Health Reform Implementation Issues: Emergency Room Costs, Consumer Websites And Small Business Questions

Kaiser Health News: The new health reform law guarantees insurance companies must cover emergency care for their beneficiaries at hospitals in- or out-of-network at the same rate. "The law also bars health plans from requiring prior authorization for emergency services. And it mandates that plans follow the 'prudent layperson' rule. For example, if a person goes to the ER with chest pain, but ends up being diagnosed with indigestion, the claim has to be covered because going to the hospital under those circumstances made sense." The provisions start for plans that cover emergency at the beginning of their new plan years after Sept. 23. "For years, insurance plans have been denying ER claims for a variety of reasons. Although there is little data on the overall scope of the problem, a recent RAND Corp. study found that at least one out of every six claims for emergency department care was denied by two large HMOs in California" (Mertens, 5/13). 

Kaiser Health News, in a separate story: Insurance regulators inundated with consumer questions and confusion over the new health law are hopeful a soon-to-be-rolled-out consumer web site will alleviate their pain. "By July 1, the Department of Health and Human Services will set up a website that has a section for each state. Consumers and small businesses can consult it when shopping for insurance plans. The federal website will have every health plan listed that is authorized by each state, a list of the plans' network of providers, the services they offer, who is eligible and how to sign up. The portal will include private plans, Medicare, Medicaid, the State Children's Health Insurance Program and the new high-risk pools. It's considered the first step in what will eventually be the state-based insurance exchanges" (Mertens, 5/12).

In the meantime, The Washington Post reports that millions in the District of Columbia metro area have pre-existing conditions that would likely preclude them from gaining health insurance coverage on their own, new reports say. "The figure comprises nearly 1.5 million people in Virginia, slightly more than 1 million in Maryland and about 114,000 in the District, according to Families USA, a liberal group that advocates universal health care." Many of these people already get coverage through employer-sponsored plans, but would find gaining coverage difficult by themselves if they were laid off. But, "[u]nder the Obama administration's health care legislation, starting in 2014, insurers will be prohibited from turning people away or charging higher premiums because of someone's medical history or health risk. ... The report is part of the advocacy group's effort to highlight specific benefits of the health-care changes in the continuing battle to shape public perception about the overhaul" (Sun, 5/13).

The Buffalo News: Insurers are urging their colleagues to be more active in negotiating "the finer details of new rules and implementing" the new health law. "Despite continuing reservations, insurers now have a critical opportunity to influence how the law is ultimately applied, said (BlueCross BlueShield Association CEO) Scott P. Serota, in separate remarks to more than 350 representatives of large employers and earlier to The Buffalo News' Editorial Board. … [W]hile some aspects of the legislation can be put into effect easily and clearly, other parts of the legislation were broadly written and require translation into specific regulations by the Department of Health and Human Services or its agencies. And those details could determine success or failure in controlling costs. ... [A]mong more than 2,000 pages, Serota said, there are 1,200 places where the Health and Human Services secretary is told to exercise his or her discretion. 'We need to make sure we influence that discretion,' Serota said" (Davis and Epstein, 5/13).

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