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Got Health Insurance? What Health Reform Means

If you have health insurance (including Medicare or Medicaid) now, health reform will still affect you. Here's how.

By Lisa Zamosky
WebMD Feature

Reviewed by Laura J. Martin, MD

The new health reform law will bring about sweeping changes to the American health care system, not the least of which involves extending health insurance coverage to millions of Americans that have previously gone without.

People who already have health insurance will also see changes and added consumer protections.

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Here's a rundown of what to expect, and when, based on your situation.

Everyone

Starting Sept. 23, 2010:

Insurers can’t drop you. Stories of insurers hunting through applications for errors (often honest mistakes) as a way to deny coverage will be a thing of the past. Insurance companies will now have to prove you knowingly lied about the state of your health on your application before giving you the boot -- a practice called rescission. So, if you have insurance coverage, it’s yours to keep. This takes effect at the beginning of a health plan's new year. For most people, that means January 2011.
Right to appeal. If your insurer denies a claim or won’t pay for treatment your doctor says you need, you're entitled to two different types of appeals: internal (your insurer reviews your case) and external (handled by an independent decision-maker).

Information about how to appeal should be easily found in your health plan materials. Instructions must also be sent to you when your insurer denies a claim.

If you haven’t gotten the information, get help from your state’s insurance commissioner’s office. You can also look for state advocate contact information on the nonprofit Family USA's web site.

Note: This doesn't apply to plans that were in effect or offered by an employer when health reform became law on March 23, 2010. Those plans are grandfathered unless they make major changes to copayments, deductibles, out-of-pocket limits, co-insurance, or other elements of the benefit package. Details are on Families USA’s web site.

Preventive care covered. New health plans starting on or after Sep. 23, 2010 must pay in full for preventive care (grandfathered plans in the group and individual markets are exempt).That means blood work to check for conditions such as diabetes and high blood pressure; cancer screenings (such as colonoscopies and mammograms); vaccines; and well baby and child visits are all free. No copayments or deductibles apply.

For a full list of the preventive services insurers must cover under the new law, check healthcare.gov.

No more lifetime maximums. In the past, people who hit their lifetime spending caps essentially became uninsured for the very illness for which they most needed coverage. Now, all health plans starting on or after Sept. 23 are prohibited from capping lifetime spending for necessary services like hospital stays. That’s a big deal for people being treated for serious illnesses, such as cancer, which can get very costly very fast.
No more annual maximums. Limits on yearly spending for medical care will be restricted for new health plans in the private market (where people buy health insurance on their own) and all group health plans, including those that are grandfathered.
ER costs limited. You don't need prior authorization for emergency care to be covered if you sign on to a plan starting on or after Sept. 23 (this doesn’t apply to grandfathered plans). And if you go to an ER out of your insurer’s network -- quite common in an emergency situation -- you can't be charged more than what you would have been charged by an in-network hospital.
Direct access to OB/GYNs. Women with a new health insurance plan starting on or after Sept. 23 don't need a referral from their primary care doctor to see a gynecologist. This doesn’t apply to grandfathered health plans.