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We have been getting a lot of calls lately about the new health insurance reform bill that passed and was signed into law now long ago. So I wanted to go over some of the key provisions in it that will take effect, either immediately or within the next few months. There's some provisions that won't be in effect for years. so we wanted to talk about the things that are really in effect now. Those affect people, of course, who have disabilities but it also will affect many millions of Americans. We'll go over some of the key provisions and then I will answer some of the frequently asked questions that were posted on the government's web site called HealthReform.gov.

So first, some of the key provisions. There are small business tax credits. Tax credits are offered to small businesses so that they can offer health insurance to their employees and have it be more affordable. The tax credits will take care of up to 35% of the premiums. Now, that's effective already. That was effective beginning this calendar year, and then in 2014, the small business tax credits will cover 50% of premiums.

Another key provision is that there is now no discrimination allowed against children who have pre-existing conditions. This just prohibits new health plans in every state, plus grandfathered group health plans, from denying coverage to children with pre-existing conditions. And that is affective six months after the date that the law was enacted, and in 2014, that will apply to everybody, not just children.

Another provision is that there's help for uninsured Americans who have pre- existing conditions until the exchange is available. This is called the interim high risk pool. It provides access to affordable insurance for Americans who are uninsured because of the pre-existing condition. Through a temporary subsidized high risk pool. And this is effective now. It ends recisions. It bans insurance companies from dropping people from coverage when they get sick. And this is effective six months after the enactment of the law.

Another key provision is that it will begin to close the Medicare Part D "doughnut hole". Not sure how familiar you are with that, but it's really the way that Congress set up the Medicare Part D, which is the prescription drug coverage for Medicare. It's sort of a complicated formula that leaves space in the middle of the coverage where the person actually has no coverage. So this now will provide a 0 rebate to Medicare beneficiaries who hit the doughnut hole in 2010. And that's affective for the calendar year 2010. Beginning in 2011, there's a 50% discount on prescription drugs in the "doughnut hole", and by 2020, that "donut hole" will be completely closed.

There is also free preventive care under Medicare. It eliminates co-payments for preventive services and exempts preventive services from deductibles under the Medicare program. And that's effective beginning January 1, 2011. It extends coverage for young people, up to their 26th birthday, through their parents' health insurance. It requires new health plans, and certain grandfathered plans, to allow young people, up to their 26th birthday, to remain on their parents' insurance policy, at the parents' choice. And this is effective six months after the enactment of the law.

There is help for early retirees. This creates a temporary re-insurance program, until the Health Insurance Exchange are available, to help offset the cost of expensive premiums for employers and retirees for health benefits for retirees from age 55 to 64. And that's effective this year.

It bans lifetime limits on coverage, prohibits health insurance companies from placing lifetime caps on coverage. It bans restrictive annual limits on coverage. It tightly restricts the use of annual limits to assure access to needed care in all new plans and grandfathered group health plans. These tight restrictions will be defined by Health and Human Services. And beginning in 2014, the use of any annual limits will be prohibited for all new plans and grandfathered group health plans.

There's free preventive care under new private plans. It requires that new private plans cover preventive health care services with no co-payments and with preventive services being exempt from deductibles.

There is a new independent appeals process. This ensures consumers and new plans that they have access to an effective internal and external appeals process to appeal decisions by their health insurance plan. It ensures value for premium payments. It requires plans in the individual and small group market to spend 80% of premium dollars on medical services and plans in the large markets an 85%. Insurers that do not meet these threshholds must provide rebates to policyholders. That's effective January 1, 2011.

It creates community health centers. It increases funding for community health centers to allow for nearly doubling the number of patients seen by the centers over the next five years. And that's effective beginning in 2011.

It increases the number of primary care practitioners. It provides new investments to increase the number of primary care practitioners, including doctors, nurses, nurse practitioners and physician's assistants. And that begins in fiscal year 2011.

It prohibits discrimination based on salary, prohibits new group health plans from establishing any eligibility rules for health care coverage that have the effect of discriminating in favor of higher wage employees. That's effective six months after the law was enacted.

Health insurace consumer information. The new law provides aid to states in establishing offices of health insurance consumaer assistance in order to help individuals with the filing of complaints and appeals. And that's effective in 2010.

And one last key point is that it holds insurance companies accountable for unreasonable rate hikes. It creates a grant program to support states in requiring health insurance companies to submit justification for all requested premium increases. And insurance companies with excessive or unjustified premium exchanges may not be able to participate in the new health insurance exhcnages. And that starts in 2011.

Now, HealthReform.gov has posted some frequently asked questions. And I went to go through some of these with you because they're really good questions! That is probably why they're frequently asked.

OK the first one is, "My sister has a barbecue restaurant in Texas. She has only six employees. Does this new health care reform bill require her to provide insurance? She currently doesn't because she's in a very small business market and needs to know for the future."

And the answer is, the new law will not require your sister to provide insurance. However, it will provide your sister with tax credits if she chooses to provide insurance to her employees. Starting this year, indeed starting retroactively to January 1, 2010, small, new business can have a health care tax credit that will provide a 35% tax credit on health premiums, with the credit increasing to 50% in 2014. Your sister's restaurant is one of about four million firms that will be eligible for this tax credit and small business owners can find out about the tax credit online.

Question: "What is the small business tax credit and how do I know if I'm eligible?"

Effective January 1st, 2010, tax credits are available to qualifying small businesses that offer health insurance to their employees. So if your business qualifies, you're eligible right now. About four million small businesses will be eligible to receive tax credits if they provide insurance. The credit's worth up to 35% of the premiums that your business pays to cover its workers, 25% for non-profit firms. Your business qualifies for the credit if you cover at least 50% of the cost of health care coverage for your workers, pay average annual wages below ,000 and have less than the equivalent of 25 full time workers. For example, a firm with fewer than 50 halftime workers would be eligible. The size of the credit depends on your average wages and the number of employees you have. The full credit is available to firms with average wages below ,000 and less than 10 full-time equivalent workers. It phases out gradually for firms with average wages between ,000 and ,000 and for firms with the equivalent of between 10 and 25 full-time workers. To learn more about the small business tax credit, you can also visit IRS.gov

"Am I required to offer insurance to my employees?"

No. That's a misconception. There is not a so-called “employer mandate” in the legislation.

"Are there small business tax increases in this new law?"

No. Another misconception. Small businesses get tax breaks for health insurance rather than tax increases under the law.

"What if my small business doesn't offer insurance today, but I choose to start offering it this year? Will I be eligible for these tax credits?"

Yes. The tax credit is designed to support those small businesses that provide coverage today, as well as those that newly offer such coverage.

"Can I join a pool now to lower my cost?"

Beginning in 2014, reform will create state based Health Insurance Exchanges that pool small businesses and their employees, which will spark competition and give you the kind of purchasing power that big businesses enjoy today. The exchange will offer the same types of private insurance choices that the President and Members of Congress have. Increased purchasing power and competition will make premiums more affordable. The exchange will also reduce administrative costs for your businesses and your employees, enabling them to easily and simply compare the prices, benefits, and quality of the health plans.

"How do I get my 21-year-old onto my health plan?"

Six months from now, 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 own employer. This requirement will take effect the next time your plan comes up for renewal. Adult children who are on their parents’ plans 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 6 months from the time this law was enacted. 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 own employer.

"Can I now get coverage now for my 6-year-old who has a pre-existing condition?"

Yes. Effective 6 months after the plan was passed, 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.

What consumer protections will I get this year if I get insurance at work?

nsurers 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 and existing employer plans. All new group health plans must provide coverage for preventive services. Recommended prevention and vaccination services will be covered without any deductibles or copayments. Plans 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-85% in the large group market and 80% in the small group and individual market - and they'll have to rebate any excessive overhead to enrollees. Similarly, starting in 2011, when your plan year starts in 2011, insurance companies 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 be operating in 2014.

"I have a pre-existing condition. How can I get coverage this year?"

This year, if you have been uninsured for 6 months and have a pre-existing condition, you will gain access to health insurance that was not previously available to you. A new program – known as a high-risk pool – will provide affordable insurance for Americans who are uninsured and have a pre-existing condition. This program will provide temporary protection for people with pre-existing conditions until 2014, when insurance companies can no longer deny you coverage based on your health.

"My insurance company wants to raise my rates. What recourse do I have?"

For most consumers today, it's hard to figure out how to challenge a rate increase. The new health insurance reform law will create a clear pathway for consumers to hold insurance companies accountable. Six months after the date that the law was passed, all new health plans will be required to have implemented a clear and effective process under which policy holders can appeal coverage determinations and claims. States must also have an external appeals process to ensure a fair and objective review of coverage disputes. Additionally, millions of dollars in grants will be made available this year to states to help create a health insurance consumer assistance office where consumers can learn how to enroll in a plan or file a complaint. There will also be a new website that will begin operating this year, which will help consumers identify and compare health coverage options. Information will be presented in a standardized, easy-to-understand format to ensure individuals and families understand their options and purchase the right coverage for their needs. Finally, new standards for the amount an insurance company must pay out in benefits as opposed to profits and administrative costs will go into effect in 2011. Insurance companies will be required to give money back to consumers if they don't meet those standards. In addition, requested premium increases will be made publicly available, and in 2014, plans that have arbitrarily raised rates previously may not be able to participate in the new health insurance exchanges.

"My insurance company just withdrew my coverage, claiming I had a previous illness. Can I fight back?"

Insurance companies will be prohibited from dropping your coverage when you get sick. This will apply to all new and existing health plans.

"When does preventive care start and will it affect my plan?"
Six months after the law was passed, all new group health plans and new plans in the individual market must provide coverage for preventive services. Recommended prevention and vaccination services will be covered without any deductibles or copayments. Seniors who are enrolled in Medicare will also no longer have to pay for proven preventive services.

"What information about insurance companies is going to be posted on the web?"

Consumers will immediately have more opportunities to take control of their health insurance choices. Effective July 1, 2010, a website will provide information to consumers to help them choose the plan that is best for them. The Secretary of Health and Human Services will establish an Internet website through which residents of any state may identify affordable health insurance coverage options in that state. The website will include information on coverage options for small businesses as well. Effective January 1, 2011, health plans, including existing plans, must annually report on what percentage of premium dollars they spend on medical care, as opposed to profits, marketing, and administrative expenses. You will be able to see that information online and may be entitled to a rebate if your plan spent too much on overhead and profits. Health insurers must also post unreasonable rate increases along with a justification for them.

"When does my free preventive care for Medicare start and what does it cover?"

It starts on January 1, 2011, and proven preventive services will be free. In addition, a new annual wellness visit that provides a personalized prevention plan services, including a health risk assessment, will be provided under Medicare.

"Can you define what the Medicare doughnut hole is?"

Medicare Part D provides prescription drug benefits to Americans who are on Medicare. This benefit comes with a 0 deductible. After you’ve spent 0, then you pay 25% of the cost of your prescriptions until the total cost of all the medicine you've gotten in a year hits ,830. Then, you are stuck with 100% of the bill until the cost of your medicines hits ,440. That inbetween place, where you're stuck paying 100%, that's the "donut hole". Can you define the doughnut hole? A: Medicare Part D provides prescription drug benefits to Americans on Medicare. This benefit comes with a 0 deductible. After you’ve spent 0, you pay 25 percent of the cost of your prescriptions until the total cost of all the medicine you have received in a year hits ,830. Then, you are stuck with 100 percent of the bill until the total cost of your medicines hits ,440. The gap when Medicare does not cover the cost of your prescription drugs. Health reform, this law, will close the donut hole. Reform also offers immediate relief by providing a 0 rebate this year to seniors who hit that donut hole.

"How will the 0 benefit toward the coverage gap be received by beneficiaries? And what’s the eligibility?"

Once you've hit the prescription drug donut hole, you will eligible for that 0 rebate. And the check will be sent directly to you from Medicare. There’s no application process and no private company will be involved in you getting that rebate check.

"I’m covered by a Medicare HMO which served my health very well. Will I be able to maintain the same coverage I have after health insurance reform is implemented?"
Unfortunately, there has been a lot of misinformation about Medicare Advantage plans. Seniors have a choice when they turn 65 and beyond, enroll in traditional Medicare plan or enroll in a Medicare HMO or Medicare Advantage Plan. Medicare Advantage plans will continue to offer services to beneficiaries. Companies right now choose whether to offer Medicare Advantage plans. Some may make the business decision to exit the market, but nothing in the new law forces these plans to stop offering benefits and services.

"I can't get Medicare until I am 62. I do not have health coverage. I cannot get health coverage because I have a pre-existing condition. Do I get a piece of this new health care plan?"

Absolutely. Beginning this year, you will be eligible to receive coverage through the new high-risk pools. Today, too many insurance companies reject Americans with pre-existing conditions or charge exorbitant rates. High-risk pools will offer these individuals access to affordable insurance and in 2014 there will be a new market that will prevent insurance companies from eliminating anyone with preexisting conditions. And you can get more detail about the high-risk pools online at HHS.gov.

Leonard from CA asks, "How will the new health care law affect those of us who are under age 65 but still disabled and on Medicare? Is there anything that is different for us than those on Medicare due to age? For people who have disabilities, how does this new law affect them?"

If you’re on Medicare, nothing will change for you. You will continue to receive your Medicare benefits and reform makes Medicare stronger. Today, Medicare beneficiaries must pay 20% of the cost of many preventive services and office visits. Reform eliminates deductibles, copayments, and other cost-sharing for recommended preventive care, and provides free annual wellness check-ups starting in 2011. Reform will also improve the quality of care you receive, fight Medicare fraud and extend the financial health of Medicare by 9 years.

So, that covers some of the key points of the law as well as frequently asked questions. we expect to have a lot more questions about this law as people access it and so be sure to send those in and we'll find answers for you. Thanks for tuning in.

The Disability Law Lowdown is brought to you by the Disability Business Technical Assistance Centers, which are a network of ADA centers that provide training, technical assistance and materials on the ADA and other disability-related laws. Funding for the centers is provided by a grant from NIDRR, the National Institute on Disability and Rehabilitation Research. You can subscribe to the Disability Law Lowdown at our Web site at DisabilityLawLowdown.com or on iTunes.



The Southwest and Rocky Mountain ADA Centers are part of a program of Independent Living Research Utilization at TIRR - Memorial Hermann in Houston, Texas, and is funded by the National Institute on Disability and Rehabilitation Research. If you have questions about disability law or would like to request materials or training, please call 1-800-949-4232. This podcast is protected by the Creative Commons Attribution Non-Commercial No-Derivative-Works 2.5 License. For more information and transcripts, visit www.ada-podcast.com.