Several new provisions of the Affordable Care Act took effect January 1 (or last fall if you signed up for a policy back then), and you could take advantage of some of the new benefits -- or be burdened with some of the changes. FYI: The federal health law supersedes Massachusetts law, so any provisions that conflict with your current state health plan will likely mean adjustments in your coverage.
At my request, experts at the Massachusetts Executive Office of Health and Human Services culled through a list of the biggest changes being implemented this month and determined how they would impact state residents.
1. Free preventive services. Any new health plan that you enroll in, either on your own or through your employer, must provide free coverage, without copays or deductibles, for a variety of screening tests, exams, and counseling services. The freebie list includes blood pressure screenings, mammograms, cholesterol checks, and vaccines, as well as depression screenings, breast-feeding support for new mothers, smoking cessation counseling, and behavioral assessments for kids.
Note: If you simply renew your old plan, you'll probably still have to pay as usual for these services since plans that were around before the healthcare law passed in March are exempt. Best to check if your own plan was "grandfathered" in and exempt from the free offerings.
2. Coverage for adult children. All plans, even the grandfathered ones, must now cover young adults up to age 26 who want to stay on their parents' plan, even if these adults are no longer dependents. The plans don’t have to cover the children of these 20-somethings nor their spouses, The 2006 Massachusetts law required coverage for children who are no longer dependents but limited it to two years after they became independent or upon reaching age 26, whichever came first.
3. Monitoring of premiums. The health law now requires insurance companies to spend at least 80 cents of your premium dollar on medical care and quality. For employer plans covering more than 50 people, they must spend 85 cents.
The Massachusetts Division of Insurance will comply with this new regulation by ensuring that companies meet what's known as the "medical loss ratio" and will review rate increases by insurance firms. It has the authority to disapprove filings where rates are "excessive, inadequate, discriminatory, and unreasonable in relation to the benefits provided" or don't meet those loss ratios. Although the division can deny unreasonable rate hikes, there aren't any specific limits in the state law on how much individual premiums can rise year to year.
4. No more lifetime caps on coverage. The federal law eliminates lifetime caps on coverage and raises yearly coverage limits to $1.25 million in 2011. Massachusetts' health insurance carriers participating in the Health Connector, the state’s insurance exchange, already didn't have coverage caps, with the exception of some carriers’ Young Adult Plans for people between the ages of 18 and 26. The state was granted a federal waiver for about 3,500 folks who have such plans, according to EOHHS.
5. Changes to health savings account expenditures. Those with high-deductible policies paired with health savings accounts will find that they can no longer use any tax-free funds they sock away in these accounts for over-the-counter medications like Prilosec or Tylenol unless they're doctor-ordered. The funds can still be used for doctor visits, prescription medications, and lab tests.
6. Free prevention visit for Medicare patients. Medicare beneficiaries will be entitled to a free doctor visit to get a "personalized prevention plan" and a "comprehensive risk assessment." A government review board will determine by March what those terms mean, but end of life counseling -- which was originally included -- now won't be.
7. Medicare drug program changes. Those with Part D coverage will pay a $310 yearly deductible and then 25 percent of the cost of their prescriptions until they've reached $2,840 in drug expenses for the year. After that, they must pay 50 percent of the cost of brand-name prescriptions until the total cost reaches $6,448, when their share drops to just 5 percent. That's a substantial change from 2010, when the entire bill in this "doughnut hole" was the patient's responsibility (minus a $250 rebate to help ease the pain).
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