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Health care reform bill vs. individual insurance buyers

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Here are some common questions raised by those who buy insurance themselves. The answers come from the White House, but are slightly edited for a better presentation without altering the messages.

In short, If you buy health insurance yourself, you have access to new insurance choices in the same insurance marketplace where all members of Congress will buy their insurance. New protections are now in place to prevent insurance company abuses and tax credits are to be given to make coverage more affordable.

Will I pay more than I am paying today?

A: No. 

Under the new health care reform bill, you will likely pay less---perhaps much less.  If you buy insurance coverage on your own, premiums are expected to drop by 14 to 20 percent compared to what you paid in the past. If you get coverage through your employer, premiums could decline by up to 3 percent.

Additionally, many Americans buying health plans in the individual market now qualify for tax credits that reduce their premiums by an average of nearly 60 percent – and they will get better coverage than what they did before the law is enacted.

Will I have to pay higher co-pays and deductibles?

A: Highly unlikely.  

Health insurance reform bill limits what you have to pay out of pocket, a protection that did not exist before the law comes into existence.  And for the first time, no one will be required to pay more than a set percentage of their income on health care coverage.  And, if you like the coverage you have today, you can simply keep it.

Can I still see specialists?

A: Yes.

Under the health insurance reform bill, you have more secure and comprehensive insurance coverage. All health plans in the exchange are required to provide a package of essential benefits --- a guarantee that is not available in the past --- and the package will include preventive services at no cost.  

Consumers shopping in the exchange will choose from options that provide different levels of cost-sharing so that they can pick a health plan that best meets their needs and financial circumstances.

Will I be able to challenge coverage decisions by my insurance plan?

A: Yes.

Every insurance plan is now required to have a process for resolving disputes around your benefits and insurance coverage, and you can appeal any plan decisions that you disagree with to an independent appeals process.

Beyond that, States will receive support to set up independent offices to assist consumers with filing insurance complaints and appeals.

What are you going to do about all the confusing forms I have to fill out?

A: Make it simple.

The health care reform bill requires plans to use clear and plain language on insurance forms so that policy-holders can easily understand what benefits and what doctors are covered in your plan. 

And, standardized forms will be used to reduce the confusing and overwhelming paperwork that all Americans have to confront in the past.

What will happen if my insurance company raises my rates?

A: The new law requires public disclosure of the percent of premiums applied to overhead costs, so that you can decide whether or not you are getting the best value for your premium dollars. 

If your insurance company spends too much of your premium dollars on overhead, such as big salaries, administrative costs and marketing, they will be required to give you a rebate. 

Until the insurance exchange marketplace is up and running, there will be a process for annual reviews of all requested increases in premiums.  Insurance companies that raise rates arbitrarily will not be allowed to sell policies in the new insurance marketplace.   This process continues even after the Exchange is up and running.

What consumer protections will I get this year if I buy coverage in the individual market?

A: Beginning in September 2010,  insurers will be prohibited from placing lifetime limits on what they will pay for your medical care, and they can only apply restricted annual benefit limits. Insurers will no longer be able to arbitrarily cancel your insurance policy when you get sick, except in cases of fraud.

Insurance companies will be prohibited from denying coverage to children with pre-existing conditions. This applies to all new plans in the individual market. 

Beginning in September 2010, all new individual market health plans must provide coverage for preventive services.  Recommended prevention and vaccination services will be covered without any deductibles or copayments. They must also have a straightforward and independent appeals process so you can appeal decisions by your health insurance plan.

Beginning on January 1, 2011, insurance companies will be required to spend most of your premium dollars on your care, not on profits and overhead -- 75 percent in the individual market -- and rebate any excessive overhead to enrollees.

Similarly, starting in plan year 2011, companies that sell insurance in the individual market that jack up rates will have to disclose requested premium increases publicly.  If that rate increase is found to be unreasonable, the insurer may be prohibited competing for your business in the new state-based exchange that will begin operating in 2014.

I’m a parent, how will reform affect coverage for my children?

A: You can get coverage for your child if he or she has a pre-existing condition, and adult children can stay on family policies until age 26.

Beginning in September 2010, it will be illegal for health insurance companies that cover children to deny coverage to your child based on a pre-existing condition.   This applies to all new employer plans, new plans in the individual market, and existing employer plans.

Beginning in September 2010,  insurers will be required to permit children to stay on family policies until age 26.  This applies to all plans in the individual market, new employer plans, and existing employer plans, unless your adult child has an offer of coverage through his or her employer.  This requirement will take effect the next time your plan comes up for renewal.  Adult children who are on their parents’ plan now but who lose that coverage when they graduate from college will have the option of rejoining their parents’ policy in the new plan year beginning n September 2010.  Those whose parents work at self-insured companies will also be eligible if they do not have an offer of employer-sponsored insurance.  Both married and unmarried dependents qualify for this dependent coverage.  Beginning in 2014, children up to age 26 can stay on their parent’s employer plan even if they have an offer of coverage through their employer.

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