Lisa Codispoti Natl Conf Presentation 2011

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					  What You Need to Know about
   The New Health Reform Law

                Lisa Codispoti
       IDF Board Member and Patient
Senior Counsel, National Women’s Law Center

              June 25, 2011
Challenges our Community Faces
    Inadequate Insurance Coverage

•   Multiple Chronic Conditions
•   Coverage for specialists of choice
•   Prescription drug coverage
•   IVIG or SubQ coverage
•   Switching to tiers of coverage
    Finding & Keeping Affordable,
    Comprehensive Health Insurance
• Insurance Rejection due to pre-existing
• Health Status rating (premiums set
  based on your health- also by age,
• Pre-existing condition exclusions
What the Health Care Law Does
              In Effect Now
• Adult children can stay on parents plan to age 26
• No pre-existing condition exclusions for kids <19
• New insurance plans must cover recommended
  preventive screenings without cost sharing like
  co-pays or deductibles
• Insurance plans for uninsured people with pre-
  existing conditions “PCIP Plans” – no more
  expensive than for a healthy person
• Lifetime limits on benefits PROHIBITED
• Annual benefit limits – restricted (prohibited
      Insurance Reforms: 2014

• Guaranteed issue – no insurance company
  can reject you from purchasing their
  insurance policy due to a pre-existing
• no health status rating- (premiums can only
  vary based on age, smoking status, family
  size, and geography)
• no pre-existing condition exclusions or
 New insurance marketplaces to shop for,
  compare insurance plans
 For individuals (without affordable employer
  coverage) and small employers
 Available plans are categorized into 4 tiers of
  coverage: bronze, silver, gold, platinum
 Plans generally cover the same health care
  services- the difference is based on how much
  you pay out of pocket.
        • Bronze – highest cost-sharing;
        • Platinum- lowest cost sharing
           Comprehensive Benefits
All plans sold in exchanges must cover:
 Ambulatory patient services
 Emergency services
 Hospitalization
 Maternity and newborn care
 Mental health and substance use disorder services,
   including behavioral health treatment
 Prescription drugs
 Rehabilitative and habilitative services and devices
 Laboratory services
 Preventive and wellness services and chronic disease
 Pediatric services, including oral and vision care
         Affordability Assistance
• Medicaid expanded – up to 133% poverty
         » Single person: $14,500
         » Family of 4: $29,725
• Sliding-scale subsidies –help with premiums, cost
  sharing (up to 400% of poverty – or $88,000 for
  family of 4)
• Caps on Out-of-Pocket costs – no plan can
  charge more than $6,000/$12,000 (single/family)
• Medicare Prescription drug coverage gap –
  phased out by 2020 (now: 50% brand name
  discount when in the gap)
      A few other insurance bits:

• New appeal rights – to challenge insurance
• Insurers will have to justify and states will review
  premium increases
   “Shared Responsibility” Provisions

 Employers: Over 50 employees must offer
  health insurance to employees or face a fee if
  their employees get subsidized coverage through
  the exchange
 Individuals: Unless exempt (ie: due to cost or
  hardship), must have health insurance or pay a
               Is the law perfect?

 Heck no – lots of stuff they didn’t get to, like our
  Medicare IVIG home infusion problem
 But it’s a start – and for a lot of people, it’s a lot
  more than they had
 They passed Medicare 47 years ago – and it’s
  still being tweaked!!
          What’s happening now?

 Federal government (US Dept of Health &
  Human Services) issuing regulations to provide
  greater details on many pieces of the law
 States are starting to pass legislation to operate
  the exchanges starting in 2014
 Several lawsuits challenging the law
  So what should we be doing until 2014?

 Advocacy at this stage is even more important!
 This is to be sure they get the details of the law
 Be ready – when we send an Action Alert- we
  need your help!
 IDF was critical in advocacy for the primary
  immunodeficiency community leading up to
  passage of this law
 IDF continues to advocate on behalf of our
  community during implementation
    Some questions you may have:

   What will happen to the health
    insurance I have through my employer?
   Will my immune globulin (IVIG or SubQ)
    be covered? Will they cover my brand?
    What about my home infusion service?
   Will all of my prescriptions be covered?
    What about formularies?
   Will I be able to see my immunologist of
Thank You!

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