies to all new and existing plans in all markets.

·         Regulated annual limits on coverage.  Insurance plans’ use of annual limits will be tightly regulated to ensure access to needed care.  This provision applies to all new plans and existing employer plans, until 2014, when the Exchanges are operational and use of any type of annual limit will be banned for all new plans and existing employer plans.

·         Fair opportunity to appeal coverage and claims decisions.  Health insurers will be required to develop an appeals process that, at a minimum, provides beneficiaries with a notice of internal and external appeals processes and allows beneficiaries to review their file and present evidence in their appeal.  This provision applies to all new plans in all markets.

·         Patients’ Bill of Rights.  Patients’ rights are protected by allowing health insurance plan members to choose any participating primary care provider, or in the case of children, any participating pediatrician, prohibiting insurers from requiring prior authorization before a woman sees an ob-gyn, and ensuring access to emergency care.  This provision applies to all new plans in all markets.

$250 for Seniors Who Hit the ‘Donut Hole’

The first round of $250 checks was mailed on June 10, 2010 to Medicare beneficiaries who do not receive Medicare Extra Help and who had already entered the “donut hole.”  The next round of checks is expected to be mailed around July 10, 2010 to beneficiaries who entered the donut hole after the first round of checks were mailed, and these checks will continue to go out monthly for the rest of the year as beneficiaries enter the coverage gap. [White House, 6/8/10]  The $250 rebate check is tax-free and seniors do not need to do anything to receive it; Medicare automatically mails a check when the beneficiary reaches the “donut hole.” [Centers for Medicare & Medicaid Services, 5/10]  Seniors should expect their check in the mail within 45 days or less of hitting the coverage gap.  Information on the number of seniors in your state who may qualify for the rebate check this year is available from the DPC. [DPC, 6/22/10]

Beginning next year, Medicare beneficiaries who do not receive Medicare Extra Help will receive a 50 percent discount on brand-name drugs and biologics they purchase when they are in the coverage gap.  In addition to the discount, coverage in the “donut hole” will increase until 2020, when 75 percent coverage on all drugs purchased in the gap will completely fill in the “donut hole.”  More information on filling in the “donut hole” and other benefits of health reform for seniors is available from the DPC. [DPC, 6/10/10]

Additional Information

The Democratic Policy Committee has released four previous updates on health reform implementation, available on the DPC website here, with the following direct links:

In addition, DPC maintains a centralized listing of health reform implementation resources which is frequently update and is available here.

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