Health Reforms That Are Happening

Starting January 1, 2011 *NEW*

Here are reforms that are starting January 1, 2011. Below that are reforms that were already in place, along with how our patients can take advantage of the reforms.  Please share this information!  To learn more about health reform topics, visit our Resource Center.

For people who are overcharged for insurance premiums:
What Will Be New: Insurers will be required to send rebates to consumers if they do not spend at least 85% (large-group insurers) or 80% (small-group insurers) of premium money on health care.
What to Do: Rebate checks should be coming in the mail automatically. 

For seniors struggling to pay for brand-name drugs:
What Will Be New: Medicare Part D recipients who are in the donut hole will get a 50% discount on covered brand-name drugs and a 7% discount on covered generic drugs if Part D is the primary payer.
What to Do: The discount will apply immediately at the pharmacy.

For seniors struggling to pay for preventive care:
What Will Be New: Medicare will now cover preventive care with no copays or deductibles 
What to Do: See the list of covered services or See details on the USPSTF recommendations

For primary care providers:
What Will Be New: Medicare will pay 10% more to eligible primary care providers.  Primary care is defined as those in family medicine, internal medicine, geriatrics, and pediatrics; this includes PA's, NP's, and clinical nurse specialists.  
What to Do: To qualify for the bonus, 60% of Medicare charges must be for primary care services.  (Note: Doctors for America does not have at present have a position on these provisions, there has been some discussion that the 60% threshold needs to be adjusted as it will leave out many primary care providers.)

For general surgeons practicing in rural areas:
What Will Be New: Medicare will pay 10% more to eligible rural general surgeons who perform major surgical procedures.  
What to Do:  To be eligible for the incentive payment, you must be enrolled in Medicare as a general surgeon and practice in a Health Professional Shortage Area (HPSA).  Read more and find links to get more information.

For those who are concerned about Medicare staying sustainable:
What Will Be New: Medicare will stop paying private insurance companies extra to provide the same level of care that traditional Medicare provides. 
What to Do: Nothing. 

For those who think we need innovative ways to deliver care:
What Will Be New: The Center for Medicare and Medicaid Services is launching a website for its new CMS Innovation Center that will work with the private sector to improve quality and lower costs.
What to Do: Stay tuned for upcoming opportunities to get involved.


Here are some of the reforms that have already been in place, as well as resources for our patients to take advantage of these reforms.  While core elements of health reform were defined by the new law, many of the details will be determined through negotiations and further legislation at the federal, state, and local levels especially between now and January 1, 2014, when the largest elements of reform are implemented (state exchanges, insurance subsidies, Medicaid expansion, individual mandate).

Getting and Staying Insured

For the patient who can afford insurance but has been denied because of a pre-existing condition:
What's New: People with pre-existing conditions can apply for a pre-existing condition plans run in all 50 states. Started July 1, 2010
What to Do: Here's the site where patients can apply.  Of note, they must have had no insurance for 6 months and have proof of having been denied coverage.  

For the small business that cannot afford health insurance:
What's New: 35% tax credit for small businesses and 25% tax credit for small non-profits that meet eligibility requirements -- started with fiscal year January 1, 2010
What to Do: See if your business qualifies

For any patient who is trying to get health insurance:
What's New: Everyone can go to a new website that gives information about current private and public health insurance pricing, eligibility, and provisions. Started July 1, 2010.
What to Do: Use the insurance finder tool

For young adults who do not yet have health insurance:
What's New: Young adults up to the age of 26 (even if they are married) can stay on their parents' insurance. Started Sept 23, 2010.
What to Do: Parents should check with their current insurers for open enrollment periods. 

For the 60-year-old who retired early and may lose their employer health benefits:
What's New: Businesses can apply for temporary federal subsidies to keep early retirees on health insurance.  Started June 1, 2010.
What to Do: 
Business owners should look into the details of the Early Retiree Reinsurance Plan   (Note: over 7000 businesses have received subsidies to date.)

For patients who have passed their lifetime limit on insurance coverage:
What's New: No more lifetime limits on new plans. Started Sept 23, 2010.
What to Do: Contact your insurance provider for more information. 

For children with pre-existing conditions who have been "uninsurable":
What's New: Children can no longer be denied coverage for pre-existing conditions.  Started Sept 23, 2010.
What to Do: Parents can look for insurance options to apply for on the insurance finder

More Provisions

For anyone who wants our health care system to focus more on preventive care:
What's New: Preventive care for new health plans is covered with no copays or deductibles, as long as they are Grade A or B recommendations of the U.S. Preventive Services Task Force.  Started Sept 23, 2010.
What to Do: See the list of covered services or See details on the USPSTF recommendations 

For the senior citizen who has been struggling to pay for medications:
What's New: Eligible seniors should have received $250 rebate checks if they are in the Medicare Part D Donut Hole, as the first step toward closing the donut hole, which will happen by 2020.  Checks are to be sent out with 45 days of the seniors reaching their coverage gap point.  Started June, 2010.
What to Do: Patients who have not received their checks should confirm with their drug plan that their status information was sent to Medicare. 

For those who need help getting through insurance company red tape to get covered:
What's New: New standard rules for appealing an insurance company's denial -- first internally, then externally if necessary.  Started Sept 23, 2010.
What to Do: Learn about the new rules or Contact your State Insurance Comissioner for more details.  


In addition to the provisions above, investments have been made in the following areas.  Stay tuned for developments and opportunities for input:

  • Prevention and Public Health Fund
  • Community Health Centers 
  • State-based Review of Insurance Rate Hikes
  • Consumer Assistance Programs
  • Primary Care 
  • Establishing State-based Insurance Exchanges

You can read about more upcoming benefits on the Commonwealth Fund's Health Reform Resource Center.  If you are interested, you can read the entire text of the law as well. In order to make sure the health care system is reformed in a way that helps the patients we serve, we as doctors and medical students will need to stay informed, vigilant, and involved.  Contact us at info@drsforamerica.org to get involved!


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