Coming health care changes you may not know about

Kaiser Health NewsJuly 9, 2010 

WASHINGTON — Several little-known provisions of the new health care overhaul law take effect in coming months that could have a lasting impact on the nation's health care system.

They include eliminating co-payments for certain preventive services such as mammograms, giving the government more power to review health insurers' premium increases and allowing states to expand Medicaid coverage to low-income adults without children.

Here's a quick look at some of the changes that are occurring this year:

PREVENTION FOR LESS

What: Insurers won't be able to require co-payments or deductibles for certain preventive services such as breast cancer screenings every one to two years, cholesterol blood tests and screenings for some sexually transmitted diseases. Insurers also will have to cover recommended immunizations at no cost to patients. Some health care analysts have suggested that premiums may rise as a result of this and other new requirements, but administration officials say that any increase in premiums would be minuscule.

When: The change takes effect Sept. 23, which means it applies to plan years that begin after that. For many plans, their new years begin after Jan. 1.

Status: The Department of Health and Human Services says regulations are on their way. Paul Bonta, the associate executive director for policy and government affairs at the American College of Preventive Medicine, predicts that manufacturers of vaccines and diagnostic tests will push for their products to be labeled preventive services in a bid to have them covered at no cost to consumers.

KNOWING WHICH TREATMENTS WORK BEST

What: A nonprofit research institute will examine various medical treatments — by looking at data and conducting its own studies — to determine which methods work best. This often is called "comparative effectiveness research."

When: The comptroller general of the United States — who runs the Government Accountability Office — will appoint the 17 members of the institute's board of governors, which will oversee the institute's operations.

Status: Everything about this institute, from its board members to its findings about treatments, is likely to generate great interest and potential controversy. The law says the board's findings can't be interpreted as requirements for how doctors practice medicine or what insurers cover. However, in the quest to control health care costs, employers, insurers and others may point to such data as rationales for changes in coverage and treatment patterns.

HELPING TO COVER EARLY RETIREES' HEALTH COSTS

What: A new program will help employers handle the cost of health care for retirees 55 and older who aren't eligible for Medicare, the federal program for the elderly. The reimbursements will cover 80 percent of medical claims that are between $15,000 and $90,000 for retirees, their spouses and dependents.

When: Applications are being accepted now to help cover claims that date to June 1.

Status: The $5 billion program is intended to help employers cover retirees' health costs until the health insurance exchanges — state-based insurance marketplaces — are up and running in 2014. A cautionary note: The Employee Benefit Research Institute found that if the subsidy were provided for all early retirees and their dependents, the $5 billion would last no more than two years.

KEEPING TABS ON PREMIUMS

What: Insurers must justify premium increases to the federal government and state insurance commissioners. If the hikes are deemed to be unreasonable — federal regulators have yet to define what "unreasonable" means — states could exclude those insurers from offering coverage on the health insurance exchanges .

When: The provision has gone into effect but federal regulations haven't been issued yet.

Status: The National Association of Insurance Commissioners is developing

recommendations for federal regulators about what information insurers should provide to state and federal officials to justify premium increases. A draft proposed by a subcommittee of the association has drawn fire from consumer advocates, who say the government should demand much more detailed information. The federal government won't have the power to regulate rates, but some states exercise that authority.

EXPANDED MEDICAID COVERAGE

What: In 2014, Medicaid, the state-federal program for the poor, will expand to include everyone who earns less than 133 percent of the poverty line, which is $14,400 this year for individuals. Currently, the program doesn't cover most poor people without children. In the meantime, however, under the law states can expand their Medicaid programs to cover these people, and get federal aid to do so.

When: States can expand Medicaid now to cover childless adults and receive some federal funding. In 2014 the federal government will pick up the entire cost of expanding Medicaid to childless adults and others who qualify.

Status: So far, Connecticut and Washington, D.C., have applied and received permission from federal officials to expand their Medicaid programs right away. Connecticut officials say that as many as 45,000 childless adults they cover under a state program will now be covered by Medicaid. That will save the state $53 million over the next year since it already covers some of the poorest single adults.

Ann Kohler, the director of health services for the American Public Human Services Association and the director of the National Association of State Medicaid Directors, said many states were worried they didn't have the money or staff to expand now. The computer systems that states and the federal government use often don't line up, Kohler said, and there may not be enough doctors to care for all the newly covered individuals.

CARE COORDINATION FOR 'DUAL ELIGIBLES'

What: Approximately 8.8 million "dual eligibles" — people who qualify for both Medicare and Medicaid, many of whom are poor elderly — could benefit from a new federal office designed to coordinate their medical care.

When: Immediately. HHS officials have said they'll release more information soon about the new office.

Status: Jim Verdier, a senior fellow with Mathematica Policy Research, a health policy research firm, said that about a dozen states already were working to integrate care but the process was complicated. For one thing, rules on how to deal with this population vary from state to state and also differ from the federal government's regulations. If Medicare and Medicaid had rules that were uniform across the country, care for these people would be easier to coordinate, he said.

FDA APPROVAL FOR 'FOLLOW-ON BIOLOGICS'

What: The health overhaul law gives the Food and Drug Administration the power to approve lower-cost versions of biologic drugs — often called biosimilars or follow-on biologics — after drug makers have 12 years of market exclusivity. Biologic drugs, which are manufactured in living systems such as plant or animal cells, can be used to treat serious diseases such as cancer and multiple sclerosis.

When: Later this year, the FDA is expected to hold the first in a series of meetings to solicit comments from the public and the industry on how the process should work. Players on all sides of the debate expect the agency to move slowly in figuring out how to bring biologic drugs to the market.

Status: Issues to be decided include how to define what constitutes a "biosimilar" drug and how to resolve patent challenges that may emerge.

(Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy-research organization that isn't affiliated with Kaiser Permanente.)

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