MedCity Influencers

Some national health reforms are here

They’re not complete cures, but supporters say the initial changes being rolled out this week as part of national health reform could offer help for some consumers. Critics, however, warn the mandates could drive up the cost of health coverage, beginning with this year’s renewals.

They’re not complete cures, but supporters say the initial changes being rolled out this week as part of national health reform could offer help for some consumers.

Critics, however, warn the mandates could drive up the cost of health coverage, beginning with this year’s renewals.

Starting Thursday, health-insurance plans must meet these new requirements when coverage is issued or renewed:

• Offer health coverage to children on their parent’s plan until they turn 26.

• Pay for nationally recommended preventive care — things such as mammograms, colonoscopies and childhood immunizations — without making enrollees pay a penny for the services.

• Eliminate lifetime dollar caps on medical care.

• Cover pre-existing conditions for children younger than 19, even if they didn’t previously have health insurance that covered those medical problems.

• Provide an independent external appeal process when an insurer refuses to cover a test, treatment, procedure or other services.

Although Jennifer Whelan doesn’t approve of all aspects of the wide-ranging health-reform measure, she appreciates the ban on lifetime caps for benefits. The 38-year-old working mother of 4-year-old twin daughters from Peninsula has good health insurance, which covers most of the care she needs to treat her multiple sclerosis.

Her insurance helps pay the $30,000 annual price tag for the daily shots she takes to slow the progression of the chronic neurological disease. With health reform, she said, she won’t have to worry about whether future expenses will be covered, too.

”From my perspective, the whole lifetime cap is extremely important, because who knows what they’re going to figure out that can cure me, but I might not be able to afford it?” she asked.

”Who knows what they can figure out from a treatment perspective that can help me continue to be a productive member of society? But if I can’t afford to keep my disease from progressing, then I just become a drain on my family and then, ultimately, a drain on society.”

The provisions in effect this month are the first in a series of requirements that will be implemented in coming years after Congress passed its sweeping overhaul of the nation’s health-care system in March.

Plans in existence by March 23 that obtain what’s known as ”grandfathered” status won’t be subject to some of the new rules, said Ken Haneline, a partner with Kastner Westman & Wilkins LLC, a law firm in Akron.

To qualify for grandfathered status, employers can’t switch insurance carriers or make workers pay substantially more for coverage, Haneline said. ”You really can’t make any benefit changes to maintain grandfathered status,” he said. ”It keeps you within a real time range of what you can increase for the employee payment.”

Grandfathered plans aren’t required to cover dependents to age 26 if the person can obtain coverage through another source, such as through a job, Haneline said. Those plans also aren’t required to pay 100 percent for preventive care. ”If your employer has a grandfathered plan, you may still have to cost-share on the preventive stuff,” Haneline said.

The U.S. Department of Health and Human Services estimates as many as 71 percent of health plans offered by companies with 100 or more employees and 58 percent offered by smaller companies will seek grandfathered status this year. By the end of 2013, the government estimates, 66 percent of small employers and 45 percent of large firms will relinquish their grandfathered status, meaning their health coverage will be subject to all the rules.

The first round of requirements probably will help only a few of the uninsured Summit County residents enrolled in Access to Care, project director Marsha Schofield said. The program links about 1,925 uninsured adults with free medical care.

Participants can’t be eligible for any public or private health coverage. Access to Care recently sent letters about the new provisions to 147 participants — 8 percent of its enrollees — who might qualify for coverage through a parent’s plan.

Along with the federal requirement, Ohio recently enacted a measure that lets unmarried children stay on their parent’s insurance plan until age 28. (The state law affects only fully insured health plans, which typically are offered by smaller employers.)

”This first wave is having a very small impact on this population we’re serving,” Schofield said. She anticipates a bigger impact in 2014, when the federal health-reform law expands eligibility for Medicaid and provides tax subsidies to buy insurance.

At that time, individuals will be required to get insurance or pay a penalty, said Jennifer Tolbert, a health policy analyst with the nonprofit Kaiser Family Foundation. Companies with 50 or more workers will be required to provide adequate coverage or face penalties.

Health-insurance exchanges also will be created to help buy coverage, she said. ”The changes that are going into effect this month are important changes, but certainly the more significant changes will occur in 2014,” she said.

Estimates vary about how much the reforms initially will increase premiums. A principal in national consulting firm Mercer’s Cleveland office estimated that the new requirements this year will increase premiums 2 percent to 4 percent. The Wall Street Journal recently reported that some insurers are seeking increases exceeding 20 percent, with 1 percent to 9 percent attributed to new benefit mandates.

Akron-based SummaCare opted against increasing premiums to cover health-reform requirements for its fully insured plans this year, even though ”pent-up demand” for preventive services could initially increase costs, said Kevin Cavalier, vice president of sales. ”A few early detections of cancer or other chronic conditions will mitigate a lot of that upfront cost,” he said. ”It fits in with our philosophy quite well. We will eat some upfront costs.”

Federal officials have warned insurers against blaming premium hikes on health reform, noting that experts estimate the impact will be less than 2 percent in 2011. But Dave Petno, a health insurance broker from Hudson and media chairman of the Ohio Association of Health Underwriters, said he’s already seeing evidence that the new mandates are driving up insurance costs.

Insurance brokers and agents in Ohio ”have all seen more 30 percent-plus increases in the last six months following health-care reform than we had in the 10 years before that,” he said.

”Every single one of these mandates increases the cost to employees and the people who purchase insurance and to insurance companies,” Petno said. ” … They’re adding mandates. They’re adding additional regulations and bureaucracy, so that makes insurance companies have to work harder to have to maintain profitability.”

Cheryl Powell is a health reporter for The Akron Beacon Journal, the daily newspaper in Akron and a syndication partner of MedCity News.