Seven Health Care Changes You Might Have Missed

You’ve probably heard that the new health overhaul law this year will provide an option for young adults to stay on their parents’ health plans and set up insurance pools for people with pre-existing medical conditions who can’t find insurance. But several lesser-known provisions also take effect in coming months that could have a lasting impact on the nation’s health care system.

These provisions include eliminating patients’ 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.

While these changes might not have gotten at lot of attention, they could help build support for the law in the run-up to the contentious mid-term elections. Here’s a quick look at some of the changes occurring this year:

Prevention For Less

What: Insurers won’t be able to charge co-payments or deductibles for certain preventive services such as breast cancer screenings every one to two years, cholesterol blood tests and some sexually transmitted disease screenings. Insurers will also 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 any increase in premiums would be miniscule. 

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

Status: The Department of Health and Human Services says regulations are on their way. Paul Bonta, associate executive director for policy and government affairs at the American College of Preventive Medicine, predicts 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 is often 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 requiring 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 Cover Early Retirees’ Health Costs

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

When: Applications are now being accepted to help cover claims dating back 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 Health Insurance Premiums

What: Insurers must justify premium increases to the federal government and state insurance commissioners. If premium hikes are deemed to be unreasonable – federal regulators have yet to define what “unreasonable” means – states could exclude insurers from offering their coverage on health insurance exchanges beginning in 2014.

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 NAIC 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; however, 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 makes less than 133 percent of the poverty line ($14,400 this year for individuals). Currently, most poor people without children aren’t covered by the program. But in the meantime, under the law, states can expand their Medicaid programs to cover these people, and get federal aid to do so.

When: States could 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, both 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, director of health services for the American Public Human Services Association and head of the National Association of State Medicaid Directors, said many states are worried they don’t have the money or staff to expand now. Computer systems used by states and the federal government 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” — individuals 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 will soon release additional information about the new office designed to coordinate care.

Status: Jim Verdier, a senior fellow with Mathematica Policy Research, a health policy research firm, said about a dozen states, including Arizona, Minnesota and Wisconsin, are already working to integrate care but that the process is 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 drugmakers have 12 years of market exclusivity. These drugs 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 these drugs to the market.

Status: Issues to be decided in the future include how to define what constitutes a “biosimilar” drug and how to resolve patent challenges that may emerge.