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Health Care Reform Benefits: What 2011 Will Bring

Your questions answered

Q. What are the new health care reform benefits that start in the new year? Do the recent court cases stop the changes?

A. So far, the court challenges to the law do not affect the benefits that began Jan. 1. Once the benefits kick in, health care policy experts and political experts predict it will be difficult to take them away. Because there are so many new benefits for this year, here are some highlights with links to past columns for more details.

Premium rate increases

In the final days of 2010, Health and Human Services Secretary Kathleen Sebelius announced new rules to crack down on premium increases.

Under these rules, which will take effect later this year:

  • Insurers will have to publicly justify premium hikes of 10 percent or more for individual and small group policies.
  • The government will not have the power to deny rate increases, but it will review them in states that don't already do so.
  • Increases the government considers unreasonable will be identified for consumers on the HHS insurance website.

As of Jan. 1

Here are the changes for all new or renewed health insurance policies that began Jan. 1 — both individual and employer-sponsored — except grandfathered and retiree-only plans:

  • Children up to age 19 cannot be denied coverage due to preexisting health conditions. (Exception: Individually purchased grandfathered plans can deny coverage to children.)
  • Limits on annual medical expenses will be phased out over three years. So when your insurance plan begins or is renewed, it now must cover medical expenses up to at least $750,000. (Exception: Individually purchased grandfathered plans can continue to set annual dollar limits on coverage.)
  • Free preventive health care services will be offered by in-network providers, including screenings to detect diabetes, colorectal cancer, high blood pressure, high cholesterol and other problems.
  • Free immunizations and other services will be available for infants and children.
  • Insurers must spend at least 80 percent of the money they collect from premiums to pay for medical care — not administrative costs or profits — for those who have individual policies, and at least 85 percent for those with employer-sponsored coverage.
HCR roundup

— Joel Sartore/Getty Images


If you have Medicare and a prescription drug plan, the coverage gap, or doughnut hole — when you have to pay the full cost of your drugs — is smaller this year:

  • You get a 50 percent discount on brand-name and biologic prescription drugs that you buy in the gap.
  • Generic prescription drugs get a 7 percent price cut starting in 2011.

People with Medicare also get free annual physical exams and free preventive health care benefits like cancer screenings. Stop-smoking counseling is also free this year, and available to all those on Medicare, whether or not they have symptoms of tobacco-related diseases.

Employer coverage or individual plans

People with employer-sponsored health coverage or individually purchased plans that renewed or started Jan. 1 are seeing these changes, which apply to all policies:

  • Young adults can remain on or return to their family health coverage until their 26th birthday. (This does not apply to employer-sponsored retiree-only plans, however.) Watch for a written notice from your insurance plan or employer that describes at least a 30-day period when you can add your children to your policy.
  • If you become sick, plans can no longer cancel your coverage because you have made an unintentional mistake on your application for insurance.
  • Plans cannot set lifetime dollar limits on coverage. If your insurance was canceled because you reached your plan's limit, you will be able to rejoin the plan.

Exemptions and exceptions

Several different types of plans are not required to include all provisions of the health care law:

  • Some new consumer protections and benefits are not required under grandfathered plans — those that were already in existence when health care reform became law. You will receive a notice from your insurer if your plan is grandfathered.
  • Grandfathered plans can lose their exemption if they significantly reduce benefits or raise members' costs.

Preexisting conditions

If you have been unable to buy insurance for the past six months because of a preexisting condition, next year three new, less-expensive options will replace the Preexisting Conditions Insurance Plan the federal government runs in 23 states and the District of Columbia.

Find out more

To find out what changes health care reform will bring in the future, check out the Kaiser Family Foundation's interactive time line covering deadlines in 13 subject areas — from making health care more affordable to increasing long-term care options for older Americans.

Susan Jaffe of Washington, D.C., covers health and aging issues and writes the Bulletin’s weekly column, Health Care Reform Explained: Your Questions Answered.

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