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How To Get the Best Out of Health Care Reform



Action on health care reform has moved to the states as they implement, or resist, provisions of the federal bill. Giovanna Rossi Pressley, a member of New Mexico's Health Care Reform Leadership Team, tells women what to watch for during this process.

Would you like your pregnancy to be covered by your insurance plan? Would you like to be assured that when you get sick your insurance won't be cancelled?

These and other reforms are guaranteed under the new Patient Protection and Affordable Care Act. Now in the preliminary implementation phase at the state level, the reform act can move us closer to a nation where, as the saying goes, “healthy women create healthy families, and healthy families create healthy communities.” If states fully embrace its possibilities, women and families across America will benefit with reduced out-of-pocket costs, improved coverage and better quality of care.

As provisions of the new law are rolled out over the next months and years, it is important that women know what the changes are and how to access them. Here are some of the provisions that will make health reform make sense for you and your family.

Bringing Costs Down

Thanks to a phase out by 2014 of premium rating based on gender, women will not pay more than men for the same insurance plan. And beginning in 2011, more of the money you pay into the system should go directly to your care, as insurers must spend between 80 to 85 percent of premiums on health benefits instead of administrative expenses or profits.

Many individually insured women will benefit from premium reductions as new Health Insurance Exchanges are established as easy-to-use insurance marketplaces to find a plan that best fits particular needs. And subsidies will be available to thousands of currently uninsured women to help pay Exchange premiums and out-of-pocket costs.

Medicaid will expand to cover thousands of Americans whose income, although low, makes them currently ineligible. And Medicare recipients who fall into the “donut hole” or coverage gap for drug prescriptions will get a $250 rebate this year and 50 percent discounts in 2011. In addition, new tax credits will help small employers who offer health insurance.

Increasing Coverage

For women, coverage will improve in several particular ways:

  • Pregnancy related services, such as maternity and newborn care, will be covered in new plans and in plans sold through the Exchange. And in 2014, when coverage for preexisting conditions will be required, pregnancy can no longer be excluded as a preexisting health condition.
  • Preventive benefits such as mammograms and pap smears will be included in health plans. And for new policies purchased after September 23, 2010, insurance companies will be prohibited from charging a deductible, co-payment or co-insurance for these and other preventive services. We have yet to see whether family planning services, including contraceptives, will be included in these benefits.
  • Employers will not be able to give lesser plans to lower paid workers, who are more likely to be women.

Generally, additional coverage improvements include the following:

  • Mental health and substance abuse will be covered in the same way as medical and surgical health: out-of-pocket costs cannot be higher, separate deductibles will not apply, and right to treatment cannot be limited.
  • Lifetime caps on coverage will be eliminated this year from new plans, and annual caps will be removed from group plans this year and from individual plans in 2014.
  • Insurance plans cannot cancel your plan when you're sick and file a claim.
  • Families can maintain family coverage for children up to 26 years old.
  • Long term care insurance will be offered through creation of a public, voluntary program know as the Community Living Assistance Services and Supports (CLASS) program. The premiums will be much lower than those for private plans.

Improving Care

Among provisions particularly for women, there is no referral needed for Ob-Gyn visits. And pregnant women will get free help with quitting smoking. Women who breastfeed are supported by a provision requiring larger workplaces (with some limitations) to provide a private space to pump milk. And the act calls for research, education and services for postpartum depression.

Improved care provisions for all Americans include funding of home visiting programs and community health centers, as well as recognizing community health workers (also known as outreach workers, promotoras, community health representatives, and patient navigators) as playing a key role in achieving goals of health care reform. Support for teens include contraception and abstinence education as well as pregnancy and parenting help.

All Americans, women and men alike, stand to gain from health care reform through specific provisions discussed above and through the general focus on preventive care and wellness. Different provisions of the reform act will be debated, limited, expanded or amended in the coming months as the reforms are implemented at the state level. Women should watch what's happening in their states and work against any state or Congressional action to limit hard earned gains.

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