Health-care law will prompt changes in 2012, unless the Supreme Court intervenes

Two years after its passage, the sweeping health-care overhaul will come before the Supreme Court late this month. The court could strike down some or all of its provisions, including the requirement that nearly all Americans have coverage beginning in 2014.

Meanwhile, however, implementation marches on. If the law stands, here are the major new provisions that will affect consumers this year:

Required coverage

Starting in August, new health plans, or existing plans that have changed their benefits enough to not be considered grandfathered under the law, will be required to provide coverage for a variety of basic women’s-health services, including well-woman visits; screening for gestational diabetes; HPV testing; counseling for sexually transmitted infections; counseling and screening for HIV; and screening and counseling for interpersonal and domestic violence.

The most controversial of these changes involve the Obama administration’s new rules on contraceptive coverage, under which women will be able to receive contraceptives without out-of-pocket charges.

Employers whose purpose is to promote religious values, such as churches, are exempt from this requirement. Colleges, hospitals and other employers that are affiliated with religious institutions are not exempt but have been given extra time to comply with the requirement while the administration works on accommodations for those that object to providing contraceptive coverage.

This requirement is the subject of a number of legal challenges separate from the case that is now before the Supreme Court.

Rebates for consumers
Under the health-care overhaul, insurers have to spend at least 80 to 85 percent of premium revenues on medical claims and quality improvement or else rebate the difference to policyholders. In most group plans, that would mean the employer.

How much consumers can expect to receive remains an open question. An analysis by the National Association of Insurance Commissioners based on 2010 data estimated that insurers would have returned $2 billion to consumers had the provision been in force then. The analysis said rebates would have gone to 53 percent of people in individual plans, 23 percent in small-group plans and 15 percent of large-group plan members.

In December, the Obama administration estimated that 9 million Americans might receive rebates totaling up to $1.4 billion, also based on 2010 data. The administration says some reports show insurers have been moderating their premium increases to avoid having to pay rebates. But other policy experts aren’t so sure.

“My guess is that rebates will be higher [than the NAIC estimate] in 2011,” says Timothy Jost, a law professor at Washington and Lee University who helped prepare the NAIC report. “Insurers seem to have raised their premiums based on projected increases in utilization that never occurred.”

Clearer descriptions

Beginning in September, at the start of the open enrollment season, all health plans will have to provide concise, consistent plan information aimed at allowing consumers to easily understand their benefits and compare plans.

Every plan will be required to give people a short summary of coverage and a uniform glossary of terms. It will also have to provide examples of how much the plan would cover if someone had a baby or was managing Type 2 diabetes — two common situations that should make it easier for people to compare plans.

Shrinking doughnut hole

The health-care overhaul is slowly eliminating the doughnut hole. This is the break in Medicare prescription drug benefits that, in a standard plan, begins after total drug spending by the beneficiary and the health plan exceeds $2,930 and continues until the beneficiary has hit the $4,700 out-of-pocket limit.

Last year, Medicare beneficiaries with high drug costs got a 50 percent discount on brand-name drugs once they reached the doughnut hole. This year, they’ll also see a 14 percent discount on generic drugs.

Drug costs will continue to diminish in coming years, until in 2020 the doughnut hole no longer exists and Medicare beneficiaries with drug plans will simply be responsible for 25 percent of their drug costs.

‘Accountable care’

Last December, the administration announced that 32 health-care organizations would participate in a three-year Pioneer Accountable Care Organization program aimed at providing better, coordinated care for 860,000 Medicare beneficiaries. Providers — including hospitals, clinics and physician groups — that work together to improve beneficiaries’ health and to bring costs down will share in the savings that they achieve.

Although Medicare beneficiaries may not realize that their health-care provider is participating in the program, they may start to notice changes in their care this year, says Debra Ness, president of the National Partnership for Women and Families. She leads the Campaign for Better Care, a coalition of organizations focusing on improving health-care delivery.

“For some of these folks, it may start to feel like they have a team working with them, or like their primary-care provider is developing an individualized care plan,” she says. “Compared to what happens now, it could feel like a pretty big change.”

This column is produced through a collaboration between The Post and Kaiser Health News. KHN, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health-care-policy organization that is not affiliated with Kaiser Permanente.

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