Health Care Reform Benefits: What 2011 Will Bring

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.

• If your plan rejects a claim or cancels coverage, the plan must explain why and must explain how you can appeal.
  

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Medicare

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.