1. Eliminating Expensive Caps on Health Coverage in South Carolina
The new health care law focuses on protecting consumers by preventing insurance companies from enacting policies that include some of the most heinous abuses and exploitations of consumers in any industry.
September 23, 2010 is the first major date for changes brought by the new law. One of the biggest improvements to our current health care system is a provision that restricts insurance from placing a price limit on the amount of health care a family receives.
People across the country are hearing all sorts of misinformation about various facets of the law. Below are a few facts about how this particular improvement will affect South Carolinians.
No More Cost Limits On Your Health Care
What Are Caps On Health Care Coverage? According to a report by FamiliesUSA, “Currently in South Carolina, a health insurance policy may stop paying your claims if you exceed an annual or lifetime cap on your coverage. Therefore, if you or a family member becomes sick and needs significant medical care, you may ‘run out’ of coverage and have to foot the bills on your own.” [FamiliesUSA.org, 3/2010]
Under Health Reform, No Lifetime Caps On Insurance Plans. According to a report by FamiliesUSA, under the new health care reform law, “[i]nsurance companies will be prohibited from placing annual or lifetime caps [amounts that if exceeded cause the insured person to pay out-of-pocket costs] on South Carolinians’ insurance polices, making sure that they aren’t left out in the cold if they get sick.” [FamiliesUSA.org, 3/2010]
Protecting 2.3 Million South Carolinians. Eliminating these caps will protect approximately 2.3 million South Carolinians who are insured through their employers. [Kaiser Family Foundation, accessed 9/9/10]
Lifetime Limits Will Be Phased Out. According to AARP, the health care law “phases out these annual limits over a period of three years: in the first year, insurers must cover medical expenses up to at least $750,000. That coverage rises to $1.45 million after Sept. 23, 2011 and increases to $2 million after Sept. 23, 2012. Limits will be completely banned starting Jan. 1, 2014.” [AARP.org, 8/23/10]
Annual Limits Are Subject to Restrictions. According to Commerce Clearing House, “For plan years beginning before Jan. 1, 2014, group health plans and health insurers offering group or individual health insurance coverage may impose a restricted annual limit on the dollar value of benefits per participant or per beneficiary only for ‘essential health benefits’ under the Affordable Care Act.” [Commerce Clearing House, 4/5/10, emphasis added]
What Are Essential Health Benefits? According Commerce Clearing House, “The Secretary of Health and Human Services (HHS) is to determine what benefits are considered ‘essential health benefits.’” At minimum, the following items must be included in all lists of essential benefits:
o Ambulatory patient services
o Emergency services
o Hospitalization
o Maternity and newborn care
o Mental health and substance use disorder services, including behavioral health treatment
o Prescription drugs
o Rehabilitative and habilitative services and devices
o Laboratory services
o Preventive and wellness services and chronic disease management
o Pediatric services, including oral and vision care
[Commerce Clearing House, 4/5/10]
Eliminating Lifetime Limits Means Fewer Out-Of-Pocket Costs. One of the goals of the new health reform law is to reduce consumer costs. According to a report by FamiliesUSA, “Insurance plans will have to place caps on how much South Carolinians are required to spend out of their own pockets for care. These caps will be set on a sliding scale, so that lower-income people will have greater protection from out-of-pocket costs. And South Carolinians will also receive income-based help for paying copayments and other cost-sharing.” [FamiliesUSA.org, 3/2010]
2. Stopping Insurance Company Abuses In South Carolina
Insurance companies have profited from the illnesses and ailments of consumers for many years. One of the major facets of the new health care law will prevent insurance companies from preying on unsuspecting Americans.
The law will make it illegal for insurance companies to drop coverage of policyholders for trivial reasons and will allow for an improved appeals process if an insurance company refuses to cover or pay for services. Here are some details on this major aspect of the law that will be implemented starting September 23, 2010.
What Is Rescission And How Does The New Health Care Law Combat It?
Insurance companies have long engaged in rescission, or taking away a person’s insurance coverage, most often when that person has been diagnosed with a condition or disease that is very expensive to cover. After diagnosis, the insurance companies look into the person’s health history and find a minor condition (i.e. high blood pressure) – generally, one that the person was unaware of – and use the condition as the basis for terminating coverage.
Under the new law, this practice is illegal.
Starting September 23, 2010, Insurance Companies Can No Longer Rescind Coverage. According to the South Carolina Department of Insurance, “The Patient Protection and Affordable Care Act was signed into law on March 23, 2010. … [H]ealth insurance market reforms become effective for plan years beginning on or after six months after the enactment of the PPACA” and include “[r]escissions prohibited (except for fraud or intentional misrepresentation.” [South Carolina Department of Insurance, accessed 9/9/10]
Currently, Insurance Companies In South Carolina Can Rescind Families’ Policies For ANY Reason. In South Carolina, insurance companies are allowed to rescind policies during a contestability period of two years “if any, even unintentional, material misstatement or omission is discovered.” [Kaiser Family Foundation, accessed 9/13/10]
Without Reform, Insurance Companies Would Have Continued To Rescind Policies For ANY Reason. NPR reported that in a hearing conducted by a subcommittee of the House Energy and Commerce Committee, “Rep. Bart Stupak (D-MI), who chaired the hearing, asked all three CEOs [of insurance companies] if they would agree to stop rescinding policies except in cases of fraud. All three said no.” [NPR.org, 6/22/09]
Appealing Insurance Company Decisions
Due to intentionally complicated forms, appealing a health insurance company’s decisions can be extremely difficult for the average policyholder. Additionally, most decisions are reviewed internally, which makes it easier for a biased reviewer working for the insurance company to deny a claim. Under the new law, companies are required to haveindependent and non-biased reviewers to ensure that policyholders’ appeal rights are not violated.
The Affordable Care Act Requires Insurance Companies To Implement An Approved Appeals Process. When insurance companies refuse to pay for services or decide not to extend coverage to consumers, the consumer will have the opportunity to appeal the decision through an improved appeals process. The new law requires all plans to provide specified internal and external health care appeal rights. [South Carolina Department of Insurance, 6/16/10]
Insurance Companies Must Include Certain Minimum Requirements. According to Commerce Clearing House, all insurance companies must implement an appeals process that, at minimum, includes the following:
o an established internal claims appeal process;
o a notice to participants, in a “culturally and linguistically appropriate manner,” of available internal and external appeals processes, including the availability of assistance with the appeals processes;
o a provision allowing an enrollee to review his or her file, to present evidence and testimony as part of the appeals process, and to receive continued coverage during the appeals process.
[Commerce Clearing House, 6/8/10]
South Carolinians Will Have the Right To An External Review Board. Consumers will have their rights expanded and will be able to have an independent, external board review their claims. According to the Kaiser Family Foundation, “[t]he rate at which external reviewers overturn health plan denials… averaged 45 percent across all states.” [Kaiser Family Foundation, 5/2002]
3. Providing Preventive Care For South Carolina
One of the biggest obstacles for ensuring a long, healthy life is access to simple preventive care. Those who are able to visit a doctor for routine check-ups – including basic vaccinations – stand a better chance for long-term health.
As of September 23, 2010, the new health care reform law provides free preventive health services for South Carolinians. The law guarantees that all new private health insurance plan holders, Medicare and Medicaid enrollees, and the uninsured are eligible to receive free check-ups for a wide variety of diseases.
Expanding Preventive Care To All South Carolinians
All New Private Health Insurance Plans Must Provide Free Preventive Care Services. The new health care reform law “[r]equires new private plans to cover preventive services with no co-payments and with preventive services being exempt from deductibles.” By 2018, all private health insurance plans must provide preventive services. [CBS News, 3/21/10]
Medicare And Medicaid Recipients Are Eligible For Free Preventive Care Services. Medicaid and Medicare beneficiaries are automatically eligible for free preventive care services. [Health & Human Services, 7/14/10; Centers for Medicare & Medicaid Services, accessed 9/20/10]
The Uninsured Are Eligible For Free Preventive Care. South Carolinians without health insurance are eligible to receive free preventive care services at their local health clinics. [Wall Street Journal, 7/14/10]
Types Of Preventive Care Services
o Cancer Screening And Preventive Medication
o Behavioral Counseling
o Mental, Vision And Dental Health Care
o Pregnancy And Newborns
o Diet Counseling And Heart Disease Screening
o Routine Vaccines
[U.S. Preventive Services Task Force, 8/2010; Richmond Times-Dispatch, 7/15/10]
Delivering Disease Prevention
The New Health Care Law Delivers Free Comprehensive Disease Prevention Services For All South Carolinians. The new health care reform law offers free preventive health services for many common diseases including breast, cervical and colorectal cancer, diabetes, osteoporosis, hypothyroidism and obesity.
Disease Prevention
Cancer: Breast, Cervical and Colorectal
Diet: Cholesterol, Obesity and Blood Pressure
STIs: HIV, Gonorrhea, Chlamydia and Syphilis
[U.S. Preventive Services Task Force, 8/2010]
The New Health Care Reform Law…
Delivers Free Routine Mammograms, Preventive Medication And Counseling For Women At High Risk. The new health care reform law provides free mammograms every one to two years for women aged forty or above. Patients that are identified as high-risk candidates for breast cancer will receive consultation on chemoprevention and genetic evaluation. [U.S. Preventive Services Task Force, 8/2010]
Provides Free Colorectal Exams And Cervical Screenings. The new health care reform law provides free screenings for colon and cervical cancer. As of 2008, nearly 35 percent of South Carolinians above the age of 50 had never received a sigmoidoscopy or colonoscopy. [U.S. Preventive Services Task Force, 8/2010; Kaiser Family Foundation, accessed 9/12/10]
Provides Free Screening For Sexually Transmitted Diseases And Counseling To Prevent Risky Sexual Behavior. The new health care reform law provides screening for HIV, gonorrhea, chlamydia, and syphilis. In addition, patients are eligible for “behavioral counseling to prevent sexually transmitted infections (STIs) for all sexually active adolescents and for adults at increased risk for STIs.” [U.S. Preventive Services Task Force, 8/2010]
Offering Prenatal Care And Support
The New Health Care Reform Law Provides Comprehensive Preventive Care To Protect Pregnant Women And Their Newborns. The new health care reform law fully funds and offers free preventive care for proven medical procedures that protect the health of pregnant women.
Preventive Care Services For Pregnant Women
Anemia Screening: Routine screening for iron deficiency in pregnant women.
Folic Acid Supplementation: Assistance with folic acid supplemental pills for pregnant women.
Bacteriuria Screening: Bacteriuria screening for pregnant women at 12 to 16 weeks of pregnancy.
Rh Incompatibility Screening: Hemolytic disease screening upon pregnancy and monitoring between the 24th and 28th weeks.
Breastfeeding Counseling: Counseling during and after birth to promote breastfeeding.
Chlamydial Infection And Gonorrhea And Syphilis Screening: Screening pregnant women for chlamydial infection, gonorrhea and syphilis.
Preventive Care For Newborns
Hearing Loss Screening: Screening newborns for hearing loss.
PKU Screening: Screening newborns for phenylketonuria (PKU).
Sickle Cell Screening: Screening newborns for Hemoglobinopathies.
[U.S. Preventive Services Task Force, 8/2010]
Delivering Dental, Vision, And Mental Health Coverage
The New Health Care Reform Law…
Provides Free Screenings For Depression. The new health care reform law offers free mental health screenings for adolescents and adults. Adolescent South Carolinians are eligible to be screened for major depressive disorder “when systems are in place to ensure accurate diagnosis, psychotherapy… and follow-up.” According to the Kaiser Family Foundation, in 2007 roughly 32 percent of adults in South Carolina reported “poor mental health.” [U.S. Preventive Services Task Force, 8/2010; Kaiser Family Foundation, accessed 9/12/10]
Delivers Free Vision Screening For More Than 295,000 Children In South Carolina. The new health care reform law provides free vision deficiency screening for roughly 295,000 children in South Carolina at or near the preschool age. [U.S. Preventive Services Task Force, 8/2010; U.S. Census Bureau, accessed 9/9/10]
Offers Free Fluoride Dosages To More Than 295,000 Children In South Carolina. Primary care clinicians are eligible to prescribe free oral fluoride supplementation for preschool-aged South Carolinians “whose primary water source is deficient in fluoride.” According to the Kaiser Family Foundation, “[t]ooth decay is the most common chronic illness among children.” [U.S. Preventive Services Task Force, accessed 8/2010; U.S. Census Bureau, accessed 9/9/10; Kaiser Family Foundation, 7/2008]
Assisting With Tobacco Cessation And Alcohol Abuse Prevention
The New Health Care Law Will Provide Tobacco Cessation Assistance For The 20 Percent Of South Carolinians Who Smoke. Clinicians are eligible to distribute free tobacco cessation products for patients. Pregnant women struggling with tobacco addiction are eligible for pregnancy-tailored counseling. According to the Kaiser Foundation, roughly 20 percent of South Carolinians smoke. [U.S. Preventive Services Task Force, 8/2010; Kaiser Family Foundation, accessed 9/12/10]
The New Health Care Law Will Offer Alcohol Abuse Prevention. The new health care reform law provides screening and behavioral counseling interventions for alcohol abuse. [U.S. Preventive Services Task Force, accessed 8/2010]
4. Delivering Health Care To Young South Carolinians
After they leave their parents’ insurance plans and before they receive health care from their employer, health insurance becomes an afterthought to many young people, who simply go without coverage. For those on tight budgets, the cost of health insurance is too high after rent, utilities, and food bills are covered.
Starting on September 23, 2010, young adults can stay on their parents’ health insurance plan until they are 26 years old. Not only will this new provision ensure proper health care for Americans as they finish their educations and begin their careers, it will also ensure a healthier generation of young Americans.
Providing Access And Affordability To Young South Carolinians
18,100 Uninsured South Carolinians Between The Ages Of 18 And 26 Will Have Access To Affordable Health Care. The new health care reform law enables young adults – until the age of 26 – to remain on their parents’ health insurance plans. This reform will enable roughly 18,100 young South Carolinians to enroll in their parents’ plans. [WhiteHouse.gov, accessed 9/20/10; Health and Human Services, 2010]
77,400 Children In South Carolina Will Automatically Receive Expanded Health Coverage. In 2014, Medicaid coverage will be expanded to roughly 77,400 uninsured children in South Carolina. To be eligible, a family of four must not earn more than $2,444 per month, which is an annual income of $29,328. [Kaiser Foundation, accessed 9/11/10; The Foundation for Health Coverage Education, 4/2010]
Guaranteeing Preventive Care Services For Young South Carolinians. The new health care reform law “[r]equires new private plans to cover preventive services with no co-payments and with preventive services being exempt from deductibles.” By 2018, all private health insurance plans must provide preventive services. [CBS News, 3/21/10]
Preventive Care For Uninsured Children In South Carolina
Hearing Loss Screening: Screening newborns for hearing loss.
Sickle Cell Screening: Screening newborns for hemoglobinopathies.
Vision Screening: Vision deficiency screening for pre-school aged children.
PKU Screening: Screening newborns for phenylketonuria (PKU).
Fluoride Dosages For Pre-School Children: Free fluoride dosages for uninsured children to prevent tooth decay.
Mental Wellness: Mental health screenings for adolescents that are at risk for depression.
[U.S. Preventive Services Task Force, 8/2010]
Uninsured Young Adults Are Eligible For Free Preventive Care Services. South Carolinians without health insurance are eligible to receive free preventive care services at their local health clinics. [Wall Street Journal, 7/14/10]
Preventive Services Available For Young Adults In South Carolina
Cancer Screening And Preventive Medication
Mental Health Care
Diet Counseling And Heart Disease Screening
Behavioral Counseling
Pregnancy And Newborns
Routine Vaccines
[U.S. Preventive Services Task Force, 8/2010; Richmond Times-Dispatch, 7/15/10]
Young South Carolinians with pre-existing conditions are eligible to receive insurance under a government-administered health program. South Carolina is participating in the Pre-Existing Condition Insurance Plan, which provides comprehensive health insurance for South Carolinians between up to the age of 34 for $301 a month. According to HealthCare.gov, “PCIP will cover a broad range of health benefits, including primary and specialty care, hospital care, and prescription drugs. All covered benefits are available for you, beginning on your coverage effective date, even if it’s to treat a pre-existing condition — there are no waiting periods.” [PCIP.gov, accessed 9/14/10]