How health care law affects premium rates

June 23

Consumers had questions about premiums and benefits for plans sold on the health insurance marketplaces as well as concerns about physician participation in the Medicare program.

I understood that under the health-care law, premiums for individuals could not increase by double digits, that rate increases were capped at under 10 percent unless approved by the government. Isn’t that right?

The law requires insurers in the individual and small-group markets that propose premium increases of 10 percent or more to publicly disclose that information and explain why they think the increase is justified. You can find details of proposed increases on many state Web sites, and a consumer-friendly version of the information will soon be available at www.healthcare.gov, according to an official at the Centers for Medicare & Medicaid Services.

States, which have primary responsibility for regulating insurance rates, provide varying degrees of oversight. Some jurisdictions don’t permit insurers to raise rates without state insurance department approval, while others require insurers to inform states of planned changes, which may be rejected retroactively. Some states have no authority over premium rate changes at all. Under the health law, the federal government reviews rate increasesin the handful of states that don’t have an effective process in place.


Insurers can impose increases larger than 10 percent, but they have to justify them. (Karen Bleier/AFP/Getty Images)

However, unless states that have the authority to do so step in, “once an insurer files a justification [for an increase over 10 percent], nothing in the Affordable Care Act prohibits them from proceeding,” says Timothy Jost, a law professor at Washington and Lee University who is an expert on the health law.

Other provisions of the health law act as a brake on unreasonable rate increases. For example, insurers are required to spend at least 80 percent of the premiums they collect on medical claims or quality of care improvements. If they don’t meet that standard, called a medical loss ratio, insurers have to return the extra premium amounts to consumers.

I am concerned that few family doctors in my area are accepting new Medicare patients. Is there a requirement that doctors who work for hospitals accept them? For example, if hospital X buys physician practice Y and pays those physicians a salary, are they required to accept Medicare patients?

No, physicians aren’t generally required to accept new Medicare patients, whether or not the doctors are employed by a hospital.

There are many reasons a doctor might refuse a new patient. Her practice may already be full, for example, or she may decide she lacks the necessary expertise to treat someone’s condition.

But the vast majority of physicians do, in fact, accept new Medicare patients, according to a recent study by the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

The foundation found that 91 percent of physicians reported that they were accepting new Medicare patients, the same percentage that reported accepting patients with private insurance. Among primary-care physicians, the figure for accepting Medicare patients was slightly lower, 88 percent.

Local market conditions can make a difference, however. Medicare beneficiaries who relocate to an area that’s growing fast, for example, may discover it’s tougher in general to find services, says Cristina Boccuti, lead author of the study.

“The same circumstances that may make it hard to find a local physician may make it difficult to find restaurants and a place to get your hair cut,” she says.

Can you provide some guidance on the age limit for pediatric dental benefits? Is it 19, when most pediatric benefits end, or, because dependents are now covered until age 26, does it continue until then?

The law requires that pediatric services, including dental and vision benefits, be covered as an essential health benefit until a child reaches age 19, with no annual or lifetime limits on coverage. This provision applies only to non-grandfathered plans in the individual and small-group markets. States can extend the coverage beyond that limit if they choose.

Large-group plans may also offer dental coverage for children, but it’s not mandatory. If such coverage is offered, kids may be covered under the same plan as their parents, with no age limits, says Colin Reusch, a senior policy analyst at the Children’s Dental Health Project, a nonprofit based in Washington. Those plans typically have dollar or other coverage limits, however, he says.

Adult children insured under their parents’ large-group plans may be able to keep their dental coverage until they turn 26. For those in individual or small-group plans, once a child turns 19 and is no longer eligible for pediatric dental benefits, coverage doesn’t necessarily have to end.

“When you turn 19, some dental plans let you purchase an adult dental plan,” Reusch says. “They generally make the transition easy.”

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. E-mail: questions@kaiserhealthnews.
org.

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