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How to navigate the newly reformed health care system

Posted Saturday, May 8, 2010

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New Report Explains What Consumers need to watch for; Lays out Next Steps

Yonkers, NY—With health reform now the law of the land, Consumer Reports Health lays out next steps for consumers in a variety of situations—those who are currently insured; Medicare and Medicaid recipients; people with pre-existing conditions; parents of children with pre-existing conditions; parents of uninsured young adults; and people who develop serious illnesses. The report appears in the June issue of Consumer Reports and online at

Consumers Union, the nonprofit publisher of Consumer Reports, has been advocating for health reform for more than 70 years. A key component of the organization’s recent push for reform involves expert analysis and advice for consumers. has become a central hub of information on all aspects of reform. The site is continuously updated and includes an explanation of how reform will work depending on your specific situation; specific tips for navigating Medicare; a timeline for health reform; and tips on how to shop for health insurance in a post-health reform world.

Among the site’s most-popular features is the “Ask Nancy” column which allows consumers to email their questions to where Consumer Reports Health’s top health insurance expert and senior program editor, Nancy Metcalf will respond and post answers online. “Our health system was already hard for consumers to understand, and it’s going to change repeatedly over the next three or four years. We have years of expertise in covering our health care system and health insurance, and that’s a resource consumers can mine to fully understand how the new law will affect them personally,” said Metcalf.

While most of the major reforms will not be enacted until 2014, there are significant changes that will start soon:

If you have any kind of public or private health insurance: Medicare, Medicaid, and all new group and individual health plans have to start covering 100 percent of the cost of proven preventive care. Translation for consumers: no co-pays, co-insurance, or deductibles on such services as immunizations, colonoscopies, and mammograms.

What to do: Check to see whether your plan has or intends to add those features, and be sure to schedule preventive care.

If you have a pre-existing medical condition: By late June, the government has to set up a temporary high-risk insurance pool for people who are unable to get coverage on the individual market because they have a pre-existing condition. This is meant to tide people over until 2014, when they will be able to buy any insurance that’s for sale. This coverage will be comprehensive and more affordable. Individuals won’t have to pay more than $5,950 a year out of pocket for in-network care and families won’t pay more than $11,900. The bad news is that to get into the pool, you have to have been uninsured for six months, no exceptions.

What to do: Our experts recommend that if you qualify for this pool—sign-up as soon as you are eligible. However, if you have a pre-existing condition and are currently insured, do not drop your coverage in order to qualify for the high-risk pool. The risks to your health and financial security are too great.

If you have a child with a pre-existing condition: Effective immediately, it appears that insurers will no longer deny coverage to children with pre-existing conditions, whether the plan is old or new. However, nothing in the new law stops them from raising premiums to cover the added costs. But, in 2014 they won’t be able to do that.

What to do: If your child is currently insured, Consumer Reports Health advises that you hold on to your current coverage until you find better coverage at a lower price. If your child has been denied health insurance, check for new insurance options in late September and compare those to what is available through the new high-risk pool to determine what is best for your family.

If you are a young adult or the parent of a young adult: Starting with the first plan renewal after September 23rd, group plans must allow adult children to stay on their parents’ health insurance until their 26th birthday provided the child doesn’t have access to job-based coverage of their own. Employers have a lot of flexibility in how they design their plans and they may charge extra for the coverage.

What to do: If your employer offers a choice of plans and your child is living far away from home, check on the availability of in-network care where he or she will be. If it isn’t good try to switch to a plan with a national care network. Young adults graduating this spring can sign up for COBRA or an individual policy to tide them over until they can get back on their parents’ plans.

If you develop a serious illness while on a plan: In the past, insurance companies have engaged in a practice called rescission where they cancel a patient’s coverage after the patient has been diagnosed with an expensive-to-treat illness such as cancer or HIV/AIDS. Insurers comb through patients’ medical records to see whether they left anything off their applications, no matter how minor or unrelated to the medical problem. Patients have lost coverage for failing to disclose pre-existing conditions they didn’t even know they had or for clerical errors in their records. Starting with your next policy renewal after September 23, insurers will no longer be able to do that. They will only be able to rescind a policy if a consumer knowingly conceals knowledge of a pre-existing condition.

What to do: The ban on rescissions is in no way a license for you to omit information on your insurance application. Come clean to insurers about everything you know about and keep up with your premiums, because insurers can still cancel your insurance if you don’t pay.

If you are in the Medicare doughnut hole: For 2010 only, you’ll receive a $250 rebate check if you fall into the “doughnut hole” of your part D drug plan. This year, the doughnut hole—the period during which you have to pay your drugs’ full cost out of pocket—begins after you and your Medicare drug plan together have spent a total of $2,830 on drugs. In 2011, you’ll get a 50 percent discount on brand-name prescriptions and a 7 percent discount on generics during the doughnut hole. In the years following, the discount gets larger until your share of costs while in the hole is 25 percent for all drugs in 2020.

What to do: The 2010 rebate and subsequent discounts will happen automatically. But the price of brand-name drugs will continue to vary depending on what kind of deal a plan has made with drugmakers. So you’ll still need to select your Part D plan carefully to make sure it has the best prices for the drugs you take.

Consumer Reports has no commercial relationship with any advertiser or sponsor appearing on this newspaper's web site.
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How to navigate the newly reformed health care system
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