Health care reform: What do I need to know now?

Published: August 15, 2013

This is the first in an educational series about Health Care Reform from Blue Cross of Northeastern Pennsylvania.

The Affordable Care Act, or ACA, which is commonly referred to as Health Care Reform, was signed into law by President Obama in March 2010. And on June 28, 2012, the U.S. Supreme Court issued its landmark decision upholding the ACA provision that requires the purchase of health insurance, thus allowing all provisions of Health Care Reform to move forward as scheduled.

But if you’re still uncertain about what Health Care Reform means for you, you are not alone. A recent poll by the Kaiser Family Foundation found that much of the public remains confused about Reform, with 4 in 10 Americans unaware that the ACA is the law of the land.

What’s important for you to know right now? Let’s start with the basics.

The Affordable Care Act was intended to help more people access and afford health care coverage regardless of their health status. The law creates fundamental changes in the way health insurance options are developed, priced and offered to consumers.

While many parts of the law won’t take effect until the start of 2014, the following provisions are already in place:

1. Health care coverage for children with pre-existing conditions.

If you have a child under 19 with an illness or disability, often called a “pre-existing condition,” he or she cannot be denied coverage. Before the law was put into place, health plans could in some situations refuse to offer coverage or could limit benefits because of a pre-existing condition.

2.  If you have children under age 26, they can stay on your insurance plan.

Parents can add or keep children on their plans until they reach age 26. Your child can stay on your plan even if they are not living with you, and even if they are eligible to enroll in their own employer’s plan, unless your plan is grandfathered.

3.  Insurance coverage cannot be cancelled if you get sick and have previously made an unintentional mistake on your application.

Health plans cannot rescind, or cancel retroactively, your insurance coverage if you or your employer made an honest mistake on your application. Coverage can only be rescinded in cases of fraud or intentional misrepresentation.

4.  No lifetime limits on coverage and restricted annual limits.

The law prohibits lifetime dollar limits on coverage and also restricts and phases out the annual dollar limits a health plan can place on most of your benefits, eliminating these limits entirely in 2014.

5.  Direct access to OB/GYN services.

All health plans must provide women with direct access to participating obstetric and gynecologic care providers without the need for prior authorization or referral.

6.  No cost sharing for preventive services.

Preventive care services are covered at 100 percent. This means that covered individuals are not charged a copayment or coinsurance for these services as long as they are received from a provider within your health plan’s network.

7.  The right to an internal and external appeal of health plan decisions.

Consumers have the right to appeal decisions made by their health plans, including the denial of a payment for a service or treatment. If your plan denies payment after considering your appeal, the law gives you the right to have an independent organization conduct a medical review of that decision.

As you can see, many of the law’s provisions have already been put into action, but the most transformational aspects of Health Care Reform will take effect in 2014. In the meantime, it’s important that you learn all you can to get the most out of your health plan for you and your family. Visit www for the latest information from the U.S. Department of Health & Human Services

Blue Cross of Northeastern Pennsylvania is committed to sharing critical information about Health Care Reform. Now that we’ve looked at what’s already taken effect, watch for the next installment of this series in July to learn more about what’s changing next, and when. And visit anytime for more resources that can help you understand what Health Care Reform means for you.

A. Paul Holdren is senior vice president and chief sales & marketing officer for Blue Cross of Northeastern Pennsylvania.

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Expert: Exchanges Could Boost Quality Reporting, Delivery Reform

Tuesday, August 13, 2013

Health insurance exchanges under the Affordable Care Act could be a mechanism for delivery reform and quality reporting, an insurance exchange expert said at an Alliance for Health Reform briefing on Friday, MedPage Today reports (Pittman, MedPage Today, 8/12).


Under the ACA, states by January 2014 must create online health insurance exchanges to provide coverage options for individuals and small businesses.

Most insurance exchanges will rely on a solid IT foundation to connect with advanced eligibility systems for Medicaid and other state-administered health programs (iHealthBeat, 6/27).

Details of Comments

Sarah Dash of Georgetown University’s Center on Health Insurance Reform said that insurance exchanges will be required to report quality measures on participating plans beginning in 2016 but that some marketplaces could ask insurers to record more data on specific items.

After the briefing, Dash said that states “might want to come up with new quality metrics that they think are important.”

According to Dash, several states will require plans sold through the exchange to report quality measures in the first year to provide consumers with more information when selecting coverage.

Dash said, “Whether consumers are going to be actively following that … I think that remains to be seen” (MedPage Today, 8/12).

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Five Ways the Affordable Care Act Helps America’s Small Businesses

Ari Matusiak

August 14, 2013
05:05 PM EDT
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Small businesses are the backbone of our economy, and for the 28 million small employers across the country, healthcare is a major concern. The Affordable Care Act provides benefits and opportunities to small businesses that will help increase access to affordable coverage options.

Here are five key ways the Affordable Care Act can benefit small employers and their workers:

  1. SHOP Marketplaces: Currently, small businesses face premiums that are on average 18% higher than large businesses. On October 1, 2013, the new Small Business Health Insurance Options Program (SHOP) Marketplaces will be open for businesses, and small employers in every state will be able to shop for health coverage on a competitive marketplace, that brings unprecedented transparency to the market and gives small businesses the same purchasing clout as big businesses.
  2. Reducing Administrative Complexity: SHOP Marketplaces include web portals that provide standardized, easy-to-understand information that will make comparing and purchasing coverage easier, and will simplify the administrative challenges that businesses often face when offering plans. Visit to learn more about the SHOP Marketplace and to get ready for open enrollment.
  3. New Tax Credits: The small business tax credit helps small businesses afford the cost of healthcare coverage for their employees, and is already helping qualifying small businesses offset the cost of insurance by up to 35%. In 2014, this tax credit goes up to 50% and is available to qualified small businesses who obtain coverage through the SHOP Marketplace.
  4. Improved Risk Pooling: The new SHOP Marketplaces will allow small groups to pool risks and reduce administrative complexity, thereby increasing their purchasing power and reducing costs for small businesses that want to provide coverage to their workers. Business can enroll starting on October 1, 2013, through their brokers, or directly through the SHOP Marketplace. Stay connected to the latest information on the Marketplaces by going to
  5. Workplace Wellness:  The Affordable Care Act creates new incentives to promote workplace wellness programs and encourages employers to take more opportunities to support healthier workplaces. Effective for plan years after January 1, 2014, final rules allow the maximum reward to employers using a health-contingent wellness program to increase from 20 percent to 30 percent of the cost of health coverage, and the maximum reward for programs designed to prevent or reduce tobacco use will be as much as 50 percent.

To help provide small business owners with the resources and information they need, the Obama Administration recently launched, a one-shop where employers of all sizes can go for customizable information about how the law impacts them, based on the size, location and future plans for offering coverage. And, the Department of Health and Human Services launched a call center specifically to serve the needs of small businesses interested in the SHOP Marketplace. This call center (1-800-706-7893) is a new resource to help business owners get information to make the right decision for their bottom line and their employees. It’s open Monday-Friday from 9 AM- 5 PM, with representatives available to help in English and Spanish.

The Small Business Administration has also teamed up with Small Business Majority to offer a weekly webinar series designed to educate small business owners about what the healthcare law means for them. To sign up for a weekly Thursday Webinar before open enrollment starts on October 1, 2013, visit:

Related Topics: JobsSmall BusinessEconomyHealth Care

The Challenge of Helping the Uninsured Find Coverage

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Published: August 14, 2013

OAKTON, Va. — Cyndy Dailey held a job fair at her nonprofit agency here last weekend, with a major caveat: she did not yet know if she could hire.

Like many organizations across the country, Ms. Daily’s agency, Northern Virginia Family Service, is hoping to win a federal grant to help uninsured people in the state sign up for coverage under President Obama’shealth care law. With the money, she hopes to hire at least a handful of “navigators” — a new category of worker created under the law to educate consumers about new health insurance options and, starting in October, to walk them through the enrollment process.

Navigators are seen as crucial to the success of the law. As the Jan. 1 deadline approaches when most Americans will be required to have health coverage or pay a fine,  navigators are supposed to explain away confusion and fear among the legions of uninsured, helping them understand how new health insurance markets will work and whether they will qualify for subsidies to help with the cost of coverage.

But as the navigator effort gets under way across the country, it is clear that their impact will vary from state to state, with wide discrepancies in how much will be spent to hire and train navigators and how many people they will be able to reach. Many will be operating on shoestring budgets, with extremely tight time frames and hostile political climates.

“There’s definitely going to be a tremendous difference, not only in navigators but also in marketing funds,” said Andy Hyman, senior program officer at the Robert Wood Johnson Foundation. “So what we’re going to have to see in states with fewer funds is a lot more ingenuity.”

Maryland is spending $24 million on a program that will soon dispatch 325 navigators and assisters around the state. Colorado is investing $17 million on 400 “coverage guides,” and New York is spending $27 million on a similar effort.

But in states like Virginia, which declined to build their own insurance markets under the law and ceded the task to the federal government, navigators will not have much money to get the word out. The Obama administration has promised up to $54 million for navigators in the 34 states where the federal government is setting up all or part of the markets. The grants are to be awarded Thursday.

In Virginia, up to $1.4 million will be distributed to navigator groups, which may include nonprofit community organizations, trade groups, chambers of commerce, unions and other public and private entities.

“It is what it is,” Ms. Dailey said about the comparatively tiny budget for navigators in her state. “All we can do is make our best effort.”

Her agency has asked for $495,000, about a third of the total navigator funds allocated for Virginia. That would cover the equivalent of seven and a half full-time navigators (some may end up working part-time), computers and other equipment for them to do their jobs, informational materials, marketing, and continuing outreach events in five counties.

The federal government did not anticipate having to cover the cost of running the insurance markets in 34 states, which is why it has only $54 million — transferred from a fund for public health prevention programs — for navigators in those states. The health care law set aside much more money for states that built their own markets, assuming that most would do so.

To fill in the gaps, other organizations will also be working to get the word out and helping people sign up for health plans through the new markets. About 1,200 community health centers around the country, which provide medical care for the uninsured, have received a total of $150 million in federal money to help with outreach and enrollment. Virginia’s health centers received $2.5 million.

In addition, many groups that did not apply for navigator funds will nonetheless help educate the uninsured about their options, connect them with navigators or point them toward the new insurance markets.

Insurance agents or brokers may also help people sign up for coverage through the markets; insurance companies selling plans through the markets will also play a role. Northern Virginia Family Service plans to enlist a network of partner organizations, many of whom already work with the uninsured, to help with outreach and enrollment or provide space and other resources.

“Other local groups may have funding or be in a position to get volunteers to do some of this work,” said Christine Barber, a senior policy analyst at Community Catalyst, a consumer advocacy group. “Everyone is anxious to know who the navigators are so that other groups can partner with them, know who to refer people to, know how to flesh out their coalitions and their outreach.”

Navigators, who will also help small businesses and their employees learn about and enroll in health plans offered through the new markets, cannot recommend any particular health plan or receive compensation from an insurance company. They will get at least 20 hours of training and take a certification test.

Opponents of the health care law have nonetheless questioned whether navigators will know enough to help consumers understand the complexities of insurance coverage, and whether they can be trusted with the personal data that consumers will include in applications for coverage.

Ms. Dailey said her agency planned to run background checks on navigators and have them sign off on ethics policies, adding, “We will do a good job because we have all these protocols in place.”

Once the federal grants are awarded, recipients will have to move quickly to hire and train navigators and set their outreach plans in motion. Judy Robinson, whose small nonprofit group in Charlottesville, Va., hopes to win a grant to hire three navigators who would team up with at least a dozen volunteers, said she was excited about the possibility despite the pressure.

Ms. Robinson said her group, the Jefferson Area Board for Aging, was already getting calls from uninsured residents seeking information about the new insurance market.

“I’m a planner, I like to anticipate things, so it is a little hard for me,” she said. “But I’m just going to try to let go, go with the flow of it and not be upset not to have it all in place.”

Ms. Dailey said her “contingent-upon-award” job fair for navigators last weekend drew about 20 people, including retirees, recent college graduates and people with compelling personal stories about health care and insurance.

“My hope would certainly be that we could do fast-track interviews,” she said. “I think I have a good pool of folks.”

A version of this article appeared in print on August 15, 2013, on page A12 of the New York edition with the headline: The Challenge Of Helping The Uninsured Find Coverage.

Language barriers could deter minorities from benefiting from healthcare reform

  • At a panel discussion, state Assemblyman Phil Ting, D-San Francisco, promoted Assembly Bill 1263.

With California at the forefront of the most comprehensive nationwide health care reform effort in half a century, it isn’t affordability but language barriers that providers and legislators fear will prevent minorities from taking advantage of greater access to coverage.

The Affordable Care Act, which begins open enrollment in October and becomes effective Jan. 1, will make health insurance more accessible and affordable to millions of Americans who now lack insurance. But in California, where nearly 16 million people, or 43 percent, speak a language other than English — it’s 45 percent in San Francisco — implementing the act presents a challenge.

At a panel discussion about this topic Wednesday, state Assemblyman Phil Ting, D-San Francisco, promoted Assembly Bill 1263, under which California would invest $200,000 to gain $270 million in federal funds authorized by the act to fund interpreter services for state Medicaid enrollees.

Interpreters are very often “our lifeline,” Ting said, noting that many immigrant families are accustomed to having their children translate when they receive medical treatment.

The U.S. Department of Health and Human Services does not recommend using children as interpreters, especially because they often lack medical vocabulary, said panelist Annis Arthur, deputy regional manager for the department’s Office for Civil Rights.

Legislation like AB 1263 would help break down language as the barrier to health care access, Ting said.

“We can’t expect our children to be there,” Ting said. “What kind of system will they be able to access? I don’t want to hyperbolize, but in these situations it’s a case of life or death.”

Members of the Asian and Latino community helped put a human face on this issue at Wednesday’s panel.

San Francisco resident Juan Situ shared how she waited hours for an interpreter to help her fill out forms for her sister’s hospitalization, only for the situation to get no better after her procedure.

“After the surgery, the interpreter was gone and we wanted to ask the doctor why my sister was in so much pain,” Situ said in Cantonese. “Finally, the doctor came to us but there was no interpreter, so we could not communicate.”

Although California and the U.S. have great language access laws, lapses exist, said forum panelist Cary Sanders, director of policy analysis at the California Pan-Ethnic Health Network.

“Part of it is they are not aware they have the right to request language access,” she said. “That is a huge issue. We heard a couple stories today but think of all the stories we are not hearing. The system fails and we don’t know about it.”