Insurance Claims - Sounds Too Good to be True?

As we await the Supreme Court decision regarding the Affordable Care Act, which has already benefited hundreds of thousands of Illinoisans, we should not get too carried away by the health insurance giants UnitedHealth Group, Aetna and Humana announcement that regardless of how the Supreme Court rules, they will voluntarily continue some important consumer protections created by the law. These include preventive health care services without co-payments, coverage of children up to age 26 and elimination of lifetime policy limits.

Sounds too good to be true? Let's be clear: the insurance companies are only talking about voluntarily extending a few of the benefits they are now required to offer. This won't cost them a nickel because the benefits were cost-efficient to begin with and are already accounted for in their premiums. And without a law to require these provisions, there is no guarantee that the insurers won't yank them whenever they want.

What the insurance companies didn't say – and what they won't do – is the real story. They aren't saying they will stop discriminating against people with pre-existing conditions as the law requires beginning in 2014. That would be a big deal, because that part of the law will stop 129 million people with chronic conditions like diabetes, high blood pressure and asthma from being overcharged or being denied coverage. They also have not offered to keep covering children with pre-existing conditions -- a provision that has already taken effect and insurers have fought.

Lynda DeLaforgue
co-director, Citizen Action/Illinois

(This post originally appeared as a Chicago Tribune Letter to the Editor on 6/22/12)

Essential Health Benefits: What’s it mean for people with HIV?

On December 16, 2011, the U.S. Department of Health and Human Services (HHS) announced that states would decide what essential health benefits will be provided under health care reform.  Although we had urged HHS to adopt a uniform, national benefits floor that states could build on, the federal proposal offers important flexibility for states. (Check out our essential health benefits archive.)

So, what does the essential health benefits announcement mean for people with HIV?  The short answer is that we’re working on it.  Here are some of the hoops we’ll have to jump through just to figure out what the benefits might look like in a state.

Which plans are we talking about?  HHS gives states the choice of:

(1) the largest plan by enrollment in any of the three largest small group insurance products in the State’s small group market;
(2) any of the largest three State employee health benefit plans by enrollment;
(3) any of the largest three national FEHBP [Federal Employee Health Benefit Plan] plan options by enrollment; or
(4) the largest insured commercial non-Medicaid Health Maintenance Organization (HMO) operating in the State.

Yeah, we weren’t sure where to start either.  There’s no centralized federal repository of health plan data, since states regulate health insurance.  Every state publishes plan information online differently, or not at all.  We’ll probably have to submit a special data request to each of the 50 state insurance departments.

What benefits does each plan offer?  Once advocates identify the largest plans, the next step is to determine exactly what benefits they offer.  You can bet that Blue Cross doesn’t publish on their website a description of each of their hundreds of plans offered in a state.  We’ll might have to ask companies directly for plan descriptions, or pour through regulatory filings at state insurance departments.

Once we have this information, we can start to figure out what the plans will look like for people with HIV.  Of course, we’ll partner with national and state advocates to gather and analyze information.  At the state level, it’s more essential than ever that advocates work together to figure out the benefit puzzle and don’t duplicate effort.

And here’s an idea:  Could advocates, employers and insurance companies collaborate to gather all this information?  Sure, old adversaries would have to sit at the same conference table to share opinions and information – but that might be just “what the doctor ordered” in the new world of health care.

Read the federal fact sheet
Read the HHS Essential Health Benefits Bulletin
Federal white paper on benefits in small group and state and federal plans
Federal fact sheet on individual market benefits

John Peller, VP of Policy
AIDS Foundation of Chicago
jpeller@aidschicago.org

Originally posted here on HIVHealthReform.org